2024: Navigating Stormy Seas: Managing Complications in Ankle Fusion Surgery
Selene Parekh MD
[{'start': '0.040', 'end': '5.040', 'text': "hey guys we're almost in the home stretch we got\xa0\nfour more hours here Aaron guy is going to take"}, {'start': '5.040', 'end': '12.000', 'text': "us uh through the next hour as the moderator he's\xa0\ngot uh a great group of panelists um one that'll"}, {'start': '12.000', 'end': '21.880', 'text': 'be virtual and uh Aaron kick us off thanks SEL\xa0\nthanks for H having us um so I had a great group'}, {'start': '21.880', 'end': '29.960', 'text': "of panelists here today I'm going to share\xa0\nmy screen here off and uh through what we're"}, {'start': '31.320', 'end': '33.880', 'text': 'all right so here we go I got uh today our topic'}, {'start': '33.880', 'end': '37.440', 'text': 'is going to be navigating stormy\xa0\nseas which is basically about man'}, {'start': '37.440', 'end': '44.680', 'text': 'complic have four panelists with'}, {'start': '44.680', 'end': '61.880', 'text': 'and um we have with us Carol Jones who is at\xa0\nOrtho Carina and the clinic Memphis Eddie H'}, {'start': '61.880', 'end': '66.760', 'text': 'at the Mayo Clinic in Jacksonville was not\xa0\nable to join us live today but we do have a'}, {'start': '66.760', 'end': '73.440', 'text': 'pre-recorded so way this basically'}, {'start': '73.440', 'end': '90.360', 'text': 'the B what factors to preoperatively to prevent\xa0\ncomplications what strategies that can be utiliz'}, {'start': '90.360', 'end': '97.200', 'text': "to address complications when they do occur and\xa0\nwhat consider next time complications don't occur"}, {'start': '97.200', 'end': '107.440', 'text': "again and I'm kick it with uh a patient that I\xa0\nhad in my practice over um that some of these"}, {'start': '107.440', 'end': '114.000', 'text': "points so here are some of my discl of which\xa0\nare relevant to this talk and here's the I'm"}, {'start': '114.000', 'end': '120.920', 'text': 'going to talk about I had a 67y old patient at\xa0\nGM 50 with poorly controled diabetes peripheral'}, {'start': '120.920', 'end': '128.160', 'text': 'neuropathy and a host of other medical he is at\xa0\nhome he South Georgia he fell from a standing'}, {'start': '128.160', 'end': '135.360', 'text': "height lost B he's not a very active guy just\xa0\nbasically hangs out at home so he walked on"}, {'start': '135.360', 'end': '142.000', 'text': "swollen before to the ER he just noticed it\xa0\ndidn't look right it swelled up and it was"}, {'start': '142.000', 'end': '150.000', 'text': 'pointing the wrong way so his x-rays revealed that\xa0\nhis ankle had fractured and also sublu and they'}, {'start': '150.000', 'end': '157.440', 'text': 'out in a rural uh South Georgia hospital they\xa0\nhave any Orthopedic call uh cover that hospital'}, {'start': '157.440', 'end': '164.040', 'text': "was splint still displaced uh he didn't have\xa0\nan open fracture but the uh skin pretty well"}, {'start': '164.040', 'end': '171.440', 'text': 'tinted medially you can see why on these xrays is\xa0\nlocated but that Medi malis is really pushing on'}, {'start': '171.440', 'end': '177.520', 'text': 'the medial skin so this is over a week out when\xa0\nhe did this so I take him to the operating room'}, {'start': '177.520', 'end': '187.480', 'text': "I uh fix him and and I was really concerned he's\xa0\na really big guy he's diabetic neuropathic so he"}, {'start': '187.480', 'end': '192.800', 'text': "doesn't well we need to add some extra Hardware\xa0\nas you can see I put in three extra cnism motics"}, {'start': '192.800', 'end': '197.640', 'text': 'all this the ladder technique thinking hey\xa0\nmaybe this will help prevent him from having'}, {'start': '197.640', 'end': '204.720', 'text': 'any issues well I was I was still a little\xa0\nbit concerned about him because because you'}, {'start': '204.720', 'end': '210.080', 'text': "know he had walked on it a week he definitely\xa0\ncan't feel anything he's a really big guy and"}, {'start': '210.080', 'end': '214.880', 'text': "normally I'll have diabetic patients that I\xa0\nfix an ankle on come in a week for a splint"}, {'start': '214.880', 'end': '219.040', 'text': "change check their wounds make sure everything's\xa0\ngoing okay for him I said you know I'm gonna get"}, {'start': '219.040', 'end': '224.800', 'text': "him in at five six days posttop um just just\xa0\nto make sure everything's okay when he came in"}, {'start': '224.800', 'end': '228.920', 'text': "he said yeah I've actually I haven't stayed off\xa0\nof it DOC it you know feels a little different"}, {'start': '228.920', 'end': '239.880', 'text': "I've been walking on it so he comes in and when he\xa0\ndoes this is so the three screws I put the those"}, {'start': '239.880', 'end': '248.440', 'text': 'those those stayed intact but uh as you can see\xa0\nhis plate 90 it failed he dislocated the angle'}, {'start': '248.440', 'end': '256.160', 'text': 'Mal was looking at us in the clinic so I him to\xa0\nthe since he has this open wound because of the'}, {'start': '256.160', 'end': '264.000', 'text': 'sign there I said you know we really should\xa0\njust Pro to a fusion just G to try to fix the'}, {'start': '264.000', 'end': '272.080', 'text': "ankle he's demonstrated that if we fix it he can\xa0\ncompliant with waveing neuropathic we're going to"}, {'start': '272.080', 'end': '281.200', 'text': 'do fusion um I decided retrogade rather than a\xa0\nhindot fusion nail made specifically for hindot'}, {'start': '281.200', 'end': '285.400', 'text': 'Fus given the fact that retrograde nails were\xa0\nthe original way hind fusions were done in the'}, {'start': '285.400', 'end': '292.760', 'text': 'first place and these rods are longer and larger\xa0\nin diameter so I thought this would be much better'}, {'start': '292.760', 'end': '299.640', 'text': "fixation for this so here's some interoperative\xa0\nphotos actually as we started to prep him you can"}, {'start': '300.280', 'end': '308.640', 'text': "there's a TI wound this is the actual I removed\xa0\nit I honestly have never before in a patient you"}, {'start': '308.640', 'end': '315.120', 'text': "know we always our patient always so here's\xa0\nwhat he had what we ended up revised fibula"}, {'start': '315.120', 'end': '321.800', 'text': 'I put a new fibular plate try to buttress that\xa0\nside put in this femoral Rod all the way up to'}, {'start': '321.800', 'end': '329.640', 'text': 'around the tibial tubic uh three screws disly\xa0\ntwo locking at the top did prep his ankle joint'}, {'start': '330.760', 'end': '337.120', 'text': 'while we were in there to try to get it to fuse\xa0\nso I keep off of it three months put them in'}, {'start': '337.120', 'end': '342.240', 'text': 'the total contact cast gets his wound healed his\xa0\nX-ray starts showing healing of the fibula using'}, {'start': '342.240', 'end': '347.160', 'text': 'of the ankle and sub tailor joint so at three\xa0\nmonths I said well this is a little bit longer'}, {'start': '347.160', 'end': '353.360', 'text': "than I usually keep someone in a cast but think\xa0\nyou're used enough that move step which is a boot"}, {'start': '353.360', 'end': '357.720', 'text': 'and allow him to weight bear and five months he\xa0\nwas still looking good so I prescribed diabetic'}, {'start': '357.720', 'end': '363.760', 'text': "shoes and Orthotics so it's six months a month\xa0\nlater he comes back he's wearing Crocs he says"}, {'start': '363.760', 'end': '367.960', 'text': 'he never got the ortho or shoes he admits I just\xa0\nnever went and got them even though I was fitted'}, {'start': '367.960', 'end': '373.240', 'text': 'for him and when I examine him a little concerned\xa0\nlittle bit of crepitus on the ankle I stress the'}, {'start': '373.240', 'end': '382.480', 'text': "ankle joint looking at his x-rays however he's\xa0\nhe's having f as you see this he's actually Fus"}, {'start': '382.480', 'end': '389.080', 'text': 'through asmosis fracture looks healed lateral\xa0\npart of his ankle looks pretty well he some'}, {'start': '389.080', 'end': '394.680', 'text': 'loosen immediately W this is a this should be\xa0\npretty solid um however I was somewhat conc'}, {'start': '394.680', 'end': '399.160', 'text': "because you can see if it's a little bit subtle\xa0\nbut if you look at the end of his rod on this"}, {'start': '399.160', 'end': '406.920', 'text': "lateral it's now it definely his an subsided\xa0\nsome and this Rod is prominent in addition one"}, {'start': '406.920', 'end': '413.320', 'text': 'of the Locking here disty has backed out was it\xa0\nwas not this far uh prominent laterally when we'}, {'start': '413.320', 'end': '419.520', 'text': "originally did it however I felt you know this guy\xa0\nI think he's fused enough let's let's move him to"}, {'start': '420.840', 'end': '426.240', 'text': "ordering a double upright with his diabetic shoe\xa0\nmaybe he'll actually get those we emphasize the"}, {'start': '426.240', 'end': '431.640', 'text': 'importance of that and so we proceed with that so\xa0\nI get that for him and then he gets his brace he'}, {'start': '431.640', 'end': '436.040', 'text': 'actually does get the brace um about three or\xa0\nfour weeks after we saw him he comes back for'}, {'start': '436.040', 'end': '443.240', 'text': 'his follow two months later yeah doc I got this\xa0\nsore on the me part of my ankle I think the race'}, {'start': '443.240', 'end': '449.560', 'text': "was rubbing on me but you I really didn't of\xa0\nit I didn't call anybody when we get him in the"}, {'start': '449.560', 'end': '455.000', 'text': 'the office however that ulcer when we probe it\xa0\nactually goes right on to the medum malus again'}, {'start': '455.000', 'end': '461.280', 'text': "his did show some continued subsidence of the fuse\xa0\nand so here's X-rays at that point I was also a"}, {'start': '461.280', 'end': '468.120', 'text': 'little concerned that not only had the anide more\xa0\nwas more prominent screws now a