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Yeah, good evening everyone. Um So we have got another masterclass today on ankle replacement for um from no one else but Tim Cl who is a, a very good friend and a fantastic uh foot and ankle surgeon based in, right and has done loads of uh ankle replacements. I think he's got one of the biggest cities in the country. So Tim has very kindly agreed to share his experience to the B fellows and without any further delays, I will pass over to Tim. Thank you very much uh man for those kind words. So, first of all, I'm really sorry for being late. Uh No excuses other than um um not, not that organized and very busy, but other than that, I'm glad uh we've now technology is working. So I've been asked to talk to you about ankle replacement. Um I can't talk to you about ankle replacement without briefly mentioning ankle fusion. I know it's uh a separate talk but um and you'll hear more on that, but there's a, just a slight, the Venn diagrams will overlap a little bit. So uh I'm just trying to get to the next slide. OK. So you all know the symptoms of end stage ankle arthritis and that's pain, stiffness, swelling, reduced activity and more pain and yet more pain and more pain. So, the indications for an ankle replacement, um, there's no complexity about this is pain and reduced activity. So it's exactly the same as if you were considering a knee replacement, you'd consider potentially some form of end stage, um, a ankle surgery, whether that be replacement or fusion. So, just to give a quick overview of what your treatment options are for ankle arthritis. Well, you'd start off with conservative nonsteroidals, physiotherapy might help a little bit. Certainly in early ankle arthritis, brace and insoles. If they have deformity that you want to correct injections only have a place in early. These are steroid injections, not uh P RP stem cell injections. The jury is out for that and steroid injections only really have a place in early arthritis in my book. And then I've put on there, surgical cheilectomy and debridement really in my book that has no role at all. Um, it certainly doesn't have a role in moderate to advanced arthritis. It's complete and a waste of time. You might consider it for impingement symptoms, but that's not really an arthritic ankle. That is, you know, uh the, the minutia of that is a separate problem. So I've put it on there. Then I've put two in italics which are options for moderate ankle arthritis, supramalleolar osteotomy, which I understand there is a talker later in the series and I put that in Italic because that is performed in Europe, particularly Germany. Unless so, er, France, uh it's not readily performed in this country, certainly in, er, you know, er, large numbers. So I have no personal experience on supramalleolar osteotomies. And the outcome, similarly, arthrodiastasis is in there in the literature, um, moderate ankle arthritis. Uh I have zero experience of that. Um, I've got experience of um people having uh frames on for various conditions. And my experience is they usually get CRP S and don't do very well. Well, I'm not going to cloud your judgment on arthrodiastasis. Uh It is not a procedure that's massively performed in the UK. So the two in blue are the two that we're gonna consider ankle replacement and ankle fusion. And my remit is really uh replacement. Those are the treatments for end stage ankle arthritis and this is what you've got replacement or fuse. And the dilemma is what should we do? So why are we considering ankle joint replacement? My ankle joint replacement is the future. Why would you have stiffness when you can have when you can have movement, if you can guarantee pain relief? Then why would you fuse a joint when you can have movement? So that's where that's the, where we are with it. Now, this is a chronic rheumatoid lady. She's had bilateral knee replacements, one of the ankles is replaced. She's had an elbow replacement. Uh We are a rheumatoid center. So the di the question for you guys is which ankle has been replaced. Her other ankle is rheumatoid. Um The answer will come up. So it's the left ankle that's been replaced and that's the range of movement that you'll get through a well functioning ankle replacement. Now, she's had that ankle fused, particularly on a rheumatoid. It's gonna throw tremendous stresses to the adjacent joints. And a rheumatoid does not do, does not like a fused joint. Ok. So that's ankle replacement. Here's another one, another rheumatoid, bilateral uh knee replacements again and just the one ankle. So just to show it wasn't a one off, this is the other ankle, it's a right ankle and that's again your range of movement through the ankle. So I know I can hear your skeptics, you'll say, well, that's actually the moving around the joint. So here we are real time fluoroscopy ankle replacement. So that is the range of movement that you're gonna get through a functioning ankle replacement. It will give you around about an arc of 30 degrees movement and that is gonna offload your hind foot joints. So, what are the indications then for ankle replacement? Well, ost end stage osteo or rheumatoid arthrosis, they both do equally well. So not everybody is suitable for an ankle joint replacement. So, what I would suggest you do is you get a weight bearing ap lateral of the ankle and basically the way you decide who's gonna do well with an ankle replacement and who is gonna do badly is you have a big straight line and everything here on the left of the screen, neutral sedentary polyarticular disease, middle aged to elderly, no instability at the ankle. A functional range of movement that doesn't mean a normal range of movement. That means 15 degree arc with some possible subtalar arthrosis at the ankle. They