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Benjamin Overley, Jr, DPM
Surgical Skills Committee
Section Editor for Trauma-Journal of Foot and Ankle Surgery
Foot and Ankle Specialist/PMSI Orthopedics
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Male Speaker: The next speaker is a very good friend of mine. A matter of fact I called him at the last minute. I said, “Get on a plane and come down here. I need you to give five lectures.” That’s calling upon a friend. Ben Overley has been a leader in the area of foot and ankle surgery for many years. He is a PMSI orthopedics in Pottstown, Pennsylvania. He’s totally involved with the American College of Foot Surgeons with total ankle joint replacement course. He is significantly experienced in Ilizarov and framing techniques. Quite frankly I just said to Ben I would love to hear a good talk on ankle joint replacement. State of the art, where it is, simple procedure to perform supposedly. With more complications that I have here in my head if you don’t do it right. At this point, please welcome Dr. Ben Overley.
Dr. Benjamin Overley: Okay guys. I think am I wrapping it up tonight?
Male Speaker: Yes you are.
Dr. Benjamin Overley: Okay. So I’m the last up and I’ll try to not keep you too long. I’m going to add some crazy stuff for you, moving out of Harold’s talk about biomechanics and pathomechanics of the foot. I’m going to take this to another level and take a look at ankle replacement as Harold said. Where we’re at today with these. Just so you understand, even though you may not be doing these procedures, you are going to be seeing these in your office. You’re kidding yourself if you think that you’re not. People are going to move from one town to another just like they always do. They’re getting these procedures done all over the place. In fact the numbers, if we go back to even 2004 and we go up to the latest survey which was 2012, ’13, we’re really at this point doing about 10 times more per year. So we’re actually building 10 times over year to year on the amount of replacements we’re doing. We’ll get to that in a second. So there’s my disclosure slide. You can see that this may be germane to this talk in so much as Wright Medical, Tornier and Stryker are all produced total ankle replacements, and I happen to speak for all of them and consult for all of them. So I show my comparison there. Just let you know that I do use all these implants so that I really don’t have a particular one that I have a pigeon hold of myself into. What I do is I do what’s right for the patient which is what we should all do. Not everything’s right for everybody. So learning objectives. Really when it comes down to who gets what and why. We can all understand ankle arthritis. I think it’s pretty straight forward. We’ll a look at some of the numbers and the types and the things that we see over. When we take a look at the general population and everybody that we’re going to run into in our office. What it comes down to, what it boils down to is that most instances we would like to say that most of our patients have rheumatoid arthritis and they’ve got some sort of inflammatory arthritic process. But that’s really not the case. Most of these patients are going to be post sprainers. They’re going to be patients who have a sprain over a lifetime of activity, sports-related things. We begin to see sort of the evolvement that knee replacement went through years ago where you have these guys that were former athletes or things like that that ended up getting knee replacements and we’re seeing the same sort of phenomenon with anchor replacement at this time as well. So again, taking a look at the ideology of this. Pretty straightforward. Almost all of these patients are going to be post traumatic. But why is the stats important? Well, they’re important for a lot of different reasons. Your knee replacement patient is not the same as your ankle replacement patient. Ankle replacement patients are different animal altogether. This is your typical knee replacement individual and this is your typical ankle arthritis individual. So where do we sort of jump the shark and jump from one thing to the other and we get out of the different sort of our patient populations and we move from one thing to the next? Well, here it is. It’s pretty straightforward. The stats are important because a lot of these patients are younger. We were constantly faced with this conundrum of do we replace an ankle or do we fuse it? I can tell you professionally, activity prompts age at this point as far as I’m concerned. As long as I know that the patient is going to try to run a marathon on it, if a 38-year-old patient needs an ankle replacement and they do not want their ankle fused and they’re adamant about not having an ankle fuse and they’re realistic about what they’re going to get out of it, then I’m more than willing to take a look at that a lot more seriously than I would have even five years ago. The other issue is that they’re still working or they’re trying to. These are not patients that have kind of bailed out on life. They’re patients that from our perspective still have a lot of life left. What is the quality that I can impart for them or the other surgeons can impart for them? By doing a replacement. Here are some advertising dollars that were well spent. You take a look at that picture. Some of you need to probably squint a little bit. So I’ll blow it up for you.
