8/16/2012 POSSIBLE CONFLICTS CONSULTANT. Jeffrey A. Mann, MD Roger A. Mann, MD Eric Horton, MD

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1 8/16/2012 POSSIBLE CONFLICTS CONSULTANT SBI AUTHOR ELSEVIER Jeffrey A. Mann, MD Roger A. Mann, MD Eric Horton, MD 1

2 8/16/2012 Study Demographics This study is a critical review of our first 84 STAR s Procedures performed Only long-term results with STAR in U.S. 84 procedures in 80 patients Average follow-up 9.1 years Average age: 61.4 yrs (33 to 86) 39 women, 41 men Patient Evaluation Pre-op Etiology of arthrosis, length of symptoms Physical Exam: ROM, alignment AOFAS hindfoot scale, Beuchal-Pappas scale Weight-bearing ankle radiographs Post-op Yearly Exam AOFAS, B-P scores WB radiographs VAS Pain scale for ADL s, recreational activity RADIOGRAPHIC DATA Follow-up AP: Varus/valgus alignment Lat: position of talus, tibia Subsidence/tilting of components Radiolucent lines/osteolysis Osteophytes around prosthesis 2

3 8/16/2012 Etiology of Arthrosis Post-traumatic * 56% Idiopathic/Primary 25% Rheumatoid 18% Chondrocalcinosis (Hemochromatosis) 1% 70% 15% 10% 5% * 21.8 years (Range = 2-57 years) Ankle Fx- Disloc Tibial Plafond Other Tibia Fx open fx RESULTS PRE-OP POST-OP AOFAS Score * Pain (with ADL s) * Pain (with rec activities) 2.7 Ankle ROM Dorsiflexion 4.3 o 4.5 o Plantarflexion 27.8 o 4.7 o * p< % SURVIVORSHIP PROBABILITY 5 YEARS 90% 10 YEARS 7 Explants 91% STARS confirmed to remain implanted at 9.1 years. 3

4 8/16/2012 Subjective Outcome Assessment EXCELLENT 31% GOOD 43% POOR 6% FAIR 20% FREQUENCY OF PAIN WITH THE STAR NONE (NEVER) RARE OCCAISIONAL INTERMITTANT REGULARLY FREQUENTLY ALWAYS RESPONSE RATES Maximal Walking Distance After STAR 3 MILES or MORE 2 MILES 1 MILE 1/2 MILE 3-5 BLOCKS 1-2 BLOCKS < 1 BLOCK HOUSEBOUND Response Rates 4

5 8/16/2012 SELF-REPORTED ACTIVITY AFTER TAR AEROBICS BICYCLING DANCING ELLIPTICAL GARDENING GOLF GYM/WEIGHTS HIKING RANCH LABOR SKIING STAIR MACHINE SWIMMING TENNIS TREADMILL WALKING WOODWORKING RESPONSE RATES Subjective Evaluation 92% would have surgery again/recommend to someone else 90% were able to perform all recreational activities they wanted 98.5% were able to perform all ADL s Wound Healing Anterior wound is difficult to heal 10% of cases have some delayed healing (incompletely healed at first postop visit, 2 weeks) Most of these heal spontaneously A few require dressing changes 5

6 8/16/2012 Wound healing If persistent delayed wound healing (> 4wks) or large wound involvement, best to place wound vac, to prevent ankle itself from becoming infected Wound Healing How to prevent wound healing problem Pre-operative evaluation with doppler to assess blood flow Referral to vascular surgeon May be unable to identify all at-risk individuals 6

7 8/16/2012 Complications: Infections 3 deep infections Treated with I&D, abx spacer 6 wks IV abx, 2 free flaps for tissue coverage All prostheses saved No recurrence of infection at avg 9.3 years Complications: Explants 2 aseptic loosening, required fusion (3, 8 yrs postop) 3 developed misalignment, required fusion due to uncorrectable deformity (avg 5.7 yrs postop) 2 revised to different prosthesis at another institution for chronic pain 91% remain implanted at 9.1 year followup Complications: Revision 2 revisions for osteolysis around the prosthesis 3 broken polyethylene components 1 aseptic loosening of talus, revised Overall 5% revision rate 7

