Arthritis in the Young Patient: Fusion vs. Replacement

Summary

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The AOFAS Orthopod-Cast

Episode: Arthritis in the Young Patient: Fusion vs. Replacement

Date: July 29, 2026
Panelists: Nick Strasser (Host), Pam Luke (Co-host), Konstantin Demetrikopoulos (Guest), Jesse Doty (Guest)

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Episode Overview

This episode of the AOFAS Orthopod-Cast delves into one of the most nuanced topics in foot and ankle orthopedic surgery: the management of end-stage ankle arthritis in young patients. The panel tackles the evolving definition of “young” in this context, the shifting paradigms between ankle fusion and total ankle replacement (TAR), decision-making criteria, patient-specific considerations, and technical pearls. The discussion is grounded in both current literature and extensive clinical experience, providing a rich exploration of patient assessment, surgical indications, and postoperative challenges unique to this population.

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Key Discussion Points & Insights

1. Defining the "Young" Ankle Arthritis Patient

• Changing Age Thresholds:
  • Historically, “young” meant under 60 or 65, but this threshold is shifting downward, similar to trends in hip and knee arthroplasty.
  • Demetrikopoulos: "The median age [for ankle replacement] is in the late 50s... I consider a younger patient somebody under the age of 50." (02:35)
• Subcategorization in Studies:
  • Studies divide groups at <50, <55, 55-70, or >70, but these are "artificial categories."

2. Assessing Suitability for Replacement in Younger Patients

• Assessing Functional Disability and Expectations:
  • Demetrikopoulos: The length and impact of disability matter. For someone who suffered traumatic arthritis at age 18 and adapted over years, “expectations have naturally reset... maybe that person is a better fit for an ankle replacement.” (03:42)
  • Patients who recently developed arthritis post-injury often compare outcomes to their previous normal, making satisfaction with TAR more challenging.
• Impact of Fracture Pattern and Pre-op Status:
  • Doty: "Range of motion... postoperatively is dependent on the pre-op range... which ties into the fracture pattern." (05:39)
  • Real cases highlighted: active young adults pursuing TAR and doing well even a decade later, when carefully selected and well educated.

3. The Depth of Shared Decision-Making

• Process and Multiple Encounters:
  • Doty: Strongly advocates for multiple visits—"some of those people were seen over a one or two year period" before proceeding (09:15).
  • Ensures patients have time to absorb information, adjust expectations, and demonstrate commitment.
• Building Trust and Caution:
  • Demetrikopoulos: "One way to get at the truth is you ask the same question multiple times, try to make sure you get the same answer from the patient." (10:28)
  • Cautious with eager, younger patients: "If they just... are ready to go, you really have to pump the brakes." (12:18)

4. The Role of Subtalar Joint Arthritis and Foot Morphology

• Adjacency Not a Decisive Factor, But Influential:
  • Doty: "Subtalar arthritis... is not the sole determining factor but it certainly molds and directs the conversation pre-surgically." (14:16)
  • Demetrikopoulos: “People who are stiff desperately want to hold onto their motion... Subtalar joint is interesting, but not very useful for me” in decision-making. (15:40)
• Foot Type Considerations:
  • Flatter feet tolerate fusion better due to flexibility; “a higher arched foot... is going to be a more rigid foot, [and] I don’t think is going to compensate as well after an ankle fusion.” (16:34)

5. When is Fusion Preferable to Replacement?

• Hard Stops and Relative Indications:
  • Doty: “Neuropathy and A1C out of control... scare me a lot” (18:45). Wary even of mild diabetics due to risk to success and wound healing.
  • Demetrikopoulos: Fusion is indicated for patients with repeated failed surgeries, prolonged disability, substantial life or social stressors, or heavy occupational demands—"That person needs success; that person does not need complications. They’ve been through a ringer." (19:18)
• Alignment and Technical Considerations:
  • “A well-aligned ankle fusion will do well for a very long time.” (20:10)
• Social Factors Matter:
  • Doty notes “big wins and some really happy patients with ankle fusions in younger people” who have difficult backgrounds, social or mental health struggles, and need predictability. (21:45)