It’s actually an upside down ankle. You notice this is a knee surgery and we can prevent this. I sure hope that they can prevent this and this is what happens when you don’t check these things before they go out and they get flipped upside down. So I’m sure that no one heard about that one. I actually had to pull over to take that picture. How miserable are ankle arthritis patients? If you take a look at sort of the whole patient population. Where do these people fall in? You can see this. Take a look at it. Everybody knows Alice and [Dylan] [05:30] up at HSS in New York City. What they came up with was these patients are about as miserable as people that have end-stage renal disease or cervical radiculopathy. Well, that’s a pretty miserable group of patients to begin with. If you take a look at that, I mean these patients are pretty significantly disabled and their pain level is real. So living with ankle arthritis. When you take a look how do we compare it throughout the body, it would be like to immediately go right up to the next level which is the knee, but it’s not. It’s more similar to the hip. If you’ve got hip arthritis and ankle arthritis, they’re pretty similar. That’s all that slide is telling you. Also when we’re thinking at doing ankle replacements and Harold sort of eluded a lot of this stuff in the different foot types and things that we’re trying to balance out. There’s lot of things we also have to take into account. The patho and anatomy that goes with ankle replacements, cyst formation. Is there deformity present? Is there prior infection? Previous hardware? As you’ve seen in some of these cases and you’re trying to dance around these things. This makes it very, very complicated at times to get these things in without doing more harm than good. So taking look at this and why do we not like fusions anymore? Were we sort of going off that fusion pathway? Well it’s pretty simple. Fusions when they come out of the gate, they work right. I will not argue that fact and I certainly won’t stand here and argue that fact. That first three years of an ankle fusion are the best or the golden years of that ankle fusion. But what we begin to see is the downturn about year three to about year five. Then we get to about year seven and these patients are miserable. They start picking up arthritis at other joints which we know already happens. They start having significant limping and they’re consuming more oxygen just to walk. So if this patient has a comorbidity, if they had COPD, they’ve got some other issue that’s going on, you’re not actually making it harder for them to breathe by fusing their ankle. Ankle replacements come out of the gate slow and then they pick up steam. They sort of do a sort of crisscross thing. Excuse me. As time goes on, where the ankle fusion is on the decline, the replacement is on the rise. So replacements where we don’t hit their strides. Probably about one half to two years. Because you really have to get the motion back and you have to teach the patient how to walk again which is sometimes not the easiest thing to do. That suspect CT scan and you can see that’s what’s showing you, the adjacent areas of arthritis with an ankle fusion. So patient selection. Granted these are all optimal patients and I agree with this sort of categorization. But if I saw this patient, I’d sort of refer this. Harold knows I say this all the time. It’s like baby pigeons. We know they’re out there but has anyone ever seen one? If anybody knows any of these patients, by the way, the ‘50s categories, please give them my card or give my number because they don’t exist in my clinic. Everybody’s got some sort of deformity, whether it’s even a mild valgus, mild varus, they’ve got their borderline diabetic, they’re mildly obese. We’re moderately obese. Some of these patients again have very unrealistic expectations for what these replacements are going to do. When we’re taking look at who qualifies for this, these other disease processes have to be brought into play, cancer, diabetes. Of course the most painful of all disease processes, Workmen’s Comp. So these guys don’t ever replace. These patients typically sort of makes sort of peace with their conditions. You’re not going to get a very good result. I sometimes question and a lot of the instances, whether there’s a potential for them to get better at all. The patients tend to identify with their conditions. Putting a replacement in them is probably not going to do you a lot of good. I can guarantee it probably won’t do them a lot of good. It will probably cause you a lot of heartache on the backend. This is like your typical patient that I get in my clinic. This woman had the good temerity to actually outline all of her medical ailments for me and put it diagram form on her body. So you can see. This is nature’s way of saying don’t get near this. What was also really nice about this is she had a page two. If you focus on your bottom right hand corner, we’re looking at a possible stroke in the brainstem. So this is somebody I’m really going to move to the head of the line in terms of ankle replacement. These are the patients that you see though. They’re definitely the ones that I see.
