Brian. So Brian's going to tell us about subtalar fusion plus your arthroscopy. Well, thanks everyone for the opportunity and privilege to be following all the esteemed arthroscopy wizards of the foot and ankle. As you can tell, I'm not Nenam Mandola, but he was supposed to give this talk. But I was his fellow for a year and then been in practice with him for several years now, too. So hopefully I can fill in his shoes. So not him, but this is who I am. No disclosures. So standard arthroscopy, I think a lot of us are using this already. These are some of the indications that we're using it for. These are the portals that all of us are familiar with. But posterior arthroscopy is kind of, I think, increasing usage and using a lot more in our practice as well. And we prefer the prone position rather than the lateral position. You can definitely do some of these portals from the supine position as well, but we prefer kind of the prone position. The main thing of posterior arthroscopy, a lot of people are scared about it, but the main thing is make sure you know your anatomy and know it very well, because it is a little bit different. And I think the key thing here is making sure that you know your FHL, where that is, because everything lateral to that is safe. So all the dangerous stuff is on the medial side of that. And then make sure you do your thorough exam, as Dr. Ferkel has taught us all how to do. So the main thing of the prone position is that you want to make sure you find the lateral malleolus, draw a line posterior to that, right up against the Achilles. It helps get you at the right level and also keeps you safe from all the structures in the back as well. Preference of whether you start with a posterior medial or posterior lateral portal, but just make sure whichever direction you're going, make sure you're away from FHL. I like to put my portal for the posterior medial first, put a camera there, hit it with my second portal, hit that instrument and follow that down, so I know I'm safe that way. But you can definitely go the other way too. There is also this burgeoning technology with these thinner scopes. I have not used them in my practice, but that's something to be aware of. They're really trying to push this for especially these small joints, including the ankle. Some data out there show that it can be effective with similar viewpoints. It would be interesting to see how much other people are using it. One of the things, as I mentioned, the posterior makes people a little more nervous is some of the complications, particularly the neurovascular structures that are in the back. As you say, it's demonstrating a higher incidence in the posterior rather than the anterior. Dr. Amendola also looked at this as well. We prefer to no distraction, which we think helps limit some of that nerve injury and stretch. When you use that technique, a lot of these things, as you can see, different indications in the top two graphs are what indications we're using for posterior scopes. If you look at the bottom graph, you can see that all the complications tend to resolve over time, so the gray being all kind of complications and the black being the ones that resolve. The majority of these do resolve, although there are early ones as well, and we do think that the non-distraction helps with that. The other reason to do posterior is kind of your access and what you can see. Looking from the front, you can see the majority of your tailor dome, so one through six you can see very well. But as you can see, in the posterior part of it, you can see it's very limited view, so you want to make sure you get a full, thorough exam, be able to look in the back as well. Several things we'll just go over and examples of when we're using it. This is a posterior impingement in a ballet dancer. Obviously, they're on point a lot and can be really plantar flexion with a lot of force and repetitively, so you have a lot of symptoms that the rest of her exam and x-rays are relatively benign. As you can see, you make sure you do thorough exams. You're looking at your gutter, you're looking at your articular surface, which all looks really good, and then you can see here a little bit of that increase of the calcifications as well as that posterior impingement, which you can easily get to with your scope. Another example is the osteogynum, so here's your FHL tendon. We're going to move it here in a second and bring it over, and you can see how that impingement can occur and cause a lot of irritation on the FHL there. So we're going to push down on this here a little bit, and you can see how that can be kind of mobile. You make sure you take that out, and there's different techniques. You can use a burr, you can use an osteotomy to take it out and make sure you get all of it, and then you check the impingement afterwards. Another thing is a posterior OLT, which Dr. Froh gave a great talk about that earlier, but the ones in the back can be hard to get to as we demonstrated by the access paper that was shown earlier. And so this is an example of looking through the back. I think there should be a video on this. There's supposed to be a video on that one. So this is looking from the back, and you can see this defect, which didn't have a video. I should have had the video from the front where you really can't see it very well, but you can see it's actually a fairly large lesion, and when you're really probing it from the back, you can see it a lot better. And so obviously you have to look at your preoperative imaging to make sure you know which direction you want to go, looking from prone or supine positioning. And this is just a similar example of where you need a good degree of looking from the back and make sure you're really addressing that OLT. And then another example here is kind of tarsal coalitions. So here's an example of an x-ray. As you can see, this is a subterranean kind of