MANAGEMENT OF END-STAGE ANKLE ARTHRITIS: TOTAL ANKLE ARTHROPLASTY

Transcription

1 MANAGEMENT OF END-STAGE ANKLE ARTHRITIS: TOTAL ANKLE ARTHROPLASTY Zackary B. Gangwer D.P.M., AACFAS, AACFAOM Diplomate, American Board of Podiatric Medicine Foot and Ankle Surgery Department of Orthopedics Faith Regional Physician Services LLC. 1

2 THE ANKLE SUBJECT TO MORE FORCE PER SQUARE CM THAN ANY OTHER JOINT 9X LESS LIKELY TO DEVELOP DEGENERATIVE ARTHRITIS THAN KNEE. CARRIES 5 X BODY WEIGHT IN NORMAL GAIT 2

3 END-STAGE ANKLE ARTHRITIS MULTIPLE ETIOLOGIES TRAUMA ABNORMAL MECHANICS OA (RARE), INFLAMMATORY ARTHRITIS, HEMOCHROMATOSIS, INFECTION, NEUROPATHIC ARTHROPATHY, TUMOR LOSS OF ARTICULAR CARTILAGE RESULTING IN BONE-ON- BONE CONTACT SYMPTOMS: PAIN, LOSS OF MOTION AND FUNCTION, INFLAMMATION 3

4 CONSERVATIVE TREATMENT OPTIONS 1.ACTIVITY MODIFICATION 2.MEDICATION 3.BRACING/SHOE MODIFICATIONS 4.INJECTABLE THERAPY 4

5 SHOE GEAR/BRACING 1.ROCKER BOTTOM 2.SACH 3.ORTHOTIC 4.BRACES 5

6 CSI 1,2,3 DURATION OF RELIEF NO LONG TERM ADVANTAGE NO LONG TERM DELETERIOUS EFFECT RISKS: INFECTION SKIN REACTION 6

7 HYALURONATE DERIVATIVES 5 HIGH MOLECULAR WEIGHT POLYSACCHARIDE PRINCIPLE COMPONENT IN SYNOVIAL FLUID VISCOSITY DISSIPATES MECHANICAL INJURY ANTI-INFLAMMATORY, ANABOLIC, ANALGESIC TYPICALLY INJECTED IN A SERIES OF 3 COCHRAN COLLABORATION FOR KNEE (76 ARTICLES) DIFFERENCE BETWEEN ANKLE AND KNEE 7

8 SURGICAL MANAGEMENT 1.ARTHROSCOPY 2.DISTRACTION ARTHROPLASTY 3.ARTHRODESIS 4.TOTAL ANKLE ARTHROPLASTY 8

9 ARTHROSCOPY INDICATIONS : OSTEOPHYTES LOOSE BODY CHONDRAL DEFECTS <1 CM CONTRAINDICATIONS: End Stage Arthritis Fibrosis Deformity Large Chondral Defects 9

10 ANKLE DISTRACTION 4 SCOPE VS. OPEN 5 MM WBAT 6-12 WEEKS HINGE 10

11 ARTHRODESIS PRINCIPLES: ALLEVIATE PAIN CORRECT DEFORMITY MAINTAIN REARFOOT ALIGNMENT/MOTION 11

12 LONG TERM 7,12 10% DECREASED GAIT EFFICIENCY 3% INCREASED ENERGY EXPENDITURE PERI-ARTICULAR ARTHRITIS STIFF HIND FOOT VS. BKA 12

13 COMPLICATIONS NON-UNION DELAYED UNION TIBIAL STRESS FRACTURE WOUND COMPLICATIONS INFECTION 13

14 HISTORY: 1970 S 1980 S CURRENT ANKLE ARTHROPLASTY 14

15 EARLY IMPLANTS 15

16 EVOLUTION 1ST GENERATION 2ND GENERATION CURRENT DESIGN 16

17 CLASSIFICATIONS CEMENTED VS. NON NUMBER OF COMPONENTS CONSTRAINED VS. SEMI-CONSTRAINED FIXED VS. MOBILE BEARING 17

18 INDICATIONS VS. CONTRAINDICATIONS STILL EVOLVING: POST TRAUMATIC ARTHRITIS R.A. >50 YEARS NOT OBESE More defined: Infection Charcot Neurologic dysfunction Poor soft tissue Vascular compromise AVN Talus 19