8 8/16/2012 POLYETHYLENE FAILURE Complications: Fractures 4 intraoperative fractured malleoli, all fixed surgically at time of TAR 3 postoperative fractures, 2 fixed surgically Radiographic Results 88% of adjacent joints had no progression of arthritis at 9.1 year average 12% progressive arthritis in adjacent joints Subtalar joint 20% Talo-navicular joint 10% Most advanced 1 grade Only 1% advanced 2 grades of arthritis No symptomatic arthritis 8

9 8/16/2012 Ballooning Osteolysis 10 patients (13%) developed ballooning osteolysis 2 patients had implant removal and fusion for massive osteolysis (3, 7 yrs postop) 4 patients required bone grafting of osteolytic lesions, at avg 6.8 years postop 2 implants loose, revised 4 patients have small lesions, being observed Radiographic Results 10 patients (13%) developed ballooning osteolysis GENERALIZED LYSIS 9

10 8/16/2012 HANG IN THERE BABY Deformity Correction 43% of patients had >10 o of varus or valgus deformity of their ankle joint preop We were able to correct up to 25 o of varus or valgus deformity with STAR, usually without need for additional reconstructive procedures 10

11 8/16/2012 Why does Coronal Plane Deformity matter? CPD is a common occurrence Restoration of alignment to neutral critical when performing ankle arthroplasty Residual malalignment can lead to failure We need to be able to recognize what deformities we can correct with TAA alone, and which ones may need additional procedures Why does Coronal Plane Deformity matter? Incidence of CPD in TAA studies HASKELL CORR 04 35/80 44% KIM JBJS-B 09 23/70 33% REDDY FAI 11 43/133 32% Our experience with CPD and the STAR Recognized that excessive varus/valgus was a problem when evaluating our first group of TAA s: 24% misalignment of prosthesis at avg 2-year f/u (Haskell, Mann CORR 04) We identified risk factors for postop misalignment: Coronal plane deformity Joint incongruency Hindfoot malalignment Non-plantigrade foot 11

12 8/16/2012 Our experience with CPD and the STAR Based on 2004 study, we made some technique changes deltoid release for moderate deformity Hindfoot/forefoot realignment for severe deformity Re-evaluated our results: (Reddy, Mann FAI 2011) 14% misalignment at 3.5 yrs f/u Have made additional recommendations based on recent results CPD and the STAR: what we have learned Congruent joint: any varus or valgus deformity is correctable with TAA alone Incongruent joint: < 25 o of deformity is correctable with TAA alone > 25 o of deformity is correctable with TAA, but requires additional procedures, to correct the underlying varus or valgus heel and/or forefoot deformities There are no published results with other TAA s and CPD Conclusion 96% 5-year survival rate with STAR 90% 10-year survival rate Good overall function, resumption of ADL s and recreational activities Acceptable complication rate CPD is correctable up to 25º 12

13 8/16/2012 THANK YOU 13

14 AOFAS symposium 2012 Dr. Tim Daniels Associate Professor St. Michael s Hospital Toronto, Ontario, Canada Disclosures The following authors (or their immediate family members) have received something of value ( $500.00) from a commercial company or institution related directly or indirectly to the subject of this presentation, as noted below: a = research/institutional support, b = misc. non-income support, c = royalties, d = stock/options, e = consultant/employee NAME: DISCLOSURE: COMPANY/SOURCE: 1. T. Daniels a Biomimetics, Integra, Carticept, Wright Medical 2. T. Daniels a, b Integra, Biomimetics, Carticept 3 Rockers of Gait hindfoot ankle forefoot 1

15 GFR is the force exerted by the ground on a body in contact with it Triphasic pattern End-stage ankle arthritis Bimodal or Monophasic gait pattern 2

