← Foot & Ankle International
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- [00:08]
A
This is Mark Easley and I have the distinct honor of talking with Dr. Sam Ford, the senior author of April's lead paper on Foot and Ankle International. The paper is titled Long term survivorship of inbound 2 total ankle arthroplasty. Dr. Ford practices at Ortho Carolina and Charlotte, North Carolina. He is part of the teaching faculty for the Ortho Carolina Foot and Ankle Fellowship and the Residency at the Atrium Musculoskeletal Institute. He also serves as Associate professor in the Department of Orthopedic Surgery for Wake Forest University of School of Medicine and is his group's Foot and Ankle Research Director. He has multiple areas of focus in foot and ankle surgery, including total ankle arthroplasty. Dr. Saltzman and I selected this article to highlight this large cohort longer term follow up of total ankle arthroplasty, in this case the Inbone 2. Welcome to the program, Sam.
- [00:59]
B
Thanks for having me on, Mark.
- [01:01]
A
Sam, as senior author, would you please provide the listeners a brief summary of your paper and its major findings?
- [01:08]
B
Sure. So this is a prospective single institution registry study of total ankle arthroplasty with a minimum 10 year follow up after Inbone 2 used as a primary component. The goal here is survivorship, so patient reported outcomes are not included as we did not collect them preoperatively at our institution back in 2010 and 2011 when we started enrolling in the registry. In total, we have 74 total ankles. Our mean age at the time of surgery is 61 and our median follow up is 10 and a half years. Our metal component survivorship rate is 93.2% and our overall reoperation rate is approximately 17%. We did see cyst rates of 22% on the tibial side and 12% on the talus side, but cysts did not lead to metal component revisions long term. We did have a trend towards higher risk for metal component revision in cases with more severe deformity greater than, you know, greater than 15 degrees compared to cases without. I'm going to read you that last sentence.
- [02:20]
A
Yeah,
- [02:22]
B
we did demonstrate a higher average deformity in the metal component revision group compared to the non revision group. 16 degrees versus neutral. And this was a trend. Right? So we had a large effect size, but a p value of 0.07. That's one of the limitations of the study. We had 74 total angles, so it's hard to look at deformity. Overall though, it's a reassuring series that really highlights the at least midterm, if not long term for total ankle arthroplasty performance of a constrained total ankle arthroplasty with a stem to tibial component.
- [03:03]
A
Great, thanks. Sam, you have considerable experience in total ankle replacement. What do you see as the advantages of the inbone 2 total ankle system?
- [03:12]
B
I think it starts with fixation. I mean it was the first system that really gave you tibial fixation beyond one to one and a half centimeters higher than the salto. The ongrowth technology is good on growth. The patients enrolled during the study were from 2010 to 2015. So at the time, you know, Stryker's updated porous surface hadn't been launched. And the big key is that the joint is first, it has to be the stem. The stem improves fixation on the tibial side. And you know, comparatively at the time, the SALTO had the most tibial fixation. And back in 2010-2015 when we were enrolling these patients, the ongrowth surface keeps the components stable and then the bearing stable. So you can do larger deformities within bone and maintain your correction due to the high congruence of the sulcus design of the bearing.
- [04:11]
A
Perfect. Thanks. A little more general question now. So Sam, you teach residents and fellows, what are your three most important teaching points to successful total ankle arthroplasty?
- [04:22]
B
This is a, this is a great question. I kind of made four into three. First, it's got to be preoperative evaluation. You have to have a good preoperative plan. You have to understand your deformity and know what you're going to do to complement your total ankle from the beginning. Second is achieving your deformity correction. And then I think component sizing and impingement avoidance is really kind of the third. We focus on metal component survivorship, but really the number one reason for reoperation is gutter impingement. Even still bony hypertrophy in the gutters, loss of motion. So getting your component sizing right and avoiding that from the get go is critical.