couple of them are'}, {'start': '468.120', 'end': '479.600', 'text': "backing out they more Pro one and I saw thisy also\xa0\nand at the so I'm given the open wound this change"}, {'start': '479.600', 'end': '487.480', 'text': 'concerned did he is he starting to develop not\xa0\nonly a nonunion but effective nonunion ulcer'}, {'start': '487.480', 'end': '495.440', 'text': 'so given his other comorbidities are very\xa0\naggressive I remember from the U the ankle'}, {'start': '495.440', 'end': '509.840', 'text': 'um six weeks with a pro uh uh pick line and we get\xa0\nthem back in double upright brace adjusted so that'}, {'start': '509.840', 'end': '516.840', 'text': 'no longer any rubbing there and he progresses\xa0\nbut by about two months later he gets another'}, {'start': '516.840', 'end': '527.200', 'text': 'new medial the ankle start to fall see still got\xa0\nhere space over here is much more Lucent so now'}, {'start': '527.200', 'end': '537.920', 'text': "I'm yeah he definitely definely has some concern\xa0\nabout some concern that this is effective non-un"}, {'start': '537.920', 'end': '543.680', 'text': 'you also see screw SC from the lateral plate I\xa0\nleft in that were exposed to the El from the first'}, {'start': '543.680', 'end': '548.360', 'text': "plate are starting to actually just I've never\xa0\nseen this before either where screw just randomly"}, {'start': '548.360', 'end': '556.840', 'text': 'is in another part of the foot but again this guy\xa0\nkeeps surprising me um so I say to him well you'}, {'start': '556.840', 'end': '562.400', 'text': "know I think the the the ship is sunk uh it's\xa0\nthere there's no point in me trying to go back"}, {'start': '562.400', 'end': '569.840', 'text': 'and revise this I really think that a below KNE\xa0\namputation is the best uh treatment option for you'}, {'start': '569.840', 'end': '574.280', 'text': "but he and his wife are like no way I'm not\xa0\ngetting an amputation uh he also refuses any"}, {'start': '574.280', 'end': '580.000', 'text': "other further surgeries including indd I said\xa0\nokay's a crow Walker we get him fitted for a crow"}, {'start': '580.000', 'end': '586.120', 'text': "Walker and for the last three years now we've\xa0\nbeen following him as and what he basically"}, {'start': '586.120', 'end': '594.920', 'text': "does very active he's now in his 70s um has\xa0\nintermittent ulcers what happens is he'll do fine"}, {'start': '594.920', 'end': '608.400', 'text': 'for for medial side since he in such a vus\xa0\ndeformity and um he comes in theic he does care'}, {'start': '608.400', 'end': '612.840', 'text': 'uh the W Care Center gets care of comes in clinic\xa0\nfor follow-ups and every time he comes in I say'}, {'start': '612.840', 'end': '618.640', 'text': "you probably need know I'm doing fine this is his\xa0\nmost recent followup I just saw him about a month"}, {'start': '618.640', 'end': '623.120', 'text': 'ago see now another one of his screws had fallen\xa0\nout this has actually been stable for about two'}, {'start': '623.120', 'end': '629.040', 'text': 'years now as one screw fell out then the other one\xa0\nfell out they just hanging out in the bottom part'}, {'start': '629.040', 'end': '638.920', 'text': 'of his foot but uh he is cruising along and has\xa0\nnot septic or sick or needed an amputation despite'}, {'start': '638.920', 'end': '645.920', 'text': 'that I think that would be his best option so some\xa0\nof the things the so the takeaways point out in'}, {'start': '645.920', 'end': '654.080', 'text': 'this case this is a complicated case but I point\xa0\nout some of the things to and this can illustrate'}, {'start': '654.080', 'end': '663.680', 'text': 'preoperatively even before his I tried ank we knew\xa0\nhe was diabetic Beast I had neur neuropathy given'}, {'start': '663.680', 'end': '669.760', 'text': 'his present um at that point the reason I said hey\xa0\nI better put some extra when I fix his ankle but'}, {'start': '669.760', 'end': '678.520', 'text': "obviously it wasn't enough um when he when we went\xa0\non to Fus to the fusion procedure had to consider"}, {'start': '678.520', 'end': '684.520', 'text': "these uh these Fusion you got to consider these\xa0\nfactors because that's going to change exactly"}, {'start': '684.520', 'end': '693.480', 'text': 'what you do for the um the fusion itself with\xa0\nboth pre and postoperative planning non with'}, {'start': '693.480', 'end': '698.320', 'text': "non weight bearing also is a consideration cons\xa0\nto look at when you're considering Fusion as you"}, {'start': '698.320', 'end': '705.000', 'text': 'may um you should consider keeping them off of\xa0\nbit longer and changing your postop protocol so'}, {'start': '705.000', 'end': '712.760', 'text': 'initially analyzing this case u a couple things we\xa0\ntried to to to um I tried to address some of the'}, {'start': '712.760', 'end': '720.600', 'text': 'the these concerns I have one was the increased\xa0\nhard we talked about him di was concerned about'}, {'start': '720.600', 'end': '728.840', 'text': 'his weight bearing and as you can see that I what\xa0\ndone prevent disaster these retrospectively these'}, {'start': '728.840', 'end': '739.600', 'text': "things I've learned yeah should have done this at\xa0\nthis guy um if you noticed on my initial R x-rays"}, {'start': '739.600', 'end': '743.200', 'text': "maybe I should have fixed it medal he definitely\xa0\nhad an incompetent deltoid I've repaired that"}, {'start': '743.200', 'end': '749.160', 'text': "should have since he's a Morely obese pathic\xa0\nguy should I've added ex increased imobil"}, {'start': '750.600', 'end': '756.800', 'text': 'fixed even rather than spint after the surgery\xa0\nshould I put in some shance pin across the ankle'}, {'start': '756.800', 'end': '764.800', 'text': 'uh temporarily just a we do sometimes with some\xa0\nthese are some things that I think I probably'}, {'start': '764.800', 'end': '771.800', 'text': 'should have done when I first fixed him um it\xa0\nwould have in retrospect prevented him from'}, {'start': '771.800', 'end': '779.120', 'text': 'bending his plate 90 degrees um in people with\xa0\nthese cobor humidities when we go to a fusion um'}, {'start': '779.880', 'end': '786.040', 'text': 'I looking at one the reason I chose\xa0\nmore robust fixation from a rod rather'}, {'start': '786.040', 'end': '791.760', 'text': 'than the the specifically designed hind for\xa0\nFusion Nails just because I this is a much'}, {'start': '791.760', 'end': '799.560', 'text': "more and for a guy that's this big not\xa0\nthick obviously we wait on it I think"}, {'start': '799.560', 'end': '807.840', 'text': "this may help protect him longer more robusto\xa0\nI did C that wasn't long enough should maybe"}, {'start': '807.840', 'end': '810.880', 'text': 'should have kept them off maybe should\xa0\nhave kept him in a cast long than that'}, {'start': '810.880', 'end': '815.000', 'text': 'maybe I should have got act scan this\xa0\nis one thing looking back uh even though'}, {'start': '815.000', 'end': '822.520', 'text': "his looked good it seemed like he was fusing\xa0\nlaterally he hadn't fused it wasn't enough I"}, {'start': '822.520', 'end': '832.200', 'text': 'should have got a CAT scan fusion and way\xa0\nthose are all considerations you look at'}, {'start': '832.200', 'end': '843.520', 'text': 'cidi diabetics like this A1C 11 we were'}, {'start': '843.520', 'end': '858.480', 'text': "that postop um and so I think you have patient\xa0\nwith these comorbidities that's undergoing a"}, {'start': '858.480', 'end': '863.320', 'text': 'fusion or total ankle replacement or something\xa0\nlike that you definitely want to get there heo'}, {'start': '863.320', 'end': '871.880', 'text': 'A1C in a more reasonable range this particular\xa0\nis a fra really have time to do that but that'}, {'start': '871.880', 'end': '880.200', 'text': 'is another big consideration thing I think key\xa0\npoints to consider um this demonstrat is that'}, {'start': '880.200', 'end': '887.080', 'text': 'when you have Fusion that fails like his did we\xa0\nhave to always consider in fact diabetic he had'}, {'start': '887.080', 'end': '892.920', 'text': 'an open ulcer that developed he had some Lucen\xa0\nxray that should the top of your list of things'}, {'start': '892.920', 'end': '898.480', 'text': "to consider in a uh in someone in this situation\xa0\neven in someone that doesn't have an open wound"}, {'start': '898.480', 'end': '907.520', 'text': "the infection is one the or can be the the number\xa0\none reason for nonunion when you don't have um"}, {'start': '907.520', 'end': '913.280', 'text': "when you do get an an infection you definitely\xa0\nshould aggressively debed T that doesn't look good"}, {'start': '913.280', 'end': '926.320', 'text': 'take add use IV antibiotics consult your\xa0\ninfectious disease to help with this remove'}, {'start': '926.320', 'end': '932.200', 'text': 'as much Hardware as possible this particular\xa0\nlateral side was okay and would provide aess'}, {'start': '932.200', 'end': '941.840', 'text': "but maybe in retrospect they should move more\xa0\nit's hard to say um and whenever you're consider"}, {'start': '941.840', 'end': '948.640', 'text': 'revising particular patient say his Fusion failed\xa0\nwas was probably to infection we had there is the'}, {'start': '948.640', 'end': '955.560', 'text': "option we could have red this however I'm G to go\xa0\nthrough another big revision to revise a failed"}, {'start': '955.560', 'end': '961.840', 'text': "ankle Fusion particularly in in this situation\xa0\nthe 's a lot of things you should and in this guy"}, {'start': '961.840', 'end': '967.520', 'text': 'his diabetes is a big concern his non-compliance\xa0\nwith post-operative um weightbearing and also his'}, {'start': '967.520', 'end': '974.520', 'text': "more obesity I think are all big things you have\xa0\nto take keep in mind you say I'm gonna proceed"}, {'start': '974.520', 'end': '983.040', 'text': 'with