19 AGILITY 20

20 ZIMMER 21

21 STAR 10,11 22

22 INBONE 8 23

23 SALTO TALARIS 8 24

24 INFINITY 25

25 COMPLICATIONS 6 IMPLANT LOOSENING INFECTION WOUND COMPLICATIONS CYSTS OSTEOPHYTES SUBSIDENCE 26

26 ISSUES 9 HIGHER RE-OPERATION RATES HIGHER COMPLICATION RATES DIFFICULT TO REVISE FAILURES 27

27 CASES 28

28 75 YO M. H/O ANKLE TRAUMA. PROGRESSIVE ACTIVITY LIMITING ANKLE PAIN FOR >5 YRS. ATTEMPTED INJECTIONS, SHOE MODS, BRACING C NO RELIEF. PMH: DIABETES, HD, HTN, HYPERCHOLESTEROLEMIA, GOUT PSH: PACEMAKER, HERNIA REPAIR X3 SH: FORMER SMOKER FH: MI -FATHER ALLERGY: NKDA MEDS: LIST PE 29

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32 HPI: 60 YO WM PRESENTS LONGTERM HISTORY OF L ANKLE PAIN. ATTEMPTED BRACING, INJECTIONS, PT >6MOS C MINIMAL RELIEF. PURSUED TAR. PMH: ULCERATIVE CHOLITIS PSH: L KNEE SURGERY, L RING FINGER, L KNEE REPLACEMENT, R BUNION MEDS: ALLERGIES: NONE FH: FATHER PASSED OF CA SH: DENIES ETOH, TOBACCO, ID PE: PAIN C WB, ROM, CREPTATIONS C ROM 33

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34 At 3 mo f/u: No pain Mild edema Function improved from preop 35

35 66 YO M. H/O ANKLE TRAUMA IN REMOTE PAST PMH:, HTN PSH: TKA B/L No tobacco use PE: PAIN, ankle deformity 36

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44 CONCLUSIONS TOTAL ANKLE ARTHROPLASY INDICATIONS HAVE INCREASED SIGNIFICANTLY AS TECHNOLOGY INCREASES AS POPULATION GAINS LONGEVITY, POST TRAUMATIC ARTHRITIS INCREASES EACH INDIVIDUAL CASE NEEDS THROUGH WORK UP 45

45 Zackary B. Gangwer DPM, AACFAS, ACFOAM Primary Clinics: Faith Regional Physician Services Foot and Ankle Surgery 301 N. 27th St., Ste. 5 Norfolk, NE Norfolk, NE 68701Ph:

46 REFERENCES 1. THOMAS RH, DANIELS TR. ANKLE ARTHRITIS. J BONE JOINT SURG AM. 2003;85-A(5): BROWN TD, JOHNSTON RC, SALTZMAN CL, MARSH JL, BUCKWALTER JA. POSTTRAUMATIC OSTEOARTHRITIS: A FIRST ESTIMATE OF INCIDENCE, PREVALENCE, AND BURDEN OF DISEASE. J ORTHOP TRAUMA. 2006;20(10): SALTZMAN CL, SALAMON ML, BLANCHARD M, HUFF T, HAYES A, BUCKWALTER JA, AMENDOLA A. EPIDEMIOLOGY OF ANKLE ARTHRITIS: REPORT OF A CONSECUTIVE SERIES OF 639 PATIENTS FROM A TERTIARY ORTHOPAEDIC CENTER. IOWA ORTHOP J. 2005; 25: RESULTS OF TOTAL ANKLE ARTHROPLASTY. MARK E. EASLEY, MD; SAMUEL 4. B. ADAMS JR., MD; W. CHAD HEMBREE, MD; JAMES K. DEORIO, MD. J BONE JOINT SURG AM, 2011 AUG 03;93(15):