- [05:01]
A
Perfect. Thanks. Yeah, that's helpful. You did mention in your review of your paper that your co authors and you indicated that you did not have the patient reported outcome measures data for these patients. And you can see it in your discussion. It's a study limitation. With that said, your investigation's conclusions are not overstated since your stated purpose is to report the survivorship. I'm aware of studies of surgical correction of hallux valgus suggesting that despite less than optimal radiographic correction, many patients report favorable patient reported outcomes for hallux valgus surgery. How important is it that you are not reporting patient reported outcome measures for the total ankle replacement in this study.
- [05:52]
B
I think when you're dealing with implants it's always nice to have patient reported outcomes. We just weren't collecting them at the time we started in 2014. We are assuming that these studies, when put side by side with other studies demonstrating improvements in patient reported outcome measures, that we're getting the same or nearly equivalent patient reported outcome measures in this series that's durable in the absence of any component changes. You would assume from the 2 to 5 year post op mark to the 10 year post op mark, you wouldn't see a major decline in patient reported outcome measures. Maybe there's a limitation of the study though and I think it's important to put it in context with that. Great.
- [06:40]
A
Kirby. Let me veer away from the paper just for a moment. You are in private practice and are committed to academics and education. Please share with the listeners how you are effective in balancing the two traditionally separate career paths.
- [06:55]
B
Well, it's a team effort, Mark, for sure. I mean I'm filling the shoes of giants here. My senior partners set this all up, right. They did research and were leaders and still are leaders in our field from a private practice setting. And so logistically on the ground we have fellows, we have residents, we have a efficient research organization and we have now a research fellow that really helps us specifically do foot and ankle research. Without, without that, that team effort, I wouldn't be able, I wouldn't be able to drive these research questions. But what you see in private practice is that you've for us we've got high volume surgery. Right. I mean we can, we can look group wide at some research questions where we have access to Data on really 15 foot and ankle orthopedic surgeons across our large private crew private practice that spans from Winston Salem, North Carolina to Rock Hill, South Carolina. Right. I mean we can really get generalizable good data to ask questions that otherwise we can't ask from a single institution. And so, you know, we, we try to take advantage of that and therefore most of our research is clinical. It means that I've got to prioritize time early in the morning or late at night to get it done. But I think most researchers in the academic space do the same.
- [08:14]
A
Fair enough. Good, good answer. You mentioned that the tibial component was one of the important features of the inbound total ankle. And there are several recent publications that have touted the same importance of stem tibial components having performed total ankle replacement with stemmed and Non stem tibial components. What is your opinion on the need for adding a stem or stem extension to the tibial component?
- [08:42]
B
I mean the HSS folks have really helped us out here. I mean I think there are clear cut scenarios. For me this is, this list is long. If you really look at the data. If somebody's had a prior hindsuff fusion you need to put us, you need to extend their tibia. Low profile tibial components have a higher failure rate in that population. BMI over 35, weight over 250, osteoporosis previous P line fracture for me age over 65. Because what are you saving the bone for when you use a low profile implant and that that patient's more likely to have worse bone density. And then a couple very critical ones I think are are considered in the deformity category. If you've got coronal plane deformity over 10 to 15 degrees, I think you should consider it. And then sagittal translation, if the talus is escaping anteriorly more than say eight nine millimeters sometimes it can really get out there a centimeter, centimeter and a half. Your, your low profile component failure rate on the tibial side is going to be high. So the list is long for me.
- [09:53]
A
Understood. Thanks. So you have been involved in development of a recently released Total Ankle system. In previous podcasts, Lou Shone and Chris Coetzee respectively shared their experiences with the Transfibular Approach Total Ankle and the Salto Telaris Total Ankle both reporting particularly favorable outcomes at midterm follow up. Likewise, it's hard to argue with the outcomes reported in your long term follow up Study of the Inbone 2. In designing a new Total Ankle system, what features did you and your co developers emphasize? And to really put this question in simple terms, if it's not broke, why fix it?
