Total Ankle Revision MasterClass Part 2

Summary

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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)

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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.

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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.

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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)

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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)

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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.

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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.

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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.

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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.

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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.

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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.

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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]

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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.

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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 |

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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.

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Transcript

[A]

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. Welcome back to the conclusion of our.

[B]

Masterclass in Revision Total Ankle Arthroplasty with.

[A]

Hosts Nick Strasser and Pam Luke and.

[C]

Guests Carl Schweitzer and Greg Alvine. Let's return to the conversation what about.

[B]

The failed talus that you were mentioning earlier where it kind of falls out the back and. Or do you start to lose that kind of posterior portion of the talus is falling down to the calcaneus and anteriorly you look at that and you think okay, I could probably get a talus in there, especially like the envision tray for example, that you run out. But then doing the subtailar joint finding enough fixation. How do you decide when I can revise that or when you need to do a fusion or a total tailless.

[D]

Some of these you may not know depending on the tailless that they have in like the star is hard to know. They get a lot of stress shielding under the tailless and you just can't see it well on a ct. I've taken people to the OR before just to explant them, put a spacer in and just to say, well we're going to figure out how much bone you have left after this, then we're going to make a decision. I've done that before because it's hard to have customs and stuff made in and then not use them. So sometimes you have to do that. But yeah, in terms of where we need to go with the tailless, it's posterior augmentation. I think that's the trouble spot and that's where we get into total tailless or staged hindfoot fusions to Taylor revisions. I've done all of that and have successes on both sides and have had failures. I can think of a lady that I did a second time revision for her Taylor failure who already had a subtler fusion and a failed star and I got her like eight years and then her tailless collapsed, Taylor mode collapsed all the way down to her calcaneus. Like devastating. I've seen that before and I put Taylor components on calcaneus before but this was incredible. It's tough. We don't. I think that's where probably experience comes into play and what you feel like you've had success with. I've used cement to fill Voids and put screws in for rebar. I've tried a lot of different things.

[A]

Yeah. That posture. Taylor subsidence. Kind of like Carl gone to more of a envisioned fixation on the Taylor neck was cement posteriorly. If they really collapse down into the calcaneus or split the tailless like the agility sometimes actually split the tailless. I have just gone to fusion. I live in South Dakota. Sioux who follows? You don't have the Duke name behind you. I think it's. Sometimes you got to be a little more careful that. Not that you're not careful. Carl.

[D]

Questionable.

[A]

I've got to be careful that down the street from us is Mayo Clinic. And I need to do something. I believe in my hands is going to last. And so those patients with the talus that's basically wrote down in the calcaneus. I typically fuse them. Not the femoral head outgraphs. Don't get me wrong. I'd rather revise them. I think that's more of a challenging patient than a revision. I'd much rather revise an ankle now than fuse it because the non union rates of that and I haven't used the cages. I've not done a tool tailless. It'd be interesting Carl's approach to that. So I've not done the told tale aside. That's where I tend to fuse them. Is that particular patient oftentimes your lateral approach use a fibular buttress. And then okay with that. But still not ideal.

[B]

It's not ideal. But if you. And those are ones I don't know. I think I learned this actually from you through. Through our mutual friend and your partner Greg. But is throwing the biologic kitchen sink at it. It's all hands on deck for some of those big TTC fusions with the femoral head allograft. Are you guys doing that at all? Carl at Duke. I know you guys are big into the 3D printing. Is there. Is that everybody there that's kind of done that that adopted that or are you guys still doing some bulk allograph for failed total ankles?

[D]

Yeah, I think that for me for a failed total ankle. That or failed revision or something. I can't revise or just needs to go to a fusion. I'll typically use a cage customer off the shelf. I guess now you could say some of them in my hands they typically require more of a pill shape. So like the off the shelf ones are mostly spherical. I think structurally they hold up a little bit better. I think I've done plenty of femoral heads. I get nervous when I have to stack two of them in there. So I feel like a metal truss cage, I feel like holds up longer. Anecdotally, I would say my fusion rate is, has been much more desirable with the cage with a night null hindfoot nail compared to how I used to do a static nail with ephemeral head. I think that I've done better there.

[B]

What do you think? Like for maybe for community surgeon that where you don't have all those resources and not that because I've run into this myself, like where it's hard to get some of those custom implants or to get them approved, it ends up being a little bit costly. Sometimes people can't travel or whatever. Like, how do we approach that? What do you guys think is the future? Is this something where we need. What did you call it, Pamela? The Excellence Society European.

[C]

The Centers of Excellence.

[B]

Yeah, centers of excellence. Kind of like you guys did in Sioux Falls with the Alpine foot and ankle center back in the 2000s. But is it, is that where we're going with it? Or you think there's still a role for not using some of these 3D custom options?

[D]

I think a lot of it just comes down to good technique, honestly. I do think the femoral heads can collapse further out. But, and I think anecdotally I think my fusion rate's been better with a cage with more biologics. But no, I think ephemeral head for a tdc, for a patient with a failed revision to ankle, you're going to probably make them pretty happy.

[A]

Yeah. Yeah. It seems like the, it's always the calcanel side that doesn't fuse on those. And I've struggled with that femoral head. I've tried the technique with femoral head using a reamer. I actually think that reamer technique may work better. I think the fusion rate might be better. I don't know why it would be. And also if I do a fibular onlay graph laterally and again add in a lot of biologics, BMP off label obviously, but you wonder if that cost of all that is the cage might be more cost effective. So we need to. I think that's one area that we need to start using more, at least researching locally is the cages. I again, I'm not a proponent of the femoral allograft. It's that it's kind of what I have available and I made it work. But I've had my failures. I trust me, I've had them fail.

[D]

I think to your question, Nick, though, I think they're already becoming more commercially available in a non custom format. So I think, I think that's going to drive the cost down too.

[B]

Yeah, I think that's perhaps, maybe that's the point is to be looking for that kind of around the, in the future, hopefully the next couple of years. What about asymptomatic lysis or cystic lesions that you see around some of these implants? They come in and they come for a routine one year, two year follow up. Hopefully it's longer than that maybe. But they show up and they're like, I'm doing well, it's been hanging in there. I can do everything I want to do. I'm very happy. And I don't know how often you guys are following these or how far out you're following your totals, but the ones that you start to see, these cysts, some assuming lysis, I guess, how are you managing those? Do you follow them just more closely or is it something where you're pretty aggressive with bone grafting for those cases and plus or minus poly exchange?

[D]

I'm not super aggressive surgically with them unless they really become symptomatic or I feel like it's creating an impending failure. The cysts are so bad on the Taylor side that we'd be better to act sooner for the sake of bone stock than later. I think bone grafting has its role. If I'm not going to operate on them and I watch a lot of them, I just follow them serially with CT scans every six to 12 months or I tell them if they really start to get symptoms and to be honest with it, then they need to call or come in.

[A]

Yeah, I'm similar. I tend to follow my ankles every two years. Not that everybody comes in every two years. And when they develop this osteolysis, whether it be the Taylor tibial side ictm, I then try to decide anecdotally whether or not I need a bone graft or not. If it looks like it's going to be an impending failure or I'm worried about it, then I will use a bone graft. And I typically use proximal tibia autograph with some type of bone graft extender. Whether that's right or wrong, that's what I've used. And if I'm just going to follow them, then I'll either X ray them in a year, six months, if I'm too concerned, follow up CT scans and make sure they're not changing so many of them for some reason get some osteolysis and then they just kind of stop for a while. They just don't change. I don't know why that is. The other ones I've seen on the agility side where they have just ballooning osteolysis involving the whole distal tibia and one step off a curve and that thing's crushing in and you try to prevent that from crushing in because then you got a big problem. It's also interesting that when you bone graft them, it does seem to set it back or slow it down. And so I don't bone graft all of them. I watch most of them. But I'm. If I'm concerned at all, I don't hesitate to bone graft them with the hopes I can slow the process down.

[B]

Are there any spots anatomically that you're more aggressive with intervening surgically? For example, like if you see a big one on the medial malleolus, that might be one where I'm like, ah, that might be. Especially if they don't have fixation in that case, like you were talking about, Carl, that I might be thinking about stepping in earlier. Is anything like that or. And certainly like the talus is hard to access sometimes you think you're going to see it, you're going to open it up, make a little cortical window and be able to see where you need to go. And sometimes you're like, I don't know, I think I got it in the right spot. But it's a little bit hard to tell. It's hard to image. Like how do you make that decision?

[D]

I think judgment on impending fracture or failure of the subsidence of the implant. I think yeah, the medial sided ones for sure. I think the big question we don't know the answer to is why do people form cysts? Right. Some people are thought just to be cyst formers. Depending on the pre op diagnosis, rheumatoids or post traumatic, it could be from like old poly and osteolysis or instability to the joint causing edge loading. I feel like I've seen a fair amount of that with the mobile bearing star. So pain is my biggest driver for a reoperation. And yeah, it's not a, it's not a huge undertaking for the patient if you can do that for them. And as Greg said, if you get like a post op CT at six months after you've done that, I sometimes surprise myself that that actually consolidated and healed and it's, it can be pretty impressive. And You've saved them a major reoperation or series of reoperations for revision. There's literature out there that says bone grafting works in the right setting.

[A]

I think osteolysis is something we have to learn a lot about. Is it Ranko mediate? Is it host mediate? Is it surgical? Is it lucency? Loosen the prosthesis. The medial is interesting because I found that sometimes very difficult to bone graft. It just kind of falls back in the joint. Not sure how to bone graft that very well. Yeah, but some people, I saw a patient there, they was 20 years out from the agility, not one minuscule evidence of osteolysis. And then some guy at three years out may have severe osteolysis. So it is a interesting phenomenon.

[C]

I'm curious as to one thing that Carl just brought up just to poll you guys, because regarding the giving prophylactic antibiotics for dental procedures, the American Dental association along with the aos, there's no recommendations that they agree on and that it's like surgeon discretion. But to Carl's point in his patient, I would imagine for like from one of mine, that would be like the worst nightmare to. Even though it's such a small percentage of patients that it happens to. But if you're that one, you're basically screwed. So curious as to Greg and Carl, what you're. You guys do for patients for dental procedures.

[D]

I look in their mouths. No, I do ask them about. You ask them about their teeth. Like, I seriously ask them, do you have anything that needs done in your mouth or do you have any dental pain? Because they. You'd be surprised the answers you get. Like, people be like, oh, yeah, yeah, yeah, I'm gonna get this abscess dealt with.

[C]

I'm surprised you want to open that box there.

[D]

Well, I'd rather know again. I'd rather know ahead of time. So, yeah, I mean, I start with that. I asked them about. Some people don't have teeth, but it's not a problem in North Carolina. But I start with that. And then I make sure that they get all their dental cleaning out of the way before their total ankle. And I tell them for. This is just anecdotal. I just tell them for 6 months, no non emergent dental work. 6 months after total ankle. And I tell them for life. Amoxyl for life. And I give him a handout and I say, this is how it is. It's different than the hip and the knee. If you have to go back in that incision more times, it's just, it's not good for you. And so I think one pill once or twice a year, the risks of that or developing antibiotic resistance or whatever, I think is outweighed by the complication of a chronically septic or hematologist strep infection, where you might have to consider explaining or even poly exchange, depending on the situation or the bug.

[A]

And we just made it kind of an office policy. We debated it long enough. We finally just say we're going to do it forever until someone else figures it out. So we have do prophylastics forever. Dental work, dental cleaning, any dental work.

[D]

And most of our dentists will do it. Otherwise I feel like we'd be writing amoxil prescriptions all the time for these people. But most of them are fine with it. Yeah, there are some that you can tell are pissed that we're saying this, but, you know, I'm the one that has to deal with it if they have a problem, not them.

[A]

Yeah, it's funny you say that because just this week I had a patient tell me my dentist thinks this is stupid. I do not need antibiotics. I said, here's your script.

[C]

Yeah, I think in California, or at least in Los Angeles, I've had dentists not want to write the prescription. And they'll be like, if you want to be on it, have your surgeon write it. And I'm so. That's nice that, Carl, that in your area that they've been willing to write the prescriptions. But I completely agree and I like just hearing it from other surgeons as well. I'm kind of surprised on the stance. I understand where the associations have to stand in terms of overall patient benefit. And I don't know how many patients they'd have to show that it's worth it for those risks that you guys talked about. But yeah, for that one person, you just, you change their world completely.