When we take a look at the myths and fables that go with ankle replacement, it’s pretty much like any other reconstructive surgery of the hind foot or even of the forefoot. Mid foot patients say, “I can’t have that surgery. My doc said I’ve got diabetes or my family members said they won’t touch you. You’ve got diabetes.” Well, that’s a myth. The only real factoid and this is the one I’ve already mentioned which is you don’t want to replace work on patients. RA patients do fantastic with ankle replacements. Do you know why? Because their demands are very, very low. They just want to get better. They want to be out of pain. So they tend to do very good with ankle replacements and any time I get an RA patient or an opportunity to do one, if they fit the criteria, I will certainly do it. RTAAs weight sensitive. Well, if we look at the evolution of man, and there it is for you, what takes place with these is the ankle replacement doesn’t know how much you weight. All it’s going to do is sort of respond to the environment. If it’s placed appropriately, there really shouldn’t be an issue. However, they’ve tried to do studies and they’ve never come up with a solid answer, at least not from my standpoint. I’ve done almost 300 ankle replacements and I can tell you I still haven’t got an answer as to what the weight limit is per thing. So we’ve sort of set this guideline at 250. I have already sent patients for gastric bypass surgery, LapEn surgery. If they can do it on their own, if they can’t do it through exercise, diet, regulation, then we can call in the big guns. I work very close with the general surgeon who does it on my hospital. We have a very good relationship. From my standpoint he does a fantastic job. I think he does very good with these patients getting them tuned up for ankle replacement or knee replacement. He does works with the sort of the orthopedic department. AVN is always a big issue. We’ve always had our issues with this particular topic. It’s very controversial because really, how much talus needs to be bad before we pull the plug on and say we’re not going to replace an ankle? We really don’t have a good answer. What we do know is high-demand activities are absolutely contraindications. These patients can’t run on them and clearly they can have things like Charcot. These patients are going to do very poorly. I mean it’s documented in the literature and we know how they’re going to end up. The reason is the environment for an ankle replacement is very persnickety. We know that the good environment or the good portion of the distal tibia’s on the poster medial side whereas the bad portion is anterolaterally. We know that when things fail they typically spit in the front. In other words, they begin to lift up in the front and that’s usually because the bone quality is really bad. So if we extrapolate that to the talus and we say, “Well, is it dead bone? Is it bad bone? Is it half? Is it 50?” What’s the number where we sort of pull the plug? We say we’re not going to do this replacement. I don’t have an answer for you in that. All I can tell you is if I really think that there is a significant chance of saving that talus and there’s enough viability, I will do a core decompression with some sort of filling graft and I will plan on coming back a year later to do the replacement once I’ve established that that bone is still viable. So taking a look at where we jumped to shark in terms of ankle replacement, it’s pretty simple. We come out of the gates and we’re very, very careful. We select our patients very carefully. We run them over with a fine tooth comb, and we make sure we get the exact perfect patient. That baby pigeon I was talking about earlier. What happens is when we move up to those next 50 is we sort of change our whole momentum and we start taking on cases and maybe questionable borderline. Then we get burned a couple of times. What I’m trying to say by this is this is not really for everybody and it’s not for everybody for do. But understanding that there is also a potential for you did get very cocky with it and then you start to get running to some issues. Taking a look at a mobile bearing implant and where it differs, how is it different than a fixed two-component design? Well, what we have is we basically have three pieces. That piece in the middle that’s coated yellow there, orange, what that does is it slides and I’ve got a little video to show you how that moves. What it does is it’s supposed to reproduce as close as possible ankle range of motion. The whole impetus by cofed with doing this is that when we take a look at that replacement and we see the way it moves, is that that thing can compensate for bad cuts and surgical technique. It will help to balance out the ankle. That’s the whole purpose between a mobile bearing and a fixed two-component. This should be a video by the way. I don’t know why it’s not playing. Let’s see if we can get this to run here. Here you go. This is the procedure. I cut this down to about 20 seconds just so we can move through. It only takes me usually about a minute and 20 seconds to do these anyways, so I’m just kidding. These can be really – they can take a long time. If you’re really accurate with them, you can get very good results. If you’re sloppy with them, it’s just like any other surgical procedure and your results are going to speak for your sloppiness or vice versa. What we want to do is we want to make sure that we’ve taken a look at all the different things.