are their ideal patient for an ankle replacement. So they'd be extreme left and your extre the this other side, your extreme right are the ones that are not gonna do well with an ankle replacement. Somebody who has already got malalignment, active single lower limb joint ie post peel on at 28 young who, somebody who's got collateral ligament laxity at the ankle. Somebody who has already got a really stiff, uh almost ankylosed ankle, poor range of movement before a joint replacement is poor range of movement after, with a joint replacement in or somebody who's got bone destruction, malleolar destruction or talar dome. And you've got to have a reasonable bone on there. Now, obviously, it's like when you're buying a house, you don't get everything that you ask for. So you plot them, you won't have complete contraindication and you won't have complete indication and you plot them on that line and if they're more towards the left hand side of the screen, then they're gonna do well with a well functioning ankle replacement. And if they're bo down at the bottom end, right, then I'd urge you to consider doing a fusion on them. And obviously, you know, it's where they are on that, on that plot. So that's real. This really is the most important slide take home slide is who's gonna do well with an ankle replacement. Obviously, you've got to put it in nicely. That'll come on. So, in terms of consent, what can you do with an ankle replacement? Well, so this is what I'll tell them. It's a midline anterior approach just like um a knee replacement. They're in hospital now about a day, ok? Uh So that's less than a hip, less than a knee. They're walking on it straight away. I keep them 4 to 6 weeks in a uh surgical boot and this is the take home you've got about an, they're nowhere near as good as a hip or a knee replacement yet. They're about a 93% 5 84% 10 and 75% 15 year survival on an ankle replacement. And the things that can go wrong are, are, are ankle fracture. You can blow off a malleolus, you can get ongoing gutter pain. You can obviously aseptically lose some failure. You can get deep infection, they can become stiff and not actually move very well bearing failure is very rare. You can have neurovascular injury, wound healing problems or a DV. TPE. So those are your, those are your risks that I tell them about in terms of consent. And this is our, uh, 15 year plus we have ankle replacements out to 2025 years. So I've plotted this out for you. Um, just to show you that it's not a catastrophic fall off. Uh, in terms of survival at 10 years, it tends to drop about 1.2 to 1.5% a year and it's a steady fall off in terms of survivorship. So we looked at our series to look uh in terms of helping you with consent for um risks. And this was a paper in um bone and joint journal that you wrote in 2018. So we had 278 consecutive ankle replacements, which we'd done over about a five year period. Uh and these are our complication rates. So we had a 10% malleola fracture. So that's not intraoperative. Our intraoperative rate was 1.5%. These are uh intraoperative plus late malleola fractures. So the late malleola fractures are a slight concern because that's showing that they tend to be a stress fracture and they tend to be recurrent hind foot deformity and it overloads usually the medial malleolus. So the if you get ama medial malleolar fracture at two years, then you're worrying that the ankle replacement is beginning to malign or the foot to heal below the ankle replacement is beginning to malign and drift usually back into virus. So we had a 3% wound healing problem. Now, we define that as a wound that's not fully healed. At three months, we have a 7% superficial infection rate. 2% deep infection rate, 10% medial, ongoing gutter pain, 2% stiffness and a half a percent baloney amputation rate. So if you're doing an ankle fusion or an ankle replacement, you must tell them about the small risk of baloney amputation. It is out there. It's a big operation, things can go wrong. So only what we had, uh you know, uh only 12% of the complications had a detrimental effect on implant, survival of all those complications. Most of which are don't require revision or surgery. And um and we can manage conservatively. So we compared our risks against um Canada's risks. So they've published theirs like very similar. We had four surgeons, 396 ankle replacements. They had six surgeons, 474 over an average uh five year period and the major complications are roughly about the same there. Ok. So let's go to the literature. How good is an ankle replacement? So as you start delving into the literature, it gets uh confusing and the more you delve in the more confusing it gets. So Goldberg wrote up a meta analysis uh now 10 years ago, looking at 8000 ankle replacements, survivorship is pretty much the same you get around a 30 degree arc of movement. There were radiolucencies. So, don't forget this is looking now at historical ankle replacements. We looked at our long term survivorship of our 200 star implants. Oh, these are at least 15 year survivals and those are our survival rates. And what we found was that at 23 years, 50% of the patients had died without revision. And that's what you're aiming for. You want one operation, one joint replacement to take them to death. But that shows that we're operating on the right set of people. They'd had their ankle and they died with that ankle replacement in. Don't forget, the average age for ankle replacement is 68. So 68 plus 23 takes them to 91 25% were still alive, not having revised, 16% were revised at 23 years. A lot of the ones that were revised, most were being revised for aseptic loosening, but 25% are being revised for a recurrent, some form of recurrent hindfoot malalignment. So let's go to the English