- [10:31]
B
I love this question mark. I think it's really a thought provoking one. You know the Zimmer systems and Ingrowth system, Zimmer TM was the first component on the market basically that we had that really could facilitate in growth. And because of the transfibular exposure the Fixation is oriented 90 degrees perpendicular and in an effective way to the normal motion of the ankle. So the tibia is really stable. They have problems on the fibula side. Right. And they have problems with surgeons not being comfortable with the trans fibrillar exposure. But I think that really set them up to have great success. And then Salto was, you know, has more tibial fixation and a, I think a bearing that's a little Bit more forgiving and allows for a little bit more inversion and eversion play. So for those two reasons, I think those, those implants have stood the test of time. You know, the question about, you know, why if it's, if it ain't broke, don't fix it. What is our goal is really the question do we want 93% or 90% or 94% in your survivorship or is our goal 97, 98? I mean hip and knee, they get there, right? And so if we can get to hip and knee levels, then we're not going to feel bad offering total ankle arthroplasty or feel guilty or feel reticent to our younger patient population that has ankle arthritis. Our whole goal here is to provide a solution that isn't an arthrodesis for a 40 year old. I mean, that's really what we're after because ankle arthritic patients are so much younger than hip and knee arthritis patients can be. And so, you know, I think from that perspective, you know, when you're designing a total ankle, it has to be, you have to help pre op plan you, you must have good fixation in both low profile and stem spheres. You must have good ingrowth technology. And I think this is where a lot of the low profile, low profile systems, when they're low profile and they have marginal fixation but they also don't have ingrowth, then you're setting yourself up for higher risk for failure. Polyethylene wear. I think we as a, as a group haven't paid as much attention to, I think we have some polyethylene wear evidence in our series with the cyst formation. Luckily we didn't see a big failure rate from those cysts. But I do worry at 20 or 30 years or in doing these totals in younger patients that may have more retained motion. I think, I think polyware is going to become more of a concern in the future. And so I think we need to really be thoughtful about bearing wear and then sizing. I think there's such a mismatch between what components we've got available and what the variation is in the ankle. And that's not just in the ankle, that's in the knee too. They have a lot of trouble with it. So, you know, getting a little bit more size options or even patient specific in the future might help us better size our implants. We know that cortical bone grows to components much better than cancellous bone does. So just for example, just for the listener, if you have A wide tibia. Great. Then you can go deep with the tibia. But if you have a narrow tibia, well, how much medial tibia are you going to take in order to get posterior cortical coverage? It's a problem we have with planning for totals every day. Right. Do you lower the joint line to try to get a more, you know, wider tibia where your component rests? That's a real problem. And I, I think we can improve there. And then instrumentation, I mean, you know, the going through the heel. I think both as patients going across the subterranean joint, we don't think it does much, but it'd be nice to avoid it. So. So being able to stem the tibia through the end through an anterior incision, I think is critical. And then when things do fail, we need better revision and revision options that to really address segmental bone loss and severe subsidence. So I think we've come a long way from before I was in training, right back when I was back in the 90s and 2000s. I mean, we've come a long way, but I still think we have a long way to go to make the systems really reproducible for every surgeon using them. And that's one other thing. You know, Mark, your design surgeon, I'm lucky to be one in young practice. Lou and Chris are, they're also design surgeons. Design surgeon series is, they're not necessarily generalizable and so it's our job to help make it so that these systems are more generalizable to the foot ankle surgeon that's out in the community.
- [15:19]
A
Great. Well, thanks for being comprehensive in that. No, no, I love it. That's good. From personal experience, I can confirm that long term outcomes research is challenging you and your co authors acknowledge your study's limitations, but provide some reassurance with further analysis of implant survival. Specifically, you indicate that irrespective of analysis method, the reported survival estimate of 92% remains consistent. According to your flow diagram, you and your co investigators identified 180 patient records for in bone 2 procedures between 2015 and 2015. You excluded 68 patients due to various reasons, including deceased patients, and noted that 37 patients were lost to follow up. This left 71 patients or 74 procedures to be included in the study. Would you please further reassure the listeners that reporting on 74 patients from the original 180 patients provides reliable data and conclusions?