a big case I felt that he was not a good\xa0\ncandidate for given his factors and that a the'}, {'start': '983.040', 'end': '988.920', 'text': "amputation best he hasn't he decided not to do\xa0\nthat so he's just getting going along weren um"}, {'start': '990.240', 'end': '998.160', 'text': "race and wound so uh so that's hopefully um we'll\xa0\nsome questions in on the I think we're going to"}, {'start': '998.160', 'end': '1005.600', 'text': 'save some time at the question for each of the uh\xa0\ntalks here today um so send those on the chat and'}, {'start': '1005.600', 'end': '1015.960', 'text': "I will try to go through those at the end but that\xa0\nmy and I'm gonna stop sharing here we're going"}, {'start': '1015.960', 'end': '1025.280', 'text': "to move on to Jones here in a second I'm going\xa0\nto turn it over to Carol now and uh he's going"}, {'start': '1025.280', 'end': '1029.560', 'text': 'to take it away here awesome great thank you yeah\xa0\nthat was a great case here and I think these these'}, {'start': '1029.560', 'end': '1036.560', 'text': "shco cases have they always have so many chapters\xa0\nand it's quite prevalent here in North Carolina as"}, {'start': '1036.560', 'end': '1044.360', 'text': "well and and we there's a lot of dis discussion\xa0\nwhen we see these neuropathic fractures um do"}, {'start': '1044.360', 'end': '1050.400', 'text': 'you fix it like you fix it with the cism monic\xa0\nuh screw ladder or do you just go straight to'}, {'start': '1050.400', 'end': '1056.160', 'text': 'primary Fusion we kind of have that debate pretty\xa0\nregularly um obviously a lot of factors that help'}, {'start': '1056.160', 'end': '1063.480', 'text': 'with that decision fracture pattern how old is it\xa0\ncompliance health of the patient Etc um I love the'}, {'start': '1063.480', 'end': '1070.560', 'text': 'nail technique obviously for the fusion I usually\xa0\njust use the largest hind foot nail but the feral'}, {'start': '1070.560', 'end': '1077.640', 'text': 'nails are great um other alternative we do do\xa0\na lot of frames with our nails for these people'}, {'start': '1077.640', 'end': '1083.160', 'text': "particularly the guy you showed who's probably\xa0\nnot going to be compliant it may just it's sort"}, {'start': '1083.160', 'end': '1087.760', 'text': "of a belts and suspenders approach I don't know\xa0\nhow much it changes the outcome but it certainly"}, {'start': '1087.760', 'end': '1093.640', 'text': 'makes us feel better so anyway that that was a\xa0\ngreat case um so moving on to my case this is'}, {'start': '1093.640', 'end': '1104.400', 'text': 'a non- neuropathic uh ankle arthritis infusion um\xa0\ncase and because this is a complications seminar'}, {'start': '1104.400', 'end': '1108.880', 'text': "I will of course this is going to come with\xa0\nwith some history here so he's a 68-year-old"}, {'start': '1108.880', 'end': '1114.680', 'text': "really really delightful guy I've gotten to be\xa0\nquite um friendly with him over the last few"}, {'start': '1114.680', 'end': '1121.920', 'text': "years uh he's a retired farmer he lives about\xa0\nan hour outside of Charlotte um loves hunting"}, {'start': '1121.920', 'end': '1129.000', 'text': "and loves golf he's he's very very active really\xa0\ndoesn't have any significant medical history if"}, {'start': '1129.000', 'end': '1134.000', 'text': "if you talk to him just about his history over the\xa0\nyears he's always had these high arched cave his"}, {'start': '1134.000', 'end': '1140.800', 'text': "feet uh as as we as we've heard the story many\xa0\ntimes uh with that he's had many many lateral"}, {'start': '1140.800', 'end': '1147.560', 'text': 'ankle sprains over the years he actually played\xa0\nuh basketball in college and um was was quite'}, {'start': '1147.560', 'end': '1155.080', 'text': 'quite an athlete at one point so that was where\xa0\nthings started with him he underwent ultimately'}, {'start': '1155.080', 'end': '1161.760', 'text': "in his 40s or so he's now in his 60s he underwent\xa0\nbilateral cavis reconstructions they were not"}, {'start': '1161.760', 'end': '1166.680', 'text': "done here in Charlotte I didn't have the records\xa0\nbut we could kind of figure out it was kind of a"}, {'start': '1166.680', 'end': '1175.920', 'text': 'bread and butter calcen ostomy first metatarsal\xa0\ndors infection osteotomy and brooms that those'}, {'start': '1175.920', 'end': '1183.440', 'text': 'did fine for a while then he developed Progressive\xa0\nankle arthritis Varys ankle arthritis incongruent'}, {'start': '1183.440', 'end': '1191.560', 'text': 'ble varis ankle arthritis and then underwent five\xa0\nyears to him presenting to me underwent staged But'}, {'start': '1191.560', 'end': '1199.000', 'text': 'ultimately bilateral arthoscopic ankle fusions\xa0\num done in another facility and that they those'}, {'start': '1199.000', 'end': '1205.960', 'text': "did well in his in his words for for a while uh he\xa0\ndidn't have any postoper problems with with any of"}, {'start': '1205.960', 'end': '1212.840', 'text': "with any of these surgeries by his report comes\xa0\nto see us here in Charlotte at this point he's"}, {'start': '1212.840', 'end': '1219.680', 'text': "five years out from his ankle fusions he's having\xa0\nProgressive bilateral hindfoot pain both sides are"}, {'start': '1219.680', 'end': '1226.120', 'text': 'equally bad and you can see this when he walks he\xa0\ndefinitely has residual Varys look at the bottom'}, {'start': '1226.120', 'end': '1234.120', 'text': "of his shoes he's worn out the lateral sides he's\xa0\nOrthotics it hasn't helped um he I think I was the"}, {'start': '1234.120', 'end': '1240.880', 'text': "the third provider he'd seen over the course of\xa0\nprobably six months um he'd seen actually two two"}, {'start': '1240.880', 'end': '1246.880', 'text': "colleagues who were fantastic so he he'd gotten\xa0\nsome really good opinions and ideas um he through"}, {'start': '1246.880', 'end': '1252.920', 'text': 'the course of that he had subtor injections that\xa0\nprovided 100% relief although they were fairly'}, {'start': '1252.920', 'end': '1259.840', 'text': "short acting um and he at this point wears he's\xa0\ntried custom bracing orthotic Etc at this point"}, {'start': '1259.840', 'end': '1266.080', 'text': 'he just likes wearing all off the-shelf lace up\xa0\nbraces particularly when he hunts and and when he'}, {'start': '1266.080', 'end': '1275.840', 'text': "golfs he is um as I said he played basketball tall\xa0\nguy 65 215 so his BMI is very reasonable he's got"}, {'start': '1275.840', 'end': '1284.240', 'text': 'healed scars bilaterally very healthy soft tissue\xa0\nenvelopes a little hard to tell whether the varus'}, {'start': '1284.240', 'end': '1290.080', 'text': "was from his heel or from his ankle you know we're\xa0\nall used to these cases where it's just a little"}, {'start': '1290.080', 'end': '1297.080', 'text': 'hard to separate the two even with good Imaging I\xa0\nthought that his ankles refused in some residual'}, {'start': '1297.080', 'end': '1303.600', 'text': 'Varys and then under that he had another 10 to\xa0\n15 degrees of heel Varys based on clinical exam'}, {'start': '1303.600', 'end': '1309.600', 'text': "and supported by Imaging which I'll show you as\xa0\nyou can imagine really stiff hind feet I mean his"}, {'start': '1309.600', 'end': '1315.760', 'text': 'subtor joints were almost locked in varis very\xa0\ntender on the sin of tar side consistent with'}, {'start': '1315.760', 'end': '1323.280', 'text': "the subtor problems you know he'd had some the at\xa0\nleast the first met aami prior and I thought his"}, {'start': '1323.280', 'end': '1329.520', 'text': 'foot otherwise looked looked pretty reasonable I\xa0\nthought really most of for me was hind foot and'}, {'start': '1329.520', 'end': '1339.120', 'text': "then some from the ankle here's his Imaging so\xa0\nbilateral standing ankle x-rays as I'd mentioned"}, {'start': '1339.120', 'end': '1347.160', 'text': 'earlier had undergone arthoscopic ankle fusions\xa0\num large Cy screw fixation fibes were spared of'}, {'start': '1347.160', 'end': '1353.360', 'text': "course and the fusions look great here I you know\xa0\nit's kind of hard to tell if the the position of"}, {'start': '1353.360', 'end': '1356.680', 'text': 'the fusions I thought the clinical exam was\xa0\na little bit easier I think you can certainly'}, {'start': '1356.680', 'end': '1362.480', 'text': "appreciate that the distal part of the Imaging\xa0\nthat that he's definitely in vars at least below"}, {'start': '1362.480', 'end': '1370.200', 'text': "the ankle fusions here's a lateral of the left\xa0\nsolid Fusion a little bit of cavis I didn't"}, {'start': '1370.200', 'end': '1377.880', 'text': 'think it was honestly too bad um at least on the\xa0\nlateral weightbearing x-ray we got standing CT'}, {'start': '1377.880', 'end': '1382.520', 'text': 'scans which are gosh are so helpful for cases like\xa0\nthis at least for me especially when the deformity'}, {'start': '1382.520', 'end': '1389.760', 'text': "analysis I'll zip through the sagul here of\xa0\ncourse you see the solid ankle Fusion inage"}, {'start': '1389.760', 'end': '1397.000', 'text': 'ankle arthritis no surprise there a little bit of\xa0\ntan arthritis as well which is a bit worrisome but'}, {'start': '1397.000', 'end': '1408.440', 'text': "his symptoms seem to be entirely from his subtor\xa0\njoints and here's the coronal I'll pause it here"}, {'start': '1410.480', 'end': '1419.240', 'text': "and you can see how much varys's heel is in there\xa0\nsub tailor joints in a bit of Varys I felt like"}, {'start': '1419.240', 'end': '1424.120', 'text': "it's it's a bit hard to tell because his ankle\xa0\nFusion is so is so um well Consolidated but I did"}, {'start': '1424.120', 'end': '1433.160', 'text': 'think he had some vars through his through his\xa0\nankle based on this CT scan so problem list um'}, {'start': '1433.160', 'end': '1439.120', 'text': 'healthy gentlemen with