N gr. So the English N Jr is the largest N Jr for ankle replacements in the world and it has 8800 ankle replacements on. Um, it's detailed now out to 2022. It's been collecting data since 2010 in the last year. Most of ours now are fixed bearing ankle replacements in the UK. So that's the infinity ankle replacement. It's completely taken over the market in the last three years. The rest are, are a small number of still mobile bearings. So you've got the star which is pretty semiconstrained. You've got the zenith which is completely dropped out of the market as has and then you've got the vantage. There are nine active brands being implanted within the N JR but most of them are the fixed bearing infinity. The published N GR revision rates are those which are very low. 5.5% at five years and 9% at 10 years. I'm gonna tell you a little secret that those numbers are totally and utterly incorrect and I'll tell you why in a minute, the five commonest uh indications for revision are aseptic loosening infection, ongoing pain, malalignment and stiffness. So those are the reasons why jot a ankle joint replacements need revising. So compare ankles in the UK to hips and knees. There's around 100,000 hips and 100,000 knees going, primary knees going in in the UK per year and there's 880 ankles going in per year. So it's 1% of the hip and knee market. Uh Everything else is roughly about the same. The average age is around 68. 90% of them have been put in for osteo and 6% in for rheumatoid. If you compare that to, we are a rheumatoid center at Wright and we put 18% of ours are being put in for rheumatoid and uh then whatever the at the rest is 82% for osteo. So if you compare our N Jr to the other N Gr s which are Australia and New Zealand, much lower numbers, they seem to have much worse survival rates. And that is not because we are better surgeons, but our data is incorrect, uh, embarrassingly and Australia's and New Zealand's is correct. So I'll tell you why. Next slide. So ha this is the paper that you need to pull out. We've pulled it B JJ, which is our British journal 2023. Um How long? Really do ankle replacements last? So the problem that we've got, we've linked the N JR data to he data and the problem that we have in the UK is when an ankle replacement fails and it gets revised. Uh When an ankle replacement goes in, we fill out what's known as an A one ankle form. So they're being filled out when an ankle replacement gets revised, it can get revised to either another ankle replacement or an ankle fusion or a hindfoot fusion depending on which surgeon it goes to. Now, ankle replacement, surgeons are very used to filling out forms. So when you revise an ankle replacement for a failed ankle replacement, you have to fill out an A two form. So if it's been revised to another anchor replacement, we'll fill out an a two form. But if it goes to a guy who just does fusions, they don't know about an A two form and they don't fill it out. And what we found is a third of our failures are not being recorded on the N JR. So these are the real figures when we compare them to he data and you can see that it's equivalent to the rest of the world. And it's what I've already told you about roughly about a 91% 5 85% 10 and 75% 15 year survival. What we've found is the newer joint replacements, the fixed bearing are doing much better than the mobile bearing. Now, the other secret, which we don't, which we know, which is not readily known is that the younger you have it under 55 you've got a 50% greater chance of revision than if you delay the ankle replacement to older age. So you will see patients who will say I want to live for today. You must resist putting in ankle replacements on those patients because they'll just destroy it. And then what are we gonna do once? It's um once it's uh failed. So this is where I'm just gonna briefly overview um fusion versus replacement. So you've got that patient. He's got end stage arthritis. You've plotted him on the, the graft, which end does he lie in the left ankle? And he say he's midlife. So you know who is he gonna do better or is he gonna gonna, should he have infusion? So this is probably a, this is a really old paper. But for me, it's the best paper that's out there. Review article, Anchor Replacement versus Fusion done by Steve Ard and Chris Coats here in America. And they found no difference between the clinical outcome of replacement versus fusion. That was a headline abstract, you pull the paper and you read it proper and when you read it proper, this next line is the secret of it. So what this is, is a basic scoring system. Excellent, good, moderate and poor and those are your percentages of for ankle replacement and fusion. And when we're looking at no difference, we tend to look at excellent and good. And if you look at those figures, they are virtually the same. 38 plus 32 is 70% do excellent and good and 31 plus 37 is down near 70% do excellent and good for fusion. The ones that are doing poor for fusions are all your non unions. 