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Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members.
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This episode was recorded at the EFAS Conference in Vilnius, Lithuania. The EFAS AOFAS Exchange Program is a partnership with the American Orthopedic Foot and Ankle Society and the European Foot and Ankle Society, where three EFAS members will attend the AOFAS Annual meeting and travel to prominent orthopedic foot and ankle institutions in the US And Canada. In exchange, three AOFAS members will attend the EFAS Congress and visit foot and ankle sites in Europe.
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Welcome to the AOFAS Ortho Podcast. I'm Matt Conti from the Hospital for Special Surgery, and I'm joined today by Bonnie Chien from Columbia Presbyterian in New York City and Cesar de Cesar Neto from Duke University. And we're here to talk about what we learned on our EFAS AOFAS Traveling Fellowship in order to give you some of the ideas that we picked up while we were here. So thanks, both of you, for joining me. I've seen a lot of you recently over the last three weeks, so I'm gonna miss our daily conversations. So I think we should start by just going kind of in chronological order about what we learned. And so our first stop was in Marseille, and we spent time with Barbara Piclay, who does a lot of minimally invasive forefoot surgery. So, Bonnie, what's the one thing that you picked up from Dr. Piclay that you're gonna take back to New York City?
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D
So one thing is, I think, considerations of treatment for hallux rigidus. I think in the US one of the main stages of treatment for us, especially for moderate but definitely advanced first MTP arthritis, is doing first MTP fusion. And I think here in Marseille, we've all appreciated looking at it in a very different way. And with Dr. Piclay and her team, they really try to preserve motion and not sacrifice the joint. So they're big proponents of doing a Youngswick osteotomy to shorten, decompress the joint and create more space. And so I think that's something that all of us thought that for the right patient, we may consider introducing that
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C
as an option for those American listeners who don't even know what a Young's Wick is, because we talk about it so infrequently. What is a Young's Wick Osteotomy So
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D
I have to admit I've never done it before, but in terms of what we've learned, there's different ways of doing it. You can do an oblique or a chevron with a long plantar limb type osteotomy and then shorten and then translate the head plantarly a bit to give the first MTB joint more space. It gives also motion to the joint. And from what we've seen with our European hosts, that these patients seem to be quite, quite satisfied and do quite well, particularly with activities that require them to go on the tips of their toes or in certain shoe wear.
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Cesar, you're gonna do a young sweat osteotomy when you come back to America, back to Duke?
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E
Yeah, well, I'll definitely consider it for the right indications. I think it's always good to have joint preserving options. And I think, you know, there's definitely applications and indications for it, and I will definitely try them.
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C
Who would be like, I was thinking for myself, like, the first patient I would do it in is someone who definitely was not short on their first metatarsal. Right. And really wants to do everything they can to preserve motion, you know, and has good motion preoperatively. Is that like the first person you would consider for someone that really doesn't want a fusion and is willing to accept maybe a little bit of pain?
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E
Yeah. Well, I think the patient wanting to preserve motion despite the fact that there's. The pain is not going to be completely gone. I think it's similar to what we talk about for a calectomy and for an interposition arthroplasty. The patient needs to accommodate the fact that it's not a final solution, that they might still need an MTP fusion down the road. And if they're in peace of mind with that and that's what they want, I think that would be a good. I would say that for the more advanced ones, even if there's not crazy amount of motion, I think the decompression and the cleaning of the joint could potentially allow some. Maybe some extra motion. So I think for those indications and the cases with metatarsus or levitis, I think those would be probably my favorite ones.
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C
What's something that you picked up from Dr. Paclay that you're taking back, other than the young SACC osteotomy?
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E
Well, if we go to the basics, I think her attention to the details is impressive. I think she's very detailed clinical assessment. I think the way she runs the. Her private practice, where the entire team Is basically setting herself to success with an orthotist with imaging ready available with radiologist technician directly related to her nursing helping with the dressing with the minimally invasive. As we know, very important to have proper dressings to keep or correct change deformities. I think that, you know, of course we try all to do like that but sometime in the U.S. the, you know, the time crunch speaks first and then you need to move and you end up choosing flow rather than details. I think she has a lot to teach us on that regard because she runs a pretty, pretty high level private practice without losing the attention to the details.
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C
Are you going to bring a podoscope to Duke?
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E
I think it's impressive. I think it's incredible.
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D
Add to the way Baron CAT scan collection the photoscope.