in stage subt arthritis\xa0\nunder what I thought were U Mal United ankle'}, {'start': '1439.120', 'end': '1449.440', 'text': "fusions and reasonable foot alignment um he has\xa0\num as I said he'd gotten some other opinions"}, {'start': '1449.440', 'end': '1456.000', 'text': "clearly the Pain's coming from his subtor joints\xa0\nbut he's got alignment issues as well and uh we"}, {'start': '1456.000', 'end': '1462.480', 'text': "kind of went through and he's at this point he's\xa0\nhe's ready to do something and we kind of went"}, {'start': '1462.480', 'end': '1468.720', 'text': 'through the list of options uh one was just do a\xa0\nsubtor Fusion alone under the ankle f fusion and'}, {'start': '1468.720', 'end': '1473.160', 'text': "correct as much as the various as you can you know\xa0\nwe all know that there's a much higher non-union"}, {'start': '1473.160', 'end': '1481.080', 'text': 'rate sub Fusion under an ankle which is kind of\xa0\nanother discussion um but that was one option and'}, {'start': '1481.080', 'end': '1486.480', 'text': "I'd considered I was considering just if I did\xa0\nthat I'd probably just do big log culated screws"}, {'start': '1486.480', 'end': '1496.720', 'text': "Alone um or this was an opinion from a colleague\xa0\nconvert the ankle Fusion especially since he's"}, {'start': '1496.720', 'end': '1503.440', 'text': 'got bilateral disease convert the what whichever\xa0\nside you want to do first Fusion to replacement'}, {'start': '1503.440', 'end': '1509.000', 'text': "which will offload a subtor joint although it\xa0\ndoesn't necessarily correct the deformity and"}, {'start': '1509.000', 'end': '1514.680', 'text': 'then you could stage the subtor fusion if you\xa0\nwanted to or do it at the same time and whether'}, {'start': '1514.680', 'end': '1518.840', 'text': 'you wanted add disl TI osteotomy or not if you\xa0\nthought the ankle was a problem you could do that'}, {'start': '1518.840', 'end': '1523.880', 'text': 'or you could just get your ankle correction with\xa0\nyour replacement so a lot to unpack there but the'}, {'start': '1523.880', 'end': '1528.440', 'text': "general approach with this one is you're going\xa0\nto convert the fusion to replacement and then"}, {'start': '1528.440', 'end': '1536.680', 'text': 'fix the foot in the subtor joint in different ways\xa0\nto sort of skin that cat number three um fuse a'}, {'start': '1536.680', 'end': '1542.240', 'text': 'subtor joint which I think you obviously you can\xa0\nget at least 10 15 degrees maybe more correction'}, {'start': '1542.240', 'end': '1552.640', 'text': 'through that and then add an ostomy at the level\xa0\nof or just above the ankle um fusion and now so'}, {'start': '1552.640', 'end': '1556.800', 'text': "went through all this with them I I thought it was\xa0\nreally down to number two or number three I didn't"}, {'start': '1556.800', 'end': '1561.960', 'text': "think a subta fusion alone would I was worried he\xa0\nwould still he'd still be in a lot of vars I just"}, {'start': '1561.960', 'end': '1568.720', 'text': "I don't personally get a feel like I get a lot of\xa0\nCorrection a lot of Correction just for sub tailor"}, {'start': '1568.720', 'end': '1573.160', 'text': "Fusion alone I mean you can do flat cuts and\xa0\nthere's there's some tricks but even then I think"}, {'start': '1573.160', 'end': '1581.400', 'text': "it's a hard joint to to realign substantially so I\xa0\nwas kind of leaning towards if I'm G to fuse them"}, {'start': '1581.400', 'end': '1587.640', 'text': 'do number three because I could take a big wedge\xa0\nout of his the his that solid ankle fusion and'}, {'start': '1587.640', 'end': '1595.440', 'text': "really get him over well um in terms of number two\xa0\nwe talked about it for quite a while he he didn't"}, {'start': '1595.440', 'end': '1604.600', 'text': "like the idea of two surgeries um pretty simple\xa0\nguy um I mean again hunts and golfs I thought he's"}, {'start': '1604.600', 'end': '1609.560', 'text': 'already basically got a TTC Fusion as stiff as hin\xa0\nfoot is so I thought if I could just give this guy'}, {'start': '1609.560', 'end': '1616.080', 'text': "pain relief with one surgery he'd be happy and\xa0\num I and and I also have not had great results"}, {'start': '1616.080', 'end': '1622.560', 'text': "with ankle Fusion takes down takedowns I I still\xa0\ndo them but I don't I think they do okay not great"}, {'start': '1622.560', 'end': '1628.760', 'text': "so we were we were on the same page with this and\xa0\nso we both we both kind of decided let's let's do"}, {'start': '1628.760', 'end': '1637.960', 'text': 'number three so our approach was trans fibular\xa0\nremove the distl fibula for for the approach'}, {'start': '1637.960', 'end': '1641.280', 'text': "through that approach you know you're looking\xa0\nright at the distl tibia you can easily just do"}, {'start': '1641.280', 'end': '1649.520', 'text': 'a little closing wedge laterally then D more disly\xa0\ndo the subtor joint prep flat Cuts if you want to'}, {'start': '1649.520', 'end': '1654.480', 'text': 'to add a little more correction depending on what\xa0\nthe Insight you prep gives you proximal tiity'}, {'start': '1654.480', 'end': '1661.280', 'text': 'autographed and then a hind foot H Fusion nail I\xa0\nthink we probably all aggressively graft our subp'}, {'start': '1661.280', 'end': '1667.760', 'text': "fusions underneath an ankle Fusion just because\xa0\nit's not un risk so here um I wish I had better"}, {'start': '1667.760', 'end': '1674.960', 'text': "images from surgery but this is an interoperative\xa0\npicture the you can see the OST we end up we've"}, {'start': '1674.960', 'end': '1682.360', 'text': "removed the distal fibula and that's the osteotome\xa0\nacross the ankle we actually use a sagil saw but"}, {'start': '1682.360', 'end': '1688.640', 'text': "there's the otone we put in there to sort of\xa0\nfree things up and where do you cut it and how"}, {'start': '1688.640', 'end': '1694.040', 'text': "much bone you take honestly I just went in kind of\xa0\nthe distal metap area because it's there's a lot"}, {'start': '1694.040', 'end': '1700.360', 'text': "of bone there it's obviously healthy canels easier\xa0\nto get correction maybe a higher Fusion rate and I"}, {'start': '1700.360', 'end': '1711.200', 'text': "kind of guesstimate the wedge I don't do any sort\xa0\nof fancy uh geome geometrics on that um it usually"}, {'start': '1711.200', 'end': '1714.880', 'text': 'ends up being I kind of start with a smaller\xa0\nwedge and if I need more take more and just'}, {'start': '1714.880', 'end': '1721.360', 'text': "go b b based on kind of clinical clinical judgment\xa0\nand then so you can see the flat cut there there's"}, {'start': '1721.360', 'end': '1726.720', 'text': 'a thises after we put the rod in of course you\xa0\ncan see where we did the osteotomy above just'}, {'start': '1726.720', 'end': '1732.120', 'text': 'above the ankle Fusion swung the the hind foot\xa0\nover as much as we could and then use the TTC'}, {'start': '1732.120', 'end': '1738.040', 'text': "nail and then put the fibula back with a couple\xa0\nof screws and there's our kind of final position"}, {'start': '1738.840', 'end': '1746.560', 'text': 'and I I I did tell him that you still have the\xa0\nopportunity to to to convert the sanle replacement'}, {'start': '1746.560', 'end': '1751.400', 'text': "down the road if you ever needed to I don't\xa0\nthink you'll need that but with the fiber sparing"}, {'start': '1751.400', 'end': '1755.480', 'text': "technique and everything else we've done here you\xa0\nyou you certainly haven't burn any Bridges which"}, {'start': '1755.480', 'end': '1761.000', 'text': 'that was another kind of point that um I wanted\xa0\nto make with this with this case so there he is'}, {'start': '1761.000', 'end': '1766.240', 'text': 'and he was nonweightbearing for six weeks and\xa0\nin a walking boot for three to four weeks and'}, {'start': '1766.240', 'end': '1775.000', 'text': 'U then we end up he did great this is here is\xa0\nhis probably six Monon posttop X-ray and then'}, {'start': '1775.000', 'end': '1783.760', 'text': "um there's a lateral and of course getting axial\xa0\nimages during surgery and after surgery um is is"}, {'start': '1783.760', 'end': '1790.200', 'text': 'very very helpful certainly during surgery to to\xa0\nassess your your realignment I thought thought'}, {'start': '1790.200', 'end': '1795.360', 'text': 'we got them he still May been a little vars but\xa0\nI thought it was it was a huge Improvement and'}, {'start': '1795.360', 'end': '1800.080', 'text': "that's with a disal tiia osteotomy I think it\xa0\nwould have been been way way underpowered if if"}, {'start': '1800.080', 'end': '1805.760', 'text': "we hadn't done that and then we end up doing his\xa0\nother side so now he's got bilateral TTC Fusion"}, {'start': '1805.760', 'end': '1812.920', 'text': 'so takeen points obviously F the ankle correct\xa0\nthe first time I think particularly these cases'}, {'start': '1812.920', 'end': '1818.560', 'text': 'that have um like the longstanding CIS foot\xa0\nand then you get various Anor arthritis above'}, {'start': '1818.560', 'end': '1823.920', 'text': 'it seems like those are the ones that sometimes\xa0\nwe under we tend to undercorrect and probably'}, {'start': '1823.920', 'end': '1830.440', 'text': "should be overcorrected if anything uh I don't\xa0\nI do arthroscopic ankle fusions but I also do"}, {'start': '1830.440', 'end': '1835.440', 'text': "open I have a low threshold for an open arthodesis\xa0\nif there's deformity I think it's just harder to"}, {'start': '1835.440', 'end': '1841.600', 'text': 'get good correction arthroscopically that may have\xa0\nbeen one hurdle here um I think somebody that does'}, {'start': '1841.600', 'end': '1846.160', 'text': "have a m un ankle Fusion I have a low threshold\xa0\nfor for realigning it I don't think it's hard"}, {'start': '1846.160', 'end': '1851.360', 'text': "to realign it and I think it's they're just