- [16:23]
B
Yeah, this is the problem with any long term outcome research. You know, doctors Anderson and Davis patients traveled to come see them and some of our patients have moved and so in that context, to have X ray follow up local, in person, you know, it can be difficult to get higher follow up percentages. You know, I think the death percentage in our cohort, that's hard to avoid. Right. I think if you're, if you're doing patient reported outcome and survey research that doesn't require X rays or in person visits, you can probably drive up that follow up percentage. But in exchange, you don't see the cysts, you don't see the deformity correction, you don't see if the deformity correction is durable. And so there are pros and cons. It'd be nice to have both together. You know, it's a limitation of the study. It's, it's, we, we really wanted to be truthful and thoughtful about the data we have. And I don't know what else I can do to reassure. I will say my, my one concern about the data is that, you know, we're doing totals in younger and younger patients and, and my, my partners before me were, they knew they had a good implant and so they were doing this in some younger people. But we know total ankles may not perform quite as well in younger patients. And so I, I do worry that, you know, my one caveat to, you know, trusting the data of 74 patients with such a high follow up rate is that a 92 to 93 survivorship percentage is what people are going to take from this paper. That's what they're going to quote. But can you quote that to a 40 year old? Right? I don't know. We gave it, we, we gave the data the best, honest, tried and true, hard look as we could.
- [18:17]
A
So yeah, like I said, it's, it is challenging. I'm doing the same thing at my institution. So hats off to you to get as much data as you could here. I'm going to take that question one step further. In your methods section, you and your co author state that survivorship analysis was performed using the full inception cohort or all 179 patients or ankles identified. You then used a competing risk cumulative incidence function to account for the 59% of the initial cohort that did not meet the final inclusion criteria, many of whom were lost to follow up or die prior to 10 year follow up. For those listeners who may not be as familiar with the data interpretation for creating the Kaplan Meier survivorship, please explain which patients were included in determining the 92% survivorship assigned to the Inbone 2.
- [19:12]
B
Yeah, I think the context is important here, Kaplmeier curves are meant for, really for cancer death, basically. So if, if somebody, if you're doing a survivorship analysis of human life and you only count deaths that are deaths because the patient died of the disease you're observing, but you throw the other deaths out, you risk overestimating the survivorship probability. So in order to address that, you, you run a cumulative incidence function which estimate, it's a way to estimate the marginal probability of the, the survivorship event as a function of its cause specific probability and overall survival probability. So that's a lot of statistics. It really allows us to give a more complete picture of survivorship over time and account for some of those patients that had an ankle and died before 10 years.
- [20:06]
A
Great, thank you. Yeah, I think that's very helpful and needs to be clarified, which you do very well in your answer but also in the paper. So thanks Mo again. Step away from the paper one more time. So I believe that you were featured on your local news channel on how to avoid injury in pickleball. A common question among my total ankle patients is, Dr. Easley, can I play pickleball on my total ankle? Sam, you've got to tell us the truth here. What do you tell your total ankle patients when it comes to pickleball?
- [20:39]
B
I don't have a hard and fast rule. This is a conversation with the patient. I think if they're a younger big guy, I worry a little bit more about it. And if they have a hindfoot fusion, that certainly leans me towards advising them not to. Oftentimes our patients are going to do what they want to do. You know, I think if you have hindfoot motion or potentially your total ankle allows for a little inversion and eversion motion, that the side to side motion, something like pickleball, is probably okay. For me, running is out of the question. Another high impact exercise like that. But to me, pickleball didn't really fall into the high impact category. We have no evidence to go on, so it's all patient counseling and understanding the risk profile.
- [21:24]
A
Perfect. I like a good patient education answer. I tell you just not to veer too much away, but I always tell my patients, you got to learn three words. Hey, good shot. You know, make sure they don't go to the extremes of trying to reach for a shot or do an overhead. Just let it. That's good advice, but the problem is the patient's always there. Everybody's competitive, so we'll see. But thanks for the answer. Back to the paper. Various malalignment is a challenge and you emphasize that in the paper, you and your co author state that the observed patterns in your study should be interpreted as a hypothesis generated observation or observations that require validation in larger cohorts. The literature suggests that with satisfactory realignment, outcomes of total ankle replacement in various ankle arthritis are similar to outcomes in total ankle replacement in anatomically aligned ankles in your hands. What are the critical associated procedures that you use to optimize your outcomes for total ankle replacement in various ankle arthritis?
- [22:30]
B
This is a, I mean this is, this is a lecture, right? So I think, you know, you got to know when to stage first of all. And that's a personal question, right? I think that's very surgeon to surgeon dependent. You've got to have a thoughtful problem list and be able to address the problems on your problem list, whether it's in one surgery or two. For me, at the time of doing a total with the various ankle. And I think everybody talks about doing a deltoid peel and doing a meet, you know, basically a medial release and doing a lateral gutter decompression just to make sure that you can correct your intra articular deformity. I, I'm, you know, the, you have to be wary of letting the cut guides do your correction for you. You have to make sure that you're uncoupling cuts in that case because there's not a cut guide out there that I'm, that I'm aware of that that builds in the angular correction for you. The posterior tibialis tendon is a bad actor. A lot of folks will just z lengthen the posterior tibialis tendon. If there's a bad cavivarous foot under the varus ankle. I'll go as far as to transfer it to the peroneals. In those cases you may be doing a peroneus longus to brevis tendon transfer anyways and I don't think it adds much. You're already cutting the tendon. You're already trying to take something that's going to hurt you in the future and may as well try to make it help you in the future. Right. And you've got to correct the foot underneath. And so if you're thoughtful about your problem list and do those things, I think you can optimize your outcomes there.
- [24:13]
A
Great. That's a very well stated answer. It was a little bit comprehensive. I appreciate you going through it for the listeners, Sam, for you and your co authors, you were thorough in your study of periprosthetic lucency and you mentioned this in Your summary of the paper, the tibial component. You noted that 83% of Lucencies identified at one year remain stable at final follow up. And for lucencies developing after one year, 90% remained stable. And then furthermore, you identified 22% periprosthetic tibial cysts and 12% Taylor cysts, none of which required removal of the metal components. You reported that the incidence of non progressive periprosthetic radiolucency is similar to that reported in other Total ankle investigations. The Inbone 2 design featured in this study was manufactured over 10 years ago. More recent Total ankle designs, including from this same manufacturer, add modifications to the implant backside design to improve on growth or perhaps even in growth into the bone implant interface. What is your current experience with newer Total Ankle systems? Do you see a lower rate of periprosthetic lucency? And given the favorable results in this study, you think it really matters?
- [25:33]
B
These are great questions. We did not expect to have zero metal component failures because of cysts. We did catch some cysts. We reoperated on some cysts. There were a couple pilot exchange and bone grafts in there. We did see some Taylor subsidence. And the question is, is that an avascular event or is that because of polyethylene wear that we just didn't catch in time and it was subsidence? That is how it presented. We don't know. But that's, that's sort of how we define things. You know, my, my experience with the newer Total Ankle systems, I think we're getting fixation that's better. But on the, on the cyst, on the, on the lucency and cyst side, we, we really need a good flush cut. First we've got to have an implant that's impacted well and then we need the implant to ingrow. And so often we, we see a little lucency. And if you've got good fixation on the tibial and talus side, I think with this paper, in the context of papers on some of the lower profile implants, I don't think we have to worry about the Lucency as much with, with the stem systems, whether it's from this manufacturer or others. I think this is, what's funny about this question is that the manufacturer we're discussing in their new stem tibial component, they removed the posterior portion of the tibial trays rail. And so for, for years I've always thought that the rail was genius because the rail hid your lucency on the tibial side on the lateral X ray because you can't see it because the rail's in the way. So are we going to see a higher lucency rate in that and is it just going to be an artifact? I think if we do, it's an artifact. I don't think it matters. But because the stem is there in stem's tibial components, if you do see lucency, I think we've all assumed it's just because we don't get ingrowth. But is it actually because we're doing, we have some stress shielding. What's really causing it? I think that's a question we don't really know the answer to.