Coronal plane deformities is – Harold was talking about, which is very similar to what he was discussing in the foot. These varus and valgus deformities and these rotational issues. We want to make sure that we got these things balanced out before we go throwing ankle replacements. You’ll notice on that slide that I put up there, if you take a look at that vertical plum one that I’ve dropped right up between those two barrel heels, you’ll notice it’s not lined up with the tibia but it is in fact lined up with the knee. So it’s really lined up in the mechanical axis. It’s just not the anatomic axis. You notice that the implant is very well balanced. Where contrarily speaking something like this where if you take a look at that plum line you can see it now going off into space and really not centered with the knee at all. It’s actually going way medial to it. This is clearly an example of malalignment in terms of an ankle replacement. These are really the four dominant ankle patterns that we see, with the bad boy being this guy right here, the incongruent valgus. Because he really doesn’t listen to anybody. He’s go shredded deltoids. You’ve got a poster tibial tendon that’s completely bagged. As Harold said earlier, we got a talar head that’s trying to escape. We’ve got that lateral peri-talar subluxation that Sig Hansen [phonetic] and talks about. Then we’ve got this foot sort of rotating away from the centerline of the body. Well, this makes it very difficult to put an ankle replacement in any of these. Here’s just an example of what you can do with them. You can see this woman actually had a fibular fracture as a result of her valgus deformity. I opted with kick-point screws just to do an isolated replacement. This required no additional off-tissue work other that some – I believe I did a poster tibial tendon transfer in her. I was able to correct out that valgus deformity with just doing an ankle replacement. You can see that lateral side was nice and open. That’s what we want to see. Incongruent varus, these are a little bit easier to treat. I get asked this all the time with my valgus patients. Do you do them all in one sitting? I don’t. I believe the valgus ankle, if you’re considering for replacement, you need to do all the hind foot work and you need to see where that plays out. You almost kind of want to put it on the shelf and forget about it for a while and see how that patient walks on it. Remember that this is a hard-wired mainframe issue for these patients. They tend to walk with their foot externally rotated. They were heeled shoes because if I had end-stage ankle arthritis, that’s what I would do. That’s how they walk. Drumming that out of them, you can put that implant in completely perfect. But getting them to walk that way is a completely different thing. So my patients typically will go through a month of prehab before even having the procedure where they learn how to walk with their foot straight or at least 10 to 20 degrees externally rotate it like they should. A lot of these patients just cast their leg out and it’s all coming from the hip level. You put an anchor replacement in them, they’re going to walk the exact same way, only with an ankle replacement. You’re not going to have a very good result. The difference with the incongruent varus ankle is that everything is coiled under the foot. In contrast to the incongruent valgus, where everything is sort of trying to escape, this is sort of growing back towards the midline. Now are the times when we really need to take a look at the forefoot and make sure that that’s balanced out afterwards because as you correct that varus out of that hind foot and out of that ankle, you’re going to create a forefoot valgus because that 1st metatarsal head is going to drive into the ground. That’s why we do these dorsiflex reprocedures. You can see these can be very tough because the structures are very lax. They can also be repaired relatively simplistically. But if you have a patient like this, this is not going to get an ankle replacement. So here’s another example. You can see incongruent varus. You see that little chip off the deltoid. A little ETLF. Fracture fragment as well. This was a CT-guided and you can see. What you can do, we’re just doing a replacement. It was not just a replacement but it’s a calcaneal osteotomy. It was a dorsiflexory first. That’s all the things I did on this one particular patient. These are all the places this patient had incisions. So, to get these things done, it is not sometimes an easy thing but it is possible to do it on one sitting. What’s often times seen is that a lot of these blocks are being caused by preexisting boney issues or ectopic bone growths. In almost all of these varus issues, we’ve got a completely bad set of peroneals. It’s just the contrast of what we saw on the medial side with the valgus. You can see with those peroneal tendons look like, it looks like a bunch of stringed-up spaghetti or something. They certainly don’t look nice and tubular like they should look. They’re very flattened and ratty looking. You can see once they’re removed and sort of retracted out of the way, you see that boney impingement which is the thing that’s really causing the varus. On all these varus cases, the lateral ankle repair is completely necessary. You must either do some sort of a transfer. Superior peroneal retinaculoplasty, all these things must be performed at this time because again, all these deformities are going to want to go back to the way they were. It’s tough to fight them. Here’s a nice example of a congruent varus. Now you notice that the ankle joint actually is lined up.