very\xa0\npoorly tolerated I mean if you fuse somebody in"}, {'start': '1851.360', 'end': '1857.920', 'text': "the wrong position at least my experience has been\xa0\nit's it's not um even with Orthotics and bracing"}, {'start': '1859.280', 'end': '1863.720', 'text': "really hard to get them over the hump if\xa0\nthey're not planning grade um I love I love"}, {'start': '1863.720', 'end': '1867.080', 'text': "H up Fusion nails for the subta fusion\xa0\nunder ankle Fusion just think it's sort"}, {'start': '1867.080', 'end': '1874.520', 'text': 'of better better stability and fixation and\xa0\nBridges bridges it all and um as I mentioned'}, {'start': '1874.520', 'end': '1878.760', 'text': 'earlier if you can save the fibula just so you\xa0\ncan leave an option open for a tar conversion'}, {'start': '1878.760', 'end': '1885.800', 'text': "down the road if possible so uh anyway that's\xa0\nit I thought that was a an interesting case"}, {'start': '1885.800', 'end': '1890.720', 'text': 'on how to what not to do the first time\xa0\nthen how to how to fix it if if it comes'}, {'start': '1890.720', 'end': '1896.840', 'text': "your way and at that point I'll I'll hop off\xa0\nand I'll turn it back over to you eron thank"}, {'start': '1896.840', 'end': '1907.600', 'text': "you thanks K that's a great case that's uh very\xa0\ninteresting very complicated um thank you for"}, {'start': '1907.600', 'end': '1912.800', 'text': "um for that um all right we got some questions\xa0\ncoming in I think we'll we'll go over each of"}, {'start': '1912.800', 'end': '1918.160', 'text': "the questions at the end of the of the talks\xa0\nhere um so I'll I'll kick it over to to David"}, {'start': '1918.160', 'end': '1924.600', 'text': 'Richardson here um and continue on with our talks\xa0\nthat that looked amazing Carol and certainly that'}, {'start': '1924.600', 'end': '1932.480', 'text': 'was a complicated uh ankle Fusion or TTC Fusion\xa0\nwithout complications from from your standpoint'}, {'start': '1932.480', 'end': '1936.880', 'text': 'I think it look good I agree with you with the\xa0\narthoscopic part of this I think you ought to'}, {'start': '1936.880', 'end': '1942.200', 'text': "have a really low threshold um you know not just\xa0\nopening it but but putting a plate I think there's"}, {'start': '1942.200', 'end': '1949.920', 'text': 'pretty good literature to suggest that a plate\xa0\nincreases their um chance of getting a fusion'}, {'start': '1949.920', 'end': '1955.640', 'text': 'and outcomes improves outcomes by adding a plate\xa0\nyou can add a small anterior plate that are out'}, {'start': '1955.640', 'end': '1961.080', 'text': "now without without opening them up too much more\xa0\nthan that but but I'm pretty quick to open them"}, {'start': '1961.080', 'end': '1968.840', 'text': 'and very quick to to put a plate on as well with\xa0\nthat but I think that that looked great um all'}, {'start': '1968.840', 'end': '1978.400', 'text': "right so managing uh complication ankle fusions\xa0\nI'm David Richardson Campbell Clinic talk about"}, {'start': '1978.400', 'end': '1984.200', 'text': "some of my mistakes because I that's going to be\xa0\nthe main part of this talk or the ways I I screwed"}, {'start': '1984.200', 'end': '1991.080', 'text': "this up and so we'll we'll go through this so 71\xa0\nyear old draining lateral ankle wound you can see"}, {'start': '1991.080', 'end': '1997.560', 'text': 'here has some drainage laterally cus maybe even\xa0\npurulent serious drainage over here laterally'}, {'start': '1997.560', 'end': '2007.920', 'text': 'looked pretty good so she had a bom fracture with\xa0\nsurgery a year prior uh walked on this it fell'}, {'start': '2007.920', 'end': '2017.640', 'text': 'part on her and U and so went back to surgery two\xa0\nweeks after the index procedure um have to have'}, {'start': '2017.640', 'end': '2025.040', 'text': 'this revised five months maybe four months later\xa0\nshe started having medial and lateral drainage'}, {'start': '2025.040', 'end': '2031.320', 'text': "from her ankle increased markers cultures are\xa0\nnegative in the physician's office placed on"}, {'start': '2031.320', 'end': '2038.680', 'text': 'Clint M she bounced along for a while few months\xa0\nlater uh had removed her heart remedially due to'}, {'start': '2038.680', 'end': '2047.280', 'text': 'continued drainage her inability to bear weight\xa0\nlast scene by the uh treating physician in October'}, {'start': '2047.280', 'end': '2053.320', 'text': 'and then presented to me about a year after\xa0\nher initial injury this is her x-rays you can'}, {'start': '2053.320', 'end': '2060.400', 'text': 'see loose Hardware uh you can see the ankle joint\xa0\nlooks pretty trash non-union of the medial M and'}, {'start': '2060.400', 'end': '2067.040', 'text': 'yes has an intered screw at this point as well\xa0\nthese are non-weightbearing films which I think'}, {'start': '2067.040', 'end': '2072.400', 'text': "matter um she couldn't bear weight but but I do\xa0\nthink you need to think through that um in looking"}, {'start': '2072.400', 'end': '2077.040', 'text': 'at this I thought her ankle joint looked pretty\xa0\nterrible but her subtor joint might at least be'}, {'start': '2077.040', 'end': '2084.640', 'text': "reduced if not and be reasonably maintained on\xa0\nthis so she's a half a pack a day smoker for a lot"}, {'start': '2084.640', 'end': '2090.040', 'text': 'of years um probably more than that she always\xa0\nsmelled like like cigarettes coronary artery'}, {'start': '2090.040', 'end': '2097.640', 'text': 'disease um importantly she had a right total knee\xa0\nin 2012 that became infected and had to be revived'}, {'start': '2098.200', 'end': '2104.760', 'text': 'two months later um has and done well since\xa0\nlaminectomy right ankle surgery that we just'}, {'start': '2104.760', 'end': '2111.000', 'text': 'talked about so on exam she had a draining\xa0\nlateral wound valgus ankle good pulses early'}, {'start': '2111.000', 'end': '2115.120', 'text': 'peral neuropathy but does have protective\xa0\nsensation good range of motion over her knee'}, {'start': '2115.120', 'end': '2122.720', 'text': 'without evidence of pain instability although\xa0\nagain non- weightbearing or infection she has'}, {'start': '2122.720', 'end': '2130.040', 'text': 'intermittent fever up to 102 degrees Fahrenheit\xa0\nunable to bear weight for three months lives alone'}, {'start': '2130.040', 'end': '2134.800', 'text': "daughter can help with some activities of daily\xa0\nliving they're not going to live together and"}, {'start': '2134.800', 'end': '2141.000', 'text': "we're pretty clear about that in either direction\xa0\ndaughter living with her or vice versa so I had"}, {'start': '2141.000', 'end': '2146.320', 'text': 'to think through that as well so uh her markers\xa0\nwhen she saw me were up WBC and vitamin D was'}, {'start': '2146.320', 'end': '2152.080', 'text': 'normally got a CAT scan some thoughts might have\xa0\nbeen to get an MRI or a taged white blood cell'}, {'start': '2152.080', 'end': '2157.920', 'text': "scan or a spec scan didn't think that was going to\xa0\nchange how I was going to approach this so didn't"}, {'start': '2157.920', 'end': '2165.440', 'text': 'do that so got a CAT scan the ankle joint looked\xa0\npretty terrible um sub tailor joint also looked'}, {'start': '2165.440', 'end': '2171.480', 'text': "pretty terrible but for some reason I I sort\xa0\nof chose to ignore that um that I'll that I'll"}, {'start': '2171.480', 'end': '2182.360', 'text': 'regret but um meditor to the hospital ID consult\xa0\nuh V conop Pine empirically per ID consulted case'}, {'start': '2182.360', 'end': '2188.280', 'text': 'management for placement performed a fibular\xa0\nosteotomy removed her Hardware you can see no'}, {'start': '2188.280', 'end': '2195.040', 'text': 'fibula here also performed a medial malar\xa0\nosteotomy um as she was still had a wound'}, {'start': '2195.040', 'end': '2200.880', 'text': 'medially and wanted to to decompress her and\xa0\nget bone biopsy and just to breed her on that'}, {'start': '2200.880', 'end': '2209.440', 'text': "side as well so that's January 14 um at that\xa0\nsurgery placed antibiotic spacer cement spacer"}, {'start': '2209.440', 'end': '2218.160', 'text': 'vamy and an Amo glycoside um is that the the\xa0\nright antibiotic spacer is is that the right'}, {'start': '2218.160', 'end': '2225.280', 'text': "anti antibiotic cement construct I'm not I'm\xa0\nnot so sure and we'll talk about that this is"}, {'start': '2225.280', 'end': '2234.680', 'text': 'the surgery I performed and importantly January\xa0\n14th 10 days later took her back and did this um'}, {'start': '2234.680', 'end': '2240.880', 'text': "to or still has that screw because I couldn't\xa0\nfigure how to get it out um at least at least"}, {'start': '2240.880', 'end': '2247.800', 'text': "doing what I was doing couldn't figure out how to\xa0\nhow to get it out so this is what I did for her um"}, {'start': '2247.800', 'end': '2252.320', 'text': 'is that the right interval I think we probably\xa0\nknow the answer to that and is that the right'}, {'start': '2252.320', 'end': '2257.400', 'text': 'construct and I think I think most people probably\xa0\nknow the answer to that as well so cultures came'}, {'start': '2257.400', 'end': '2265.560', 'text': 'back as methol inist sensitive and resistant staff\xa0\nAras bobc result should osteitis of her fibula but'}, {'start': '2265.560', 'end': '2271.920', 'text': 'not ativia or tus admitted to a nursing facility\xa0\nafter a few days in the hospital to assist with'}, {'start': '2271.920', 'end': '2279.720', 'text': "adl's ambulation um placed on vamy IV based\xa0\non sensitiv ities bone stimulator was ordered"}, {'start': '2279.720', 'end': '2288.520', 'text': 'but but denied by Insurance because she had not\xa0\nhad 90 days to to have an established non-union'}, {'start': '2288.520', 'end': '2295.160', 'text': "so it came back uh what five months later or so\xa0\nlooking