13%. The ones that are doing poor for anchor replacement, 24% is the ones that have been put in badly. Don't forget this is, you know, 2007. So we would anticipate that that 24% has dropped down. But herein lies your issue if you do an ankle replacement, well, it's gonna do well, similarly if you do, but it is a much more difficult operation to do well than a fusion. You got 10% non union rate for a fusion. And they had so in 2007 America, which was using an absolutely rubbish ankle replacement. Then at that stage only had a 77% 10 year survival. Now, this bottom line, I cannot in any way understand and neither will your ankle fusions. They quote a 1% below the amputation rate for re for a replacement and outrageously, a 5% below the amputation rate on a fusion. Now, I can't remember me ever chopping a leg off for an ankle fusion. So I just wonder whether they're chopping off their, all their non unions. I have no idea why it is so high but they have quoted two papers with a similar rate of percentage below the amputation rate for primary fusions. Ok. So let's go to another study, California. Uh again 2007 in 2007 in a 10 year period, the number of fusions to replacement was 10 to 1 in the, in the state of California. They have revisited this in 2019 and the number of fusions to replacement in the State of California in 2019 was 1 to 1 and that is what is happening. Now. Replacements are certainly in America are becoming much, much more common and are equaling the number of fusions. But their headline story was ankle replacements, high risk of major revision or surgery, ankle replacement, lower risk of subsequent subtalar effusion 1% at five years compared to 3% at five years for ankle fusion. So let's go to Canada. Uh and what do they do they had? So this is slightly later. Um So they had 208 to 1 replacements versus 100 and seven consecutive fusions. The same highly skilled 6 ft and ankle surgeons at four centers, obviously a follow up 70% revision for replacement, 7% revision for fusions. That must be their non unions. 90% major complication rate for replacement. Seven for fusion. That's all they non unions. But the A OS scores are similar. So basically your bottom line is you do an ankle replacement. Well, the clinical outcome is gonna be similar to a well performed fusion, but the rate of reoperation and major complication rate is higher for a replacement. It is a much more difficult operation to do so ta trial. So in the UK, we um had this er u uh government funded trial. Tava stands for total ankle replacement versus arthrodesis. And that was a prospective randomized controlled trial. The government put in millions of pounds, I think about 2 million to try and find out which do better replacement versus fusion. And these are the two year results. So we had 282 patients minimum follow up at two years over 17 UK hospitals and there was no difference in the Mox FQ walking er or standing scores of replacement to fusion in those two groups of patients. Now, 54% of the replacements that went in were fixed bearing. But the subset of data, the interesting subset of data is when you subanalyse the fixed bearing versus an ankle fusion, the fixed bearing replacements, which we know now do better than mobile bearing have better Mox FQ walking, standing scores than an ankle fusion. So in answer to the question at the moment, there is no difference between replacement and fusion, but it may be that with more modern replacements and we're moving to fixed bearing, the modern replacements may do better than a fusion. But we don't know that yet. 61% of the fusions were arthroscopic. 39% open. What we did find was that replacements had greater wound healing problems and nerve injuries. There was a 7.2% reoperation rate for replacement at two years compared to a 5.6% reoperation rate for the fusion, a fusion. So this is top surgeons in the UK fusing. 61% arthroscopic had a 12% radiological nonunion rate or a 7% symptomatic. So 5% of the radiological non unions were a were said to be asymptomatic. So only 7% symptomatic nonunion rate requiring revision or surgery. So that is the latest outcome. Two year results for the ta a trial. So in replacement versus fusion, this is a summary why have stiffness when you can have movement? The replacement is not suitable for all you're neutral, sedentary polyarticular, more than one joint affected. Certainly a rheumatoid, middle aged elderly, no concomitant ankle instability, no malalignment functional range of movement with some subtalar oa that you want to offload, then they are your ideal candidate for a replacement. It is more difficult surgery. So if you're gonna do it, get yourself trained well, choose your surgeon things that can go wrong. Technical interoperative efforts, blowing off a malleoli and recurrent instability. There's much higher risk of complications, superficial infection, deep infection, malleola fractures with a replacement and you've got your risk of wearing out requiring revision. Sorry, I was just gonna go over um some interoperative uh images for ankle replacement. So what do we do when we do ankle replacement? So like any joint replacement at writing, writing is a, is a kind of joint replacement factory. We do double prep, we use toga gowns, we ankle replacements, we do under x-ray. X-ray comes in from the same side uh for me afterwards, they go three weeks in a cast and they're in one day. So this is our double prep. So they get prepped in the anesthetic room and then they get brought in um in that position. So the limb is exposed, it's been prepped once we go for a double prep. Uh this is me doing the second prep. And uh these are us wearing our toga gowns and this is what we're left with in terms of exposure um of the ankle. So the patients are obviously supine uh and the legs, you know, the ankle prepared. So everybody is on our side of the toe, which is on the same side as the limb. The theater staff are on the end of the table and the trays go at the bottom of the table and round the other side. X-ray comes in from the same side. This is x-ray comes in from the same side as the limb that you're doing. OK. So this is, we use an infinity which is the fixed bearing. And these are the external uh alignment jigs which you put in uh and check your alignment under X ray. So it's no different than doing a tibial nail. When, if anybody that does trauma or tibial nails, you just take a few quick flashes uh and get your alignment sorted out. So then we swing to a lateral. So the big sea arm goes underneath the table and that's