Podcast Summary

Podcast: The AOFAS Orthopod-Cast
Episode: Total Ankle Revision MasterClass Part 2
Date: September 17, 2025
Host: AOFAS Podcast Committee (Nick Strasser & Pam Luke)
Guests: Dr. Carl Schweitzer (Duke University), Dr. Greg Alvine (Sioux Falls, South Dakota)

Overview

This episode represents the conclusion of a comprehensive masterclass on revision total ankle arthroplasty. Leading foot and ankle surgeons—Dr. Carl Schweitzer and Dr. Greg Alvine—share their firsthand experiences, discuss techniques for managing complex failed ankle replacements, debate optimal approaches for bone deficits and fusion, and reflect on how handling revisions has reshaped their strategies for primary ankle arthroplasty. The episode also delves into approaches for osteolysis, infection prophylaxis around dental work, and challenging deformity corrections, culminating in practical lessons for contemporary practice.

Key Discussion Points & Insights

1. Management of Failed Talus and Posterior Subsidence

[00:39–03:51]

• Challenge: Determining when to attempt revision or switch to fusion in cases of talar collapse, particularly posteriorly into the calcaneus.
• Approaches:
  • Dr. Schweitzer often puts in a spacer to assess bone loss before deciding on further management. “Sometimes you have to do that… you don’t know how much bone you have left until you’re in there.” (Schweitzer, 01:07)
  • Posterior talar subsidence is a recurring trouble spot; augmentation and even sitting the talar component directly on the calcaneus have been attempted in catastrophic cases.
  • Dr. Alvine tends to fuse in severe collapse cases: “Those patients with the talus that’s basically [collapsed] down in the calcaneus, I typically fuse them.” (Alvine, 03:06)
  • Surgical choices are highly individualized, guided by prior experience and judgment.

2. Options for Bone Loss: Femoral Head Allograft vs. Custom Cages

[03:51–07:15]

• Contrasts between using femoral head allografts (often done in resource-limited or community settings) and metal 3D-printed cages (more common in tertiary centers).
  • Schweitzer finds higher fusion rates with cages plus hindfoot nails, feeling they structurally “hold up longer.”
  • Alvine notes graft availability sometimes determines the technique; he has seen variable success with femoral head techniques and wonders if cages, factoring in all the extra biologics, might actually be more cost-effective in the long run.
  • “I think, anecdotally, my fusion rate has been much more desirable with the cage with a nitinol hindfoot nail compared to how I used to do a static nail with [femoral] head.” (Schweitzer, 04:20)

3. Technology, Resource Constraints, and the Future

[05:08–07:15]

• Community surgeons often face difficulty accessing custom implants, and there’s an ongoing debate about whether “centers of excellence” for such complex cases are the future.
• Schweitzer sees a role for both off-the-shelf and custom implants, as “they’re already becoming more commercially available in a non-custom format... that’s going to drive the cost down.” (07:07)

4. Management of Asymptomatic Osteolysis and Cystic Lesions

[07:15–11:50]

• Scenario: Asymptomatic lytic lesions or cysts seen in routine follow-up.
• Both experts generally monitor these with serial imaging (CT or X-ray), intervening surgically only if there are symptoms or impending failure.
• Alvine uses “proximal tibia autograft with some type of bone graft extender” for at-risk cases to slow progression.
• “So many of them, for some reason, get some osteolysis and then they just kind of stop for a while.” (Alvine, 09:14)
• Certain locations (e.g., medial malleolus) or severe cysts on the talar side make them more likely to intervene earlier.

5. Etiology and Surgical Access for Cyst Management

[11:15–11:50]

• Discussing the challenge of understanding why some patients are “cyst formers.”
• Most aggressive surgical intervention is driven by pain or clear radiographic evidence of impending failure.

6. Infection Prophylaxis for Dental Procedures

[11:50–15:21]

• No consensus exists between major associations regarding lifelong antibiotics around dental work.
• Both Schweitzer and Alvine adopt a cautious approach, recommending amoxicillin for any dental procedures “for life”—“I give him a handout and I say, this is how it is. It's different than the hip and the knee... one pill once or twice a year—the risk… is outweighed by the complication.” (Schweitzer, 12:46)
• Some dentists resist; ultimately, the surgeon deals with the consequences of infection, so patient and office policy reflect maximum caution.