6. Risk Factor Management: Smoking, Vaping, Comorbidities

• Strong Emphasis on Smoking Cessation:
  • Doty: "I beat them up pretty bad about smoking. I threatened nicotine tests...I really encourage them those first few weeks." (22:53)
  • Demetrikopoulos: "If you can cut it in half, cut it in half... If you can quit, that would be ideal. And so I dictate and I do all the counseling... it's your ankle, not mine." (24:06)
• Comorbidity Stacking:
  • Smokers with other comorbidities (obesity, diabetes) decrease suitability for TAR. Might opt for less invasive or minimally invasive arthrodesis. (24:06)
• Vaping:
  • Higher nicotine concentrations—treated the same as smoking. Younger, healthier vapers still advised to decrease or stop. (26:01)
  • Doty: "Every time you take a break, puff, the nicotine constricts your blood flow... chemicals aren't good for you." (26:01)
• Diet and Wound Healing:
  • Surprising impact of diet (e.g., excessive soft drinks) on wound healing. (26:49)

7. Surgical Technique Challenges: Revising Post-traumatic Ankles with Multiple Incisions

• Preop Vascular Workup & Use of Existing Incisions:
  • Always check pulses, sometimes order advanced imaging, may coordinate with plastic/vascular surgeons pre-op if concern for soft tissue compromise. (28:20)
  • Use existing incisions when possible (curvilinear anterior approach; Tim Daniels approach). (28:56)
• Staged Approaches for Difficult Soft Tissue:
  • Doty: "I've done hardware and bone grafting, taken cultures if you need to... I always explain it as a soft tissue challenge." (30:21)
  • Two-stage approaches lower risk of wound issues and allow better surgical conditions for TAR. “I don’t think I’ve ever regretted staging that.” (31:26)
• Technical Pearl:
  • Stagger skin and fascial incisions to improve wound closure and healing (31:37).

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Notable Quotes & Memorable Moments

• On Patient Selection and Expectation Setting:

  • “Once you take that bone out and you put the replacement in, they have made a turn. Right? We’ve gone down a path and we can’t go backwards.... you really want them to understand those implications and consequences.”
    — Konstantin Demetrikopoulos [12:18]

• On Social and Psychological Context:

  • "The society we live in, tremendous amount of mental health, illness and substance abuse issues... An ankle fusion can be a big win in somebody like that."
    — Jesse Doty [21:45]

• On Risk Factors:

  • "It’s your ankle, not mine. And if this goes south, you’re going to know that what you did contributed to it…"
    — Konstantin Demetrikopoulos [24:06]

• On Surgical Technique:

  • “There’s no shame in staging that patient... you can control their swelling at the final implantation stage and get in and out quicker. And I’ve just had much better success with that.”
    — Jesse Doty [30:21]

• On Diet and Wound Healing:

  • “I’ve become a real believer in these dietary influences, where I’ve had two or three patients who can’t heal their wounds until they stop drinking three Mountain Dews a day.”
    — Jesse Doty [26:49]

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Timestamps for Important Segments

• Defining "Young" Patient: 02:35–03:38
• Assessing Longstanding vs. Recent Disability: 03:42–05:26
• Fracture Type and Range of Motion: 05:39–08:41
• Shared Decision-Making & Multiple Clinic Visits: 08:41–13:12
• Subtalar Joint & Foot Morphology Considerations: 14:16–17:39
• When to Fuse Over Replace: 18:45–22:37
• Smoking and Risk Factor Management: 22:51–26:01
• Dietary Influence on Wound Healing: 26:01–27:23
• Technical Tips for Scarred/Multiplanar Ankles: 27:46–32:31

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Conclusion

This episode offers an invaluable, pragmatic window into the real-world dilemmas faced by surgeons treating young patients with end-stage ankle arthritis. The discussion is equal parts evidence-based and experience-driven, emphasizing careful patient selection, shared decision-making, nuanced surgical planning, and risk mitigation.
Listeners are left with the resounding message that there is no single algorithm—each patient’s anatomy, history, expectations, social situation, and comorbidity profile must be accounted for in choosing between fusion and replacement.

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Transcript

[Jesse Doty]

Welcome to AOFAS Ortho Podcast, where leaders

[Konstantin Demetrikopoulos]

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.