[D]

I just patient today in clinic, the whole dental sple pre op before his total ankle next month. And his wife interrupts me and goes, what? She goes, I had this total hip done and I've never even heard about that.

[A]

Carl makes a good point. We're the ones that have to deal with the infection. The dentist doesn't. I have no problem just following that protocol for now. Maybe literature will change and say that's not necessary, but for now that's what we do.

[B]

And it's nice that you have a unified front that you kind of all agreed upon it.

[A]

Yeah.

[B]

Carl, is everybody kind of on the same front at your institution?

[D]

I Honestly don't know. I don't know. I know they will have an opinion on it. I don't know what they're.

[B]

Sometimes that's better.

[A]

Yeah.

[B]

Well, I think we're getting kind of to the end of our time here. I am curious though, how both of you have managed complex revision cases and dealt with like follow ups. But how has that shaped how you approach primaries? Is it the conversation? Is it how aggressive you are? Like, can you talk to me about what? What Maybe lessons you've learned in dealing with revisions that you now apply towards your primaries?

[A]

I think maybe I hit on earlier. I think with the ability to revise the ankle, not have to go to a fusion, has made me more comfortable replacing ankles and offering less fusions because 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 that wasn't available 20 years ago, 25 years ago. So that's changed how I look at it. I still offer Fusions to, like I said, the heavy farmer. That's not going to listen to me. I think it's just better to fuse it and then not worry about it. They still do pretty well with the fusion. They come with a subterranean joint pain. I'm still not sure what to do with that because I can't get that to fuse. That's the biggest trouble I have. But the ankle replacement, I feel pretty good about having the revision option. Basically.

[D]

I would echo that. The question about how do I approach my primaries? I'm super particular, like with stability, like interop assessing it. I have a very low threshold to do a lateral ligament reconstruction. I feel like that's something I can do relatively well and quickly in that setting. I just don't feel like there's any room to accept something that you're like, I wouldn't want mine to tilt like that. Or I know we all have different thresholds and there's not much written about what's unstable in a total ankle. What'll heal in scar in four weeks in a cast. If I'm in there and I feel like it's gapping, I'm going to do something about it. So I've just got in more particular on the workups. Like it's very regimented, like weight bearing CT scan. I look at that if I'm doing psi. We didn't talk a lot about that tonight. But like I really look at the scan and feel like, all right, like I did one or looked at one last week, and I was like flipped it from a minimal resection to a stem because I just wasn't comfortable with their distal tibial bone stock. And they were 44. You're like, what do you do? Well, in that case, I want to lead with my best foot. Like, I don't want to do something because they're 44 and I think I could get away with it. That never feels right. And if it means I have to do something that a lot of us use as a revision, I don't like to use trade names, but like, I've done envision tailors as a primary before because I felt that was the best bone and that was the best choice for the patient. I don't like that concept. I feel like there's two or three tailor options before that, but that's what I felt was their best shot. So I think on these that we start thinking more about how can you do your best job on the primary. I think eventually we won't, hopefully won't be having to talk as much about revisions, but I think we will.

[B]

Yeah.

[A]

Also, the deformity is a whole different discussion, but the varus ankle, I don't worry so much about the deep delta release, calc osteotomy first metatarsal osteotomy, gastroc release, brostrom repair. You can do all that and realign that pretty safely and reliably. The valgus ankle can be a different challenge, whether they have flat foot, rigid, flexible, how bad it's tilted, how much erosion if it's eroded laterally. That's a whole different discussion in which valgus ankle is really an easy or a primary ankle and which one's not. So I think that valgus ankle is probably the one thing that I still think hard about when I'm approaching a primary ankle.

[D]

I agree, and I would say I don't have as much experience as you, Greg, with total ankle. But like I would say in the last two or three years, if you pulled the fellows what my primaries have looked like, I would say before, like six years ago, I had never really staged a primary before. Well, in the last two years, I've done six or seven staged for Valgus, really bad valgus deltoid out. And I've staged primary 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. And I had never really thought about doing that and I look back at some of my cases, I did my first secret practice and I. I feel like I. I was a cowboy in some ways. And I feel like I've honed it in and been like, I'm not afraid to tell a patient I can do this. In my hands, you may see someone else that says they can do this safely in one procedure. But in my hands, where I'm at right now, having more experience in some patients, I will tell them I can do this better in two stages than one.

