BIPEDAL

The core biology and historical framework are consistent with the orthopedic literature: Codivilla described early limb-lengthening work in the early 1900s, while Ilizarov's later work established distraction osteogenesis as a reproducible clinical method and characterized the importance of distraction rate and frequency. Modern bone transport remains an important option for critical-sized defects, particularly when infection or major bone loss makes conventional grafting difficult. Growing new bone by distraction is an extremely useful tool for repairing segmental defects, lengthening congenitally short segments, or where bone loss has occurred that exceeds the size of reasonable bone grafting. This method has routine use by surgeons with special training in the method. The classic apparatus used in the procedure is the circular or ring fixation, commonly called an 'Ilizarov' device. The purpose of the device is to anchor to bones internally while controlling their stability and motion externally. Axial lengthening is the archetype for understanding the procedure. First, the device is mounted to the limb using thin tensioned wires or larger diameter pins. An osteotomy is performed at a specific location, and the procedure then stops there for a latency period. This is often a week, which corresponds perfectly with the conversion of the initial hematoma into a soft callous phase. I'd refer you back to the podcast on bone healing for more information about the cellular events occurring during this transition. Once the latency period is complete distraction begins, often at the programmed target rate of 1mm per day. In numerous studies this rate was shown to be the ideal lengthening parameter for time and distance. The rhythm however must be monitored, as premature regenerate consolidation or failure of regenerate formation can be a result of too fast or too slow a distraction. Distraction occurs until the target length is achieved. Then comes consolidation, where the bone converts from soft to hard callous and ultimately gains its structural integrity. Once consolidation is complete the apparatus is removed and unconstrained tension is applied to the limb to allow further strengthening and mineralization. It is important to remember than fixation, whether internal or external, shields the bone from some stress that is required for bone to reach its full mechanical and structural potential. Axial lengthening is easy to understand. Angular deformity correction is simply distraction around an axis. The axis of deformity correction can be mathematically plotted on radiographs to establish an apex. The fixation is then constructed to work around this apex, with the end result being conversion of a crooked limb or bone into a straight limb segment after distraction is complete. This concept can be uniplanar or multiplanar. In these more complicated deformities hexapod ring systems and computer software may be employed for developing distraction schedules that result in all three planes being corrected simultaneously. After performing hundreds of these procedures, the miracle of osteogenesis is still fascinating and rewarding each and every time. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Platelet-rich plasma has become a popular treatment in sports medicine, orthopedics, and podiatry. But what exactly is PRP, and how much evidence do we actually have that it works? In this episode, we break down the science, clinical applications, and controversies surrounding PRP. What Is PRP? PRP is a concentrated preparation of a patient's own blood containing a higher concentration of platelets than normal blood. Platelets do more than help form blood clots. They contain numerous signaling proteins and growth factors that participate in tissue repair, inflammation, angiogenesis, cellular recruitment, and tissue remodeling. How Is PRP Made? The process generally involves: Drawing the patient's blood Processing the blood, usually with centrifugation Separating blood components Concentrating platelets Removing or retaining varying amounts of white blood cells and red blood cells Injecting the resulting preparation into the target tissue Importantly, PRP is not one standardized product . Different systems can produce substantially different platelet concentrations and cellular compositions. What's Actually in PRP? Depending on the preparation, PRP can contain: Platelets Plasma Growth factors Cytokines White blood cells Fibrin Small amounts of red blood cells We discuss why leukocyte-rich and leukocyte-poor PRP may behave differently and why the optimal formulation remains uncertain for many conditions. The Science Behind PRP Activated platelets release biological mediators that can influence: Fibroblast activity Collagen production Angiogenesis Inflammatory signaling Cellular migration Extracellular matrix remodeling Tissue repair But biological plausibility doesn't necessarily equal clinical effectiveness. One of the major themes of this episode is the difference between mechanistic evidence and patient outcomes . PRP in Orthopedics We discuss the evidence surrounding PRP for: Knee osteoarthritis PRP has some of the more encouraging evidence in this area. Several randomized trials demonstrate improvements in pain and function, although the magnitude and durability of benefit remain debated. Rotator cuff tendinopathy Evidence is mixed, but some newer studies suggest PRP may provide greater longer-term improvement than corticosteroid injections. Tennis elbow Despite a strong biological rationale and widespread clinical use, recent placebo-controlled