like this really didn't have much pain"}, {'start': '2295.160', 'end': '2303.320', 'text': 'was ambulating I was fairly pleased with this but\xa0\nas Carol Jones has has taught us in the past with'}, {'start': '2303.320', 'end': '2308.360', 'text': "some of his literature um you really don't know\xa0\nwithout a cad scan whether that's a fusion or"}, {'start': '2308.360', 'end': '2316.360', 'text': 'not it can look pretty good radiographically but\xa0\nnot necessarily once you get a CT scan um so that'}, {'start': '2316.360', 'end': '2321.760', 'text': "certainly looks iffy when you zoom in it's sort of\xa0\nsort of wondering but she wasn't hurting and doing"}, {'start': '2321.760', 'end': '2327.720', 'text': 'pretty well so we bounced along a little bit came\xa0\nback a few months later now she is hurting still'}, {'start': '2327.720', 'end': '2333.880', 'text': "weightbearing but has pain that's looking even\xa0\nmore iffy at this point still see that screw sub"}, {'start': '2333.880', 'end': '2339.880', 'text': 'tailor joint looks uh certainly a little worse\xa0\nso a little more unstable there and so we got an'}, {'start': '2339.880', 'end': '2346.120', 'text': 'AIT alignment view released an axial view of her\xa0\nheel and that certainly looks unstable looks like'}, {'start': '2346.120', 'end': '2353.080', 'text': "she's an asymmetric valgus sign valgus on the left\xa0\nside too but significantly asymmetrically valgus"}, {'start': '2353.080', 'end': '2362.440', 'text': 'on the right side um obtain a CAT scan show some\xa0\navascular changes of her tailor body a non-union'}, {'start': '2362.440', 'end': '2368.040', 'text': 'of her tibio Taylor joint and significant\xa0\nhindfoot vgas this are calcal 2 a little'}, {'start': '2368.040', 'end': '2376.200', 'text': 'tough to see right there but a significant vus in\xa0\nher hindfoot that was in November this is her cat'}, {'start': '2376.200', 'end': '2383.240', 'text': "scan that's going to show that that same thing\xa0\nshe has a non-union of her ankle joint um seen"}, {'start': '2383.240', 'end': '2390.280', 'text': 'here and then this H this significant instability\xa0\nof her SE Taylor joint and then dramatic hindfoot'}, {'start': '2390.280', 'end': '2399.520', 'text': 'balgas lab workups were really normal um CT scan\xa0\nwe just talked about the um ankle looked all right'}, {'start': '2399.520', 'end': '2403.360', 'text': "she didn't have any draining wound didn't have\xa0\na lot of swelling she's unable to bear weight"}, {'start': '2403.360', 'end': '2408.440', 'text': "you can see she's in a wheelchair obviously she\xa0\nhad bounced along she wasn't willing to undergo"}, {'start': '2408.440', 'end': '2414.000', 'text': "more surgery and I don't blame her she had had\xa0\na been through a lot but now she's not able to"}, {'start': '2414.000', 'end': '2420.400', 'text': "to walk on it she lives by herself she's pretty\xa0\nmiserable so wants something else done so we go"}, {'start': '2420.400', 'end': '2428.600', 'text': 'in I do put a put a guide pin in and Reed from\xa0\nthe plannerly up through the Cal and tus and dir'}, {'start': '2428.600', 'end': '2433.480', 'text': 'tiia so I can get this screw I do have to make a\xa0\nlittle cortical window which I made through the'}, {'start': '2433.480', 'end': '2437.440', 'text': 'previous screw hole sites I connected to screw\xa0\nholes over here so I could stabilize because I'}, {'start': '2437.440', 'end': '2444.400', 'text': "was starting to push that screw up towards her\xa0\ntotal H knee this did not work by the way it's"}, {'start': '2444.400', 'end': '2452.120', 'text': 'just what I had had saved I had to grab that screw\xa0\nand then put a long kous roner up once I had it'}, {'start': '2452.120', 'end': '2457.520', 'text': "down enough to be able to grab it and that's how\xa0\nwe got it out then I put antibotic beads which"}, {'start': '2457.520', 'end': '2462.720', 'text': 'probably better for her I increased antibiotic\xa0\nconcentration with the beads rather than the'}, {'start': '2462.720', 'end': '2471.640', 'text': 'spacer but put these beads in in March um and\xa0\ncultures now just methylin sensitive staf arus for'}, {'start': '2471.640', 'end': '2479.160', 'text': 'the culture results positive biopsy for osteitis\xa0\nof the tus negative on the Tivia admitted to skill'}, {'start': '2479.160', 'end': '2487.240', 'text': 'nursing again dapy and based on sensitivities\xa0\nand referred to a nutritionist the um'}, {'start': '2489.320', 'end': '2498.160', 'text': 'which perhaps should have been done early so um\xa0\ncame back in May this is about two months later'}, {'start': '2498.160', 'end': '2506.160', 'text': 'and did a tibio tibio calcal fusion essentially\xa0\nthe tus was pretty terrible sort of fell apart'}, {'start': '2506.160', 'end': '2511.520', 'text': 'I do have a little bit of the tailor head left\xa0\nbut the body and neck are pretty gone used a five'}, {'start': '2511.520', 'end': '2518.240', 'text': 'degree valgus locking plate or five degree valgus\xa0\nplate so I could try to get as much uh fixation'}, {'start': '2518.240', 'end': '2524.840', 'text': 'in the calanus as possible already in a lot of\xa0\nvalgus but I did want to make sure I got good'}, {'start': '2524.840', 'end': '2533.240', 'text': 'fixation of the calcan so chose this uh one of the\xa0\nindustry has a a valgus nail so used that valgus'}, {'start': '2533.240', 'end': '2541.520', 'text': 'nail for a load bearing and load sharing construct\xa0\nso this is 18 months later or so 17 months later'}, {'start': '2541.520', 'end': '2547.120', 'text': "she's done very well weightbearing is tolerated\xa0\nand and ended up healing after being through"}, {'start': '2547.800', 'end': '2554.400', 'text': "put through a lot more than she probably deserved\xa0\num so why did she fail I think that's why you need"}, {'start': '2554.400', 'end': '2559.880', 'text': "to all ask what you need to ask yourself when\xa0\nthese don't go right so nutrition she was non-"}, {'start': '2559.880', 'end': '2566.280', 'text': "ulating she's a smoker she lives by herself she's\xa0\nelderly she's somewhat frail she almost certainly"}, {'start': '2566.280', 'end': '2573.120', 'text': 'was malnourished I did not really work that up\xa0\nshe has osteoporosis been on fosx for three years'}, {'start': '2573.120', 'end': '2580.040', 'text': "didn't really work get her reexamined and see if\xa0\nthat might be optimized in any way I did what we"}, {'start': '2580.040', 'end': '2588.840', 'text': 'all do you should stop smoking increases your\xa0\nrisk but did not send her for any nicotine um'}, {'start': '2588.840', 'end': '2598.360', 'text': "uh supplementation or or transition nicotine um or\xa0\nget her off nicotine uh and um and then she's able"}, {'start': '2598.360', 'end': '2603.720', 'text': "to she's unable to comply with weightbearing she\xa0\nhad been through through multiple rounds of this"}, {'start': '2603.720', 'end': '2608.240', 'text': 'a lot of people had tried multiple different\xa0\nways to tell her not to put wait on this and'}, {'start': '2608.240', 'end': '2613.440', 'text': 'she was going to bear weight and I needed to\xa0\nto understand that that was going to happen so'}, {'start': '2613.440', 'end': '2619.280', 'text': 'understanding the chronicity she had been through\xa0\na lot more than she she needed to be it had been'}, {'start': '2619.280', 'end': '2624.960', 'text': 'a year when she first saw me she had been through\xa0\nthree surgeries I needed to be to do everything I'}, {'start': '2624.960', 'end': '2631.200', 'text': 'could to make this the the definitive treatment so\xa0\nI needed to have understood the chronicity of this'}, {'start': '2631.200', 'end': '2637.320', 'text': "that I didn't very well understood the patient\xa0\nbetter than I did understand that I was getting a"}, {'start': '2637.320', 'end': '2642.360', 'text': 'non-weightbearing physical exam because she could\xa0\nnot bear weight and be careful with that take a'}, {'start': '2642.360', 'end': '2647.160', 'text': "little more time with that and understanding that\xa0\nI couldn't watch her walk I couldn't just watch"}, {'start': '2647.160', 'end': '2652.200', 'text': "her even stand and get an idea of her alignment\xa0\nthat way and she corrected really well it's just"}, {'start': '2652.200', 'end': '2659.360', 'text': "sitting on the table but that's on me to recognize\xa0\nthat surgical construct maybe beads in and then a"}, {'start': '2659.360', 'end': '2667.200', 'text': "nail so I wasn't reaming through a potential area\xa0\nof infection so perhaps the beads to get rid of"}, {'start': '2667.200', 'end': '2673.240', 'text': 'infection in that area first and then a subsequent\xa0\nnail and then a load sharing construct might have'}, {'start': '2673.240', 'end': '2679.000', 'text': 'been better for her in order a a bone stimulator\xa0\npreoperatively she had a non-union from her'}, {'start': '2679.000', 'end': '2682.560', 'text': 'fracture side I probably could have gotten a\xa0\nbone stimulator if I had done it on the front'}, {'start': '2682.560', 'end': '2688.040', 'text': 'end said she had an established non-union of ref\xa0\nfracture could have had that ready for her and'}, {'start': '2688.040', 'end': '2695.320', 'text': 'used it earlier and not had to wait 90 days for a\xa0\nbone stimulator so this is the antibiotic uh that'}, {'start': '2695.320', 'end': '2700.200', 'text': "uh that was chosen I've already shown this is\xa0\nthe correct antibiotics probably correct cement"}, {'start': '2700.200', 'end': '2707.520', 'text': 'construct probably not is it the right interval\xa0\ncertainly not so antibiotic cement so venamy'}, {'start': '2707.520', 'end': '2716.560', 'text': 'plus an aminoglycoside um is is probably the right\xa0\nempiric treatment broad coverage um aminoglycoside'}, {'start': '2716.560', 'end': '2723.040', 'text': 'promotes meamy release uh ought to leave this in\xa0\nat least 90 days per the per I excuse