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E
Yeah, yeah, the photoscope is very interesting and you know, the way that she follow up her patients and the way that she keeps her data very organized in the system with pre op and post op X ray clinical podoscope and weight bearing CT data into the chart. I think it's impressive and you know, stuff to replicate exactly like that. But it's definitely something that we will consider.
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C
Yeah, I mean I think for those who don't know the podoscope is like basically the patients stand on and you guys can jump in if I'm describing wrong. But they basically stand on a piece of glass and there's a mirror underneath that kind of reflects the bottom of their foot. And so from it you can kind of see where the patient's weight bearing on the plantar surface of their foot, whether their toes hit the ground, what's on the ground for their forefoot. And it's just a way to look at, for basically the foot from the bottom of the foot that we don't really see when we're looking at it from the top.
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E
Is that exactly. Yeah, it's like a, it's a straightforward way to have a pumpkin autobiography without having the pressure assessment in terms of numbers. Right. But you can definitely see where the pressure is going in both feet.
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C
Yeah, I mean I think for me too like the, her clinical documentation is incredible and I think that's really helpful because it also, I think it's really informed a lot of how she treats things and how she treats patients. And she is very thoughtful about everything she does. And so whether it's a hammertoe or hallux rigidus or a bunion, she spent a lot of time kind of thinking about it. She really takes like a holistic approach to medicine and I found that to be really inspiring and something that I'll probably take back to the States. I'll also take back the fact that from the OR you can see the ocean. So I'm gonna ask HSS if they can give me an ocean view in my or.
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D
You get a seashell.
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Yeah, exactly.
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Patients start getting better before they even have the surgery done.
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Exactly.
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Well, we can't leave this without talking
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about the fdb, the FTB tendon, both the transfer and the release.
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Yeah, yeah. So I think that the technique part is really interesting. Also her algorithm, I think I really learned a lot from that. I mean, she's published papers. I think people can review that. And I think for me is separating the flexible and rigid deformities. But really the go to workhorse is the FTB release that she does plantarly. And with really good understanding of the anatomy and how to do it safely, flexing the pip joint down, you can release the capsule plantarly at the same time. And then having a low threshold to then do a P1 oblique osteotomy, and you can really set the toe anywhere you want. The FDL is protected. Then you flex the pip joint and then then another low threshold to do a percutaneous edal release. So I think we all learn, like, simple, but I think very powerful techniques. How to use like a beaver blade and like ride it over the tendon and swipe it. And I think that's something that we can carry on with her legacy and reproduce over here in North America.
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C
Yeah, for sure. I mean, if I'll just describe the technique, I mean, she basically goes proximal to the pip joint and flexes the toes, and from there takes a beaver blade under the the pip joint and is able to release the capsule of the pip joint and the FDB tendon through this small percutaneous incision. And that releases the flexion deformity at the pip joint. And so that's in contrast to doing an FDL tendon release where, you know, you can get a. You get a floating toe and they can't bend their toe at the distal aspect anymore. So definitely something that I had never really even considered. And so also taking that away. And so that's something that, you know, I think we're all going to bring back. So then we had a great time in Marseille, saw Marseille play the Paris Saint Germain football team, and then we moved on to Oxford. And so, Cesar, what was something that you're taking away from our time? Well, actually went to London first, but that was more for fun. And then what are you taking away from your time at Oxford?
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Well, I think, you know, the Oxford experience was a little bit, in some ways, a little bit closer to what we're used to do. So it was interesting to see similar ways of thinking in a different scenario. I think we all have challenges, different challenges in different countries, different services. They have their challenges with the universal public system and the access to care, similar to other countries, such as my own country, Brazil and Canada and etc. So there's a lot of struggles in terms of or availability, staff availability, cancellations, and, you know, I think we were able to be exposed to that. Things that we don't see that frequently in the United States. And it's important for us to see how patients and surgeons struggle to be able to do their work in other countries. So we also give credit and are grateful for what we have in the United States. I think, you know, very basic principle, but just explaining, you know, the access related to or time, start time, finish time and even to have a room available for you, depending on availability of staff related to NHS and some government issues is not under their control. So I think they brilliantly navigate through this to provide great care for patients.
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Bonnie, what about you? What are you taking away from your experience at Oxford and the nhs?