The tibia pretty much parallels or matches the top of the talus. But you can see it’s tilted in that varus formation. Again, just by good surgical planning and by also understanding the mechanics involved, you can cut that deformity out without really doing a whole lot except for the soft tissue work which you only do accompany. You can see the dorsiflexor review is really nice. She has good range of motion. That’s actually a 58-year-old physical therapy that works with special needs children. Physical therapist. She’s about four years out and doing fantastic. Congruent valgus I believe we all have, at least to some degree. Valgus works in the human body, at least to some degree. Varus typically doesn’t. If we have a little bit of valgus in our knees, that works. If we got a little bit of valgus in our great toe, we can fit into shoes. All these things. I think we all have a little bit of valgus in it. In all of my patients I really take a very close look when I’m doing replacements because I want to make sure that I’m not leaving something behind and there’s not going to be – I’m not going to be upset with myself later because I do believe that they do present with, again, a little bit of valgus. Here’s a perfect example. This patient actually have a rarity. There’s really nothing you can do for osteochondral defects in the distal tibia. You can really antegrade fill them because unless the cartilage is intact, everything just falls into the joint. When the lesion is big enough like this individual, his lesion basically took up his whole distal tibia. There’s nothing much to do. He’s a younger guy. He’s getting close to retirement there. Ended up eventually retiring from UPS and was very active. Wanted to play with his grand kids. What did come out the gates was the ankle replacement but you see the alignment is off. So what do I do with that? How am I going to fix that? Well, this sometimes necessitates, you have to not bury your head in the sand. Have a very frank discussion with your patient. Say listen, this is the way you’re balancing out. We noticed that forefoot varus that Harold was just talking about and I got to get that first metatarsal down because as long as that thing is up, he’s going to continue to be malaligned. So with a simple cut osteotomy, I can get that 1st metatarsal head down and additionally a medial slide osteotomy of the heel. I can also correct out that deformity and correcting out any appropriate planes and get him where he needs to be. So what do you do if you have something like this? This was also one of my patients. I’m not trying to – I’m always distrustful of guys who don’t show their bad cases because anybody can get up here and show you their good stuff, but you learn nothing. Bobby Jones who said, “I’ve never learned anything from a tournament that I’ve won.” I truly believe that. We go through these things and it’s a learning process for all of us. This was a woman that it was all the rage to really undersize the talus. You can see, I really did undersize that talus. But that left a significant space laterally. So what’s the natural kick point here? I’m trying to give her more motion by not overstuffing her joint. But how much? There’s only so much you can do. It’s a size or size two and it doesn’t matter what company it is. It’s going to be millimeters of changes that are going to go occur. So if I go up, now I’m smacking into her fibula. So what took place overtime was this very similar thing that you just saw in the last case which she began to sort of drive that out. Again, she began to walk the way she was conditioned to walk. The woman had a post-traumatic ankle arthritis for 20 years. Who was I to think that I was going to drum this out of her in a one and a half hour procedure and fix all this? It’s sometimes foolhardy to think that you can. So again. Coming back doing an PTD FDL because her PT was shot doing a medialized calcaneal osteotomy cut on the forefoot. I was able to correct that out and get that longitudinal axis where I needed to be and that sagittal correction where I needed it to be. Complications, we’ll just get through these really fast. I mean seriously, where do we get started with these? Harold sort of eluded to this. Listen. Anybody can put these things in. It’s what to do when you see them come back and you don’t know what’s going on. Wounds, they’re sort of their own special thing. As I said earlier, this release a result. If we take a look at our first 25 to 50, we’re really careful. Then we start going into beast mode. We start taking on a lot of patients in cases we probably shouldn’t. Then somewhere around 100 we start to come back down that slope again because now we got wise from those second 50 where we really pushed the line. Is there a correlation between learning curve and this? Absolutely. Especially complications, no doubt about it. There’s got to be some sort of a thing that we can look at and we can extrapolate. You can see that’s reoperation with TAA. Look at that 51 100 compared to the 250 to 300. All way down at the bottom right. IT’s why we got better. We got smarter. We started to listen to ourselves which we were doing in the beginning.