me at least'}, {'start': '2723.040', 'end': '2730.400', 'text': '30 days per the literature use a cement um spacer\xa0\nif you need to to go back and do a total knee or'}, {'start': '2730.400', 'end': '2736.560', 'text': 'total ankle to to preserve that that soft tissue\xa0\nbut perhaps beads would be better um the the'}, {'start': '2736.560', 'end': '2743.840', 'text': 'elucidation of the antibiotic the how it leeches\xa0\nout of the cement is based on surface area so if'}, {'start': '2743.840', 'end': '2748.560', 'text': "you have beads they're going to do they're going\xa0\nto leech a lot more of antibiotic and that's been"}, {'start': '2748.560', 'end': '2754.520', 'text': "shown in in plenty of literature more so than a\xa0\nlarge spacer is going to and that's probably what"}, {'start': '2754.520', 'end': '2760.560', 'text': 'she needed is high concentration of antibiotics\xa0\nand people have asked why not just do both you got'}, {'start': '2760.560', 'end': '2768.840', 'text': 'to be really careful about that because the first\xa0\n24 hours uh these these antibiotic cement um has a'}, {'start': '2768.840', 'end': '2775.240', 'text': 'significant spike in the amount of antibiotics and\xa0\nso they can get toxic and locally or systemically'}, {'start': '2775.240', 'end': '2782.400', 'text': 'so be careful about that literature to say that\xa0\neither way they probably maintain the Min minimal'}, {'start': '2782.400', 'end': '2787.160', 'text': 'inhibitory concentration for up to four months\xa0\nbut but for her I think probably beads would have'}, {'start': '2787.160', 'end': '2793.120', 'text': 'better um this construct I probably should have\xa0\nIncorporated the sub tailor joint right off the'}, {'start': '2793.120', 'end': '2798.160', 'text': "bat I'm not probably I should have Incorporated\xa0\nthe sub tailor joint off that and used a load"}, {'start': '2798.160', 'end': '2804.280', 'text': 'sharing device so what I should have done the hard\xa0\nwork except perhaps that I am screwed right off'}, {'start': '2804.280', 'end': '2809.400', 'text': "the bat so I'm not reaming up through an area\xa0\nof infection she has a total knee above her I"}, {'start': '2809.400', 'end': '2815.480', 'text': "was very worried about infecting her knee she had\xa0\nalready had an infection had it revised she's a"}, {'start': '2815.480', 'end': '2821.880', 'text': 'smoker I was just concerned about that so uh maybe\xa0\nleave the am screw but do this uh construct right'}, {'start': '2821.880', 'end': '2828.360', 'text': 'off the bat um and leave it in for at least 30\xa0\ndays then perhaps come back at 30 days then put'}, {'start': '2828.360', 'end': '2837.320', 'text': "in an intermed uh antibiotic cement nail is shown\xa0\nhere this is H one of Dr Ryder and Dr ruof they're"}, {'start': '2837.320', 'end': '2843.680', 'text': 'both my partners and I think this technique was\xa0\ndescribed by by my previous partner Dr Perez just'}, {'start': '2843.680', 'end': '2848.480', 'text': 'to give everybody their their due here um but\xa0\nprobably should have done this come back and'}, {'start': '2848.480', 'end': '2855.960', 'text': 'and done that and then put in this load uh this\xa0\nconstruct um to give her a chance to maybe put'}, {'start': '2855.960', 'end': '2863.400', 'text': 'some weight on it and and have her first surgery\xa0\nLa have her last surgery first key takeaways'}, {'start': '2863.400', 'end': '2868.440', 'text': 'review notes prior to visit this is not someone\xa0\nthat I could have figured out in 15 minutes the'}, {'start': '2868.440', 'end': '2876.320', 'text': 'the 15 minute patient visit you know I looked over\xa0\nit beforehand but it was a ton of of notes and I'}, {'start': '2876.320', 'end': '2882.680', 'text': 'did not take my time to really know her Predator\xa0\na visit slows slow down when it feels complicated'}, {'start': '2882.680', 'end': '2889.160', 'text': "this certainly felt complicated I just needed to\xa0\ntake more time if it's a non-ion if it comes to"}, {'start': '2889.160', 'end': '2893.840', 'text': "you then then consider a bone stimulator obviously\xa0\nif it's your patient you might have already gotten"}, {'start': '2893.840', 'end': '2899.000', 'text': 'a bone stimulator by this time but if it comes to\xa0\nyou as a non-union consider going and ordering a'}, {'start': '2899.000', 'end': '2904.440', 'text': 'bone stimulator before you get them set up for\xa0\nsurgery careful physical exam especially if they'}, {'start': '2904.440', 'end': '2912.040', 'text': "can't bear weight cons consult uh those who need\xa0\nto be consulted and communicate with them call"}, {'start': '2912.040', 'end': '2916.960', 'text': "them beforehand get everything set up be sure\xa0\nthey're going to get in to see these folks in a"}, {'start': '2916.960', 'end': '2922.480', 'text': 'timely manner let them know this is a complicated\xa0\npatient as we just talked about so talk it through'}, {'start': '2922.480', 'end': '2928.760', 'text': 'with them ID consult a nutritionist uh would\xa0\nbe helpful we have I just said a family nurse'}, {'start': '2928.760', 'end': '2933.320', 'text': "practitioner because that's what we have here we\xa0\nactually have two who help us with peroperative"}, {'start': '2933.320', 'end': '2939.040', 'text': 'optimization are very good with this I actually\xa0\nprimarily work in a satellite clinic so they fall'}, {'start': '2939.040', 'end': '2944.840', 'text': "off my radar in a way that they shouldn't at\xa0\ntimes consult the case manager for placement"}, {'start': '2944.840', 'end': '2950.320', 'text': "early if it's staged due to infection consider\xa0\nyour cement construct the type of antibiotic and"}, {'start': '2950.320', 'end': '2954.440', 'text': "dosing you're going to use and the interval and\xa0\ntalk through that with the patient so they're"}, {'start': '2954.440', 'end': '2961.760', 'text': 'prepared consider patient social situation ability\xa0\nto maintain weightbearing status um when you have'}, {'start': '2961.760', 'end': '2967.320', 'text': "a complication draw these patients close you know\xa0\nthis is the time to let them know know you're"}, {'start': '2967.320', 'end': '2972.960', 'text': "going to be there you're going to get through this\xa0\ntogether you care about them as one of my mentors"}, {'start': '2972.960', 'end': '2979.720', 'text': "would say love them up um just uh just be sure\xa0\nthat they they know you're with them any patient"}, {'start': '2979.720', 'end': '2984.600', 'text': 'with a complication gets my cell phone number\xa0\nright off the bat my assistant knows to give'}, {'start': '2984.600', 'end': '2988.960', 'text': 'that to them soon as they have a complication\xa0\nthey have my cell phone some of you may may do'}, {'start': '2988.960', 'end': '2996.640', 'text': 'that with everyone but uh but I do it certainly\xa0\nwith complica complications and so love them up'}, {'start': '2997.200', 'end': '3002.680', 'text': 'um this is a lot of you guys know might know\xa0\nmy father and so I was going to put that on'}, {'start': '3002.680', 'end': '3007.200', 'text': "there this is a few days ago at a service event\xa0\nwe we were doing he's the one that taught me to"}, {'start': '3007.200', 'end': '3012.280', 'text': 'love love the specialy so my mom and dad came\xa0\nand stopped by so there he is all right thank'}, {'start': '3012.280', 'end': '3019.640', 'text': "you all right thank you David that was that\xa0\nwas a great case it's uh I'm still wondering"}, {'start': '3019.640', 'end': '3024.080', 'text': "how that screw got up there in the intermediary\xa0\nCanal that's that's I don't think I've ever seen"}, {'start': '3024.080', 'end': '3029.400', 'text': "that but that's very interesting so but thank you\xa0\nthat's a very uh very complicated case and brings"}, {'start': '3029.400', 'end': '3033.800', 'text': "out a lot of the points that we're trying to make\xa0\nhere of of evaluating your patients considering"}, {'start': '3033.800', 'end': '3037.840', 'text': "all the factors when we're going through a\xa0\ncomplicated surgery like this for treating"}, {'start': '3037.840', 'end': '3043.640', 'text': "them and as well as treating the complications\xa0\nso uh last thing I'm going to try to pull up uh"}, {'start': '3043.640', 'end': '3049.440', 'text': "Eddie how is not able to be with us he's uh\xa0\nI have another commitment but he has a um a"}, {'start': '3049.440', 'end': '3056.840', 'text': "talk that he's uh put together I'm going to try to\xa0\nrun that video now um see if I can bring that up"}, {'start': '3056.840', 'end': '3061.920', 'text': "here hello my name is Eddie halp I'm a foot\xa0\nanle orthopedic surgeon at the Mayo Clinic"}, {'start': '3061.920', 'end': '3066.400', 'text': "in Jacksonville Florida I'm going to talk\xa0\nabout some ankle Fusion complications uh"}, {'start': '3066.400', 'end': '3072.760', 'text': "this one's specifically about Avast necrosis from\xa0\ncovid-19 treatment uh first about me I'm actually"}, {'start': '3072.760', 'end': '3077.640', 'text': "from Central Florida I'm from a place called merid\xa0\nIsland Florida which is right next to Cape canabal"}, {'start': '3077.640', 'end': '3082.960', 'text': "think the notable things about that area is it's a\xa0\nbeautiful place but uh almost every were the space"}, {'start': '3082.960', 'end': '3088.280', 'text': 'industry or NASA or the cruise ship industry uh\xa0\nI went on a football scholarship at University of'}, {'start': '3088.280', 'end': '3092.120', 'text': 'Florida we were very successful in that period\xa0\nof time this is from the first of two national'}, {'start': '3092.120', 'end': '3097.320', 'text': 'championships when I was there I stayed there at\xa0\nUniversity of Florida for medical school I was a'}, {'start': '3097.320', 'end': '3104.600', 'text': 'resident there as well and uh you know classic\xa0\nFlorida man here Heisman with a uh an alligator'}, {'start': '3104.600', 'end': '3108.760', 