us with the lateral bar in and you'll see that on here up on X ray. So that's our ap that's our lateral, we get our alignment and once we've got our alignment correct, you then pin the jig on. So this is a us with the, with the jig pinned on. And then once you've got your jig pinned on it then becomes very easy. You've got you, you, you mate your cuts around the ankle and you uh you've got it. You take out a block of bone around the ankle, which is a lined of radiology. You then obviously put your tibial plate on and that's your tibial plate. Check an X ray, make sure that it's properly seated. And this is us actually implanting the tibial tray and then the um talar dome. And then this is the jig that puts, then the fixed bearing inserting. So that clips in just like uh the old fixed bearing knee replacement, uh polys clip in um to the tibial, you know, onto the tibial tray. We've got a flat tibial tray, this clips in onto the bottom of the uh tibial tray. Uh And that's the, that's the jig to put it in. So that's your end result. That's your ankle replacement put in. Um uh and uh that's kind of where we are. So this is, you know, your real life situation, you're gonna get a 61 year old, possibly male, generalized oa retired subtalar joint is stiff. He's arthritic, he's bone on bone at the ankle. So yes, you could do a fusion, you could do an arthroscopic fusion, but his Subtalar joint is not great and it's arthritic. So you, you're then into doing a total hindfoot fusion or doing an arthroscopic ankle fusion and hoping the subtalar joint doesn't fail. But if you do an arthroscopic ankle fusion and have to come back to do a subtalar joint fusion. The literature says that your rates of nonunion then of your subtalar joint can be up to 40% but that is not a great route to be going down. So, what do we do? Well, we do a combined subtle joint fusion and ankle joint replacement. Bang, sorted him out so we can do that at the same sitting. Ok. Here's our next one end stage, fairly young, isolated oa and joys golf accountant. So he would do really well with an arthroscopic ankle fusion. So, and that's not the wrong thing to do. I'm not trying to sell you an operation, but we can offer him both and we go through the pros and cons of it with him and it's which one do you want, sir? And you know, he's like, well, why should I have it fused when I can have it replaced? And that's where we are. He's had uh an ankle joint replacement. So it's not that there's a right or wrong thing to do. But um and at the moment, one is not superior over the other, but there are early signs that a fixed bearing is gonna end up starting to become better than and confusion. But at the moment, we don't know that convincingly yet. Ok. So really, that's, that's all I've got to run over. So, very happy to take questions. Thank you. Tim. That's brilliant. Um I'm sure fellows will ask questions. So uh Tim, um when did you change to fixed bearing? You were doing stars before, but you're doing infinity now? Uh Yeah. So um shall I come off screen Scott? I don't know how to come off screen, Scott. Yeah, you can stop sharing your stop. Uh Just go to that. I don't, I pass got hard to come off. You are screen sharing. How do I come off it? Um No, I don't, I don't know. Um, don't worry too much about it, don't worry about it too much. Yeah, forget it. All right. So, uh, so we've, we've used a few. So we start, we start from 1997 when they first came out to about 2003, from 2003 to about 2016. We used mobile bearing, mobile bearing was thought to be the way to go and then the infinity came out in 2016, which was radiologically guided. Uh And as a byproduct, it was fixed bearing. We moved then to uh the infinity, not because it was fixed bearing, but because it was radiologically guided cos up to, then it was just done by your eyes and experience. So we moved to infinity uh for radiological guiding, you know, um to give us AAA much more uh predictable and um er accurate implantation. Um And what's come on the back of that very quickly from following them up. We realized without getting any data, this is just anecdotal from seeing them was that they were doing much better, much quickly. So a fixed bearing at three months was as good as a mobile bearing at six. So I was like, wow, there's something in this, you know, they were much more secure on their ankle. This is that and it's only the later data as we've tracked. So because we from 2016, we now have a over five year data on fixed bearing and it's only just beginning. There's obviously the lag phase you see from N JR, but it's only just becoming coming out and it's coming out interestingly across all three N Jr S US A Australia and New Zealand that they do better. Great. Um We take a question from fellow. You want to ask a question? Uh Yes, please. Thanks. So this was a very impressive talk. Thanks for sharing your experience. Um So, uh regarding the tar study, the meta analysis showed earlier. So uh uh it says that um um uh with a fixed bearing. Yeah. Um Yeah. Uh you uh there is a superiority regarding uh in terms of the outcome. Yeah, uh as compared to the fusion. Yeah, but uh maybe this difference, you, you are not saying how much difference there is there. So this difference might be statistically significant but not clinically significant if it's just one or two grades then I don't know whether it's that important. And the second question is whether you are aware of studies, uh, comparing the cost of the one method over the other. Yeah. So, um, in answer to your question, it is statistically significant. Um, between the two, I don't have, I've not, uh, I've not got the, um, thing to hand but if you, that, that's the, um, that's where it's written up. So you'd be able to download that and read that it is. So we weren't expecting it. Um It, we, I found no difference. And then when you start, when you find no difference, you start looking into subsections. So the DEA the, the study was not set up to pick up that difference. So as there's been no difference out to two years, then the statisticians start looking at subanalysis and that's what they've picked up. So, the whole design and ethos of the study was not to see if fixed bearing did better, but there is a statistical significance. Now, ankle replacements cost more than um ankle fusion. There's no doubt about that because you've got the cost of the implant. So privately, uh in the UK, I think, you know, a self pay cost of an ankle replacement is probably, well, a self pay cost of a hip replacement is now about 14 grand. So I would say that the self pay cost of an ankle replacement is not much different. 