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Foot & Ankle International
FAI September 2025 Podcast: Immediate Postoperative Weightbearing Following Arthroscopic Bone Marrow Stimulation for Talar Osteochondral Lesions: A Matched Cohort Study
00:41:08
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- [00:03]
A
This is Mark Easley and I have the distinct honor of talking with Dr. Gino Kerkhofs, the senior author of September's lead paper in Foot and Ankle International. The paper is titled Immediate Post Operative Weight Bearing following Arthroscopic Bone Marrow Stimulation for Talar Osteochondral Lesions A matched cohort study. Dr. Gino Kirchhoffs is a world renowned orthopedic surgeon and an MD and PhD. He serves as the Chair of the Department of Orthopedic Surgery and Sports Medicine of the Amsterdam University Medical Centers. He also chairs the Academic center for Evidence Based sports medicine or ACEs, and chairs the IOC research center in Amsterdam. Dr. Kirchhoff has a broad background in research, but more recently has dedicated his research focus to ankle cartilage and muscle injuries of the lower extremity with special attention to the elite athletes. Dr. Saltzman and I selected this article that investigates the feasibility of immediate weight bearing after arthroscopic bone marrow stimulation for talar osteochondral lesions through clinical and radiographic follow up and analysis of return to work in sport. Welcome to the program, Gino. Gino, as senior author, would you please give the listeners a brief summary of your paper and its major findings?
- [01:17]
B
Sure. Happy to summarize. Mark. First, thank you for having me. That's really great. I would say. In this match cohort study we aim to evaluate whether immediate post op weight bearing after arthroscopic bone marrow stimulation cause or convolutions of the talus would lead to different outcome compared to a more traditional delayed weight bearing approach. So what we did is retrospectively included 26 patients, 13 in each group, matched on the key clinical factors and followed them for 12 months. So our main finding was that both groups showed similar improvement in pain and function over time with no statistically significant differences in clinical nor radiological outcomes. So interestingly, larger proportion of patients in the immediate weight bearing group exceeded the minimal clinically important difference pain reduction and also showed a trend of towards the earlier return to work in sport. So while our sample size was small and the study exploratory in nature, these results suggest that immediate weight bearing may at least be safe and potentially beneficial alternative to delayed protocols. Of course, larger prospective trials needed to potentially confirm these findings.
- [02:33]
A
Perfect.
- [02:33]
B
Yeah.
- [02:34]
A
Thanks for giving us an overview, Gino. Bone marrow stimulation techniques are probably relatively consistent among surgeons. However, as for any surgical procedure, there are subtle differences in technique. John Kennedy and others have suggested that with longer follow up micro fracture may be harmful to the subchondral bone. Given your extensive experience in the management of osteochondral lesions of the talus. Would you please share with the listeners your tips and tricks for optimal bone marrow stimulation?
- [03:03]
B
Yes, it's a great question. So bone marrow stimulation, particularly micro fracture, has long been the workhouse for treating talia ostrich condy lesions and while principles are consistent, small technical differences really define outcomes. So from a technical perspective I would highlight a few essentials. So first we always start with precise lesion debridement, ensuring stable vertical shoulders, removal of vitalized cartilage and for the marrow stimulation itself, nowadays prefer low impact techniques with small diameter picking under arthroscopic control rather than a traditional larger size house actually to reduce the risk of compaction or unintended subcontral bone injury. Now regarding the long term concerns raised by John Kennedy and others, especially about the biological inferiority of the fibrocartilage, I would say those are valid. Fibrocartilage simply does not replicate the mechanical resilience of native hyaline cartilage nor its ability to protect the subcontinental bone. Over time that has fueled growing interest in the orthobiologics and their regenerative techniques to augment or improve outcomes after micro fracture. However, I would state that the clinical evidence supporting routine use of biologic remains limited. For instance, in the long term follow up study by Corydol in the Foot and Ankle International, isolated microfacture without augmentation still showed excellent outcomes at over 90% survival at 10 years and a high return to sport rate. Similarly, in our own GBGS study on over 260 patients we observed an 82% survival rates 10 to 15 years, again without the use of biologics. So while promising, we believe orthobiologics need to be critically evaluated in terms of cost, accessibility and also clinical benefit before they can worldwidely be recommended. Having said that for larger or cystic osteocondal lesions where traditional bone marrow stimulation may not be sufficient might be a different question. So to round up my answer on tips and tricks for optimal bone marrow stimulation that would need mandicular lesion prep a minimal trauma to the circumal plate controlled marrow stimulation, ideally through small diameter holes and a critical patient selection as ever, especially with emphasis to the BMI and foot cough muscle strength as well as balance and also a realistic approach to biological augmentation not so much as a default but as a tailored tool when indicated. And of course regarding to our paper, we are also learning that early mobilization, even immediate weight bearing might not compromise outcomes which has the potential to simplify rehab and improve patient satisfaction. That would be maybe a little bit long. Answer to your question, no.