- [27:40]
A
That's a good answer. I like that. That's funny you say that when Mark Riley designed this ankle originally had that anti rotation feature that when you look at the lateral X ray you can't see that interface between the bone and the implant completely. I always wondered about that. So I'm glad you touched on that. But a great answer. And I have a lot more to learn too. In the ankles. I do. So this is great. Your surgical technique states that 92% of patients in this study had BMAC as an adjunct of bone graft material to enhance osseointegration at the bone implant interface. Although you may not have been directly involved in the primary procedures for this study, would you briefly describe details of how BMAC was obtained and applied to the bone implant interface? And do you routinely do this as part of your current total ankle procedures?
- [28:35]
B
I do not for fear of infection, but that's probably over overkill fear on my part. The hip and knee and shoulder arthroplasty surgeons don't use it. So why do we need to. That's, that's kind of the logical line. I fall the history here at least my understanding is that Dr. Hot, Dr. Davis and Dr. Anderson were using it because Dr. Shone was using it and kind of had basic science data to back it up. And so the process in our, in our series was iliac crestbone maraspirate was obtained with a Jamshida needle. It was centrifuge concentrated. It was quote unquote gelled with some thrombin additive to make it stay and then put on the back surface of the component before implantation because Dr. Anderson and Dr. Davis were using that as an adjunct for their totals trying to get some on some, you know, stickier on growth of the components. Now that's we, that's why we have it in 92% of the patients. But I don't currently in my practice do the same.
- [29:40]
A
Got it. Well, thanks for clearing that up. And it's interesting. I don't routinely do it, but I can understand why it may be employed. So it's good. So I'm going to pull you away from the paper for one more question. You practice in Charlotte in North Carolina. Professional sports in Charlotte have suffered for years, but recently there's been a lot of promise. The Carolina Panthers football team made the playoffs, wild card game. And even though they lost to the Los Angeles Rams, they had beaten them in the regular season. Likewise, at the time of this podcast recording, right now, the Charlotte Hornets basketball team just beat the Miami Heat in an exciting play in game to possibly make the playoffs for the first time in many seasons. Which team do you predict is most likely to make a championship run? The Carolina Panthers or the Charlotte Hornets?
- [30:32]
B
That's a great question. I, I think it might be the Hornets and it depends on how you define championship run. Great question. I grew up a Falcons fan and had to switch to the Panthers when I came back here for my full time job just because it's our, our city's team and it's not really paid any less benefit. The Hornets have a lot more excitement around them this season because of the turnaround they've, they've gone through. I think if, you know, if championship run means make it deep in the playoffs, I think in the next three years the Hornets have a better chance than the Panthers. But we'll see. Maybe, maybe we get both.
- [31:13]
A
Yeah, fair enough. It's fun to watch. And I'm here in, in the triangle area of North Carolina watching the Carolina Hurricanes hockey team. So let's see if they can take it to the next level for they make the playoffs but they can't make it too far. So we'll see how they do this year. Sam, correct me if I'm wrong, but I believe that for this study all Taylor implants were flat cut Taylor components. What do you favor? Flat cut or resurfacing Taylor components? And in your hands, what are the indications for a resurfacing tailor component?