14, 14.5 grand, an ankle fusion, self pain. What have you gotta pay for? Two screws, three screws. So, ankle fusion is 8.5. So, yes, you've, you, you, you know, it's three grand for the implant. So you've got the cost factor, uh, to look at. So, you know, if more people are doing it, I guess the cost of the implant will come down. But, you know, that's where we are. But yeah, health economics is, is certainly something that we can't ignore. Thanks. That was two very good questions. II fantastic. Uh Well done. I mean, it's true, isn't it? Um I mean, it's, it's still we are in the phase where, which is better and to be honest with you, I feel that both have their indications. Yeah. Uh uh a young patient who has got uh posttraumatic arthritis. He like 10 years. He confusion. Yeah, he absolutely, he would do well, I personally, so I'm, I do a lot of ankle replacements like I do a lot of ankle replacements, but I have fairly narrow indications. I will argue, you know, you, you've got Andy Goldberg who will, who will do it? You have to walk into the room and then they get an ankle replacement, you know, effectively, but I don't like doing them on the younger end of the spectrum. I don't like doing them if they've got significant mal deformity. And I know the literature and son D says you can correct that morm to form a flat, you know, a, a neutral foot and then put an anchor replacement in the a and, uh, you know, as they're leaving table, it looks fantastic. But in five years our experiences of the deformities come back and then you've got a big hole and a failed ankle. You know, and I know, yes, you can do a revision. But you think I should have just done a fusion here. So I don't like doing them on a lot of deformity. And the other one that it's not really written about, but in an experience, the ones that to my mind don't do well are significant lateral l ligament laxity. Or if they've got a flat foot below it, a flat foot below it throws tremendous stress through an ankle joint replacement. And I know you can, you know, do a major flat foot correction and then come back and do an ankle. But I would like, you know, well, if I give you a good functioning neutral ankle fusion and then give you insoles for your flat foot, you're gonna love me. So, yeah, I, you know, I'm, I'm, I am, you know, fairly narrow, not rigidly narrow, but I'm fairly narrow. In my indications. I think it's gonna be, it's gonna be 20 years before we see anywhere near a significant difference between replacement confusion. So for our generation, we can, we can just carry on as it. Yeah. Yeah. No, absolutely. I mean, the other thing, uh and I don't know what, what your thoughts are about it but, and, and you eluded it in your talk, you talked about adjacent kind foot arthritis and logically speaking, if you refused one joint, then you will get arthritis in the neighboring joint. But I've actually looked at the literature and there's no convincing proof that you get significant hind foot arthritis because of an ankle fusion. Uh maybe I'm wrong but this is what I've looked at. Uh Yeah. So uh I've also looked at that. So there's a difference between clinical and functional. So the Americans look at, oh I do an ankle fusion and then I'll take an X ray 10 years later and they've got a lot of radiological arthritis. But very few of those a are actually clinically significant uh in that they're coming asking for that joint to be fused. So the bit that I worry about is, is a rheumatoid because they don't do well with an an they do well with a triple fusion, but they don't do well with an ankle fusion. They, they go on to get a lot of hind foot disease. I don't like, I don't like fusing a rheumatoid. And the other one is um if the subtalar joint, if the ankle is bad and the subtalar joint radiologically is ropey. And then I know you can do test injections and see um y you know, II II am much more inclined, like I showed to do a replacement on those and then either leave the Subtalar joint across my fingers or do them both at the same time because I don't wanna fall into the trap of doing ankle fusion. And then five years later, the subtalar joint failed. And, you know, you've got a one in three chance of that not uniting. Yeah. No, II mean, completely. I agree. I think you're absolutely right. Rheumatoid arthritis, um where there's arthritis, ankle replacement has a major role. Uh and, and ankle arthritis and septic joint arthritis. There is this, I mean, you said 40% I think the risk in literature to as high as 50%. That's what the Sheffield paper was that if you have got um, a fused ankle joint or the se no, as high as 50%. So those two are absolutely, you see what happen with that? You see what happens there. The guys in Sheffield are not as good surgeons as guys in leads. It was, it was late. Yeah. No, no, II II agree. I mean, practically though this is the thing, I mean, I, I've done ankle replacements and II