- [06:13]
A
That's great. That's what people want to hear and that's what I want to hear. So thank you for sharing that and you touched on this. But I'll ask you one more question along those lines. So, while it's debatable, osteochondrial lesion size and location probably influence outcomes of the surgical management of OLTS. In Table 1 of your paper, your inclusion criteria state that on the preoperative CT scan, all lesions treated in this investigation were less than 15 millimeters in all three planes. You and your CO investigators did not demonstrate any differences between the immediate and delayed weight bearing groups, although beyond the scope of this investigation. And again, you hinted toward this. Would you please share with the listeners your experience in treating lesions greater than 15 millimeters and if BMS or bone marrow stimulation may be applied to larger lesions?
- [07:01]
B
All right. Yeah. So our experience with larger lesions for I would say more than a decade ago is that these do not so well in more than 50% of the cases. So we stopped using BMS for these lesions. So it's also the reason that we have tried to develop a structural autograph technique called topic, which stands for Taylor Osteoperiostic grafting from the iliac crest. So it's a breast fit graft that you discussed very nicely for the lateral dome lesions matured in the June podcast. So I would say this press fit graft combines cortical bone periosteum harvested from the iliac crest and aims to restore not only volume but also biological activity. What we saw from the medial lesions, often more challenging due to depth or cystic changes that occur. Also the relative size that's large used a medial mallear osteotomy in the GS 2023 paper, including the first 43 patients, we again saw subtransal clinical improvement using this technique. So I would say that could be robust single solution for the larger selfish type lesions offering both structural support and biological stimulation. And as a good alternative to the allograft that you used to use in complex multi stage cell based therapies that might be much more costuous. Perfect.
- [08:29]
A
Thank you. You and Dr. Stukins and your team are starting to take over Foot and Ankle International. Great work and contributions are extraordinary. So one more you and your CO investigators recorded lesion location based on the nine zone method described by Elias et al. In your team's experience, does lesion location influence outcomes of bone Marrow stimulation.
- [08:51]
B
Yeah. I would say if you look at this series, the most lesions were in zone 4 and 7, meaning central, medial, or post remedial. To be honest, we did not find any differences in outcome between the groups when comparing these zones to the other zones. Also not for recurrence rate of the cysts, but I would say it's most probable because our numbers in this study were too small for this. I would also comment from my experience that there is a probably a correlation between location and outcome of BMS treatment, but that would be more technical reachability. I don't know if that is dunglish or good English, but hope you get what I mean. So the reachability of the lesion to really perform a perfect procedure. In the revision cases that are referred to our clinic, we often see that there's still some or part of an original cyst left untouched, and that might be the reason for the continuous pain. And the patients say, well, nothing really changed. That's less likely to happen in lesions that are easy to reach and much more likely to happen in difficult to reach lesions. So it's maybe not only the lesion location itself, but also factors like ankle stiffness, shape of the tailless, like bow head, or more flat. And fixing that into the term reachability, that might be something that really potentially influences the outcome of BMS and not so much the location in itself. If it's where, well, that's great.
- [10:24]
A
That's very important. The access to the lesion. I like that you and your colleagues, and Dr. Van Dyke, too, have just taught surgeons all over the world how to not only address these lesions, but also how to perform the optimal arthroscopic technique. So we thank you for that as well. So that certainly helps patients as well. Thank you very much. Let's go back just to add to the previous question. And you touched on this too, but in your radiographic analysis, you studied associated subchondral cysts. Would you please share with the readers whether the presence of a subchondral cyst influences outcome of bone marrow stimulation for olts? And if you perform any additional procedures when the OLT is associated with a subchondral cyst, then also you study the OLTs with CT scanning. I recognize that MRI may help identify associated ankle and hind foot pathology, but do you also routinely obtain MRI scans to better define the olt?