16 Decreased hindfoot dorsiflexion Decreased hindfoot rotational motion Reduced ground reactive forces Reduced peak kinetic values Reduced walking speed Reduced Cadence Insert jwwalk03 pre The Role of Ankle Replacement 3

17 TARs followed for avg 14.7 mo Poor gait pattern: slow, short steps De-functioned gastroc-soleus complex Sagittal motion improved from 22 to 30deg Patients with arthrodesis functioning better TAR abandoned in the 1980 s Nuclear Winter 4

18 ankle dorsiflexion/ plantarflexion When it works, it works well! vertical ground reaction force knee extension Triphasic pattern Lower Leg Muscle EMG Activity During Gait Medial Gastrocnemius Lateral Gastrocnemius * Soleus Tibialis Anterior 5

19 Under powered Biased selection process Two segment foot model TAA control arthrodesis Under powered Groups not comparable Gait analysis 6 cameras 2 segment model TAR and Ankle Fusions Increased speed Improved Cadence Stance phase shortened Symmetry of the gait improved Ground reaction forces improved 6

20 TAA control arthrodesis No pain gait begins to normalize One of the limitations of this study, or any gait study, is that it is not possible to determine conclusively to what extent the changes in gait are attributable to pain relief and to what extent they are related to improvement in biomechanical function. Both groups had enhanced gait parameters Improved stride length Improved gait velocity 7

21 Insert jwwalk03 pre Insert jwwalk03 post Recent Comparative Studies: Ankle Arthroplasty and Ankle Arthrodesis Prospective Gait analysis compared to Controls Daniels TR, Singer S et al. manuscript under review 8

22 Sagittal Ankle Power Generation During Gait Power = joint moment and angular velocity Daniels Brodsky Controls have significantly more power Power improvement from pre to post ----preoptar postoptar Comparing Sagittal Ankle ROM preop arthritis similar to postop arthrodesis TAR similar to controls Improved dorsiflexion Improved Plantarflexion (ROM 3.7 ) With regard to ankle motion, several questions remain. Does this change, although it is significant, actually represent a meaningful clinical improvement? To what is the change in range of motion attributable? On the basis of these data, the contribution to the increase in range of motion that was attained cannot be attributed to the specific surgical technique, to the specific prosthesis, or to the characteristics of the patients ankles themselves. Why are we seeing subtle differences between gait studies? 9

23 Insert Pre Craig Roberts_walk03 Insert Post Craig Roberts_walk05 Summary Pain resolution results in improvement of gait parameters The differences between fusion and replacement are real and appreciated by the patient Neither fusion or replacement return gait to normal Long term benefits need to be established 10

24 If you can get your patient pain free they will appreciate the movement The questionon is for how long???? 11

25 When I prefer fusion over replacement and why Dr. Alastair Younger, Associate Professor, University of British Columbia, Vancouver, Canada. Disclaimer Institutional support from Linvatec, Smith and Nephew, Cartiva, Wright Medical, Integra foundation, BMTI, Acumed, Bioset, Synthes. topics What has changed in time between TAA and Ankle fusion When an arthroscopic fusion is my preference When an open fusion is my preference When an ankle replacement is my preference 1

26 Not all ankle replacements are the same Results have improved in time A modern total ankle out performs an open fusion for satisfaction A modern total ankle out performs an older TAA However An arthroscopic ankle fusion out performs an open fusion A fusion is more cost effective A fusion results in fewer reoperations Wound complications Wound complications are the problem to solve in foot and ankle surgery An arthroscopic fusion out performs both an open ankle fusion and TAA for wound complications 2