evidence has not demonstrated a convincing benefit over placebo. Achilles tendinopathy This is one of the most important examples discussed in the episode. Despite a compelling biological rationale, recent randomized placebo-controlled studies have failed to demonstrate a meaningful advantage of PRP over placebo. PRP in Foot & Ankle Medicine We examine potential applications for: Plantar fasciopathy Achilles tendinopathy Peroneal tendinopathy Posterior tibial tendon disorders Selected ligament injuries Osteoarthritis Selected postoperative or surgical applications The evidence varies considerably between conditions. PRP for Plantar Fasciopathy Some studies suggest PRP may provide longer-term improvement compared with corticosteroid injections. However, comparisons against corticosteroid don't answer the same question as comparisons against placebo. The key question remains: Does PRP itself provide a clinically meaningful benefit beyond the effects of the injection and rehabilitation? PRP for Achilles Tendinopathy Despite being one of the most popular applications for PRP, high-quality placebo-controlled evidence has been disappointing. Recent meta-analyses have found no significant improvement in pain or function compared with placebo. This illustrates an important lesson: A treatment can have a highly plausible biological mechanism without producing a meaningful clinical benefit. Why Placebo-Controlled Studies Matter Injection studies are particularly susceptible to placebo effects. Patients receive: A physician consultation A procedure A needle Post-treatment instructions Often physical therapy And the expectation that treatment will help Therefore, PRP needs to be compared against an appropriate control—not simply against doing nothing. Statistical Significance vs. Clinical Significance A statistically significant result doesn't necessarily mean a patient feels substantially better. We discuss the concept of the minimal clinically important difference , which asks whether the magnitude of improvement is large enough for patients to actually notice and value. Why PRP Studies Often Disagree One of the major problems with the PRP literature is lack of standardization. Studies may differ in: Platelet concentration Leukocyte concentration Red blood cell contamination Activation method Injection volume Number of injections Injection technique Ultrasound guidance Rehabilitation protocols Patient population Severity of disease Follow-up duration So when someone says, "Studies show PRP works," an important follow-up question is: Which PRP? For which condition? Compared with what? PRP vs. Corticosteroid Corticosteroids can provide relatively rapid symptom relief through their anti-inflammatory effects. PRP is intended to influence the biological environment and may have a slower onset of benefit. For some conditions, PRP appears to provide more durable improvement than corticosteroid. For others, the difference is minimal or uncertain. Neither treatment should automatically be considered "better" without considering the diagnosis and evidence. Is PRP a Stem Cell Treatment? No. PRP does not introduce stem cells into the injured tissue. It uses the patient's own platelets and the biological mediators associated with them. Does PRP Regenerate Cartilage? This claim requires caution. Laboratory and animal studies demonstrate potentially beneficial effects on cartilage biology. Some human studies demonstrate improvements in pain and function. But symptom improvement is not the same as proven regeneration of normal articular cartilage. Clinical improvement should not automatically be interpreted as cartilage regeneration. What Should Patients Ask Before Getting PRP? Before undergoing PRP, consider asking: What is my exact diagnosis? What does the evidence show for PRP specifically for this condition? What type of PRP are you using? What is the platelet concentration? Is it leukocyte-rich or leukocyte-poor? How many injections will I need? Will ultrasound be used? What rehabilitation will accompany the injection? What improvement should I realistically expect? What are my alternatives? What will it cost, and is it covered by insurance? The Bottom Line PRP represents an exciting area of orthopedic and regenerative medicine. There is legitimate science behind the concept. There are biologically active molecules within platelets that can influence tissue healing. But the clinical evidence is far more nuanced than many advertisements suggest. For some conditions, PRP appears beneficial. For others, the benefit is modest or uncertain. And for certain conditions—including Achilles tendinopathy and tennis elbow—recent placebo-controlled evidence does not demonstrate a meaningful advantage over placebo. The most important lesson is that PRP should be viewed as a treatment option—not a cure-all. The right question isn't: "Does PRP work?" The better question is: "Does PRP work for my specific condition, using this particular preparation and treatment protocol, and is the expected benefit worth the cost and alternatives?" That is the conversation patients should be having with their physicians. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Arthroscopy involves using small scopes placed into a joint to evaluate or treat intraarticular conditions. The ankle, subtalar, and first metatarsophalangeal joints are commonly explored using this technique. Needle arthroscopy has presented a newer modality for even smaller joints in the foot. Classically, exploration of a joint in this manner was for evaluating tissues that we can't normally seen any other way. Cartilage condition is not able to be determined externally by any method, until severe degeneration occurs and the underlying bone shows changes. Small loose bodies (sometimes called a 'joint mouse') can also be missed in imaging if the slices on MRI are imperfect or the object is hiding in the recesses of the joint. OLT's or OCD's are a very common indication for arthroscopic evaluation, and if small enough management as well. Probes can be used to test the integrity of the cartilage, curettes and shavers can be used to remove loose cartilage, and abraders can be used to stimulate bleeding from the underlying bone to promote fibrocartilage formation. Impingement especially anteriorly is also a common condition where arthroscopic treatment can be beneficial. Post sprain impingement (sometimes called 'Bassets impingement') where a part of the synovium or anterior talofibular ligament folds into the joint with certain movement is particularly amenable to treatment using a scope. The corresponding synovitis, inflammation of the inner lining of the joint, can also be removed with this method. Occasionally arthroscopy is only part of a larger procedure. For example, some ankle fracture patterns would benefit from intraarticular assessment in addition to open reduction and fixation (ORIF.) Any occult damage can be visualized and either documented or repaired as required. These injuries can be missed in "routine" ORIF depending on injury pattern. Arthroscopic assisted fusion is becoming more common in certain settings. When no deformity exists requiring angular correction, using scope portals to introduce aggressive abraders that can effectively remove all of the cartilage and subchondral bone plate can be very enticing. This minimizes soft tissue disruption and potential vascular embarrassment, and can achieve the goal of adequate joint preparation for fixation. Because this technique is not nearly as common compared to open fusion methods it is unknown if fusion rates exceed or are less than traditional methods. Patients must understand - using a scope does not necessarily mean this is minor surgery ore recovery will be faster. The surgery is what it is, regardless of how we visualize or the tools we use to fix the pathology. For example, just because a fusion is performed arthroscopically doesn't make the bones unite any faster. Recovery is based on the procedure performed, not the tools used to perform the procedure. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

This episode is designed for anyone interested in foot and ankle health, including patients considering flatfoot surgery, athletes dealing with progressive deformity, medical students, residents, podiatrists, orthopedic surgeons, and anyone interested in understanding how complex reconstructive foot surgery actually works. The rigid flatfoot is not simply an arch that has fallen. It is a three-dimensional structural deformity involving the bones, joints, tendons, and ligaments of the entire foot and ankle. The goal of reconstruction isn't simply to make the arch look better. It is to create a plantigrade, stable, well-aligned, functional, and substantially less painful foot. Arthrodesis is a cornerstone of reconstructing the rigid or grossly unstable flatfoot. This involves fusion or permanent stiffening of one or more joints to achieve stability and reduce pain and dysfunction. In the case of severe adaptation or arthritis this approach has the highest likelihood of long term success. Isolated talonavicular or subtalar joint fusion are often performed, in conjunction with gastrocnemius lengthening or corrective osteotomies. However this would be entertained in earlier presentations of a painful non-reducible flatfoot. In later stages, a double or triple arthrodesis is commonly chosen for its predictability in restoring all of the major deformity components and long term stability. Often, the surgeon is tasked with developing a treatment plan based on clinical and radiographic evidence. This approach - a single recipe for a set of circumstances - is in my opinion archaic. Modern reconstruction should not follow a recipe, rather careful assessment of the condition and patient expectations and choosing the least destructive procedures to get there. A well trained foot and ankle surgeon should be nimble enough to make decisions after careful inventory both pre- and intra-operatively. And if the deformity magnitude is extreme, staging may be appropriate. Oftentimes a single procedure can be effective. For example, with profound peri-talar subluxation without adjacent joint arthritis an isolated talonavicular joint arthrodesis may be all that is required. This procedure will realign the TN joint to restore stability, reduce forefoot abduction, and effectively stabilize the calcaneus underneath the leg by way of retrograde stiffening. I have performed calcaneocuboid distraction arthrodesis in isolation for the same purpose when this joint alone is degenerated. Swinging the forefoot around on the talar head and stabilizing the lateral column from further luxation can be achieved this way, while preserving subtalar motion required for traversing uneven terrains. I have also planned for isolated joint fusion and ended up fusing multiple joints and rerouting tendons and ligaments in the end. No two flatfeet are alike, so they cannot be approached that way. The most important principle of all: Don't reconstruct the flatfoot from a recipe. Reconstruct the deformity. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Pes cavus (high arch) is notoriously difficult to approach since there are so many manifestations. It may be masked since there are a variety of ways the foot and leg will compensate, and often the presenting symptoms seemingly have nothing to do with the deformity. A classic example is the chronic ankle sprainer. While the injury is in the ankle, the set up for the injury is rigidity in the foot structure. Another example is multiple hammered toes. The patient sees their curled toes, but the reason is mechanical instability across a structurally high arch leading to imbalance and downstream contractures. Notably, many of these patients suffer from neurological issues, which may not have even been discovered yet. Part of the workup for pes cavus is a thorough neurological inventory - reflexes, range of motion, muscle strength, gait observation, and occasionally EMG/NCV studies or even back MRI. The practitioner has to keep all options open for reconstruction. The goal is a stable, plantigrade foot. Lowering the arch height may be the visual objective, but restoring balance and stability is the surgical objective. This is why so much time is placed in clinical and radiographic evaluation - to formulate the best treatment plan, which is often multi-dimensional. Tendon transfers are commonly performed as part of a comprehensive surgical reconstruction. This involves changing lever arm directions and power. Assisting weaker muscles or weakening over powering muscles is the goal. When we think about the foot moving about the ankle, the lever arm and power of the tendon becomes important - tendons attaching further from the axis exert greater torque about that axis, and tendons of greater diameter exert more force than tendons of smaller diameter. Therefore it is a careful balance of force enhancement and force reduction along with force vectors that is very much an art on the part of the surgeon. Bone work is done to create a stable platform across which the tendons can function. When a structural deformity exists (for example a rigidly plantarflexed first ray) then tendon transfer alone will not achieve the goal of stability. This is when osteotomy or arthrodesis is used. In cases of neurological deficit we almost always choose arthrodesis, for its predictable long term success and maintaining a sufficient structure upon which to balance and ambulate. At least for as long as possible, and some of the neurological conditions are progressive and degenerative. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

End stage of arthritis in the distal lower extremity has almost always dictated fusion of a joint. Until relatively recently this was the case in the ankle. However, due to its essential role in normal gait, surgeons have long sought ways to replace rather than fuse this joint. Replacement joints have existed for decades. Early versions were fraught with complications and required revision and conversion to fusion very often. Like many procedures, refinement in design of the implant, instrumentation, and patient selection has resulted in newer versions that have fairly decent and predictable durability. The ideal patient has lower functional demands, although physically active. Adequate bone stock, a lower BMI, and adherence to strict post operative protocols round out the characteristics for a patient who will likely benefit. Morbid obesity, uncontrolled systemic comorbidities, peripheral vascular disease, neuropathy, and patients who cannot follow through with strict rehab protocols will likely have less than optimal outcomes, often requiring revision or conversion early on in their recovery. The decision to replace rather than fuse is highly individualized. Regardless of patient health, they must understand that the likelihood of some further intervention is high. This is due to the wear characteristics of the polyethylene component and high load going through the relatively small ankle joint surface area. Despite this, maintenance of sagittal plane motion becomes a deciding factor along with age, adjacent joint health, and overall desire for a more normal gait (not entirely 'normal') for a longer period of time. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Boradly speaking, there are three types of digital contractures or hammertoes: Flexor Stabilization: This is the most common mechanism, often driven by overpronation (flat feet). As the foot flattens, it unlocks the midfoot, causing the flexor tendons (the muscles underneath the foot) to fire earlier and longer to stabilize the foot. These overactive flexors overpower the smaller stabilizing muscles, forcing the toe to buckle downward at the proximal interphalangeal (PIP) joint. Extensor Substitution: Common in individuals with high arches (pes cavus), this mechanism occurs when the extensor muscles (top of the foot) overpower the lumbricals and interossei muscles. The extensor tendons "bowstring" over the toe, pulling the base of the toe upward (hyperextension) at the metatarsophalangeal (MTP) joint, which in turn forces the tip of the toe downward. Flexor Substitution. This is the least common mechanism and usually results from calf muscle weakness or nerve issues. In this case, the deep flexor muscles take over to help the foot push off the ground, overpowering the stabilizing muscles and causing the toe to curl. The formation of hammertoes occurs in phases, beginning with a flexible deformity with mild muscle and tendon contracture, and often primarily a functional condition seen in weight bearing and ambulating. Later the deformities become rigid, where the affected tendons and joint capsules shorten and tighten permanently. The bones in