- [11:18]
B
Okay, great questions, Kenmar. So the presence of a cyst in the lesion before the BMS treatment for OLT means that we would advise to do a debridement of the cyst cavity walls and break the sclerotic wall of the cyst to allow that to heal as part of the BMS treatment. Having said that, after the OLT treatment procedure, especially for the larger lesions, we we know that we might see a high percentage of new cysts formation, for example in the graphs or in the topic graphs or in the allographs. And recently published a meta analysis in Cartilage evaluating cyst recurrence and concluded there that post operative cystic occurrences is common in the autograft transplantations for over 40% allograft, over 50% in osteoporiosteal transplantation, over 30% in the osteocoma lesions of the talus without significant intertreatment differences. So I would say that in a clear statement also that the postoperative presence of these cysts was not correlated with clinical outcomes in any of these patients. So pre op cyst important to treat post op cyst aesthetically not nice to look at, but seemingly at five to seven year follow up not related or correlated to the clinical outcomes. And then as to the CT scan, we like the CT scan because it gives a very easy measurable view on the diameter or the volume of the subcontal bone defect. MRI with the edema might lead you to oversize that a little bit. Although I agree totally with your remark that MRI is very useful in identifying other pathology.
- [13:08]
A
Perfect. Great. Thank you. So osteochondrial lesions of the talus are a little bit lower than the native cartilage. So I'm going to ask you a question about your homeland. So you're in Amsterdam in the Netherlands, which I believe means lower or low country. And I believe that that's due to the lower elevation of the country. So correct me if I'm wrong, but the Amstel river flows through Amsterdam and into the Eye Bay and then into the North Sea. With the risk of rising sea levels, what does low lying Amsterdam do to protect from flooding? And what is the room for the river concept? Could you share that with the listeners, Mark?
- [13:47]
B
That is, yeah, very confronting. But you are absolutely right. The name Netherlands literally means low countries. And a large part of our country lies below sea level, including Amsterdam. So in order to manage that, we protect it by an extensive system of over 16,000 km of dikes along with canals and pumping stations. Water management is something we've done for centuries. So that is really part of our DNA. And that's not only the water we use in our beers. So let us come to the room for the river concept. That is indeed something else than simply raising the dikes because we actually create space for our water by widening riverbeds or designing areas that can safely flood when water levels rise. So it's a relatively smart way to live with the water and not just fight it. So yes, I would admit we're flat and wet, but fairly well organized.
- [14:52]
A
Thank you. Yes, I was always curious about that, but thanks for sharing that. Back to the paper. One other question I have regarding the characteristics of the OLT and could not find in the data that you presented is whether the OLT studied were contained or non contained. And you had mentioned earlier about the debridement and how you prepare the defect when you're performing the procedure. So I know that you and your colleagues have a comprehensive approach to managing OLTs with a full complement of surgical techniques and you touched on the topic technique. But would you please share with the listeners if contained vs non contained makes a difference when applying bone marrow stimulation to osteochondral lesions of the talus?
- [15:28]
B
Thanks Mark. That's another very interesting question. Not an easy one to answer, but I'll give it a try. So when we talk about containment in osteocondal lesions of the talus, probably we are essentially referring to whether the lesion is surrounded by intact stable cartilage. So contained lesion as cartilage margins all around which helps to hold reparative tissue in place after a vms. So the non contained lesions by contrast lack that stable cartilage border, often extending, tailor shoulder or even the edge of the joint. That makes biological repair inherently more challenging. That would be the theory. So this distinction has a significant impact on treatment selection for contained lesions. Especially small to midsize BMS stimulation techniques like drilling microfracture were usually considered appropriate for the non contained lesions, especially when large or cystic we tend to consider structural grafting options. And like I said before in our center we would like to use the topic technique in such cases which would provide both mechanical support and biological stimulation. That said, my thought is that in our experience it's not just preoperative containment that matters. I would emphasize that would actually be more relevant is post offer containment so that containment that we achieve with our surgery, particularly in the weight bearing portion of the talus, because that's where the healing potential plays out. That's also why we did not include containment status in our studies not include preoperative containment status in our study, because I believe that preoperative containment only does not fully reflect the biological environment for healing after bms. I don't know if that answer makes sense to you. It does.
- [17:24]
A
Thank you. Yeah, I just was curious. Thanks for sharing that. Let's turn you to another question that I had about it with your you mentioned that 13 patients in each group were a limitation, but you identified 73 patients for potential inclusion in the study. And aside from patients with incomplete data, would you please review with the listeners the other exclusion criteria for your investigation?