- [31:48]
B
I like flat cut. I really do. I think that if you're, if, if you're not sacrificing Taylor's fixation with a flat cut and that's, that's debated right Then the flat cut talus gives you more exposure to introduce greater fixation on the tibial side whether it's a mid tibial component or a stem component. And I think, you know, early failures are tibial and late failures are talus. And so I lean flat cut just because it lets me instrument the tibia easier. You know, flat cuts don't have to be big flat cuts. They can be a little skinnier. I do worry about a resurfacing talus component when you have a really sclerotic, a really dense bone in the talus where that posterior saw cut skies a little bit, and then you don't get enough bone resected, and then your component doesn't really sit down as a cap like you really want it to. And I don't like resurfacing Taylor components that take an aggressive medial or lateral tailless resection. When I was a fellow in Dallas, we, Danny Scott and Shannon Alejandro and I looked up all the stars and we saw a really high tailless component rate and, or Taylor's component failure rate. And, you know, there, that was the multifactorial issue. That was a, you know, poly issue and a polyware issue, but tailless failure rate there. I, I couldn't take it out of my mind that resecting aggressively on the medial model talus may cause a vascular insult to the tailless. So. So if, if I do do a resurfacing Taylor component, I like it to be one that maintains the lateral and medial cortical bone stock of the talus.
- [33:37]
A
Got it.
- [33:38]
B
Perfect.
- [33:38]
A
It makes perfect sense. And thanks for sharing your experience with that. Sam. You and your co authors acknowledge the financial relationships of several investigators to the implant studied and share the strategies and safeguards to mitigate bias. I have two questions for you. First, your former senior partner and mentor, who you've already mentioned, Hodges Davis, is not included as a CO investigator between 2010 and 2015 at your institution. You've already clarified or mentioned that he was one of the surgeons implanting the inbone two. Why is he not a co author? Did his retirement from practice eliminate him from being involved in the study? And second, as a design surgeon for a competitive total ankle system, once you have collected data to report your total ankle system's results, what do you plan to do to limit design surgeon bias?
- [34:30]
B
Great questions, mark. Yeah, so Dr. Davis, he's been out of clinical practice for a couple years and he's full time employed as a, as a direct employee for the manufacturer of the implant. So what I did want to do is have our residents and fellows collect all this data meticulously. And then a certain subset of readers read it and say, yeah, but Dr. Davis is an author. I bet he manipulated this. Right? I didn't want there to be unjust judgment placed on the paper based on the authorship list. So we thank him for doing these surgeries. Right. And we kept him apprised of the results because he's excited. Right, because they're his patients. But we didn't think it would be, it would be best served to include him. And he wasn't involved in the data collection or writing of the manuscript. It is difficult to remove your bias from the results, but at the same time we need to report our results. So when we get 2 and 5 year minimum follow up on new components. Sometimes it's the design surgeons who have first access to data with enough patients to do it. I think one of the best ways to do it is make sure that the data is collected by residents, fellows and a research fellow. Remove yourself from the data collection, remove yourself from the analysis and you can be there for the discussion and guiding the aims of the paper. But we need to be honest because that's what our patients deserve.
- [36:13]
A
Perfect. Very nice. And thanks for spending some time on that question and that answer wrote that question to finish here. I just want to tell you this is excellent work. And as our podcast here comes to its conclusion, is there anything else you'd like to share with the listeners?
- [36:33]
B
Yes. So first of all, it's our duty to know when to stem the tibia. I think in the last 10 years there's a ton. The burden of proof on tibial fixation has really come out and driven that. I think newer age polyethylene should help our survivorship and cyst formation. I'm hoping that leads to greater survivorship up towards the total knee range. We need real ingrowth surfaces on our components. I do have concern about youth in our total ankle arthroplasty patients and the associated higher levels of activity that they'll maintain. And to reiterate it, tibial fixation matters.
- [37:19]
A
Well, Sam, thank you very much. That's great. And I'd like to thank you, Dr. Ford, for providing your insights on your and your co authors Foot and Ankle International publication Long term survivorship of in bone 2 total ankle arthroplasty. And I would like to thank everyone for participating in this month's Foot and Ankle International podcast. This is Mark Easley and I look forward to next month's Foot and Ankle International podcast.