[Nick Strasser]

Welcome to the AOFAS orthopodcast. My name is Nick Strasser, and joined by one of my fellow panelists, Pam Luke, and we're talking about young patients in total ankle arthroplasty and decisions on Fusion. And we have two really great guests tonight. We have Konstantin Demetrikopoulos and Jesse Doty, both people that I have a ton of respect for and learn so much from their work. And so as we were putting this together, you know, it was natural that we wanted to get you guys on the podcast to discuss this, because as I was thinking about this, at least when I came out of training, it was what constituted as a young patient, and it was more 60, 65. That was kind of the safe answer. And then you start to see that pendulum swing down to younger and younger, kind of like hip and knee arthroplasty. And then maybe the one article on Total Ankle that Konstantin has not written came out of Duke, which was talking about young patients in total ankle arthroplasty and how the reoperation rates were a lot higher. And I think what you've also shown has been patients who have reoperations don't do as well as those who do. So it kind of all fits together in some convoluted way in my head. And now I'm wondering, as I've kind of experienced more younger patients, because it's a different animal than an older patient who comes in and says, I forgot about that. I even had my ankle replacement. The young person doesn't really come in and tell you that. And so I think we're still trying to figure out where we land when it comes to ankle arthroplasty and when do we apply that in a young patient and how that conversation is happening. So Pam's put together some cases to kind of lead the discussion. But, gentlemen, thanks so much for getting on the podcast tonight. Really appreciate your time.

[Pam Luke]

Yeah, definitely. Welcome. Constantine and Jesse, you guys have both spoken at a lot of our annual meetings and big symposium, and I just always learned so much listening to both of you. I know Konstantin just did another Alphas webinar recently, talking about total Ankles, and I learned a lot from that presentation, too. So I guess starting off before I get to the cases, not just to Guide us if we need to, but in your guys practices, just like Nick has been saying, what constitutes a young patient to you guys now in terms of thinking about for total angle.

[Konstantin Demetrikopoulos]

Well, Nick and Pam, I'll say thank you for having me on this and I'm sure Jesse feels the same way. We're honored to be here to talk about this topic with you all. And I agree that the concept of a young ankle arthritis patient has changed as it relates to our decision making for ankle replacement. When you look at the median age of patients that get an ankle replacement, it's in their late 50s. It depends on the study, but I think of it as 58 or 59 years old. And so if that's the median or the average age of somebody getting an ankle replacement, I consider a younger patient, somebody under the age of 50. Studies have tried to split up patients into different groups, whether it's under the age of 55, as you mentioned Nick and the Duke studies, we divided patients under the age of 55, 55 and 70, and then 70 and older. But these are artificial categories and you can split it up any which way you want. But at least in my practice, when I get ready to give the young patient talk to somebody that comes to see me, it's somebody under the age of 50 who's considering an ankle replacement.

[Pam Luke]

How young have you gone, Konstantin, for ankle replacements?

[Konstantin Demetrikopoulos]

I think that's a great question. And you really want to think about the type of arthritis that someone has. So if we consider post traumatic arthritis as the most common type of arthritis in those individuals is probably, and I can't say for sure, but it's been somebody in their late 30s. So whether it was 37 or 38, if you consider patients with JRA or patients with hemophilia that can be younger, the most important thing that I think about in patients that are young who are facing this problem is how long have they been disabled? I think that's a really important consideration, one that doesn't come out in research very well. So for example, take somebody who has an accident traumatic event, they're 18, they're 19 years old, they have a complex fracture, they develop arthritis, and now it's 20 years later, they're in their late 30s. That person is fundamentally different than somebody who has a terrible injury when they're 36 and two years later they have terrible arthritis. Not only is the nature of the injury different in terms of an injury so bad that two years later they have end stage arthritis, but the 36 or the 38 year old who injured themselves two years ago still remembers themselves as someone without ankle arthritis versus someone who maybe was 18, 19, 20 years old. They had a really bad injury. They've carried that disability for a longer period of time. And so they have in many ways reset their expectations naturally over time. And maybe that person is a better fit for an ankle replacement than someone who really remembers themselves as being somebody that had a normal ankle. And now, of course, they will not have that opportunity again. They can have a better ankle, but not a normal one.

[Nick Strasser]

Take the post traumatic. Does the type of fracture matter? Talus versus a pilon versus an ankle fracture. Maybe that was mal reduced or just very common. Does that part matter at all, do you think?