- [17:49]
B
Yes, of course. So from the original group of 73 patients, main reason for exclusion was indeed incomplete baseline or follow up data for the primary outcome. Aside from that, we also excluded patients who had concomitant procedures during the same surgery that would potentially alter the post op protocol. So that included surgeries like ankle ligament reconstruction or lateral ligament reconstruction, syndromotic repair or malaria osteotomies. Idea behind that was to isolate the effect of the bone marrow stimulation itself and the weight bearing strategy specifically on that procedure after ulcer convalescent repair. So without confounding from other surgical interventions that would require different rehab timelines. So in the end we aimed for a clean comparison between two weight bearing protocols and patients we were otherwise treated uniformly for their olts.
- [18:46]
A
Great. Perfect. I'll ask you a few more questions just about study design since you have a great experience with this. But in your discussion you and your co author suggested that the retrospective manner of study of the prospectively collected database represents a limitation. Do you believe that your outcomes would have been different had you reported your findings as a prospective randomized study?
- [19:09]
B
Yes, that's a valid point, something we addressed in the discussion or tried to address. Well, although we used to prospectively collect data set, the study was retrospective in nature. Patients were not randomized. They received either immediate or delayed weight bearing based on the surgeon preference. So to your question, would the outcomes have been different in a randomized design? Possibly not so much in terms of the clinical results that would say themselves, which were quite consistent, but more in terms of evidence level and reduction of bias. So a randomized controlled trial will give stronger claims around causality. Do think that this study already provides an important takeaway. So immediate weight bearing appears safe with no increase in complications. Patients in that group actually tended to return to work and sport little earlier. So it's also simply more comfortable and practical for patients. So you could ask if a more restrictive protocol does it offer clear benefit and immediate weight bearing is safe and better tolerated? Would we really need a larger RCT to prove what already makes clinical sense? So in my view immediate weight bearing not Just safe. It's also a sensible choice in most cases.
- [20:30]
A
Got it. Yeah. Thank you. I'll just steer back to Amsterdam one more time. It's been a long time since I visited Amsterdam and it is a beautiful city and seems really bike friendly and I saw so many people riding their bikes around the city. However, what I also noticed was there were so many old and dilapidated terrible looking bikes. And maybe that's changed this up in there. But why is or was that it seems like Amsterdam would have all nice bikes. Why did I see so many old terrible bikes?
- [21:01]
B
Yes, you're absolutely right there. I would see that you need an invitation to come to Amsterdam, so you got one straight now and then you. You will still probably see hundreds of bikes that look that they've survived five very cold winters and and one or two canal dives and honestly they probably have. So in Amsterdam, bikes are a form of everyday transport. So not a fashion statement in itself. It's all about practicality. So rusty beat up bike is less likely to get stolen, you know, can handle any weather and still get you from A to B. So in fact maybe it's the worse it looks, the more likely it is still to be waiting for you outside the supermarket. So yes, it's not about having the nicest bike, it's all about having a bike that works and one that nobody else wants. That's not how we treat our surgical instruments at the Amsterdam umc. But yeah, so much to the bikes. Thanks for question.
- [22:04]
A
That's a great answer. Thank you. So, just curious. That's good to know. Back to the study. The focus of last month's FAI podcast article was on the trajectory of recovery after total ankle arthroplasty and specifically the improvement over the first year with intervals of study at 3 months, 6 months and then a year. You and your co authors identified the lack of Data points at 3 months and 6 months for your study as a limitation. If you were to repeat the study in a prospective format, would you anticipate differences between the immediate and delayed weight bearing groups at 3 months and 6 months?
- [22:41]
B
Really a great point, Mark. And I completely agree that having more frequent data points would have added value. If we were to repeat the study. Perspectively, I would definitely include follow up at three and six months because I actually think that that's where the most relevant differences between immediate and delayed weight bearing might show up. Based on our experience, I would hypothesize a steeper recovery curve in the immediate weight bearing group, not necessarily better outcomes. Twelve months, which were quite similar, but a faster return to function, less stiffness, and also earlier improvements in pain and mobility during the first few months. Idea would be that the earlier you start loading and moving quicker you activate neuromuscular recovery, regain balance and strength, and restore confidence to the patient. So yes, I do think earlier follow up might have shown more rapid progress in the immediate group, and that's definitely something we'd like to explore in future perspective work. So the end point might be the same, but the road to get there could be a lot smoother with immediate weight bearing.