Wounds are always a big issue with ankle replacement. Anterior approaches, we know how bad they are. We think we’ve got them figured out but they still happen. You’re faced to doing all these crazy things to get things better. In the end, you’re still staring at tendons you don’t want to be looking at. The worst part is when you’re looking at metal. Here’s a perfect example of a woman that goes in for ankle replacement. Gets sent into me. She was in the nursing home. Toe started not feeling so good. Emergently admit her, get an A-gram and you can see she’s got a crushed pipes in. This is a RA patient on long-term steroids. You know where this is going to end up. There’s 10 days later. You know where we’re going from here, at least I would think you do. What I’m trying to do is basically keep that implant in. As a blessing she passed away from renal cancer about two months after this because I’m not sure if I could have ever gotten her healed. She was probably looking at a BKA or a below-knee amputation. Here’s a perfect example on why these are all interposed like this. This was actually one of mine. Stage 4. This was back in the old days. For ankle arthritis and I do and the combined foot deformity but in one sitting performed a triple. You see that navicular calcaneal screw. Fixation. Everything is going fine. We end up with a wound issue. These I sort of grade on how bad they look and how deep they go. This was immediately referred to my local plastic surgeon before we needed a free flap. Ends up with drainage. It goes to a plastic surgeon. Plastic surgeon sends her to an ID guy. ID guy says everything’s got to come out. It’s all infected. I disagreed. They both charted it was infected. So guess what, everything’s coming out because you can’t leave it in at that point. You have a gun here and a gun here. So you got to make the call. Everything gets explanted. But what do you once this thing is explanted? Well, clearly you have to put something in there so you’re going to put that poly methyl methacrylate lock in there and you’re going to just try to cement her and keep her braced. She actually liked that very much and tolerated it well. As all good things must end, eventually she couldn’t tolerate anymore and wanted a revisional surgery. The only thing that grew was the wound. Nothing was infected. This was a health implant that was taken out and didn’t need to be. This is just a good example of [indecipherable] [27:30] which I did not in that case. I have learned since then. So what do you do with this patient? Can’t go in the front. So this is a good time to enter from the back door. But it’s eating out the Achilles tendon. Getting to the posterior manifold. Once this is open, I can remove that old poly methyl methacrylate. I use hip reamers to create a nice phorus thermal head. Place those in. Push your fixation and all I’m trying to do at this point is get a plantigrade foot that’s going to function somewhat and can be braced. What about malalignment and fracture? Well they’re tied in ever since the days of this buccal path that you see here. If you put in an implant wrong, guess what happens. These things. No one knows what’s going on with any of these implants, especially the talar resurfacing ones, until they fall apart. The reason is because we’re cutting the blood supplies front, back, and both sides sometimes, and then we’re capping it with a piece of metal that we can’t see because of the CAT scan. So we take a look at – now the overfractures. They can happen either post op or in your intraoperatively. If it’s intraoperatively, it’s probably you’re like Hanz and Franz here. You’re being a little bit too aggressive. These patients haven’t move in years and you’re really trying to rep. I’ve heard of stories with the Achilles tendons being torn, FHL tendons, everything, when you try to get these patients back to moving. So you can see what goes on with malleolar fracture and where they tend to occur. Here we’re just comparing start of agility and you can see the agilities typically happen intraoperatively. Postoperatively is where you see the start fractures happen and I’ve had my share of those. I’ve also had my share of the other companies and in-bones taking place. Malleolar fractures do happen. If the patient is a little too aggressive with their weight bearing, they don’t listen to you, compliance issues, things like this, or just bad surgical technique like this where you can see that this thing is completely posterior lift-off and completely too far forward. Check that out. We basically get no medial malleolus. How long till that thing breaks? We also forgot to take out a little wedge of bone here. This all comes down to the tool behind the tool, not the tool itself. What if you run into something like this? This was a patient of mine. Mobile bearing as you can see, ankle replacement. Doing great. Fantastic. Works at a high school locally. Couldn’t be happier with the way she was functioning.
All sudden it starts to shut down and I don’t know what’s going on. So, what do you do? What I did do was scope it because I wanted to see what was going on. A lot of her pain was in the front. That’s where the implant is supposed to be. There should be a video right now playing. I don’t know if it’s – the way would you see if you could – I want you to all imagine that I’m playing a video for you right now, okay? What it’s showing is that the implants actually – the poly [phonetic] is actually incarcerated and it’s trapped. What takes place with a lot of these, especially mobile bearings but it can happen with fixed two-component designs, is that the soft tissue will incarcerate or encapsulate or insinuate everything you want to put it into the replacement and it gets stuck in there. You got to get it out. The best way to do it at least in my hands is not to officially open that patient up. Run fluid through it. This can be a little disorienting at times when you get that back flash from the metal, one of your shaver and on to the metallic implants. It’s also very tricky to do this. But once you get very good at it getting those things to viridity, it’s not that difficulty. Two of the things that I’ve learned overtime. Really the surgical hubris is probably the best thing. I thank Superbones for having me down here. I look forward to seeing you guys …