The AOFAS Orthopod-Cast

Episode: 2024 IFFAS, Roger Mann, and Leonard Goldner Award Winning Research
Date: October 16, 2024
Hosts: Nick Strasser, Joe Park (AOFAS Podcast Committee)
Guests: David Gordon (IFFAS Award winner), Dr. Elizabeth Cody (Roger Mann Award winner), Dr. Cesar de Cesar Netto (Leonard Goldner Award winner)

Episode Overview

This episode, recorded live at the AOFAS 2024 meeting in Vancouver, BC, features discussions with recipients of three prestigious foot and ankle orthopedic research awards. The hosts engage award-winning researchers about the genesis, findings, and take-home messages of their studies, offering listeners insight into high-impact research shaping current and future clinical practice. Topics include long-term outcomes in minimally invasive bunion surgery, implications of radiographic lucency in total ankle arthroplasty, and cutting-edge diagnostics for syndesmotic instability.

Key Discussion Points & Insights

1. Minimally Invasive Chevron/Akin for Hallux Valgus (David Gordon, IFFAS Award)

Study Genesis & Data Collection

• David Gordon describes collecting prospective outcome data since starting his consultant practice and notes the challenge and diligence required for such long-term research.
  • "It's a single surgeon series, all my work... I started as a young consultant... built that into my practice immediately." (C, 01:18)
• Paper-based outcome forms transitioned to digital; consistent follow-up enabled robust long-term data.

Key Findings

• Largest and longest series to date (mean follow up 6.7 years).
• Validates the effectiveness and durability of minimally invasive techniques for bunion correction.
  • "We know now after this long time period... that it's a successful operation." (C, 02:24)
  • Overcomes early skepticism and provides confidence for wider adoption.

Study Parameters

• Primary focus: Patient-reported outcome measures (PROMS), especially the Manchester Oxford Foot Questionnaire (MOXFQ), assessing pain, function, and social interaction via patient self-report.
  • "Using PROMS was the foundation of this paper... combine those three domains into the index and that's the overall score." (C, 04:46)
• Cohort: 333 patients at 2 years, with 292 followed to 6.7 years.
• Radiological outcomes not included in this paper but planned for future analysis.

Learning Curve & Clinical Implications

• Minimally invasive surgery offers less pain and opiate use.
  • "The aim of minimally invasive surgery as we know in the literature: less pain, less opiate use." (C, 03:59)
• Technical difficulty and need for training/support emphasized.

Notable Quotes & Moments

• On the real value of long-term data:
  • "There's no way to ruin an outcome like long-term follow-up... sometimes you think you're doing a great job and it turns out you're really not." (D, 07:16)
• The importance of patient-centered outcomes:
  • "You ask the patient how they are and how they're doing, that's the most important thing." (C, 06:30)

2. Periprosthetic Tibial Lucency After Low Profile Total Ankle Arthroplasty (Elizabeth Cody, Roger Mann Award)

Study Motivation

• Elizabeth Cody sought to clarify the clinical significance of tibial lucency seen on X-ray after low-profile total ankle replacements—in particular, how this should impact patient counseling and management.
  • "You'll see patients where you have an implant that looks loose... but they're really happy not having any pain... what is the clinical significance of that lucency?" (F, 09:18)

Key Findings

• Multiple low-profile implants included: Vantage, Infinity, Adaptus, Cadence; study included various surgeons.
• Found that 6.5% of implants developed lucency; just over half of those patients were clinically doing well at 2 years.
  • "Over 50%, so close to some 60% of the patients were doing well clinically at final follow up." (F, 13:46)
• Lucency and loosening are not necessarily interchangeable; true loosening confirmed only intraoperatively.
  • "Surgeons often, I think, use interchangeably... but we don't know for sure that it's loose." (F, 11:32)
• No immediate changes to management, but more candid and nuanced patient counseling now possible.
  • "I do see them back more often if they have that finding." (F, 12:19)
  • "I use way more stemmed implants than I used to, in part to avoid this problem..." (F, 10:53)

Clinical Pearls

• Lucency may not warrant immediate revision, and careful longitudinal follow-up is appropriate.
  • "If it seems to be stable, and they know the alternative is another big surgery... often they're good enough that they don't want that." (F, 12:19)
• Patients frequently prefer to wait rather than undergo revision unless dysfunction is severe.