loved infinity. But my, and I've stopped doing them and I stopped doing them post COVID. And the reason for that is um quite two or three main reasons and one of them is that, as you said, ankle replacement is much more difficult operation. It takes time to do it properly. Uh, infinity. Got us the jigs. But then you do a lot of X rays. Um, ankle fusion, arthroscopic ankle fusion. I can not almost close my eyes but I can do it fairly. I don't need assistance. I can, I can do it. Uh, whereas for ankle replacement II won't be. And then the potential risk, you quoted that paper, Steve and I know exactly what you mean. And when I looked at that paper, my thoughts were the same that 5% baloney amputation following ankle fusion is bizarre. But I suppose they had some very complicated open fractures, extremities. I don't know why they right. L like you, II have not seen touch wood uh and, and, and uh an amputation following uh and uh uh uh and confusion. So those my, those, those are my and then in terms of the patient satisfaction in general, you know, a well performed operation does well. So if you've done a good ankle fusion, I've got so many patients who are extremely pleased I've done by electrical ankle fusions. There's no issue. So I II think, you know, you do, you do it right. Yeah. Uh put it, put it in perspective. I, you know, I do a lot of hind foot work and I would say that I'm 1 to 1 replacing I, I'm not replacing it. You know, I do a lot of ankle fusions, a lot of ankle fusion. Um I might even do more fusions and replacements. I don't know. But, uh, yeah, and, and then that, that, that, that comes, then this, especially in the UK, I don't talk about other countries, you know, and we, it's, it's hot topic that how many ankle replacements should you be doing to keep your skills up? Because we know there's a big learning curve and if, if you don't do it regularly then you're out of practice. So, you know, an ankle replacement to be done. Well, you need to justify, you need to do 34 a month, one a week. And that's not possible. Well, nobody's doing that. Nobody's doing that. Nobody is doing it. Yeah, it's probably nobody in the world I would say. Well, there, there are figures, I mean, we have published on that looked at how ma how many ankle replacements you need to do a year to do them properly. And I think the number which comes up, I mean, these might be arbitrary numbers but they are 20 plus numbers a year and not many surgeons in the UK do more than 20 ankle replacements outside personally. Outside. Well, it's less than 10. It might, it might only be five. Yeah. So, and that can be a good and that's one of the reasons Tim I II have stopped doing them because if the numbers are not there, then you know, you, you don't want this headache and then no, no cause cause your denominator is low. Uh, you know, so you only need one in your numerator and then it's a high percentage. Absolutely. And one thing I would say about nonunion versus failed ankle replacement. Sorting out a non union, yeah, an ankle fusion is not that difficult. Whereas sorting out a failed ankle replacement is a bloody nightmare. I, well, that, that's why you get your bad for though, isn't it? Uh, that's what you get out of bed for to sort out your headaches. I, well, it depends on what your age is. Well, it's been a really good talk and I think you have given a very balanced view and you have given a, you know, in terms of patient selection, what implant to choose, um, you've shown the technique, I think it's been immensely beneficial and not all the fellows could attend, but because of the different time zones, they tend to see the recording. So I'm going to put this straight away uh on the website so people can watch it in their own leisure time. Ok. But it's been absolutely fantastic having you, Tim, are there any other questions, fellows? Anything else before we let Tim go? Yes. Go on. Then I, oh, we got more than one. OK. I first and then Louis uh one final question. So any experience with the, the, the, the custom made implants, those that you don't need the jig, maybe it's easier to put in to place them. Yes. So um, they did form part of the, um, I know they didn't put in, there were two trials going consecutive. So we don't, and the reason we don't is, uh, that our hospital won't pay the increased price of them. So you're talking prophecy, custom made, um, implants. So, at the end of the day, the, the, the, the, er, so we have done a prospective, um, 500 anchor replacements in the UK. Er, now no one center could put in more than 20%. It was nine centers. We were one of them. We put in 100 out of those 500 all of ours were non prophecy. Essentially, most of the prophecy was done down South cos, they've got loads of money down south. So London, um, so of the 534% were prophecy. The remainder were non prophecy and there is no difference in outcome. So the only advantage of prophecy is it's a quicker operation because you just pin the jigs on. Um, and you use a lot less x-ray, but the implant is the same. So if you, you know, I II, if you use your x-ray properly, you will get to the same, you know, starting position of putting the implant in as you would with, um, a prophecy jig is just, you, you're getting there 10 minutes earlier with, with virtually no X ray. So the implant is the same, you're just making sure that your your, your cuts are square, you know, ap and lateral, which you can do through X ray. Mhm. Mhm Yeah. OK. So for the benefit of our audience, Tim uh just to clarify. So you talked about prophecy which is act uh uh and, and, and it's mainly the, isn't it, it's not the tibial side, it's not one component. So the, the prophecy is a uh is the name of the uh ankle replacement that uses custom um jigging. So the implant is