coalition. Kind of obvious you can't miss that on an x-ray. But how do you address that? And so this is an example of addressing that. Maybe from a video here. Maybe not. Addressing this from the back as well. So the same kind of anatomy, looking back there and addressing that. And so this is after the debridement, and you can see now there's a lot more movement there. You can define between the two where that coalition was and how you can separate that and get in there nicely. And very minimally invasive, just the two incisions, two stab incisions. And just final pictures here showing the x-ray and showing every section done nicely, again, with two small posterior incisions. And the last one here to talk about is the PASTA, or the posterior arthroscopic subterranean arthrodesis. There's obviously several techniques for this. You can do this in a lateral position or a posterior prone position. Our preference is in a prone position. Again, it's for isolated joint involvement, minimal deformity, and it's effective in relieving pain as well as improving function. So why do we do this? I think we're in arthroscopy, we're all minimally invasive here, but just kind of preaching to the choir, you know, doing a science test approach versus three small stab incisions. The anatomy you've got to be aware of. And so different ways to define this is with posterior medial, posterior lateral, which we demonstrated earlier. And you also have accessory lateral portals, posterior lateral ventral, anterior lateral dorsal, anterior lateral ventral. Other names of these in the literature are your central, posterior, and anterior parts of your subterra. So just different nomenclature but same portals. Again, make sure you're aware of your anatomy. So you have your nerves, your superficial perineal nerve, your serral nerve and branches of that. But you're relatively safe if you're aware of your anatomy and pay attention to and respect it. So there's several studies out there showing that weights of fusion is very good. If this is greater than 90%, the majority of these studies. And so this is kind of a technique and a position that Dr. Amendola describes and uses and that we've used as well. So there's three portals, posterior medial, posterior lateral, as well as this accessory just posterior to the fibular head. And what we use to put the scope here and here, and this actually is just a probe. It can be anything. We're going to help distract it as you're putting in your 4.0 burr from here. And we like to use the 4.0 burrs a little bit bigger. And just, again, another picture of the positioning and a closer view of where the instruments and camera is going. The nice thing about this procedure, if anybody works with trainees, you can kind of, you know, someone who doesn't know arthroscopy very well, you kind of give it to them, give them the burr, and they go at it. You don't have to worry about it too much. You're taking down the cartilage anyway. So it's kind of nice in that respect in terms of teaching arthroscopic skills. So just examples of, you know, what we're doing here. You kind of assess it at first, and then you slowly get that burr in there. And then you have that probe coming in from the back, just serving as kind of to prop it open so you can get the rest of your instruments in there and debride everything out. And then you can pass your screws. You can look at it while you're putting it in, or just do it arthroscopically. Just another example of kind of how you position it and how you get the x-rays in. So the leg is always hanging off the bed, which facilitates the imaging as well. So a study of presenting kind of a consecutive series, comparing both open versus this PASA procedure. Fifty-two were consecutive of the open, and then 56 of the PASA patients. And these were their findings. And so I just want to highlight. I'm going to go through it quickly. But the green demonstrates benefit for an arthroscopic approach. For your operative time, slightly about the same, but maybe slightly lower. Length of hospital stay was less. Time to union was less. Time to return to activities was less. Return to sports was less. Time to work was less. Union rates, or blue, is about the same. Union rates are the same. VAS scores and the rest of your PROs are about the same as well. So definitely we felt a benefit to do this arthroscopically, both from a cosmetic standpoint, but also from a functional and return to activities kind of standpoint. So overall, these are going through the same findings, open versus PASA. Both relieve pain and do well. But arthroscopically, we feel it's better for various reasons. Just an example here, and it's kind of showing the same thing as well, just a little video kind of showing that. Really don't have to worry much about what your trainee is doing. Just let them take down the cartilage. It's really good for training, learning triangulation. And this is kind of our protocol. And then this is her at six months out doing very well here. The video goes on showing all these different positions and her running on a treadmill, which she's doing very well with. And so, you know, more recent systematic review, demonstrating good results as well, and time to union, very good as well. So I think it's easy to do. I think it's standard portals, just a prone position, which I think is easy, and it facilitates the procedure as well. Different reasons to do posterior arthroscopy, and they're increasing as well. And, you know, Kevin gave a great talk about doing crazy Taylor fractures as well, and that's another great technique as well. So posterior arthroscopy is involving something, I think, which should involve in your practice. It's very useful for techniques and, I think, easy to pick up. But you still make sure you respect the anatomy and practice, practice, practice, using the anti-orthopaedic learning centers can facilitate that as well. Awesome. Thank you. We