The AOFAS Orthopod-Cast

Episode: 2025 EFAS/AOFAS Exchange Program Highlights

Date: April 1, 2026

Episode Overview

This special episode of the AOFAS Orthopod-Cast, recorded at the EFAS Conference in Vilnius, Lithuania, features three American surgeons—Dr. Matt Conti (Hospital for Special Surgery), Dr. Bonnie Chien (Columbia Presbyterian), and Dr. Cesar de Cesar Neto (Duke University)—sharing their insights as participants in the 2025 EFAS/AOFAS Exchange Program. The conversation flows chronologically through their journey to leading European foot and ankle centers in Marseille, Oxford, and Vienna, highlighting differences in surgical philosophy, clinical practice, and innovations they plan to bring back to North America.

Key Discussion Points & Insights

1. Marseille with Dr. Barbara Piclay — Minimally Invasive Forefoot Surgery

Hallux Rigidus: The Youngswick Osteotomy

• Paradigm Shift: European surgeons prioritize joint preservation over fusion for hallux rigidus, contrasting with standard US practice.
• Youngswick Osteotomy (01:53–03:59):
  • Dr. Bonnie Chien: "With Dr. Piclay and her team, they really try to preserve motion and not sacrifice the joint... They're big proponents of doing a Youngswick osteotomy to shorten, decompress the joint and create more space." (01:53)
  • For moderate to advanced first MTP arthritis, the Youngswick—a variant of distal metatarsal osteotomy—offers an alternative to fusion, allowing select patients to maintain joint motion with reasonable expectations regarding residual pain.
• Patient Selection:
  • Dr. Cesar de Cesar Neto: "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...that would be good." (03:59)

Practice Details & Team-Based Care

• Attention to Detail (04:49–06:19):
  • Dr. Piclay’s private practice integrates orthotists, radiology, and precise documentation, allowing for high-quality, patient-focused care.
  • Cesar: "Her attention to the details is impressive...very detailed clinical assessment." (04:49)
  • Clinical Tools—Podoscope (06:19): Used for plantar foot assessment: "You can see where the patient's weight bearing on the plantar surface...it's just a way to look at the foot from the bottom..." (Matt, 06:19–06:49)
  • Documentation: Noted as thorough and holistic, supporting well-rounded decision-making.

Technical Pearls

• Minimally Invasive Techniques for Lesser Toe Deformities (07:51–09:07):
  • Matt: "We can't leave this without talking about the FDB tendon, both transfer and release." (07:51)
  • Dr. Piclay’s percutaneous flexor digitorum brevis (FDB) release technique provides treatment for flexible deformities while avoiding issues tied to other approaches (e.g., floating toes after FDL release).

2. Oxford & the National Health Service (NHS) — Systemic Challenges and Evidence-based Practice

Access & Resource Constraints

• Universal Health System:
  • Cesar: "We all have challenges, different challenges in different countries, different services...They brilliantly navigate through this to provide great care for patients." (10:11)
• Staff and OR availability impact case scheduling and care delivery, fostering resilience and gratitude for US resources.

British Surgical Philosophy & Data Culture

• Registry and Collaboration (11:39–13:12):
  • National joint registries provide robust, population-based outcome data, influencing surgical decision-making (esp. ankle replacement vs. fusion).
  • Bonnie: "The British also have quite an impressive registry of data...really adding to the global literature of the outcomes of ankle replacement." (11:39)
• Technical Pearls for Ankle Fusion:
  • Emphasis on systematic arthroscopic fusion: "Just because it's arthroscopic doesn't mean it's necessarily rushed. It's still very systematic...making sure you take down bone...so that you can really get a good compressive surface." (Bonnie, 12:48)
  • Description: Ideal joint surface resembles a "crunchy bar" once sufficiently prepared (13:13).
• Implant Selection Differences:
  • US has a growing trend toward stemmed total ankle implants; UK prefers lower-profile implants, prioritizing bone preservation.

3. Vienna with Dr. Thomas Trnka — Tradition Meets Innovation

Surgical Heritage & Modernization

• Classic Techniques Endure:
  • Bonnie: "It makes us really appreciate some of these techniques that seem to be old school, but really are very effective graphically and clinically...he really has brought together the old and the new." (15:34)
• Minimally Invasive and Hybrid Approaches:
  • Dr. Trnka blends chevron osteotomies and newer MIS (minimally invasive surgery) techniques for hallux valgus.

Conservative Care as a Foundation

• Thresholds for Surgery Are Higher (16:45–18:24):
  • Cesar: "Conservative treatment is very high in his preferences...Maybe of all the patients that we've seen with him, the surgical indication was what, 5%, 3%, very small." (16:45)
  • Thorough, participatory explanations (often with ultrasound/MRI at bedside) encourage patient buy-in for non-operative treatments.
• Plantar Fasciitis Perspective (18:24):
  • Viewing common non-operative orthopaedic problems with renewed patience and engagement: "I think just seeing Dr. Trnka, how he explains biomechanically to these patients, really spends a lot of time offering different treatment options..." (Bonnie, 18:24)

Innovations and Quirks

• Bioabsorbable Bone Implants (20:30):
  • Use of gradually absorbable allograft screws for hammer toe and fusion: "It becomes bone...I'd be very curious to see how this goes in terms of just patient responses...differences in infusion rates." (Bonnie, 20:30)
• Electromagnetic Field Therapy (19:43–20:28):
  • Playful segment where Cesar credits an electromagnetic device for saving his knee and finger during the trip, calling for further British registry research:
  • Cesar: "It's amazing. It's incredible, I promise you." (20:11)
  • Bonnie: "We have to send it to the British and they'll have a long-term study..." (20:15)

Memorable Quotes & Moments

• On Cultural Differences:
  • Matt: "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...when we come together, we are stronger as a group..." (21:32)
  • Cesar (on practice style): "Simple is also good. So it doesn't have to be extremely technical and complicated to lead to good results." (19:05)
• On the Exchange Program's Impact:
  • Matt: "If you don't know something, then the eye doesn't really see what the mind doesn't know...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..." (21:32)
• Running Joke:
  • Cesar’s dependence on Coke Zero and Matt’s request for an ocean-view operating room, highlighting camaraderie and the value of international fellowship (07:44, 21:14, 21:25).

Notable Timestamps

• Youngswick Osteotomy in Hallux Rigidus: 01:53–04:43
• Clinical Practice and Detail in Marseille: 04:49–07:02
• FDB Tendon Techniques (minimally invasive): 07:51–09:07
• NHS System & Registry Data in the UK: 10:11–13:18
• US vs. UK Implant Selection: 13:18–15:01
• Vienna: Classic and Modern Surgical Approaches: 15:34–16:45
• Conservative Orthopaedics in Austria: 16:45–18:24
• Bioabsorbable Implants & Electromagnetic Therapy: 19:43–21:14
• Cross-cultural Reflections & Wrap-Up: 21:32–22:55

Takeaways for the Listener

• Expect a richer appreciation for joint-preserving techniques, attention to clinical detail, and the importance of thorough documentation and team-based care.
• Exposure to international systems (NHS, Austrian model) reveals different constraints—and creative ways to provide quality care.
• Conservative care is alive and well in Europe, and sometimes less is more—particularly when paired with patient-centered communication.
• The episode is permeated with humor and camaraderie, bolstering the exchange’s value beyond just technical insights.

For practitioners: This episode is a goldmine of subtle clinical pearls, practical innovations, and a reminder that solutions in foot and ankle surgery, while deeply influenced by cultural and systemic context, are most powerful when shared globally.