[Jesse Doty]

Yeah, I mean, I think for sure it does. If you look at the range of motion that you can expect after surgery, a lot of that's going to be dependent on the pre op range of motion. And I think that directly ties into the fracture pattern. I was just listening to Constantine talk about his experience with younger patients and post traumatics that have had a normal ankle and then an unforeseen event, never anticipated with trauma, and they end up with a bad ankle on day one. And I was going back when you really put him on the spot and asked him what age, what's too young, and you brought up trauma. And I remember a case in my fellowship with Dr. Coughlin and we had this rock climber who was super active and she ended up with a talus fracture that healed no avnot, and she was probably maybe 28 at the time. And it was just crazy. But she was well educated, great motion, and she asked for an ankle replacement. And he said she really deserves to have what she wants. And so that was that typical example of someone who had a normal functioning ankle and they're not going to really be satisfied with an ankle fusion. And I was trying to think back. I had a similar guy, a lineman who was late 20s, and again, I'm not advocating that. I recommend this for all my young patients, but he was late 20s, he had an ankle dislocation, so no fracture and reduced and ended up with really no cartilage on the Taylor Dome after about a year. And I tried everything to the degree that I ended up essentially trying to micro fracture the Taylor dome. And I did a distraction arthroplasty with a small wire frame and it didn't work. And I went back and this has been probably 10 years ago, Nick. I went and it was, I thought, gosh, I hope I'm not making A bad mistake. But this guy, looking at all the demographic factors, looking at his expectations and his ability to comply post operatively, he said, I've done the research, I really want an ankle replacement, no deformity. And he's done well. He's now 10 years out. And I think to myself, what would I want? And I know you and Constantine treat your patients the same way. There's so many more factors than age and you don't want to make a bad decision and do a surgery on somebody that you regret. But you've got to look at all the circumstances and you really have to go back. The beauty of the medicine that we get to practice is we really get to allow the patients to have autonomy. And so a well informed patient can help you make that decision as a surgeon, as long as you put up guardrails and you set expectations in that same way.

[Pam Luke]

I mean, I guess some patients, when they come with you and depending on how long you have to have for your clinic appointment, I feel like some of these discussions, they sometimes take more than one visit. Like are you guys often bringing them back for discussion even after you tell them everything and you feel like they're well informed, that they are compliant, they're going to do the right thing all the way through. Is this something that you recommend, like especially to the younger members who are definitely getting the training in their fellowships now with all this, like, is this something that you just sign a patient up for right away or is this something that you bring them back and have several discussions and in your clinic 100%?

[Jesse Doty]

I think if you over promise and under deliver and you don't have a relationship with a patient, and your total ankle replacement falls in that 6% of tibial lucency or aseptic loosening and pain, then you really haven't built the trust. Whereas I feel like I have an ethical obligation to try some non surgical things and to get to know the patient. And then in all those patients I brought up, those young patients, they were, some of those people were seen over a one or two year period. And then it came down to clearly this is either a fusion or a replacement. Or live with it, embrace it with an afo, which generally is not conducive with the lifestyle, someone our age. And so I'm a big proponent of multiple visits. I think it depends on the practice you're in. If someone comes to you and they've had three or four opinions, and I'm sure Constantine sees that all the time, then that's a different scenario. If they fly in and they've been seen by someone that he finds reputable and they know they want a replacement. Then I think you look at each case independently.

[Konstantin Demetrikopoulos]

Yeah, Jesse, I think you're absolutely right. Building the relationship is very important and something that we do for all our patients. So let's say I see a 67 year old patient, they've had arthritis for many years, they've known they've had arthritis for many years, they've been cared for by another provider with all the appropriate non surgical treatment and they come to see me for an ankle replacement and we have a thorough discussion and I'll probably spend 20 to 30 minutes with a new patient just counseling, just talking about setting expectations. What can they expect from surgery, the recovery? And I might say to them, okay, well, when you're ready, you let me know and we'll bring you back for your pre surgical visit. We do a pre surgical visit for every patient, includes medical clearance and we'll get your CAT scan at that time. I don't use patient specific instrumentation, but I do a CT on everyone before surgery just to make sure I have the correct size, look for cysts and any other things in terms of alignment. And we'll do that a month before your surgery. Now let's take that very similar patient, but let's make them 47, 37. I'll say, well, you know, we need an MRI. Let's get an MRI first. And they'll say, oh, okay, we need an MRI. Well, yep, yep. And why don't you come back after the mri, let's review those results. Okay. Okay. Now we should get a CAT scan. Why don't you come back for those results? And so you're building those visits in because in many ways that person is just as ready. They have reviewed all their options, they've met with many doctors, but I have to force the issue. I need to get multiple visits in to get to know them, ask them the same question multiple times. What do you expect from this? What are you hoping to do after this replacement? Right. One way to get to the truth is you ask the same question multiple times, try to make sure you get the same answer from the patient. And so I'll build those visits in before then we can commit. And I think if a young person is really struggling with that decision to pull the trigger and do the replacement, that means that they understand in some way what they're getting themselves into. It's impossible for patients to truly understand the consequences of surgery because they frankly have never been through it. It's our job to best explain it to them. But in reality it's still an unknown for them. It's a leap of faith, but if they struggle with a decision, then they're probably understanding of what you're trying to tell them. If they just don't, you tell them everything and it just in one ear, out the other, and they just are ready to go, ready to run through a brick wall, then you really have to pump the brakes and really slow things down because you really want to have some sense that they understand the consequences. Once you take that bone out and you put the replacement in, they have made a turn. Right? We've gone down a path and we can't go backwards. And so you want to feel that they really understand those implications and consequences.