7. Impact of Revision Experience on Primary Ankle Arthroplasty

[15:39–19:17]

• Revision possibilities have made Alvine and Schweitzer more comfortable offering ankle replacements over fusions.
  • Alvine: “I do feel that I can revise it down the road… I don't like to fuse a failed ankle if I can help it. I prefer to revise it.” (16:05)
• Focus during primaries is to optimize alignment and stability, with a low threshold for additional soft tissue procedures (e.g., lateral ligament reconstruction).
• Advances in revision options decrease the threshold for offering primary replacements, except in very high-demand or noncompliant patients.

8. Complex Deformities (Varus/Valgus) in Primary and Revision Cases

[18:35–24:03]

• Varus ankle deformities: Less concerning due to effective surgical strategies; multiple soft tissue and bony interventions can achieve reliable correction.
• Valgus ankle deformities: More problematic; often staged with hindfoot realignment and soft tissue reconstruction before considering ankle replacement.
  • Use of cement spacers and allograft deltoid reconstructions to maintain alignment in staging.
  • “I've done six or seven staged for valgus… doing a hind foot realignment arthrodesis with a cement ankle arthroplasty in an allograft deltoid ligament reconstruction, and then come back in and done a pretty neutral total ankle replacement.” (Schweitzer, 19:17)
• Willingness to stage and occasionally “overcorrect” valgus to protect against relapse is a key takeaway.

9. Staging and Correction in Complex Surgical Scenarios

[21:48–23:22]

• Management of failed triplanar fusions or under-corrected deformities will often require a staged approach, sometimes with aggressive bony realignment.
• Key is to “get the foundation right”; otherwise, outcomes suffer.

Notable Quotes & Memorable Moments

• “Sometimes you have to do that [use a spacer]: you don’t know how much bone you have left until you’re in there.”
  — Dr. Carl Schweitzer [01:07]

• “Those patients with the talus that's basically [collapsed] down in the calcaneus, I typically fuse them... I'd much rather revise an ankle now than fuse it.”
  — Dr. Greg Alvine [03:06]

• “I think, anecdotally, my fusion rate has been much more desirable with the cage with a nitinol hindfoot nail.”
  — Dr. Carl Schweitzer [04:20]

• "We finally just say we’re going to do [prophylactic antibiotics] forever until someone else figures it out."
  — Dr. Greg Alvine [13:46]

• “With the ability to revise the ankle… has made me more comfortable replacing ankles and offering less fusions.”
  — Dr. Greg Alvine [16:05]

• “I would say in the last two or three years… I've done six or seven staged for valgus… and then come back in and done a pretty neutral total ankle replacement…”
  — Dr. Carl Schweitzer [19:17]

• “It’s amazing what one or two bad outcomes can do to your psyche.”
  — Dr. Carl Schweitzer [20:42]

Practical Pearls

• Assessment in the Operating Room: Sometimes intraoperative judgment is required, especially for unknown talar bone loss.
• Fusion vs. Revision: Decision depends on extent of bone loss/collapse, available implants, and patient factors.
• Biologics and Bone Grafting: Use liberal augmentations in high-risk fusions; consider evolving options like cages.
• Follow-Up Regimens: Serial imaging for asymptomatic cysts, with surgery saved for symptomatic or high-risk lesions.
• Primary Replacement Technique Evolution: Careful, patient-specific workups; willingness to do more complex soft tissue procedures; increasingly staged approaches for deformity.
• Staging in Valgus/Deformity Cases: Proactive staging with realignment/fixation, followed by replacement, offers better results—and prevents difficult-to-salvage failures.

Episode Flow & Segment Timestamps

| Topic/Content | Timestamps | |-------------------------------------------------------------------------------------------------------------------------------------------------|---------------| | Introduction and opening | 00:01–00:39 | | Failed talus and decision-making for revision versus fusion | 00:39–03:51 | | Bone grafting (femoral head allograft, cages), surgeon experience, and technique preference | 03:51–07:15 | | Accessibility of custom implants, centers of excellence, resource constraints | 05:08–07:15 | | Approach to asymptomatic osteolysis, cysts, and bone grafting | 07:15–11:50 | | Infection prophylaxis (dental procedures, office protocols) | 11:50–15:21 | | How revision experience shapes approach to primary ankle arthroplasty | 15:39–19:17 | | Complex deformities (varus/valgus): primary and revision strategies, experience with staging | 18:35–24:03 | | Closing reflections, episode wrap-up | 24:03–end |

Closing Thoughts

This episode offers a thorough, candid window into the real-world dilemmas of revision total ankle arthroplasty. The blend of nuanced surgical judgment, adaptation to resource availability, and willingness to update protocols as new data and technology emerge makes this discussion invaluable for any surgeon facing complex failures or looking to optimize primary ankle replacements in a modern practice.