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28 Prospective Comparison of Open and Arthroscopic Ankle Arthrodesis using Validated Outcomes M Di Silvestro, MD FRCSC, F Krause MD, A Younger MD FRCSC, M Glazebrook MD PhD FRCSC, D. Townshend, MD, M Penner MD FRCSC, K Wing MD FRCSC University of British Columbia Vancouver, Canada Dalhousie University, Halifax, Canada Results Open Arthroscopic Tourniquet Time 99min (SD16.4) 106.5min (SD19.5) Hospital Stay 3.7d (SD 1.8)* 2.25 (SD 1.3)* Nonunions 1 (6.6%) 0 Complications 1 delayed wound healing *Significant Difference Radiographic Position Coronal: 5.6 (SD 5.3) Sagittal: 20.4 (SD7.3) 2 symptomatic screws. 2 minor wound, 1 peroneal tendonitis Coronal:2.4 (SD 2.3) Sagittal: 19.8 (SD 6.8) Results: AOS Time Open Arthroscopic Significance (SD 20.6) 56 (SD 17.7) NS 6 months 34.9 (SD 19.4) 29.6 (SD 21.7) P< year 33.5 (SD 21.0) 17.5 (SD 15.9) P< years 29.2 (SD 24.1) 17.2 (SD 17.9) P<0.05 4

29 AOS Baseline 12mon Change Patient Expectations and Satisfaction of Ankle Replacements and Fusion Cassandra Lane Dielwart MD. Orthopaedic Surgery Resident Drs. Alastair Younger; Murray Penner; Kevin Wing Department of Orthopaedics: University of British Columbia, Canada; British Columbias s Foot and Ankle Clinic; Providence Health Care 5

30 Benefits of the arthroscopic fusion over an open fusion Less pain Less swelling Shorter recovery time Fewer wound complications Likely lower cost Shorter hospital stay Better long term outcomes Better satisfaction More likely to meet expectations Fusion vs TAA Revision rates higher in TAA Outcomes worse if a revision has to be performed JBJS A May 2011 Krause, Younger, Wing, Penner 6

31 Fusion vs TAA - Cost. Glazebrook, Younger, Lau, MacLean, Penner, Stephen, Wing, Daniels, Leighton and Dunbar Cost of TAA = TKA and THA Cost of Ankle Fusion <TAA, TKA and THA What operations are we doing now in BC

32 Benefits of arthroscopic fusion over TAA Cost Wound complications Less swelling Lower revision rate More robust Shorter recovery time Satisfaction, expectations, outcome the same Personal indication for arthroscopic fusion Younger patient Patient with a high demand Elderly patient wanting early mobilization Post traumatic arthritis and a stiff ankle Good bone stock Minimal deformity intra articular and extra articular Personal choices of surgery I do Arthroscopic fusion Open fusion Primary TAA Revision TAA 8

33 Indications for arthroscopic fusion Elderly Post trauma Haemophilia Well aligned joint Isolated ankle arthritis or combined ankle and subtalar arthritis 9

34 Case 49 year old haemophiliac End stage ankle arthritis End stage subtalar arthritis Prior knee fusion HIV +ve Well controlled on medication 10

35 Surgical plan Arthroscopic ankle fusion Arthroscopic subtalar fusion Retrograde rod fixation COFAS stage 4 ankle arthritis Postop xrays Indications for open fusions Deformity correction Charcot arthropathy Bone loss 11

36 Indications for TAA Patient preference Age 60 to 75 Or COFAS 4 (extensive hindfoot arthritis) Particularly if a triple arthrodesis is required 12

37 Indications for TAA COFAS 4 Revision TAA Best to do a revision to another TAA Ankle replacement to fusion has not been good in my practice! 13

38 Summary Improvement in ankle replacement design will change the indications of TAA Currently Arthroscopic ankle fusion is my preferred operation Specific indications Open ankle fusion Total ankle arthroplasty Thank You 14

39 New Horizons in TAA: Importance of Accuracy Gregory C Berlet MD Murray J Penner MD CT Custom Guides? The concept is pre-operative navigation for TAR Virtual 3D positioning of the components is performed on a patient s CT-based 3D model Surface-matched guides derived from the patientspecific 3D model are made using Rapid Prototyping Technology These sterile guides position the pins and jigs to guide all cuts and reaming A Paradigm Shift in Instrumentation C-Bracket Assembly Alignment Guides Many different types of External Cut Guides 1