the joint can luxate, meaning the toe cannot be straightened manually. This rigid phase leads to painful corns on the top of the toe or calluses on the ball of the foot from friction against footwear. Correction methods centers around the biomechanical cause, the rigidity of the deformity, adjacent joint stability, and likelihood of recurrence. Broadly speaking, either arthroplasty or arthrodesis is performed. For retention of flexibility arthroplasty is utilized, but for long term success more often than not arthrodesis is performed. This involves removing the articular cartilage and retention of the bone ends together through the bone healing phases. Satisfaction with these procedures approaches 90%, with the most likely complication being recurrence, especially when either arthroplasty is performed or when adjacent deformity or instability is not addressed. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

The "Diamond Model" (or Diamond Concept) of bone healing is a theoretical framework in orthopedic surgery and regenerative medicine that outlines five interdependent factors needed for successful fracture repair and non-union treatment: Osteogenic cells, Osteoinductive mediators, Osteoconductive scaffold, Mechanical stability, and adequate Vascularity. The first four are connected by vascularity - without blood flow no healing can occur. When evaluating a nonunion, this framework gives us a checklist upon which to determine the cause of the nonunion. A failure in any of the pillars of the model will result in a failed fusion or fracture to heal. Some conditions present specific challenges to bone healing that are not obvious. For example, obesity is widely known as a risk factor for nonunion. But it is not enough to just categorize high BMI solely; the obese individual poses challenges due to mechanical stability being inadequate, chronic inflammation where adipose tissue releases pro-inflammatory cytokines creating an environment favoring osteoclastic activity, and metabolic abnormalities such as insulin resistance and vitamin D deficiency. For me the key to a successful outcome of surgery or conservative treatment of fractures is mitigating risk factors when possible, or circumventing them altogether. However when faced with a nonunion, the surgeon has to answer the two questions - how can I improve mechanics around the nonunion site and how can I improve the tissue/organ/whole body biology? Without answering these the nonunion will likely persist leading to even further morbidity. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Instead of understanding a flexible flatfoot as a single condition, it should be understood that it is in fact multiple simultaneously occurring conditions resulting in mechanical failure. And since there are multiple components: The surgeon should ask themselves "What component of the deformity am I correcting?" Every operation has a purpose. Every procedure corrects a different deforming force. That framework helps both patients and residents understand why flatfoot reconstruction is often a combination of several procedures rather than a single operation. And for patients, why they emerge from an operating room with incisions on the medial and lateral sides of their foot along with the back of their leg thinking I am just "giving them an arch." Careful assessment of the dominant planes of deformity clue the surgeon into where the pathology lies. For example, strictly sagittal plane dominance may be a result of spasticity in the heel cord only. This is often the case in pediatric presentations. Likewise, frontal plane dominance may occur in the forefoot, the hind foot, or both. Consequently procedures designed to correct on these planes may be required at one or both levels depending on extent of deformity. Some procedures have a powerful impact in multiple planes. For example the Evans osteotomy will effect transverse plane (forefoot abduction) and frontal plane (forefoot supinatus) simultaneously. This is why we often use these procedures to complete a correction, so as to minimize the total surgical disruption and recovery time. It should also be noted that correcting a flatfoot is not necessarily about arch restoration, which is an obvious external sign of success. It's about creating a mechanically stable propulsive foot that is pain free. We can't make someone an olympic-level runner simply by raising an arch, but we can improve the mechanics that lead to a failure of the arch mechanism. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

There are three types of cartilage in the human body, although the one we most commonly pay attention to is hyaline cartilage since this makes up the articulation between bones. The gliding and shock absorbing function of type 2 collagen makes hyaline cartilage particularly suited for absorbing force. It is arranged in a very specific manner to absorb forces and maintain structural integrity under load. When damage occurs to this tissue, the integrity becomes compromised, and similar to the laminated structure of a car tire, begins a disintegration process. Delamination will occur in phases, and often correlates to the radiographic and clinical findings a patient will present with. As a surgeon, my job is to determine the origin of the degradation (whether normal age related or traumatically induced) and assume certain prognostic factors, like stage and rate of degradation that is likely and secondary or collateral effects of this degenerative process. There is no one-size-fits-all approach to joint degeneration. Since this is a slow process in most cases there is time for decisions related to interventions, whether conservative or surgical. When surgery is considered, there are joint sparing and joint eliminating procedures, the choice of which is highly dependent on the knowledge and skillset of the surgeon evaluating the condition. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Symptomatic OLTs represent one of the most common causes of persistent pain following ankle injury. The condition is often missed due to the volume of ankle sprains seen in clinics that are routinely imaged with plain film X-ray only. These lesions not only do not appear on xray unless there is obvious bone involvement but sometimes evolve over time after the initial insult. Therefore the foot and ankle surgeon must keep this pathology in mind when pain persists beyond a reasonable amount of time in recovery. Lesion patterns sometimes can correlate with the mechanism of injury. Inversion sprains which are the most common type of injury, tend to produce more shallow, anterior located lesions if there is a dorsiflexion component, while deeper posteromedial lesions occur if the foot is plantarflexed at the time of injury. Cartilage damage is particularly challenging in that the body does not have a capacity to heal hyaline cartilage. Thus when damage occurs it can lead to symptomatology that persists well beyond the bodies repair of the surrounding tissues. This is why careful attention to the timeline after injury is so important. There is no universal clinical presentation for these lesions. Therefore MRI is essential when OLT is suspected. Larger lesions almost always require some type of intervention, especially with cartilage or cartilage-bone displacement. These tend to be more challenging, both in the type of repair required and the access to the joint to repair properly. Malleolar osteotomy is occasionally performed for access since direct cartilage replacement is likely the procedure of choice. Smaller lesions can often be treated either arthroscopically or in retrograde manner, tunneling to the lesion from underneath and performing a repair in a way that does not introduce larger injury to the joint surface. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

The lateral collateral complex is made up of the ATFL, CFL and PTFL. The ATFL is probably one of the most commonly injured ligaments in the human body, due to the relative weak nature of the ligament and anatomic position on the outside of the ankle joint. Along with the CFL they are poor resistors of inversion since the torque of the body over these small structures can easily overwhelm their ability to contain movement beyond a certain point. Consider this an 'evolutionary weak point.' When inversion injuries occur, a square bone is turned or rotated inside of a square recess - not a good scenario. The shoulders of the ankle bone wedge the fibula outward, causing tension on the ligaments which will ultimately tear. In addition the cartilage and surrounding structures (capsule, tendons, and muscles) also sustain damage. Surgical repair involves inventory of all of these structures, including the syndesmosis that holds the tibia and fibula together. In this episode I focused on the direct repair or augmentation of the most common situations. In the next episode I will dive into more detail on osteochondral defects, and later on the high ankle sprain and more occult injuries that are commonly missed even by astute practitioners. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Achilles tendon rupture is a potentially catastrophic injury. However modern repair methods can restore the integrity of the tendon complex regardless of age or extent of injury. It is the rehabilitation protocols afterwards that are the best predictors of complete recovery, not the ability to put the tendon back together. I have repaired tendons on relatively sedentary patients, weekend warriors, and elite athletes - and everything in between. The factor that is most important for all of these patients to succeed is understanding the quality of the repair and gearing post operative rehabilitation accordingly. No two injuries and no two repairs are identical. Each has its own nuance, from the mechanism of injury, the patient's functional demands, the patients ability to comply with rehab directions, and the social safety system (home assistance) they employ. This is why a "one size fits all" repair method or rehabilitation program is destined to produce erratic results. If you understand the biologic processes and their required time to progress, you can understand the length of time these tendons need to fully heal. And the tendon is only one factor - the calf muscle strength suffers tremendously as well. Rehab programs must be designed to improve tendon elasticity while not over lengthening and coupled with strengthening to limit atrophy. This is a delicate balance. One other factor clinicians often forget is the psychological recovery. First is prolonged guarding, which can lead to prolonged recovery. Surgeons should appreciate that the longer they immobilize a patient the longer they have to become apprehensive about return to function. This must be monitored since patient engagement with rehab is essential to successful functional recovery. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