- [23:47]
A
Got it, thank you. That's good. Just along those same lines then, as far as outcome data points and I'll just focus back on last month's podcast one more time. In that podcast, Dr. Thordason and I discussed the two year follow up rule for Foot and Ankle International publications specifically pertaining to total ankle arthroplasty studies. Based on your experience, what do you think the outcomes would be for a minimum two year follow up of your two patient cohorts? In your experience, do outcomes of bone marrow stimulation for osteochondral lesions of the talus deteriorate over time?
- [24:21]
B
Thanks. Makes sense, I would say for bms. Based on both our experience in the literature, I wouldn't expect that those major changes at two years compared to what we saw at one year. Go back to the GPS study with over 260 patients. We found stable outcomes even at 10 to 15 years post op. So for most patients the gains after BMS tend to hold. Of course there are exceptions, especially patients with obesity or prior failed treatments might be at higher risk for deterioration. But overall I think that one year results are reliable indicator of what we can expect longer term.
- [25:04]
A
Great. Thank you. Yeah, and I know you'd mentioned that before that you have longer outcome data. I just was curious and just the follow up world. That was a nice discussion we had with Dr. Thorderson, who everyone knows was the former editor in chief of Foot and Ankle International. So this was curious. Back to the paper, your first paragraph of the discussion. You and your co authors forewarned the readers by stating the results support the feasibility of immediate postoperative weight bearing but should be interpreted with caution because of the exploratory nature of the study and limited sample size. And you touched on this in your overview. When you first talked about the paper, you acknowledge that with greater than one year follow and more than 13 patients in each cohort, the findings would be more robust. Despite these shortcomings, you are asking the readers to accept your one year Data and limited sample size for each group. I think you just answered this, but I'll ask you one more time. Based on your experience, do we really need to be cautious or can we trust the data presented here?
- [26:02]
B
Thanks, Mark. I would say yes, we can. I'll explain a little bit more. We deliberately included that cautionary note in the discussion to acknowledge the limitations of the study. Sample size is somewhat small, study is exploratory by design, so we're not claiming definite conclusions. That said, I do think the results are meaningful. And actually in orthopedic outcomes research, one year results are often fair predictors of two and five year outcomes. So that applies especially to the pain function and return to activity which tend to stabilize within the first 6 to 12 months after surgery of OTs. So although the numbers are limited consistency across clinical and radiological outcomes, an absence of harm in the immediate brain burning group gives us enough confidence to say yes, this approach is feasible and safe and likely to be beneficial for many patients. I think in my view these results can absolutely help guide clinical decision making. So not being the final word, but to provide a clear direction in terms of what we can safely offer our patients.
- [27:09]
A
Perfect. Thank you. In the discussion of limitations to your study, you and your co investigators also mentioned that the duration of symptoms might influence the success of treatment. In your experience, does duration of symptoms prior to bone marrow stimulation make a difference?
- [27:25]
B
Yeah, did mention that shortly in the discussion. And I do think duration of symptoms before surgery can matter though. It's a complex issue. So in cases where symptoms have been present for many months or even years, we can see signs of pain sensitization where the pain experience becomes more amplified or disconnected from the actual tissue damage. That can surely influence recovery because even if the lesion is treated successfully, orthopedically, successfully, the patient may take much longer to perceive improvement. Also, there is a physical aspect. Chronic pain often leads to reduced activity that can result in deconditioning, especially in the foot and calf muscles, even in the balance or proprioception. But these patients may also take longer to regain full function post op, not because the surgery didn't work, but because the whole system needs more time to recover. And of course also the psychological burden of long standing symptoms, frustration, fear of movement, loss of confidence may play a real role. So yes, in my experience, the longer the systems persist after treatment and before treatment, sorry. The more likely it is that recovery is slower after treatment and less linear, even when the structural result seems good. Also on radiological follow up, that's great.
- [28:49]
A
Experience and thanks for sharing because I think that's a question many have. So that's very important. I'm going to get you back to Holland. Holland is known for its superb Dutch men's soccer team or football team. However, year in and year out, the Dutch women's field hockey team is the best in the world. Why is Haaland so great in women's field hockey?
