Ankle Arthritis and Ankle Replacement

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1 Ankle Arthritis and Ankle Replacement Ryan DeBlis, MD Disclosures I have no disclosures. 1

2 Diagnosis Ankle arthritis Majority (70%) of patients are post-traumatic (ie, after ankle fracture) Primary arthritis (7-15%) & inflammatory arthritis (6-12%) & neuropathic (5%) are uncommon Ankle degeneration must be quite advanced before it becomes radiographically detectable Age, joint morphology, genetics & environmental factors are all important determinants in ankle arthritis Common Symptoms Pain Limitation of motion Limitation of function (eg, walking) Swelling & warmth of joint Ultimately the goal is to reduce pain & improve function 2

3 Treatment Options Conservative Cortisone injection Synvisc or PRP $$$ NSAIDs Custom ankle braces & PT Operative Debridement (ie, remove spurs, open vs arthroscopic) Ankle arthrodesis TAA Distraction arthroplasty Conservative Treatment Cortisone is helpful to break the pain cycle and the long lasting anti-inflammatory effects can provide weeks to even months of relief Synvisc Human trials have indicated intra-articular injection of hyaluronic acid may be helpful & can last several months but unclear if it possesses any disease modifying properties NSAIDs have long history in treating arthritis Helpful at improving function & reduce inflammation Braces & PT PT assist in appropriate exercises to improve or maintain motion to keep BMI in ideal range of 25 Braces & orthotics are noninvasive methods of improving gait & function and attempt to slow disease progression and disability 3

4 Debridement Amount of improvement depends on degree of underlying cartilage loss Tol et al = Arthroscopic debridement for anterior impingement, good results (77%) in pts that did not have diffuse arthritis compared to arthritic pts ~53% good results Only 35% had improved ankle ROM even though symptoms were improved Sometimes XR look better than actual joint since the space is often held open by small amounts of cartilage &/or synovitis Ankle arthrodesis PROS Gold standard for end stage ankle arthritis Excellent pain relief Low rate of complications Foot still moves up & down (ie, moves through hindfoot & midfoot) CONS Function is good but not normal Gait shows decreased stride length & velocity Adjacent joint arthritis 50% DJD at 8 yrs increasing to 100% at 20 yrs 4

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6 TAA Ideal pt is light weight (BMI<25), no deformity, low demand & good ROM Replacement of ankle joint with metal & plastic Cobalt chrome & polyethylene Avg 5 yr survival rate >86% Pro #1 Alleviates ankle pain, #2 ROM is increased Con Subsidence, lysis, fracture, persistent pain, stiffness, instability 6

7 TAA Historically less successful than hip & knee replacements Forces across ankle are 2-3 times higher than hip & knee joints Newer implants have improved success Wright Medical Prophecy Infinity CT scan derived alignment guides Wright Medical INBONE Zimmer Total Ankle Replacement Others: STAR (Scandanavian Total Ankle Replacement), Salto Talaris +/- osteotomies to attain neutral alignment of leg & foot +/- ligament stabilization procedures +/- gastrocnemius lengthening (ie, lack of 5 deg DF after implantation) 7

8 Calf Atrophy at 1 year 8

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12 64 yo F, ~1 year after left TAA VIDEO High Risk TAA patients Severe deformity Prior multiple operations Higher risk of wound complications Poor blood supply DM Bone loss History of avascular necrosis 12

13 Operative Schedule First visit (2 weeks after surgery) Splint & suture removal CAM boot vs cast depending on wound & quality of repair Non weight-bearing for additional 4-6 weeks (crutches, walker, knee scooter) but start ROM Second visit (6-8 weeks after surgery) Start weight bearing and physical therapy Third visit (12 weeks after surgery) Start strength training physical therapy Expect full recovery 12 months after surgery Potential Complications Infection, bleeding, nerve, vessel or anatomic structure injuries Persistent pain Need for revision Failure of implants 13