[Nick Strasser]

One thing I'll oftentimes hear patients say is they have end stage arthritis and they'll come in interested in an ankle replacement, but 100% against a fusion. And you kind of have to take a step back a little bit. I don't know how you guys approach that conversation, but if you get to the point of doing an ankle replacement, like you said, you've made a turn in one particular direction, there's no going back. And so their potential is there. If things loosen or heaven for there's an infection or a fracture, you could still end up with an ankle fusion. I don't think patients understand that enough, that this is a life changing decision, hopefully for better, but there can be bad consequences that that happen as well. Does subtail joint arthritis play a role for you at all? I know that's something we've talked about, something we kind of, you know, if they have adjacent joint arthritis, does that factor in your decision making with some of these patients, infusion versus replacement discussion, or is that something that you're like, I just kind of almost say ignore it. But it has less of a factor than we used to think?

[Jesse Doty]

Yeah, it's definitely impactful. I don't think it's the determining factor, but I think we know even from some of Constantine's work, if they're rigid in their subtalar joint with less motion, then that can have impact on the success of the ankle replacement. But the problem, the catch 22 is, well, it also can have an impact on how well they do. If you fuse their ankle, then their subtalar joint is more arthritic. So I know that it's something we all look at and we all think about. For me, it's not the sole determining factor, but it certainly molds and directs the conversation. I have pre surgically, people say, well, what's the worst thing that can happen? And then I usually tell them and they laugh. I usually say, well, you could die, but I haven't had that happen with an ankle replacement. And then we talk about amputation in some studies. But what are the most likely things that we run into that are unexpected, unforeseen or unanticipated? And I think subtalar arthritis, any kind of mechanical axis deformity is going to impact that discussion and give you a little bit of a parameter to follow with your pre op discussion on how optimistic you are and the longevity of the replacement. And so it certainly has an impact.

[Konstantin Demetrikopoulos]

You know, I'll say every patient has some subtalar arthritis to some degree. Those that have significant subtal arthritis tend to have a more stiff ankle. And it's really remarkable just how much the subtalar joint and the ankle work hand in hand, even endorse flexion and plantar flexion. So those that have a lot of subtalarthritis or fairly advanced subtal arthritis will actually be more stiff. And people that are stiff desperately want to hold on to their motion. They're not ready to give it up. Right. They say, well, I only have 5 or 10 degrees, I sure don't want to lose this motion. And those that have a pretty minimally arthritic or something you can't really appreciate on an X ray in terms of their subtalar arthritis, they'll have great ankle motion and they absolutely don't want to give up their motion. So motion, it's like if you have a little bit, you don't want to lose it. And if you have a lot, you don't want to give any of it up. And so the subtalar joint is an interesting thing, but I don't think that is very useful for me. One thing I will say though, because not everybody gets a replacement, right? There are some patients that maybe should or choose to have a fusion and that's certainly fine and a good option as well. I look at foot type and so a neutral foot or a slightly flatter foot, let's say within the normal range. Right. But one that leans towards a more flat foot will have better kind of motion. Right. We know that a flat foot is a more flexible foot, inherently a cavus foot, again within the boundaries of normal. But a higher arched foot is going to be a more rigid foot. And so the higher arched patient I don't think is going to compensate as well after an ankle fusion than a patient who has a more flat foot. And I don't know how. And there may be a study that looks at this. I don't know of one. And if you guys can think of one, it would be great to bring it up or let me know. But I think that is something that I've seen in my practice that I haven't really seen described in our literature.