47 REFERENCES 1. JONES A, DOHERTY M. INTRA-ARTICULAR CORTICOSTEROIDS ARE EFFECTIVE IN OSTEO- ARTHRITIS BUT THERE ARE NO CLINICAL PREDICTORS OF RESPONSE. ANN RHEUM DIS. 1996;55: CREAMER P. INTRA-ARTICULAR CORTICOSTEROID TREATMENT IN OSTEOARTHRITIS. CURR OPIN RHEUMATOL. 1999;11: AYRAL X. INJECTIONS IN THE TREATMENT OF OSTEOARTHRITIS. BEST PRACT RES CLIN RHEUMATOL. 2001;15: VAN VALBURG AA, VAN ROERMUND PM, MARIJNISSEN AC, VAN MELKEBEEK J, LAM- MENS J, VERBOUT AJ, LAFEBER FP, BIJLSMA JW. JOINT DISTRACTION IN TREATMENT OF OSTEOARTHRITIS: A TWO-YEAR FOLLOW-UP OF THE ANKLE. OSTEOARTHRITIS CARTILAGE. 1999;7: HENRY DEGROOT III, MD, SOFIA UZUNISHVILI, MD, ROBERT WEIR, MD, ALI AL-OMARI, MD, AND BRUNA GOMES, BS.INTRA-ARTICULAR INJECTION OF HYALURONIC ACID IS NOT SUPERIOR TO SALINE SOLUTION INJECTION FOR ANKLE ARTHRITIS.J BONE JOINT SURG AM. 2012;94: MOECKEL BH, PATTERSON BM, INGLIS AE, SCULCO TP. ANKLE ARTHRODESIS. A COMPARISON OF INTERNAL AND EXTERNAL FIXATION. CLIN ORTHOP. 1991;268:

48 REFERENCES CONT. 6. LISA M. COESTER, MD, CHARLES L. SALTZMAN, MD, JOHN LEUPOLD, MD, WILLIAM PONTARELLI, MD. LONG-TERM RESULTS FOLLOWING ANKLE ARTHRODESIS FOR POST- TRAUMATIC ARTHRITIS. J BONE JOINT SURG AM. 2001; 83 A: TIMOTHY R. DANIELS, MD, FRCSC, ALASTAIR S.E. YOUNGER, MB CHB, CHM, FRCSC, MURRAY PENNER, MD, FRCSC, KEVIN WING, MD, FRCSC, PETER J. DRYDEN, MSC, MD, FRCSC, HUBERT WONG, PHD, AND MARK GLAZEBROOK, PHD, MD, FRCSC. INTERMEDIATE-TERM RESULTS OF TOTAL ANKLE REPLACEMENT AND ANKLE ARTHRODESIS. J BONE JOINT SURG AM. 2014;96: KARL M. SCHWEITZER JR., MD, SAMUEL B. ADAMS JR., MD, NICHOLAS A. VIENS, MD, ROBIN M. QUEEN, PHD, MARK E. EASLEY, MD, JAMES K. DEORIO, MD, AND JAMES A. NUNLEY II, MD. EARLY PROSPECTIVE CLINICAL RESULTS OF A MODERN FIXED-BEARING TOTAL ANKLE ARTHROPLASTY. J BONE JOINT SURG AM. 2013;95: BY NELSON F. SOOHOO, MD, DAVID S. ZINGMOND, MD, PHD, AND CLIFFORD Y. KO, MD, MS, MSHS. COMPARISON OF REOPERATION RATES FOLLOWING ANKLE ARTHRODESIS AND TOTAL ANKLE ARTHROPLASTY. J BONE JOINT SURG AM. 2007;89: SAMUEL BRUNNER, MD, ALEXEJ BARG, MD, MARKUS KNUPP, MD, LUKAS ZWICKY, MSC, ASHL. THE SCANDINAVIAN TOTAL ANKLE REPLACEMENT LONG-TERM, ELEVEN TO FIFTEEN-YEAR, SURVIVORSHIP ANALYSIS OF THE PROSTHESIS IN SEVENTY-TWO CONSECUTIVE PATIENTS. J BONE JOINT SURG AM. 2013;95:

49 REFERENCES CONT. 11. MANN JA, MANN RA, HORTON E. STAR ANKLE: LONG-TERM RESULTS. FOOT ANKLE INT MAY;32(5):S MAZUR JM, SCHWARTZ E, SIMON SR. ANKLE ARTHRODESIS. LONG-TERM FOLLOW-UP WITH GAIT ANALYSIS. J BONE JOINT SURG AM. 1979;61: