Okay, he has a little lead in, okay. So this is a fellow who's in his early 30s. He has ankle pain, it's chronic, it's medial, sensation of instability, but no clinical laxity whatsoever. He's had injuries in the past but can't really specify, and you can see here, and I'll preface this early part by saying I'm not throwing any curveballs right here, you can see he's got a defect in his medial talar dome, and there's an MRI scan. So Rick, as you look at this, let's assume that I haven't thrown you a curveball, that this is the problem he has. What things about that, what characteristics of that lesion as you see it make it suitable for either a more of a traditional approach, let's say, versus a more aggressive approach to treatment surgically? Well, again, the first issue is the size. It doesn't look to be too big. I mean, I don't have the size, but I suspect it's probably size-wise a centimeter squared or a little less, and I think that way would be good. You look at the location, which is probably an uncontained lesion, which makes you a little concerned, and it's probably central. So for size, we're good. I think for size, you're good. On your Venn diagram, we're on the good size per side. Containment isn't quite as good. We know uncontained lesions don't do quite as well with marrow-stimulating activities, but I still think probably can be done arthroscopically with a marrow-stimulation technique, and it can be done in the supine position. Anybody up here have any other approaches? So this patient, this is before he got to me, underwent, well, I'll tell you right away, he fell into the hands of a podiatric surgeon in town, and he had an arthroscopic debridement and microfracture, according to the note. I did not have any photographic documentation, no video, no photos. So he has persistent symptoms several months later, and that's his X-ray. That's his MRI scan. And I think if you look, hang on. If you look here, you can see that the lesion's still there, and there's still probably even a little bit of a bony fragment there, and that's confirmed on the MRI scan. So basically, you have a failure there. I'll tell you right now, he's still in the hands of the podiatric surgeon, but what would you do under this circumstance if he came to your office and you were the second guy seeing him? Steven? Well, we know second scope surgery has a much poorer outcome, but I think it's difficult to, when you don't know exactly what was done. I've been caught by that before, where I went in to do a note, and they hadn't even debrided the lesion. But the note said they had, so you've got to be very careful. You still might fall into the siren song of doing the easy thing. I think if you're going back to do something, though, I think my definition of stupidity is doing the same thing over and over again when it doesn't work. Well, just wait. Just wait. So what I do, I would do something different. So if I was going to scope it, and it'd be something I'd talk to him about, I would definitely do something biologic with it, and I'd make sure I looked at alignments, make sure he's not in VAERS. Yeah. And he didn't have any of that. So I'll tell you, he had, interestingly enough, a medial malaria osteotomy. And even though the same fellow had done a debridement, he fixed it this time with some absorbable tacks. So he apparently found something that he didn't before. And so that's a post-op radiograph of his surgery. There's a little bit of, it's a little hard to see, but there's a little bit of a malunion, minor malunion there. But you can see he still has the lesion. So now what would you do? Rick? Well, this is unfortunate. So I would do a redo arthroscopy, excise the lesion, and probably do some type of cartilage transplant. And, you know, unfortunately, the decisions for the cartilage transplant, the results, we are going to report our results on juvenile cartilage, which actually are pretty good in the 18 cases that we have with long-term follow-up. And we're looking up now the micronized cartilage. I don't know which of these procedures is better. Some of it, unfortunately, comes down to what the patient can afford, since none of them are covered by insurance. So option number one is to excise it again in marrow stimulation activity, maybe add some PRP. That's the cheapest thing you could do. Option number two would be some cartilage transplant arthroscopically, because he's already had an osteotomy. So if you can do it arthroscopically, I would strongly encourage the patient to have that done. So if you're using the micronized cartilage, I would also do the BMAC at the same time. We mix them together and insert that after some marrow stimulation activity. Anything to add? No. OK. So this is me. So you can see here a little bit, you can see the malunion there. You can actually see the joint really doesn't look as good as you'd hope on the tibial side for a guy who's had an osteotomy. And then in the hopes of helping him, you can see he just still had loose bony fragments there. And I took the approach of, well, the first of what Stephen was saying, this guy's never had a good initial procedure. So with all the other things that he had been through, and also, you know, I got to tell you, Milwaukee is a little bit different than Southern California. We got a lot, this is a working guy. And you know, there's a big difference in getting a working guy back to work after a debridement compared to some of these other bigger procedures. And is this me, Stephen, with all you have is a hammer so everything looks like a nail, and I'm going to debride that sucker? Did I have any hope of success? Yeah, I think you did. I mean, if you'd done this day one, you'd be quoting, what, an 85% chance of being better? Right, the literature would suggest that. So, but he's got the, he's going to have some issues at post-osteotomy, degenerative change possibly in that shoulder of his joints. I would say to him, it's unlikely you're going to be pain-free completely, but it's likely your pain will be better and you should be able to go to work. He didn't even come close. That's disappointing. So, and I think you're seeing exactly what he said, you know, our results after a failed previous surgery, never mind two previous surgeries, never mind another previous surgery that's given him essentially the earliest form of osteoarthritis. So six months later, despite, you know, rehabilitation and everything, you know, he's bad, so now what? Rick? Well, now, again, you can... We're back where we were. Yeah, we're back where we were. Just put your money down, what would you do? You could do the cartilage transplant, or if you're really concerned about that, the way Bill Bugbee does his allografts is he does them through a total ankle approach so you don't have to worry about the osteotomy. With a little distraction device, and that would be another option, be doing allograft through the anterior approach, staying away from the osteotomy, and just replacing that whole area. Steven? If he is a working man, as you said, and he's had a lot of bad experience in surgery, I would try not to burn his knee, potentially, so I would have done OATs as his second procedure way back if I had been involved earlier, but I would do a mast or a version of AMIC on him. That's what I would do. Owen, any ideas what J.K. would do? He'd probably go for some kind of cartilage. I think he'd probably look at doing an OATs. Yeah, I think J.K. I can speak for J.K. here and say that he would do an OATs in this particular situation. He would do a cartilage transplant using either one or two plugs from the knee, and he would say that the fact that it's a shoulder lesion doesn't matter, because I've asked him these questions, and he would recreate the superior surface and not worry about the gutter, basically, I think is a reasonable way to show it. He probably would have to redo the osteotomy, then. Precisely. Which is very worrisome, compared to what you showed us. So we did redid the osteotomy, and we chose not to do the type of osteochondral allograft that you described, that Bugbee describes, and I think in retrospect, that actually may be an easier thing to do than what we did here, actually replacing the whole thing from front to back. It gets to be a little bit of a scrum fight, you know, getting, even though you have a match-sized talus, to do a fresh osteochondral allograft, but this is excision of the lesion. This shows the fresh osteochondral graft. We sized it. We're not particularly sophisticated in Milwaukee. We did it all by hand, and like I said, it's a bit of a scrum fight, getting that to size up there as well as you can. And he ended up having the osteochondral allograft, which matched pretty nicely, I think, and you can see it there. And actually, near-term follow-up at about two years has done pretty well since then. So any comments from Italy? I was just about to say, you would have been smarter and not made all the mistakes in the minute. He didn't. Yes, he did, but he didn't, and I think that you can't account for poor surgical technique. When I was in my training, and the residents would present cases to all the attendings, after one of the cases, one of them would raise his hand and say, that guy would have been better off left in a ditch than be treated by you residents, and he would have been better off with another person. Rick? I was just going to point out also, I make a big issue of getting every operative report from previous surgeries, and sometimes they'll say, the patient will be told one thing, but you read the op report, that wasn't even done. We had the op report, but again, unfortunately, no photographs, and actually, the CT and whatever, the MRI, you know, belied the report. Any questions from the audience? So, if this is your case from the first, you will do excision of uncontained fragment and microfracture? If I had that patient the first time, I think for the reasons Rick said, I would have done an excision. To tell you the truth, I don't think you'd need a microfracture. I think once you took that lesion out, you'd be in subchondral bone, you're in bleeding bone. In my opinion, if you're in bleeding bone, you do not need to do a microfracture. You will supplement it with arthrodiastasis? Say that again? Arthrodiastasis, I mean, destruction? I do it under, personally, I do it the same way, I think we all do it, actually, the same way. So, typically, 2.7 scope, distraction, and Rick will make the point, and it's a good point, having that posterolateral portal is very useful sometimes for more posterior medial lesions, because you can use it for instrumentation sometimes, or visualization from posterior while you're using anterior instruments. And for marrow edema, in Italy, you use something for marrow edema? In the case of marrow edema, it's due to the lesion, it's the injury. Due to the lesion, right. And I think from Kennedy's lab, and we'll learn more in the future, hopefully, from our speaker here, either bone marrow aspirate and or PRP, particularly bone marrow aspirate, will facilitate, we hope, healing of these lesions done with marrow stimulation. There's some, John's, I think, put one paper out on that already, but. Yeah, and I've got a series showing a lower re-operation rate, so this was published last year. So, it is 11.01, the end of our time, and I thank you all for coming.

chronic ankle pain

ankle instability

medial talar dome defect

surgical approaches

lesion treatment