effectively the same. But so what you do is you have to take AAA preoperative CT that gets sent to uh us. Uh and from that CT, they can make jigs that you but basically pin on. So you don't have the jig that you have to set up on X ray for ap and lateral. You get custom jigs custom from the CT of that patient and you just pin those on and cut and then you put your blood and, and, and, and, and that is for both the tibial and tay or just the tide. Yeah, it's for both but it's uh it's for both. Yeah. Ok. Thank you. Um Louis. I think you raised your hand earlier and then it's gone down. Do you have a question? Yes. Hi doctor. Uh I have a question. Do you have any special consideration in case of converting an ankle arthrodesis to a nephroplasty? So, uh it is beginning to come out there in the literature. I have never done one. I would never recommend you do one. II II, you know, so why would we be doing that? You know, a solid ankle fusion in a good neutral position will last forever? You know? So why would we run the risk of? Uh, so I know people do it. They're doing them in really no low numbers. I personally, II, there's a guy in London who's done one or two, there's a guy in Nottingham who's done one or two. You can count the numbers in the whole of the UK. On probably one hand, you'd worry where it's gonna be in five years. Um, you worry, why are we doing it in the first place? Um, as you say, if it's for a, if it's for a painful non unit of ankle fusion, I'd rather have a second go of a, of an ankle fusion than so. For me, we know anybody who does a knee who used to do knee replacements like I used to do knees and yy, you know, you know, the ones that the knees that don't do. Well, a stiff knee knee before does is a stiff knee with a joint replacement in a stiff ankle that has only almost, virtually ankle low. Yes, you can release the tender achilles. Yes, you can cut the posterior capsule. Yes, you could do this. You can do that, but they just seem to stiffen up. So they might have a 10 degree arc of movement and you think, was it really worth it? The, the ankle replacements in there? It's not functional. It probably lasts forever because it's not moving. Um You know, so if they've had a ankle fusion and you create a huge big window in the bone, the soft tissues are gonna be ankylosed and gonna be just not nonfunctional, not moving. And you know, the X ray might look pretty. but he, he saw my picture of the uh of, of the ankle replacement. Maybe this one. I don't know whether it's still showing on that. Yeah, it's not gonna move like that, you know, it'll just have a nice looking X ray and you know, it, it, it, it just won't really be moving. So why would you do it? I, so that's, that's me. Who's a skeptic of it? Bye. I have a question. I have a question. Yeah. Yes, please. Hi team. Now, now we have a reverse shoulder. Now we have a reverse hip. Do we have a design of Reval? Now? Uh no, I take the Mickey out of the um I take the, I take the Mickey out of the er hip surgeons by saying you've put it in the wrong way. I said you need to put that stem in the er pelvis and put the ball on the uh on the other finger. No, no desi no design for that. I mean, is there a, is, is there, is there a good shoulder operation? That's why I asked my shoulder surgeons cos they, they've designed something to go in the wrong way around and say it works better. But, but he, he works very well in a trial phase in America. I don't know. We might, we might do a flat cut, flat top Ts and put a dome on the, um, on the bottom end of the tibia and say it's working great. Interestingly interestingly, the f so the first designs of ankle replacements, the really basic primary ankle replacement. Yeah. So those would be like in the early to mid 19 eighties, ankle replacement really came out probably early nineties. I have an X ray somewhere of that, of exactly that where somebody, it was obviously done at Wright, somebody had put a short um Charley hip replacement up the bottom end of the tibia and uh put the ball in the tibia and the flat cut on the talus and created some poly sandwich in between. It didn't do well. Yeah. Yeah. It might be because the ankle is uh a reverse knee replacement, isn't it? Yeah, that's all it is design wise. Yeah. It's an upside. It's an upside down. A Yeah. So it might come changes of design because uh what we are not getting is a moment, isn't it? In spite of doing all these things? Yeah. Yeah. So who knows? This is where we are. So, as I say, the the, the take home message is w we have stumbled across and do better. Uh the mobile um and that is the direction of travel at the moment. Could, could they, could they be doing better because we are using more imaging? No, I don't think so. So I don't think so. So like we look at our of so I mean, we were putting in mobile bearings, you know, zenith mobility pretty well just off eyes, no x-ray. Uh they weren't put in badly. But even so, even for mine, I II knew something was happening because I would see my infinities at three months and they'd be so happy whereas it would take six months for a mobile bearing to get to that stage. And I was, I was saying to the other guys, I was saying, you know, they are doing much better, much quicker than a mobile bearing and, and they said, yeah, that was their experience as well. Also, I think the fixed bearing do not have that much incidence of the gutter pain as compared to no. And, and yet we don't know why. I don't, I don't know why. I don't know. Yeah, good stuff. Well, good. Thank you very much, Tim. It's really appreciated. You came and gave us your pulse of wisdom and uh fellows, I'll be posting this tonight on medal and thank you very much for joining and we'll see you next week. Have a good week, very much. Thank you very much.