- [29:09]
B
So honestly Mark, I think the Dutch women's field hockey team is one of the best sports teams that I've ever had the privilege to work with as an orthopedic consultant. These women are extremely competitive, so technically gifted. They combine individual fitness with deep tactical knowledge and strong, unshakable team spirit. So it's a culture of performance that's been developed over many years. I would say it starts young. If you walk past the sports field on a Saturday or Sunday morning in August, you'll see hundreds of young girls picking up field hockey stick coached by former players immersed in a structured, supportive environment. So it's not a surprise that field hockey is a national sport for the girls in the Netherlands. And there's a clear pathway from grassroots to world class level. So they for me, truly set the bar for what a high performance team culture can look like. And thank you for acknowledging that. That's really special.
- [30:06]
A
That's good. I just love watching them. They're so good and I just don't know. It's amazing what they do. But that's good information to see how it starts at a young age. So we're getting toward the end of the podcast, but I have a few more questions for you I think are practical and then some more where you can share your experience. In the introduction, you and your co authors cite several references describing post operative weight bearing protocols for BMS. In Table 2 for immediate weight bearing, you note that crutches are needed for the period without full weight bearing and that physical therapy started at one week. In general, when do you your early weight bearing patients truly fully weight bear without crutches? And please share with the listeners your recommended physical therapy protocol. Specifically, when are these EMS patients allowed to perform high impact physical therapy exercises?
- [30:52]
B
Thanks Mark. Often we get that. Okay, so in the study start with that we define immediate weight bearing as tolerated from day one. So with crutches used as needed in practice, I would say that most patients use crutches for the first one to two weeks depending on pain control and confidence. That's not about pushing full weight bearing immediately, but about removing restrictions and allowing patients to self regulate based on their symptoms and function feelings. So then let's get to range of motion exercises. We start range of motion exercises right after surgery, even in the pressure bandage first day, usually with dose of plantar flexion motion to avoid stiffness from the start. And then formal physiotherapy typically begins in the first week. Normally I would ask the patients to go to physiotherapist, have him or her take the bandage off after three days and look at the wound, the stable and then start from there and then also from there we would allow a progressive rehab pathway not based strictly on time, rather on functional milestones. So first look for good range of motion and basic baseline balance. Then focus on restoring intrinsic foot and calf muscle strength. Both flexors and extensors focus on normal gait pattern including proper push off and then crucially ability to tolerate full dorsiflexion under load without reactive pain or swelling. So once these elements are in place, we will begin to expand activities, including dynamic and eventually high impact work, always adjusting to the patient's progress and sports specific demands. Although we provide a general framework for recovery, the actual pace of progression is individualized, guided by the patient can handle and not really by the calendar. Of course, progress only works if it's a team effort. So we work closely together with the physiotherapists or performance staff to monitor each step and depending on the patient also involve a sports dietitian or psychologist. Recovery is not purely mechanical, so it's physical, nutritional, mental. So I would say that the real pearl is the team working.
- [33:09]
A
Perfect. The next question flows from what you just stated. And so I just was curious, given your background and taking care of elite athletes, and I know that everyone that we treat is an athlete, but you routinely treat many high level athletes for osteochondral lesions of the talus. Is your method of BMS the same for all patients or is it different for high level athletes? And is your post operative protocol the same for all of these athletes as it is for other patients that are not elite athletes?
- [33:37]
B
That's great question. I really like the way you stated that. Agree with you there. So the short answer is the surgical technique may be similar. Overall approach is definitely even more individualized, especially when it comes to the real high end athletes. So for any patient's athlete or not, as you stated, we base our treatment on the best available evidence and what we know from the literature. But at the same time each case needs to be tailored to individual sports goals, physical condition and timeline. So with the elites we often have the possibility to optimize every detail, at least on a weekly basis, sometimes even on a daily basis. From load progression to neuromuscular training, to monitoring inflammation or imaging. That really allows us to make real time adjustments throughout the whole rehab process. And then also, I would say the top athletes have exceptional physical and mental resilience, high level body awareness. So all that can accelerate recovery. And I've accepted that it's a true privilege to work with these athletes. The core principles of biological healing also apply to them, but they just go faster and also. And then we don't skip steps, we just manage them in a very focused and high performance environment. So while the procedure might be the same, the way we guide the trajectory is more dynamic and even more individualized. So we apply the same science, but the environment allows us a different pace.