Next Steps

• Plans for continued follow-up using the total ankle database to clarify long-term outcomes past two years.

3. Semi-Automated 3D Distance Mapping for Syndesmotic Instability (Cesar de Cesar Netto, Leonard Goldner Award)

Study Overview

• Developed and validated a semi-automated technique for diagnosing subtle syndesmotic injuries using non-weightbearing CT scan with external rotation stress—a practical alternative for settings lacking weightbearing CT.

Key Insights

• Original manual measurements on stressed CT showed high diagnostic accuracy; new study used automated distance mapping, with even higher precision (tenths of a millimeter).
  • "The thresholds, the values that we're able to see are much smaller than we were able to measure... for the distance mapping we can get below millimeters, tenth of the millimeters." (E, 16:28)
• Cadaveric studies established the methodology's validity before use in clinical cohorts.

Limitations & Future Directions

• Current cohort does not include operative correlation (arthroscopic gold-standard confirmation).
• Next steps: Apply the technique to surgical cases and perform multi-center studies for greater generalizability.
  • "That's the next step that we're doing both with weight bearing CT and with non weight bearing CT." (E, 17:49)
• Algorithm openly shared for broader adoption, especially in resource-limited settings.

Clinical Impact & Broader Value

• Offers valuable diagnostic tool for syndesmotic injuries, especially where weightbearing CT is not available.
• Potential applicability to MRI—limited by acquisition time and motion artifact.

Notable Quotes

• "If you can see in the cadaver just by cutting the ligaments, you should be able to see in any clinical conditions if the ligaments are really gone." (E, 20:02)
• "[The clinical dilemma is] when to pull the trigger of doing surgery... there's still a lot of clinical expertise that's involved." (D, 17:59)

Notable Quotes & Memorable Moments

• "There's no way to ruin an outcome like long-term follow-up." – Joe Park, 07:16
• "These are the results. Once you get there and start become competent... this is the result for the better of the patients." – David Gordon, 03:59
• "You ask the patient how they are and how they're doing, that's the most important thing." – David Gordon, 06:30
• "Lucency and loose are not necessarily interchangeable... all of them were found to be loose, but... I don’t know that you can use the terms interchangeably." – Elizabeth Cody, 11:32
• "If you can see in the cadaver just by cutting the ligaments, you should be able to see in any clinical conditions if the ligaments are really gone." – Cesar de Cesar Netto, 20:02
• "As a clinician, I think [new measurements] help to point you in the right direction. But there's still a lot of sort of clinical expertise that's involved." — Joe Park, 17:59

Timestamps for Important Segments

• 00:27 – Introduction of award-winning guests and topic overview
• 01:18 – David Gordon on the genesis of the minimally invasive chevron study
• 02:24 – Discussion of findings and implications for minimally invasive bunion surgery
• 04:46 – Explanation of PROMs and study outcome measures
• 07:16 – Reflections on long-term follow-up and its humbling nature
• 09:03 – Elizabeth Cody introduces her study on tibial lucency and total ankle replacements
• 10:53 – Changes in implant approach and patient follow up
• 12:19 – Managing patients with radiographic lucency
• 15:24 – Cesar de Cesar Netto explains 3D distance mapping and syndesmotic instability diagnostics
• 16:28 – Comparison of automated mapping versus manual measurements; clinical validation
• 20:02 – Discussion of cadaver validation and future applications

Summary Takeaways

• Commitment to robust, long-term outcomes research is vital for practice-changing evidence in foot and ankle surgery.
• Minimally invasive surgery for hallux valgus is validated long-term: patient-centered outcomes are essential, and adopting new technique requires perseverance and training.
• Periprosthetic lucency after total ankle arthroplasty is common yet not always clinically significant; nuanced patient dialog and enhanced implant selection (e.g. stemmed implants) can improve care.
• Innovative imaging approaches for syndesmotic instability offer promise, particularly in settings without advanced equipment; cross-disciplinary and multi-center collaboration is encouraged.

This episode highlights the translation of rigorous research to day-to-day foot and ankle orthopedics, emphasizing both the importance of long-term outcomes and adaptability of new technologies and methodologies in diverse clinical settings.