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Yeah, well, I think that the British Foot and Ankle Society have a very principled approach and we were really fortunate to be part of their, I think, like monthly or every few months, psych conference, where a lot of foot and ankle surgeons from the Greater London area travel and meet up and they give talks about different topics, their research, and then they have case discussions. And I think it's an amicable forum where people can raise different opinions and discuss them. So we're really fortunate to be part of that. And the British also have quite an impressive registry of data, starting from back in the hip and knee days and then extending now to ankle replacements and really following these patients, large numbers of them over time, and really adding to the global literature of the outcomes of ankle replacement. And we also appreciated how, I think they do a lot of time tried and true procedures such as an ankle fusion. They do them mostly arthroscopically. And so I think we also gained a lot of, like, technical pearls in terms of how to do that. Just because it's arthroscopic doesn't mean it's necessarily rushed. It's still very systematic. And they explained a lot about how to prep the joints, well, the gutters, making sure you take down Bone from the tailor neck and head area, if there's excess bone there, so that you can really get a good compressive surface. What was the candy? They said it looked like after your joint surface is prepped. They were saying it looked like, oh,
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like a crunchy bar.
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Crunchy bar? Yeah. Like you got to get to a crunchy bar. Yeah.
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Yeah. I mean, I think they bring up a good point because we saw one ankle replacement and then two ankle fusions, which is, you know, that I think we're biased in the US And I think I certainly am. I actually tell my patients this. You know, we're biased towards doing a total ankle replacement, but the data is, you know, there's definitely some advantages to doing a total ankle replacement, but the ankle fusion still has good outcomes even at longer term follow up. And so it made me, you know, every time I do an ankle fusion, I kind of feel bad. I'm like, gosh, I wish I could have given this patient a total ankle replacement, but. But now I'm like, well, it's a good procedure and maybe I won't feel so bad fusing an ankle. Because, you know, I think from their data, their patients seem to do pretty well after an ankle fusion. And definitely I learned though, since I do a lot of in bone and I think in the US I was just talking with someone who was saying that in the US this year in bones will actually stemmed implants will actually surpass low profile implants in at least for the. For Stryker, who's keeping track of the data. And. And so I think we do a lot of stemmed implants in the US And I think a lot of companies are trying to come out with stemmed implants. And here it's like absolute blasphemy, I think, to do a stemmed implant off the bat. And they do a lot of lower profile, total ankles with a lot of success. So, you know, I'm not sure the stemmed ones seem to do well, but, you know, at the same time, they're low profile. Tibial data is really good here. And so, you know, maybe something to consider, preserving more bone. And then finally we moved on and we went to Vienna and spent the weekend in Vienna going to the opera and having spatzle. And. And so that was fun. And then we spent schnitzels. Oh, so many schnitzels. Yeah, that's right.
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Dessert, Lots of dessert.
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I love dessert. So that was important.
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Comfortable, uncomfortable coffees.
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So many coffee. At some point I had like, probably a liter of coffee in me and zero water.
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So it cost Zero. Yeah.
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And then, well, throughout the trip, I mean, I don't think Cesar loves Coke Zero, so I'm not sure we wouldn't go anywhere where there wasn't Coke Zero, which was important. And so then we spent time with Dr. Trnka in Vienna. And so, Bonnie, what did you take away from Dr. Trnka?
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D
So Dr. Trnka comes from a very impressive class of co fellows of Dr. Mark Easley and Dr. Peter Lam as his co fellows who all trained with Dr. Meyerson et al. And so we had the great honor of reviewing one of his seminal papers on the chevron osteotomy for Hox Valgus correction in the early 2000s, I believe was when it was published. And so it still holds true and is a very effective procedure. And he does it in an extremely slick way even today. And I think it makes us really appreciate some of these techniques that seem to be old school but really are very effective graphically and clinically. So I think Dr. Trnka also has adopted some of the newer, like Mis hallux valgus Correction techniques, DMMOs. So I think he really, for me, has brought together the old and the new. I guess almost like Vienna bringing the old traditions and the classics with the modern in a really balanced way.
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E
Yeah, well, I second what Bonnie mentioned. I think that it was Also, you know, Dr. Trinka also runs a private practice and in, you know, his own building, similar to what Barbara does in Marseille. And I think it also got a lot of our attention. You know, of course, the population, the patient population is different. He's seen different patient population than most of us see in the United States. But, you know, conservative treatment is very high in his preferences. Not that we don't do conservative treatment. Maybe we get the patient after some conservative treatment was already done. So I think our threshold for surgical recommendation is lower from the fact that these people usually have seen other providers. But I feel that maybe, I don't know what you guys think, but probably of all the patients that we've seen with him, you know, the surgical indication was what, 5%, 3%, very small. And so I think, you know, exhausting conservative treatment. We saw him taking care of his own insoles, modifications in the insole, recommending different shoe wear that we do as well, but investigating every detail of the pathologies with ultrasound and MRI and rarely CT scan. Right. But MRI and ultrasounds, and I saw the patients being extremely happy with the propositions or the recommendations for additional conservative treatment. So it was this medical patient relationship and convincing the patient that trying more conservative treatment is probably the way to go. I think it was very interesting for us to see from a different perspective in different patient population.
