BIPEDAL

The history and evolution of bone grafting: Bone grafts have been used for centuries, beginning in 1668 when a piece of bone from a dog's skull was used to repair a cranial defect in a Russian soldier. The first autograft was successfully performed in 1821, meaning this technique has centuries of experience and science behind it. 

This episode is broken into sections:

The biology of bone healing. We reviewed this in prior episodes, but the key concept are osteoconduction, osteoinduction, and osteogenesis. Conduction refers to a scaffolding that adjacent bone cells can use to integrate a graft. Induction is the biological stimulation by the graft to incorporate, and osteogenesis refers to using orthobiologics to cause bone formation. Different grafts perform different functions, sometimes combinations of functions, and the specific needs of a surgery dictate the choice of graft material. 

Autograft versus allograft. This refers simply to whether the origin is the patient themselves or some external source.

Structural and cancellous bone grafts. Structural grafts are used to maintain position or alignment, while cancellous grafts are primarily void fillers. 

Demineralized bone matrix and synthetic substitutes. While not structural, these aid in fusions where bone cell contact with like cells promotes osteointegration and successful bridging of defects. 

Bone marrow aspirate and growth-factor-based orthobiologics. Newer technologies have become standard in revision and reconstructive surgery, with these being used to supplement traditional grafting, not replace it. 

Graft selection for fusion, deformity correction, and revision surgery. Surgeons are faced with a wide variety of conditions that require grafting. Therefore the myriad of available products have to be considered as there is no one size fits all. A specific type of graft or material in one situation may be entirely inappropriate in another. 

Donor-site morbidity and graft-related complications. Specific to autografts, harvest sites may present their own complications unrelated to the primary procedural region. This is why selection of an autograft should outweigh the risks of donor site comorbidity over using an allograft. 

Patient optimization and postoperative recovery. Grafting by its very nature is tedious, and implies perfect anatomy, apposition, alignment, biology, or blood supply may be constrained. If you remember back to our bone healing episode, the ideal situation is primary bone healing, which requires direct approximation of biologically intact bone ends with rigid fixation. The use of a graft in an intervening space will necessarily skip this for secondary bone healing, or something other than direct vascularization. 

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.

• What is brachymetatarsia? Shortening of one or more metatarsal bones, often causing a toe to appear shorter or sit farther back than neighboring toes.
• Common causes: Premature growth-plate closure, developmental or genetic factors, and less commonly growth disturbance following trauma, infection, or surgery.
• Prevalence findings: Surgical literature shows a marked female predominance and identifies the fourth metatarsal as the most frequently affected. These are clinical-study findings, not precise general-population prevalence estimates.
• Symptoms: Cosmetic concerns, difficulty with shoes, toe malposition, calluses, and sometimes metatarsalgia.
• Diagnosis: Clinical examination and weight-bearing radiographs.
• Nonsurgical care: Footwear modification, padding, orthoses, and activity adjustments can address symptoms but do not lengthen the bone.
• Surgical correction: Single-stage lengthening with grafting versus gradual lengthening through distraction osteogenesis. For minimal deficits (up to 5-6mm) certain osteotomies can effectively lengthen the bone without the need for more complex reconstruction. For deficits up to 1cm, interposition bone grafting is often performed. Beyond this point we have to consider the acute lengthening in the setting of vascular stretching which can result in compromised perfusion to the toe. In these circumstances gradual distraction is preferred.  
• Patient expectations: Length gains and appearance vary. Recovery can take months, and stiffness, malalignment, delayed bone healing, infection, and additional surgery are possible.

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.

Approximately 6% of the general population reports Achilles tendon pain during their lifetime, and roughly one-third of those cases are insertional. This is a large amount of the population suffering a specific clinical condition. 

The pathomechanics are complex. The Achilles tendon is under resting tension, ready to pull the calcaneus upward causing forward propulsion the second the brain decides to take a step. Sometimes this resting tension is excessive. This may begin a slow, chronic degenerative pattern at the attachment to the calcaneus. There of course is an age-related phenomenon, with more degenerative changes seen in collagen (the primary structural composition material of tendons) over time. As time goes on, more degeneration, more tension, and more compression leads to more degeneration, responsive bone formation, increasing size of the associated bursa as well as the calcaneus. More one formation leads to more substance being rubbed on by the shoe. This process ultimately leads to an acute inflammatory episode, but is often the last symptom to appear in a slowly forming degenerative process. By the time symptoms have developed and patients present to the office, radiographs show a large bone spur and severely thickened Achilles tendon. These don’t show up instantly. They reflect the years-long degeneration that has been underway without the patient even being aware. 

Clinical assessment is designed to determine inflammation versus degeneration. MRI is helpful to visualize all of the structures involved in the condition, including accurately distinguishing acute inflammation (what we call tendonitis) from degeneration (tendinosis.) The term 'tendinopathy' is the best descriptor of the condition, since either way a process of collage degradation is occurring, the mechanics of which needs to be addressed in addition to the acute painful condition. 

When conservative options fail - and they do, often - surgical management has to be tailored to the individual presentation. There is absolutely no one size fits all in calcaneal and Achilles surgery. What would be the point of debriding a degenerative tendon while leaving a large posterosuperior bone prominence and chronically inflamed bursa behind? Thus the decision to operate and what will accomplish the surgical goals must be determined by careful analysis, not by what the patient will recover from the fastest. 

In my experience most patients respond well to heel lifts, NSAIDs, resting the tendon, icing, and a tailored physical therapy program. When faced with a severely thickened tendon, large amounts of calcification within the tendon or an abnormal posterior calcaneal geometry (so called 'Haglunds deformity') I will discuss realistic expectations of conservative therapy working. 

Surgical repair is technical, regardless of the methods employed, because there is a higher incidence of wound complications in this area. Therefore this should only be performed by someone extensively trained in foot and ankle surgery. 

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.

Plantar fibromas are nodules in the plantar arch area, which may or may not be painful. Histologically a collection of fibroblasts and myofibroblasts, the lesions lie somewhere between excessive scar formation and muscle tissue. 

Notoriously resistant to conservative care, these lesions sometimes are simply monitored. If they do not fit a classic pattern, show rapid expansion or become painful, they are often imaged with ultrasound or MRI to confirm the pathology.

First line treatment for these I will recommend shoe and shoe insert modification. Medication such as verapamil is also applied topically, sometimes with warm compresses, in attempt to shrink the lesion. Intralesional cortisone is also sometimes tried. When this fails, surgical management is usually the most effective treatment. 

Complete excision is the goal, and this may range from simple isolated nodule removal up to total fasciectomy, depending on size and number of nodules. Surgery is not a benign approach - incision planning, understanding anatomy, and realizing the cost of lesion removal may be a painful scar are all considered before excision.

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 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.

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.

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.

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.

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.

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.

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.

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?

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.

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.

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.

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?

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.

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.

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.

Before undergoing PRP, consider asking:

1. What is my exact diagnosis?
2. What does the evidence show for PRP specifically for this condition?
3. What type of PRP are you using?
4. What is the platelet concentration?
5. Is it leukocyte-rich or leukocyte-poor?
6. How many injections will I need?
7. Will ultrasound be used?
8. What rehabilitation will accompany the injection?
9. What improvement should I realistically expect?
10. What are my alternatives?
11. What will it cost, and is it covered by insurance?

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.