- [35:09]
A
Perfect. Great. Okay. One more thing that I'm curious about, and you touched on this too. You showed a slight difference, but the question of adding to your statistical analysis, or at least your interpretation of the data, the minimal clinically important difference. So from my perspective, this investigation seems to be a routine comparative study relying on commonly used statistical methods. The unpaired T test, the Mann Whitney U test. You and your co authors review that in your study. According to the propensity score matching strategy described in the statistical analysis, you demonstrated no difference in outcomes of return to work or sport or radiographic outcomes. However, you go on to suggest that a difference favoring the early weight bearing group is based on the minimal clinically important difference or the MCID and raising the possibility that early weight bearing could be a preferential or preferable approach. And you mentioned this before. Would you just please review with the listeners who may not be familiar with the MCID or minimal clinically important difference method what level of confidence they may have in the conclusions drawn from the additional MCID analysis.
- [36:19]
B
Sure. The minimal clinically important difference or MCID essentially is the smallest change in the score that patients perceive as meaningful. So it potentially adds a layer of clinical relevance on top of statistical significance. So in our study, while the between group differences weren't statistically significant, a larger proportion of patients in the immediate weight bearing group exceeded the MCID threshold for improvement in pain during walking. So that doesn't prove superiority, but it does suggest that more patients in the immediate weight bearing group had a clinically meaningful improvement, which we felt was worth highlighting, especially when safety outcomes were similar. So while it's not a definite conclusion, it helps raise the possibility that immediate weight bearing may offer a practical advantage for certain patients.
- [37:15]
A
Great. Thanks for clarifying that. I just see that being used more and more as a statistical or another layer of statistical analysis. So thank you for describing that and also for adding it to the study. One more question about you and then we'll wrap up the podcast. In October of 2016, you started as chair of the Amsterdam Academic Orthopedic Department Department of the Academic Medical center of the University of Amsterdam. From your experience, what do you perceive as the greatest challenges are the greatest challenges in getting our younger generation interested in becoming orthopedic surgeons and foot and ankle specialists?
- [37:48]
B
Well, that is a thoughtful question. So in our experience in Amsterdam, we actually see a lot of motivated young colleagues entering the field. And I believe that might be because we in the last decade start very early. So already in the first year of the medical curriculum we expose students to orthopedics. So 189 year olds get to do nartroscopy on cow knees, plates, a DHS hip screw on soft bones and operate on an ankle fracture with placing positioning screws. So and then thereafter through the research programs in the first, second and fourth year of the curriculum they quickly get involved in topics like sports medicine for the night surgery. So from early on we invite them to be there, be joining the team to present the conferences, write papers and perform solid statistical analysis so they don't just learn the science, but also experience the excitement of giving a contribution to our field. And one particular example I'm very proud of is the early Friday morning meeting which We've held every second Friday at 6am in the morning for almost a decade now. And it's organized always by our youngest researchers. So 18, 19 or 20 year olds. It connects students and clinicians from all over the globe with national international expert in a really dynamic way. And main topic there is ankle olts but sometimes we switching topics and that's very motivating also for myself to be honest. So yes the fuel is demanding as you stated, but I think young people are might be still be drawn to us because orthopedics, especially foot and ankle offers something very tangible. So good result can dramatically improve patient's quality of life and get them in young, they they're able to see that and you see that you can make a difference as you know, even quite quickly and that's extremely rewarding. So I believe that what continues to attract or could attract the next generation is we have a meaningful and challenging and deeply rewarding human work.
- [39:56]
A
Great answer and thank you for your contributions. So excellent work. Also with this paper as our podcast comes to its conclusion, is there anything else you'd like to share with the listeners?
- [40:06]
B
Cheers, Mark, I really enjoyed this. Thank you. And Dr. Saltzman, of course, also not only for selecting our patriot, also for your inspiring work and continued dedication to the foot and ankle community over so many years. So also thank you our amazing team of departments, especially our young researchers who are the true pearls of the department and senior members who continuously give our every best to this patient care of the patients. It's a privilege to do this work with such great people and to share ideas through this platform. So thanks again, Mark. Next time you're in Amsterdam, the bike tour will be on me.
- [40:45]
A
That's great. Well, I'd like to thank Dr. Kirchhoffs for sharing his insights and his and his co authors FAI publication. Immediate post operative weight bearing arthroscopic bone marrow stimulation for Taylor osteochondrial lesions. A matched cohort study. And I would like to thank everyone for participating in this month's FAI podcast. This is Mark Easley and look forward to next month's podcast.