have a couple of minutes for questions at 612. It's Friday night, and there's a ball game on. So anyway, I always worry about what my trainees are doing. I'm afraid I can never just let them go. But maybe I'm just too control-free. Anyway, any further questions? So I've been seeing some on, like, sort of a primary fusion. Does anybody add biology to a tip tail, or are they scoping it, prepping the joint, calling it a day? On the paper we did with, you know, with that posto, we put in a little bit of putty. I'll tell you, I think every fusion should have some bone graft substitute, and it's not to prevent nonunion. It's about earlier return to function. So Mark and I did a paper with Karl Aland, and we used sort of the pilot study for Amplex. And it was an RCT, and it was just 10 in each group, and we showed faster fusion rate with the Amplex than autograft. And what it means for patients isn't that they're not going to go back to the OR. That's a really hard thing to measure. But if they get back on their feet sooner, just like Brian just showed you, you know, like if we use arthroscopic and every tool we can to get them to fuse quickly, then they get better faster. They get back to their job faster. They get back to their sports faster, and they have better outcomes. So Mark and I published a paper on the augment patients, and we showed the more you fuse, the less you hurt. That's what we should be thinking of, not like union, nonunion. We should be thinking of how much fusion are we going to get, how much faster are we going to get it. And if I was a patient, like every time, the bone graft substitute plus the arthroscopic is going to be the winner. So I want all my patients to get better faster. If I have a, you know, I say for the sake of argument, you know, arthroscopic versus open-ankle fusion, and I have a 5% nonunion rate in both groups, but in the arthroscopic plus bone graft, they got better faster. They returned to work, you know, two weeks sooner. They got back to their sport two weeks sooner. They had, you know, like AOS scores of, you know, rather than of, you know, they had five points better in their AOS scores. To me, that's a huge winner. And so I think we have to think about it differently. The pushback from payers is it's more expensive. To me, this is the cost of doing orthopedics. We need to go to our hospitals and say this is the cost of good orthopedics. So in our hospital, they give us pushback. We spend $2 million per year on our orthopedic equipment. They always grind on us about it. And if we did biologics in these patients, maybe our, you know, we'd be up to, say, $2.5 million per year for our ortho equipment budget. But they give away $42 million worth of HIV medication in the basement every year. So, you know, like what we spend is peanuts. And we don't advocate enough for our patients. They're young. They're mobile. Our hospitals and our colleagues do not understand the importance to their lives of the things we do because it's not cancer. It's not HIV. It's not the things that are obvious to the hospital boards and the payers. But it's still really important to these patients. And to me, these are the things that we should be doing. And these are the things we should be arguing for so they get better results. That's where I've been after 24 years of doing all this stuff. And I advocate for that for our patients. But the future is bone graft substitutes. If we start using them and we start understanding them and we know what works and what doesn't work, they will become cheaper because the manufacturing is going to become cheaper. I think that they're going to be a huge bonus to our patients going forward. I think we're just beginning to see that right now. And the only way that's going to get better, the only way that we're going to understand them is to use them and study the outcomes. So we just talked about it, Mark and I and Tim and a whole bunch of the Canadians, we met in April in Toronto and we had a little meeting about a bone graft study. And Tim Daniels argued, and I agree with him, that we should be using bone graft substitutes in every fusion we do. I mean, no question about ankle, but I'm thinking more and more that we should be doing it in every case. And while you can use autograft, autograft doesn't improve the science. If we use, you know, whether it might be BMAC or PRP or, you know, PDGF or whatever else there is now available, but I think it's our duty to study it and get the science, whether we do it through registries. And then the outcome measure is faster return to normality and the actual final outcome scores, not non-union rates. So the studies have always got hung up, you know, FDA wants union, non-union, Mark, Mark Holden, Christy Giovanni, and Judy Bumho and Sheldon Lynn will tell you how difficult that is to actually define union, non-union in a concrete manner. I mean, there is no definite way of doing that. And the problem is you're taking a binary outcome, union, non-union, out of a continuous variable because it's actually sort of, I mean, if you think of the patients who have ongoing pain and you're thinking about revising them or not revising them, and you finally go back in there and you're sort of looking at it saying, is this fused or not fused? I'm sure we've all been there. You know, it's understanding that if they fuse more, they hurt less, and think of it as a continuous variable, not a binary outcome, and I think if we start doing that, we'll be much smarter about how we're doing our fusions. Long answer to a short question, but anyway. It's just after 6.15, so thanks everybody for staying to the last and listening to what we have to say. And thank you to our faculty, too, for being here and supporting Anna, Rick, Andy, and Jim had to go, but thanks everybody. So thank you.

subtalar fusion

arthroscopy

posterior arthroscopy

flexor hallucis longus tendon

neurovascular structures