'text': "uh when I was there I was you know very blessed\xa0\ngot married I had three little girls I couldn't do"}, {'start': '3108.760', 'end': '3114.240', 'text': 'this without them for sure we went to California\xa0\nfor Fellowship for Foot and Ankle training at'}, {'start': '3114.240', 'end': '3119.280', 'text': "Cedar son Medical Center it's a wonderful program\xa0\nvery grateful to have trained there and now I'm"}, {'start': '3119.280', 'end': '3123.680', 'text': "back in Florida I'm in Jacksonville now though\xa0\nand and I'm at the M clinic in Jacksonville where"}, {'start': '3123.680', 'end': '3130.400', 'text': "I've been in practice since Fellowship so uh happy\xa0\nto be here here's my disclosures I think nothing"}, {'start': '3130.400', 'end': '3135.440', 'text': "pertinent to this and then here's our objectives\xa0\nwe'll talk about complications in ankle arthodesis"}, {'start': '3135.440', 'end': '3142.000', 'text': "some challenges of aest necrosis and some\xa0\ndiagnosis of complications of ankle Fusion we're"}, {'start': '3142.000', 'end': '3146.720', 'text': "going to really frame this all one case is I have\xa0\na 59y old female she's a history RoR arthritis"}, {'start': '3146.720', 'end': '3153.640', 'text': 'she takes a biologic called Orencia which impairs\xa0\nt- Cell Activation her BMI is 29 she does have a'}, {'start': '3153.640', 'end': '3160.040', 'text': 'history of very well controll diabetes um\xa0\nand takes a glp1 Agonist but otherwise uh'}, {'start': '3160.040', 'end': '3166.920', 'text': 'no insulin A1C is less than six she has uh high\xa0\nblood pressure and high cholesterol she was doing'}, {'start': '3166.920', 'end': '3172.200', 'text': 'fine until February 2022 when she got covid\xa0\nwhen she had covid-19 she was in the ICU for'}, {'start': '3172.200', 'end': '3176.440', 'text': 'three weeks she was getting highy to steroids\xa0\nand high flow oxygen while she was intubated'}, {'start': '3177.160', 'end': '3184.520', 'text': 'um you know six months after that she noted that\xa0\nshe had severe ankle pain and radioraps identified'}, {'start': '3184.520', 'end': '3190.560', 'text': 'avas necrosis affecting the distl tiia and the\xa0\ntaus that eventually went on to U collapse and'}, {'start': '3190.560', 'end': '3196.000', 'text': 'so just to follow her err is pretty interesting\xa0\nso here this is like right around uh shortly'}, {'start': '3196.000', 'end': '3202.040', 'text': 'thereafter uh the hydo steroids for covid and\xa0\nyou clearly she has a what looks like a area of'}, {'start': '3202.040', 'end': '3206.440', 'text': "hyperdensity in the tiia I don't think the ankle\xa0\njoint there looks very collapsed as time goes on"}, {'start': '3207.080', 'end': '3212.240', 'text': "you know two months after that she pretty pretty\xa0\nrapidly collapses there's like a you know Aion"}, {'start': '3212.240', 'end': '3217.240', 'text': 'noted there on the lateral radaph you can see\xa0\nthe large zone of Avan as time goes on she even'}, {'start': '3217.240', 'end': '3222.160', 'text': 'develops a Codman triangle up here in the distl\xa0\nTivia having some in insufficiency fractures and'}, {'start': '3222.160', 'end': '3228.400', 'text': "collapse of the tibia which is a little bit more\xa0\nUncommon than it is uh within the tus here's an"}, {'start': '3228.400', 'end': '3234.520', 'text': 'MRI showing that lesion lost of cartilage and\xa0\nsome collapse so she fails non-op management um'}, {'start': '3234.520', 'end': '3240.440', 'text': 'her local surgeon treats her non-op really\xa0\nappropriately uh for several months uh she'}, {'start': '3240.440', 'end': '3244.760', 'text': 'ultimately ends up getting an ankle Fusion uh\xa0\nwith an anterior approach anterior plate June'}, {'start': '3244.760', 'end': '3250.240', 'text': '2023 there at the time of the surgery they they\xa0\nperformed a proximal T autograph bone Harvest to'}, {'start': '3250.240', 'end': '3257.440', 'text': 'supplement this area of aester necrosis and they\xa0\nuse an anterior plate with a interr screw she had'}, {'start': '3257.440', 'end': '3262.360', 'text': 'an uneventful recovery she was adherent to all\xa0\nprecautions from resurch in at the three-month'}, {'start': '3262.360', 'end': '3268.160', 'text': 'Mark she was still noting significant pain with\xa0\nthe ankle said that uh has told me since that she'}, {'start': '3268.160', 'end': '3274.920', 'text': "never reported any Improvement uh she can't walk\xa0\nand she uh also notes a new pain at the medial"}, {'start': '3274.920', 'end': '3279.800', 'text': 'proxia radiation down the at the side of the graft\xa0\nHarvest three months after you know she tells her'}, {'start': '3279.800', 'end': '3286.400', 'text': 'surgeon this documented the notes and talk she\xa0\njust be having a prolonged uh clinical recovery'}, {'start': '3286.400', 'end': '3292.440', 'text': 'at six months she notes same symptoms the local\xa0\nsurgeon got a CT which was read as healed by her'}, {'start': '3292.440', 'end': '3297.680', 'text': "by the radiologist so here's some cuts from that\xa0\nCT and there areas where you can see some of the"}, {'start': '3297.680', 'end': '3303.040', 'text': 'joint line but uh there are other areas where it\xa0\nlooks like there may be some consolidation across'}, {'start': '3303.040', 'end': '3308.440', 'text': 'um you know so not not a perfect looking CT but\xa0\nalso not one that that looks overly concerning'}, {'start': '3308.440', 'end': '3312.960', 'text': "for non-union I think I think in some of these you\xa0\nknow hindsight being 2020 it looks to me like it's"}, {'start': '3312.960', 'end': '3318.840', 'text': "probably not healed but nonetheless uh I don't\xa0\nit' be hard to say it jumps off you know on that"}, {'start': '3318.840', 'end': '3322.760', 'text': 'same CT scan think you can see the ankle a little\xa0\nbit there at the bottom of the screen with some'}, {'start': '3322.760', 'end': '3328.160', 'text': "worrisome looking Cuts there's this area where\xa0\nthe patient had axal t a graft Harvest um the"}, {'start': '3328.160', 'end': '3333.080', 'text': 'radiologist down there read it as a as a possible\xa0\ntibial mass and I think nobody ever talked to the'}, {'start': '3333.080', 'end': '3339.800', 'text': 'F ankle surgeon because she got referred here for\xa0\na bone tumor which is how she became my patient so'}, {'start': '3339.800', 'end': '3342.880', 'text': 'uh nonetheless that was just an area they back\xa0\nfilled after approximately to a graft Harvest'}, {'start': '3342.880', 'end': '3349.320', 'text': 'there was not a tumor there anyway so when I saw\xa0\nher uh about almost a year after the index surgery'}, {'start': '3349.320', 'end': '3353.760', 'text': "she can't walk because she can't get her foot\xa0\nflat on the ground she's painted the ankle she is"}, {'start': '3353.760', 'end': '3358.400', 'text': "paint at the most proximal edge of the plate it's\xa0\nthe worst at the ankle second worst actually the"}, {'start': '3358.400', 'end': '3362.560', 'text': 'proximal edge of the anterior plate and then the\xa0\nthird worst is at the proximal T at the side of'}, {'start': '3362.560', 'end': '3368.240', 'text': 'the graph tus um you know so these are the things\xa0\nthat I was thinking about so for the far as that'}, {'start': '3368.240', 'end': '3371.360', 'text': "not be able to get your foot flat is that just\xa0\nbecause it hurts or is that because you're fusing"}, {'start': '3371.360', 'end': '3377.520', 'text': "ainus that' be the main thing i' be worried about\xa0\nthere the proximal tiia graph site seems radi down"}, {'start': '3377.520', 'end': '3386.600', 'text': "the it's a nerve issue the plate there been\xa0\ndescriptions of stress the plate and then"}, {'start': '3386.600', 'end': '3394.040', 'text': "know if there's a nonunion so I think that\xa0\nwatching her you know any G she dorsal flexus to"}, {'start': '3394.040', 'end': '3400.040', 'text': 'zero not enough for the nextus and when attempts\xa0\nto walk there is no tibial progression at all'}, {'start': '3400.040', 'end': '3404.160', 'text': "with a progression angle which again that could\xa0\nbe due to pain but it could also be that she's"}, {'start': '3404.160', 'end': '3412.280', 'text': "mechanically not able to she's at her Maxum dors\xa0\nenough as a portion of the planning for uh surgery"}, {'start': '3412.280', 'end': '3417.520', 'text': 'we did get a standing CT scan and so if you you\xa0\nknow if you draw between the ti to the floor'}, {'start': '3417.520', 'end': '3423.880', 'text': "you know it's 83.5 de and you I think most people\xa0\nwould be going for about 5 degrees dorsiflex and"}, {'start': '3423.880', 'end': '3429.160', 'text': 'so radiographically this looks good you know and\xa0\nso you know however you could ask the question is'}, {'start': '3429.160', 'end': '3432.200', 'text': "the two aquinus for her and I think on there's\xa0\nsome other cuts that I've showed where you can"}, {'start': '3432.200', 'end': '3437.040', 'text': "see that four foots significantly cavis so maybe\xa0\nthat's what it was but yeah I can't say I would"}, {'start': '3437.040', 'end': '3444.320', 'text': 'critique the surgeon here much at all the saus\xa0\nnerve symptoms um I had arranged an image guy a'}, {'start': '3444.320', 'end': '3448.960', 'text': 'saus nerve injection she got complete Rel of\xa0\nthe medial pain so something is up with the'}, {'start': '3448.960', 'end': '3459.360', 'text': "S ner prox har here's the options for to do\xa0\nanything you could just observe an option to"}, {'start': '3459.360', 'end': '3470.000', 'text': "hey guys hey just wanted to let you know we\xa0\ngot to cut it off I'm sorry we got to get the"}, {'start': '3470.000', 'end': '3476.520', 'text': "other other session started well thanks elen that\xa0\nthat's thanks to all you guys for uh participating"}, {'start': '3476.520', 'end': '3480.000', 'text': 'this was a great session and\xa0\nthanks a lot for uh asking us LAN'}]