There is debate among orthopedic and podiatric surgeons regarding operative and no operative repair of ruptured Achilles tendons. Why the debate? Because outcome studies have shown satisfactory results when comparing each treatment. These studies focus on strength restoration, pain scores, and quality of life. Unfortunately, we cannot directly compare individual patient outcomes, since a patient can only have been treated one way or the other. In my experience surgical repair is generally preferred for this injury unless there is compelling reasons to treat conservatively. This would include excessive smoking, uncontrolled systemic conditions like diabetes, demonstration of non compliance with physician direction, or extremes of age. Otherwise, this tendon can be repaired in a way that matches the contralateral limb in function and power and can be restored to its pre injury state predictably with surgical methods. That goes for chronic and delayed repairs as well. I trained in an era before percutaneous techniques emerged. Open repair is the gold standard for surgical treatment. This method allows complete visualization of the injury, direct reapproximation of the tendon ends, and the ability to match the injury to the mechanical construct required for repair. Without visualization, the surgeon cannot adequately assess the integrity of the ruptured ends, instead relying on the instrumentation that employs a "one size fits all" approach. Coupled with a higher incidence of sural nerve injury, there is little benefit in my mind to not simply opening the injury and fixing it. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Hallux limitus and rigidus are a spectrum of a disease involving progressive degeneration of the first metatarsophalangeal joint (MTPJ). There are multiple causes known to cause this condition, from biomechanical (elevated first metatarsal, elongated first metatarsal, etc.) to medical (gout, rheumatoid arthritis, infections, etc.) As a surgeon, I have to determine the condition of the joint at the time of presentation and the symptoms patients relate. Not all radiographically destroyed joints are symptomatic, and not all radiographically normal joints have mild symptoms. There is a spectrum of disease that has to be carefully evaluated against the conservative and surgical options available. Simple procedures like cheilectomy can buy time. Decompression osteotomies can do the same thing. However, if the joint degeneration is fairly advanced, the only likely outcome is secondary procedures. This is because the surgeon chose a procedure that increases painful motion. If a joint has undergone degeneration 'past the point of no return,' joint destructive procedures must be employed. This includes arthroplasty and arthrodesis. The former involves removing part of the joint, the latter meaning fusion or permanent removal and stiffening of the joint. In my experience, preservation of sagittal plane dominant joints (first MTPJ, ankle, knee) is critical to undisturbed gait. Therefore all measures should be explored before fusing these joints. Many patient have been referred in because they were given the only option of fusing the great toe joint. This is often not necessary, as implant arthroplasty has excellent long term survival rates in the right population and if performed technically well. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Most fixation failures are not really implant failures. They are failures of the interaction between biology, mechanics and time. When assessing broken bones (or fusions, osteotomies, etc) we have to appreciate that achieving the result of bone healing is a balance between mechanical and biologic forces. Too much or too little of either is not beneficial, and occasionally is deleterious. Modern orthopedic approach is to control the influence of both. We do this with a deep reservoir of materials, implant choices, implant constructs, biologic augmentation materials, and careful assessment of critical points in the healing process. It is no longer acceptable to wonder why a bone did not heal or a fixation construct failed. With a keen understanding of fixation principles, the answer should be obvious. Then undertaking revision involves a strategy to reverse what plagued the initial attempt. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

A fracture heals biologically. But biology is governed by mechanics. Bone cells are mechanosensitive. They respond to motion, strain, compression, shear, and tension. And that means one central truth: The surgeon is not simply fixing bone. The surgeon is engineering the conditions under which biology can succeed. Strain in terms of bone healing describes the amount of motion relative to the fracture gap. Too much strain, and the local biology will favor granulation tissue formation. Small amounts of strain will lead to cartilage or callous formation, and very little strain sets up the environment for bone formation. The surgeon is tasked with determining the fracture needs - sometimes absolute stability (low strain) is required and sometimes relative stability. For example, in deformity correction and reconstructive surgery, the desire is to create absolute stability. In certain fracture scenarios, such as comminution, relative stability is preferred to allow the multiple fragments to unite without excessive compression and without further devitalizing bone. The choice of fixation- the construct, the materials, and the placement - are all variables a surgeon puts together in the operating room depending on the specific circumstances. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Understanding internal fixation is critical to our later discussions on surgical techniques for a variety of conditions. We started in Episode 1 of Season 2 discussing bunion surgery. This was meant to be an introduction to how we approach realignment and repair of bone segments. Everything we have learned about fracture fixation in emergent conditions, we have refined and honed to use in our reconstructive efforts. Bunion surgery involves just about every surgical principle we will cover in this season - soft tissue envelopes, anatomically safe corridors, biomechanical tension and compression, deformity realignment, and bone fixation. Throughout human history we have suffered broken bones. Only until recently were broken bones stabilized with devices more complicated than a tree branch and leather straps. Once we had a grasp on aseptic techniques, metallurgy, and the biologic processes involved in bone healing, modern internal fixation of bone injury was achievable. The current methods and devices are essentially derivatives from the Swiss AO group, a collection of surgeons who outlined the important principles for the use of these devices: anatomic reduction, stable fixation, preservation of blood supply, and early mobilization of joints. Manufacturing has come a long way, with forging and machining of basic screws and plates being replaced with 3D printing and patient-specific prostheses generated from complex weight bearing CT scans. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Bone is a Living Tissue. It is formed of living cells in a matrix designed to withstand load and to constantly replace and repair itself. When injured, bone immediately begins the repair process, with dedicated cells immediately taking over and beginning a complex signaling event that ultimately results in complete restoration. Because healing is phase oriented, certain systems must in place at the right time to effect the healing cascade. This begins with inflammation, which is immune system mediated. A hematoma forms, which is filled with platelets, cytokines and growth factors. There are important meditators at work- PDGF (platelet derived growth factor), VEGF (vascular endothelial growth factor), BMPs (bone morphologic proteins), interleukins, TGFa (transforming growth factor), and more. These signaling molecules recruit osteo-progenitor cells and ignite angiogenesis. The system must maintain balance between normal inflammatory response and excessive or prolonged inflammation which can impair the process. Angiogenesis means "new blood vessel formation," a process critical to repair. The biology of bone healing thus begins with restoration of blood flow. There are two main types of bone healing - primary and secondary. Primary healing is direct laying down of matrix between two fracture ends. This occurs when there is adequate blood flow, close approximation of bone ends, stability at the fracture site, and low tissue strain . Secondary bone healing occurs when there is relative stability, not absolute rigidity. This involves a cartilage intermediary, a tissue type visible in the healing process. This concept of strain is critical to understanding how bone behaves. Strain is basically the change in gap length divided by the original gap length. Different tissue types tolerate different amounts of strain. Granulation tissue tolerates high strain, bone tolerates very low strain. This means that the tissue type that will form at a fracture site is heavily dependent on the mechanical environment. Bone healing does not like extremes. Too much motion leads to delayed healing and persistent fibrous tissue. Too little will suppress callous formation and stress shield the bone leading to poor biologic recruitment. Healing likes the environment to be stable enough but not necessarily absolutely rigid . This is the art in surgical practice - determining how and when bone needs stability, how much stability, and when to progress to load and stress again. Of course, mechanics alone are not a sure bet that the bone will heal. Biologic constitution also is a factor. Low vitamin D, low calcium levels, high sugar levels, presence of carbon monoxide, and more can lead to poor healing of bone tissue. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

There is no simple solution to a complex problem. This is true in life, and in bunion surgery. A bunion is a complex condition resulting from either structural anomaly or biomechanical instability, and often both. Careful evaluation of the condition is required; no two bunion deformities are identical. Mistakes are made when patient expectations are unrealistic, physician capabilities are limited, there is no sound surgical plan to address every component of the deformity, or the procedure is poorly executed. The failure often occurs before the procedure is carried out. Proper planning includes complete evaluation for causation. Removing the bump may provide short term relief, but not addressing all the causative factors will result in long term failure. That is why clinical and radiographic parameters are so critical. Along with an arsenal of procedure selection in the surgeon's pocket to choose from. Distal osteotomy procedures are the least technically demanding and have the lowest complication rates. The good news, most patients will fall into this category. More proximal procedures are required for extremes of the deformity - rigidity, age of patient and deformity, and profound dynamic forces acting across the first ray. For the segment of patients that fall into this category, expectations should be set accordingly - the more complex the procedure, the more can go wrong. Nonunions, neuritis, hardware complications, and load transfer related issues all have a higher incidence with these procedures. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.