[Nick Strasser]

Yeah, I'm glad you brought that up because I feel like I've had a number of patients relatively recent and they're a little bit above the threshold of considered young. Like this late 50s male patient, Hodges, has a way of describing them. But that to have this varus ankle, arthritis and a little bit of a cavis foot, and I've seen a couple of them come in and be recommended. No, you need a fusion from elsewhere, from respected people. But I think you're right. I think there's something to it that's going to leave them pretty stiff. And sometimes to get that actually that ankle into neutral to slight valgus, to actually unlock that hind foot, you actually have to like, have to cut the fibula sometimes. Like, it's not a straightforward fusion in those cases.

[Konstantin Demetrikopoulos]

And.

[Nick Strasser]

And I think thinking more about arthroplasty in some of those cases has kind of changed the way I've practiced as

[Pam Luke]

well, kind of off what you guys are saying. So we invited both of you guys thinking that you guys did have a tendency, or I assumed, towards total ankle. So in what Constantine said, if the patient is asking for it, is there any other instance in which you guys would do fusion or push for fusion over a total ankle?

[Jesse Doty]

Yeah, I think for sure. I mean, the hard stops for me, neuropathy and A1C, that's just out of control. And I even I cringe with any diabetics or pre diabetics because even in replacements that have been technically I felt like successful and stable on the table. I've seen the issues with lack of ingrowth and then later consequences a few years down the road. And I would say diabetes and certainly with neuropathy scare me a lot.

[Konstantin Demetrikopoulos]

Yeah, Pam, I have done fusions. Some people think I've never done an ankle fusion, but I have fused patients and young patients. So let's say, for example, I'm thinking of a couple patients in particular. So let's say someone is 27, 28 years old, they had an accident, let's say four or five years ago, and they've had in that span of four years or so, they've had three or four different surgeries. None of the surgeries have worked. They've had pain since the day they fractured their ankle or since their initial injury. They've had surgery after surgery, let's say one surgery per year for the last four years. None of them have worked. They've been in pain this whole time. You get a CAT scan, you get an mri, the bone looks beat up. They've had multiple cortisone injections and they have just not had any success. Okay? That person needs success. That person does not need complications. They've been through a ringer, they're crying in their first visit with you. That person needs an arthrodesis. It's that simple. Just give them something that's reliable, it's going to heal, it's going to last them a long time, and then we'll cross the next bridge when we get there. Right? If they get adjacent joint arthritis, when they get adjacent joint arthritis, if it's symptomatic, a well aligned ankle fusion does very well for a long time. Now, yes. If you malalign the ankle, you put them in a little varus, you put them in a little valgus, you leave the foot crooked, those patients will have problems sooner. But a well aligned ankle fusion will do well for a very long time. Somebody like that that's been through a lot in a short period of time, has had a lot of failure and needs success, is going to not tolerate a complication very well. That person is better off with an ankle fusion. Let's take another example. Let's take somebody in their 30s or 40s, he's the breadwinner of the family, manual laborer, let's say he's an electrician. He works for the sanitation department. He's heavy, he's got deformity. Maybe he just needs an arthrodesis. Right. He just needs something that he can beat up. He can't go easy at work, he can't delegate, he doesn't sit in front of a computer and work on an Excel spreadsheet. So that person maybe does need a fusion and is going to do great. Again, you got to consider alignment and do all the right things, but that person should have a fusion. So I think Jesse brought it up earlier. You have to really treat the patient and the individual, look at their expectations. But in many cases, a fusion is the right option. That's why we have to really get to know our patients and where they're coming from and where they're looking to go.

[Jesse Doty]

Yeah, I think that's A great point. There are a lot of parameters around the foot and the ankle that really are going to steer you towards fusion. And as I listened to that, I recall some patients with even some social contributors at a young age where I like the way you put that, they really needed a win. It's unfortunate, but the society we live in, tremendous amount of mental health, illness and substance abuse issues. And I've had some really big wins and some really happy patients with ankle fusions in younger people where they've done exactly what you said. They've had a litany of operations from trauma, soft tissue issues, and then combined with social issues and an ankle fusion can be a big win in somebody like that.