[A]

Yeah, I'm the same way with the valgus ankle, but the stays valgus, but the cement delta reconstruction, so forth, and then get the foot realigned, whatever you need to do, then come back to an anchor place. I'm the same way. That's changed a lot how I approach that ankle, that valgus ankle, staging it, it's amazing.

[D]

Like one or two patients I've had where I thought I could get away with it, and I did it in one stage and it collapsed back into valgus, even though I thought on the table it was perfectly stable and the foot was perfectly neutral. It's amazing what one or two bad outcomes can do to your psyche.

[A]

That's. That. That's really hard to fix at that point afterwards.

[D]

Totally. Yeah.

[A]

Really hard. Really challenging.

[B]

Yeah.

[A]

Oftentimes you're wearing a brace forever.

[B]

So I just in follow up to that question because I've seen that occasionally, sometimes my own, but seen it with other outside referrals. And where you get that valgus sometimes that previous triple. You've seen that previous triple that comes in that's a little bit undercorrected, and now they're falling into valgus at the ankle. Because I consider that a little bit like a revision case. Right. The deltoid's incompetent, the foot's still not fully corrected. But to get the foot corrected, are you taking down the triple completely? Are you just adding like an MDCO and then going after the soft tissues with the spacer? Like, how do you manage that case?

[D]

It depends on where the mal union is. But I would say my most common way to tackle that is. Is a staged revision. Well, I guess, yeah, I'll call it a revision, but they don't have an ankle in. But yeah, I think the, like the biplaner, transverse tarsal, whatever you want to call closing wedge derotational osteotomy is super easy to do from the top of the foot. And you can slide the heel, I've re cut through the subtailer joint at Times I hesitate to do that, but some cases, I feel like it's so bad. And you'd still have to do that even if you're converting them to a pan tailor. Right. You can't, like, ignore that. So that stuff needs dealt with either way. And then, yeah, if I feel like their deltoid really needs the attention, then I'll do what I think is the right thing and do the allograft in a cement spacer to hold it neutral. And it's painful. It's a year.

[A]

It's.

[D]

It's a minimum of four months to get to the second surgery, and then it's another. It's a lot for the patient. But I think if you tell them ahead of time, there's no surprises.

[A]

Yeah, really getting that medial column plantar flex so they almost want to tilt in the varus when they stand, I think helps protect it a bit.

[D]

I think sometimes the mistake. And I've fallen into it myself, where you're like, oh, I could just get away with the dorsiflexion osteotomy. I could just get away with a cotton here. If they've had a triple and it's maligned, I feel like you got to go all in on the hind foot and get the hind foot, get the foundation right. And that's a lot of surgery to do with the total ankle, and that's a lot of work around the tailless, and I think that's. You're flirting with blood supply issues there.

[A]

Yeah, definitely stage it, too.

[D]

Yeah, yeah.

[B]

This staging, I think, is really, I think, the important point. And sometimes on those, I'm hesitant to even go down that path because I feel like if I go, they come in and I'm thinking, well, I could do maybe a TTC fusion right from the get go versus doing a triple and then coming back and doing a total. You have to get the triple right.

[D]

Right.

[B]

You made this point before, Carl, that you got to get. You got to get it right. And sometimes. And, Greg, you said this. You almost have to. I don't say overcorrect, but you have to almost shoot to overcorrect a little bit because you leave them under corrected at all, the ankles is going to fall apart, and I've been burned by that for sure. Any other questions, Pam?

[C]

No. This has been fabulous, and I think our listeners will enjoy it as well. Thank you, Greg and Carl, for your time and all your helpful insights.

[B]

Yeah, thanks so much for spending some time with us and leaving us with all your pearls. It's been awesome.

[D]

Thanks for inviting us. And I learned a lot. And Greg, I learned a ton from you.

[A]

Yeah, well, I appreciate your. Like I said, your revision experience, I'm sure, is more than mine. I've just been salvaging agilities for my last 20 years.

[D]

Now I know who I can call for the advice on the agility. The ones I've seen have fallen out. So.

[B]

Got a guy. All right, thanks so much for joining us.

[A]

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