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Yeah, I think to add on to Cesar's point, it really gave me a new appreciation for plantar fasciitis. I know we all typically dread having to see these patients and managing it because it typically is non operative. But I think just seeing Dr. Trnka, how he explains biomechanically to these patients, really spends a lot of time offering different treatment options. One of his colleagues, Carl, does office bedside ultrasounds and really shows the pathology to the patients and explains it to them. So I think that's just, I think a different attitude and perspective to take the next time I may see a patient with plantar fasciitis.
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E
I think another thing is also like when he does indicate surgery, I think he's got a very straightforward, simple way to think about it without creating too much, you know, complications in terms of what to do is very straightforward and very classic with his indications in terms of the procedures and so straightforward surgical plans for sometimes straightforward problems, sometimes not as straightforward. But I think simple is, you know, simple is also good. So it doesn't have to be extremely technical and complicated to lead to good results. And we can't stop this. Before talking about the electromagnetic field that saved my knee and my finger, I was gonna.
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C
It was on my list of things that was what I was gonna bring up next. But he does have an electromagnetic, I'm not sure exactly, electromagnetic machine. And I mean you were running, I mean you're running a lot while we were here and you were running in Vienna and then you ended up with some knee problems because you're getting old.
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Extremely old.
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Extremely old. Probably ancient degenerative meniscus problems. And so, I mean, we were interested. I mean, does the electromagnetic field work?
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It's amazing. It's incredible, I promise you.
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Yeah, I think we have to send it to the British and they'll have a long term study of tens of thousands of patients in their registry.
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I think it's a good idea, but definitely saved your knee and potentially. How's your finger?
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I'm a new person.
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Yeah, it's amazing.
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D
If we have time. Another technique or implant really that I just wanted to mention with Dr. Trinka and his team is like a allograft, gradually absorbable, I guess, made from bone implant like screws. So we saw that for hammertoe fixation it's placed like in an intramedullary way at the pip joint and then over months it becomes bone we saw him use it for a second TMT fusion. So I think we've seen similar implants out there in the market. And I think I personally be very curious to see how this goes in terms of just patient responses to something that's not metal and then maybe even contributing to any potential differences in infusion rates. What do you guys think?
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I think we have to finish because I need a Coke Zero. So. Yeah, it's time to finish.
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Yeah, I mean, it's. I mean, it's been about an hour since you've had one, so it's going
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through withdrawal, tremors, and, you know, my fingers don't stop moving. I don't know what to do.
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D
Magnetic therapy.
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C
Yeah, exactly. I'm gonna have to send you back to Vienna. Well, now we're in Vilnius, and we're attending the EFAS Congress here, and it's been an incredible day with people talking about different techniques. And so I would encourage you, if you're interested in potentially taking a trip even to the EFS Congress to see what they're talking about. And I think one thing to sum up that we've taken away is that foot and ankle is cultural, and we don't have answers for a lot of problems. And so people think about it in different ways, and many people have good outcomes. So there's a lot of ways to get good outcomes for many patients. But. But at the end of the day, we're trying to get the best outcomes for every patient. And so if you don't know something, then the eye doesn't really see what the mind doesn't know. Right. And so just having experience, I think we've taken away things, and we may incorporate them not for every patient, but a little bit in our practice here and there and kind of expand our indications. But I think that's what's amazing about coming to Europe or any of the other conferences across the world is that people have different opinions and have different solutions to problems that work for them. And I think when we come together, we are stronger as a group of people, foot and ankle surgeons across the world to solve problems for our patients. So. Well, thank you guys for traveling with me for over the last three weeks and putting up with me. I'm not sure if my wife could travel with me for three weeks, but it's been great traveling with you guys, so. And it's been an honor to be part of the fellowship, so thank you, guys.
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Thank you.
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D
Likewise. Thank you so much.
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Thank you for listening to the AOFAS Ortho Podcast a Convey Med Production. To learn more about joining our dynamic community of of highly skilled orthopedic specialists, visit aofas.org.