[Nick Strasser]

What about smoking? That's something we kind of talk a little about. I'm assuming for probably everybody here that you make them quit, undergo a smoking cessation before any of these procedures, or am I misunderstanding that?

[Pam Luke]

Definitely, yeah.

[Jesse Doty]

I beat them up pretty bad about smoking. I threatened nicotine tests. I don't know if I've canceled one. And I've only tested when I really, the bells were going off and the alarms where I knew this is going to be a bad deal if I do a replacement. But I know for a fact I've been lied to multiple times about the smoking issue. And I always go back and I, I say listen, and you got to remember the patients I see and you see a lot of the same patients, Nick, but it's a free country. You can do what you want. But I'm begging you, I'm going to put up some parameters. I need you to elevate this. We're in this together. If you smoke, understand that it's dose dependent. One cigarette or three cigarettes is better than a pack. And even my smokers who quit or tell me they quit, I just, I really encourage them those first few weeks because we know how detrimental a wound problem is. And so they're all on a multivitamin. They all get berated about smoking history and smoking discussion. And it's strict elevation. And I've been fortunate around some of my nicotine users, but I think heavy smokers, for sure, it's a no go.

[Konstantin Demetrikopoulos]

I think it really depends on the combination of comorbidities. So let's say they're a smoker, but otherwise healthy, that's one thing, right? If they're a smoker and they're obese and they're diabetic, and now all of a sudden we have three different independent risk factors, maybe a less invasive or minimally invasive Arthrodesis might be better. Whereas if they're a smoker as an isolated risk factor, that's something more tolerable. I'm very fortunate in my practice that we have very few smokers in New York, so I'm probably not the right person. I do tell them, just like Jesse said, right? If you can cut it in half, cut it in half. If you can smoke one less cigarette per day, then do that. If you can quit, that would be ideal. And so I dictate and I do all the counseling. I don't test them because I tell them it's your ankle, not mine. And if this goes south, you're going to know that what you did contributed to it, and you are okay to live with it. It's your decision. I'm very forward, straightforward forward with them on that. And I've had patients quit, and I've had patients not quit. I've had patients quit and not start up again. And I've had people just say, thanks, but I'm not going to stop. But again, it's a very low number of patients, I must admit. It's. I could probably think of all of them right here. I could write down their names. There's not many along those lines.

[Nick Strasser]

What about vaping? What are we doing with that? That's maybe more of a. Because I have a tough time telling. Unless they're actively tell you or they're vaping in the room, which sometimes they do. But you think that changes things for

[Konstantin Demetrikopoulos]

you, you have to ask, because a lot of people won't. Depends on how you ask the question. And they might not tell you. And if you don't ask correctly, they may not really be lying to you or hiding something. It just might not have come up. But in truth, vaping, the nicotine concentration is much higher, right? So you don't have the toxins of cigarettes, but the nicotine is much higher. And so it falls under the same. At least I treat it similarly. I don't treat it differently. Jesse, I don't know if.

[Jesse Doty]

Yeah, no, the same. And I usually. I just ask them when I'm signing someone up for an ankle replacement. They probably get sick of hearing it because I ask them every visit about smoking and diet, and I usually just say, do you use nicotine? And some of them dip, say, all right, less is better. A lot of people vape. And I ask them, okay, can you vape without nicotine? The chemicals aren't good for you. And I explained to them, hey, every time you take a break, puff the nicotine constricts your blood flow, and then they think about it and they're like, oh, I get it. My foot's further from my heart. But here's the interesting thing. To Constantine's point, most people who vape are younger and healthier, at least at this stage of the game. So they don't have a lot of comorbidities. And I also know they're going to go home and be really bored for two weeks. I'm like, look, I know you're going to be bored. I know you're going to go insane. Don't kill anybody. Anybody. Please decrease your nicotine dose. But I'll tell you what, Nick, the worst issues I've seen have been subsequent surgery or where I've had to do wound care, and I can finally get the wound to heal when they'll stop vaping or stop their nicotine. But I've seen the same thing with soft drinks, and it's been unbelievable. And I've become a real believer in these dietary influences, where I've had two or three patients who can't heal their wounds until they stop drinking three Mountain Dews a day.

[Nick Strasser]

Well, Tennessee is where Mountain Dew was started, so that tracks, right?

[Jesse Doty]

I think it's probably the first drink I had after birth. I probably. I remember. I don't know if big lots started in Tennessee as well, but I remember standing outside of a big lots in Rogersville, have a Mountain Dew and Little Debbie. You're lucky I'm not a smoker.