40 What are the Goals of Technique? Improve ease of use and potential for: Less radiation less operative time less opportunities for error Improve component positioning Accuracy Reproducibility Accuracy Matters Standard in TKA is to be within 3 of intended prosthetic position Keys to success & longevity are: Accurate component alignment Joint line reproduction Most failures can be attributed to: Incorrect ligament balancing Incorrect prosthetic alignment Specific implant type not nearly as important as positioning Insall et al: CORR 192, 2005 What about TAR? 2

41 TAR conversation until now Amount of bone resection Poly bearing configuration: Mobile vs. Fixed Good questions but, as for TKA, NOT the KEY question What is the KEY question? Are we positioning the implants appropriately? Positioning in TAR at least as Sensitive as in TKA What do we know about TAR positioning now? Too little, unfortunately But, what we do know suggests positional accuracy should be at least as important in TAR as in TKA, if not even more so 3

42 Clinical Outcome vs Position The results of our study strongly support the assumption that proper positioning of the talar component in the sagittal plane results in: greater postoperative pain relief, and better functional outcome, especially ankle range of motion Barg et al, JBJS (A), 2011 Position vs Implant Loading Talar component malrotation resulted in: increased peak pressure, decreased contact area and increased rotational torque Talar component malrotation may contribute to: premature polyethylene wear, as well as potential talar loosening secondary to rotational torque Fukuda & Haddad, FAI 2010 Position vs Bone Loading To avoid off centre forces on a prosthesis and possible collapse of the weak lateral tibia, proper alignment of the prosthesis and adequate ligament balancing of the ankle must be achieved Kakkar & Siddique, Foot Ankle Surg

43 Position vs Survivorship To improve long-term results, proper positioning of the investigated implants in version is likely an important requirement Kakkar & Siddique, Foot Ankle Surg 2011 Malposition Affects. Clinical outcome Pain relief, ROM Poly contact stresses May result in poly wear & osteolysis Bone-implant interface stresses May result in aseptic loosening Off-center forces Potential tibial subsidence Probably implant survivorship Component Position. is the KEY to successful TAR So, how easy is it to achieve this? One of the main challenges in doing total ankle replacement is inserting the implant in the optimal position Saltzman et al, CORR

44 What is Current Accuracy? Looking at talus alignment relative to tibia in 368 Hintegra TARs: Mean AP offset ratio was 0.0±0.06 (range 0.21 to 0.16) Approximates to -9mm to +7mm AP variation 34.5% on axis 37% anterior (mean 0.06, ~3mm) 28.5% posterior (mean 0.07, ~3.5mm) Barg, Hintermann et al, FAI 2010 What is Current Accuracy? Reasonably good. but good enough? And, this is in the hands of the designer, who has done >1000 TAR Two Key Questions How can we make accuracy even better than this? How can we sustain reproducibilty? 6

45 The Answer may be. Patient specific cut guides Pre-operative navigation Implant Placement Accuracy and Reproducibility Using Pre- Operative Navigation in Total- Ankle Arthroplasty Gregory C Berlet, MD Murray J. Penner, MD, FRCSC Steven L. Haddad, MD W. Hodges Davis, MD Robert B. Anderson, MD Thomas H. Lee, MD Sarah L. Lancianese, PhD Paul M. Stemniski, PhD Richard M. Obert AOFAS 2011 Purpose Planned Implant Placement Actual Implant Placement 7

46 Validated 3D Measurement System Tracked Placement Patient specific surgical guides set pre-operative planned resections and implant placement Guide precision: Translation < 0.5mm, Rotation < 1.0 3D measurement by a sub-millimeter accuracy motion capture system Planned vs. actual placement compared Pre-op vs Post Op Accuracy PROPHECY INBONE vs. Traditional INBONE or STAR Study Conclusion We have shown placement accuracy: Within an average of 2 of pre-op plan Equal or better than conventional INBONE or STAR 8

47 Summary Component position is the KEY for TAR outcomes Just like in TKA Patient specific guides provide highly accurate: Implant position planning Component insertion accuracy & reproducibility THANK YOU 9