[Nick Strasser]

Man, oh, man. We got Jack Daniels and Mountain Dew. What else could you need? What about, like, incisions, prior incisions? And how are you managing those? I know a lot of these, like, post traumatics, young patients, but I think post traumatic, and they have a lot of skin incisions. How are you navigating that? Because I've seen some really fairly catastrophic problem for some of these anterior incisions when they've had multiple incisions and approaches. And like you said, Constantine, multiple surgeries. Any tricks or tips you guys have for managing that successfully?

[Konstantin Demetrikopoulos]

Well, I'll say that probably the one physical exam maneuver that I do on every single patient without a fail is check their pulses. I mean, I might skip some things, but I'll never skip checking their pulses. I think it's very important, obviously, but especially when you see poor wound healing. So let's say they've had a previous incision. This could be with a Pilon, or let's say in the context of a revision replacement, where you see a terrible looking scar, I'll say to them, okay, well did you have trouble healing that? And they'll say, oh yeah. So then my next question is, well, did you save any photos? Because everyone takes photos of their incision. So then a lot of times they'll have them ready or I'll tell them, all right, when you come back next time save them in a folder and we'll look at all the photos of your incision. Those patients, I might even if I do feel a pulse, I might indicate them for an Mr. Angiogram or a CT angiogram or something just to make sure that they've got a good blood flow. But separate from that, if it's just simply that they have a lot of incisions, I'll try to incorporate an older incision. That's the one time I'll use sort of the approach that Tim Daniels popularized a few years ago, sort of a curvilinear anterior approach as if they have a previous antromedial incision, then I'll utilize that approach. Now, if the incision is a little bit too medial or a bit too lateral, and let's say it's been some time since that incision, I might have a little bit more confidence to make a standard anterior approach and be a bit closer than I would normally like. But I think it is tricky in cases where let's say they have really poor wound healing, they've had a previous skin graft, God forbid they'd had a flap, their Mr. Angiogram or CT. I've done a total ankle in somebody with a one vessel ankle and it was the anterior tibial artery. So it's like it's all right there. I'll have them see plastics before surgery because it's easier to have that discussion beforehand and God forbid they need it afterwards, it doesn't come as much of a surprise. So it is important if you are worried to have vascular and plastics on board before the surgery.

[Jesse Doty]

Yeah, I agree with all those things and specifically one thing I've done over the course of my career. I used to try to be heroic and do everything in one operation. And someone I'm concerned about wound healing who has a front back pilon approach and a fibular plate and they're just look like the terminator from the knee down and I'm concerned about their soft tissue. There's no shame in staging that patient, taking out their hardware, bone grafting cysts, taking cultures if you need to. But I always explain it to them as look this is a soft tissue challenge. You're going to swell tremendously by the time I get all this metal out of your ankle. I'll tell you. It accomplishes two things. It gives you confidence as far as their skin healing. It also allows you to do their total ankle quicker and have less of an inflammatory response. And so I feel like you can control their swelling at the final implantation stage and get in and out quicker. And I've just had much better success with that.

[Nick Strasser]

You kind of test it, too. It's a bit of a test. I've had a couple times where I've done that, and I thought, I'm really glad I took out the hardware first, because they could barely heal that percutaneous incision.

[Jesse Doty]

And a lot of times, if you're taking out broken hardware and then you're making other unforeseen incisions at that index operation to get broken screws that are going to be in the way for your stem. I agree with you. I don't think I've ever regretted staging that. You brought up that 10 Daniel study. So I used to go straight anterior on everything until probably four or five years ago. And now I do the medial apex kind of over towards the medial male. And I feel like that's been a game changer for me, especially in the ankles I'm concerned about. And so your skin incision can be more medial and then peel that flat back and then I'll make my extensor retinaculum approach through that deeper tissue at a different interval so they're not in line with each other. And I feel like that's helped me a lot. And so if they end up with a little skin incision, there's still good fascia there. Periosteum.

[Pam Luke]

That concludes the discussion portion of our episode on arthritis in the young Fusion versus replacement. Join us next episode as we dive into case studies with Drs.

[Nick Strasser]

Strasser, Luke, Dimitri, Copulous, and Dodie.

[Konstantin Demetrikopoulos]

Thank you for listening to the AOFAS Ortho podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.