Dr. Ashish Shah MD Dr. John Kirchner MD Dr. Sameer Naranje MD

Transcription

1 Dr. Ashish Shah MD Dr. John Kirchner MD Dr. Sameer Naranje MD Assistant Professor, UAB Orthopaedic Surgery, Foot & Ankle Section, th Street South, Birmingham, AL Clinical Instructor Fellow, UAB Orthopaedic Surgery, Foot & Ankle Section, th Street South, Birmingham, AL 35205

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3 Total ankle arthroplasty (TAR) provides an alternative to arthrodesis for management of ankle arthritis. 1. TAR has short and long term complications like gutter pain,impingement stiffness, locking sensation, infection, subsidence, aseptic loosening, per prosthetic fracture. 2-5 The role of arthroscopy following total joint replacements in knee is well established 6. To our knowledge there have been only two peer reviewed publications on role of arthroscopy in managing short term complications of total ankle replacement limited information as regards to clinical outcome 4;7. The main purpose of this paper was to retrospectively evaluate results of arthroscopic intervention on total ankle joints for management of impingement, synovitis, loose bodies other painful conditions that would otherwise have required an arthrotomy. We also described the technique of arthroscopy in patients with TAR, possible different intra operative diagnosis, modalities of treatment and results.

4 Retrospective evaluation of 18 patients (10 men and 8 women) who underwent arthroscopic surgery for pain in the ankle after TAR during April 2008 to June 2011 was done. We used patient s medical charts for data gathering. Institutional Review Board approval was obtained for this study. The diagnosis for primary ankle arthroplasty in these patients were post traumatic osteoarthritis in 10 patients, primary osteoarthritis 6, Lupus 1, Posterior Tibial Tendon Dysfunction stage IV 1. All patients had previously underwent Salto Talaris Total ankle Replacement who then underwent ankle arthroscopy (Fig.1) from October 2007 to September The mean age at the time of ankle arthroscopy was 57.8years [range: 40 to 78 years]. 8 left and 10 right ankles were scoped. 8 out of 18 patients had associated arthritis &/or deformities of foot & ankle which includes 7 subtalar arthritis, 1 patients with Transverse Tarsal joint arthritis and cavovarus foot. 9/18 patients underwent one or more surgeries before or along with total ankle replacement surgery.

5 Ankle arthroscopy was performed in these patients following TAR for one or the other reasons which included synovitis (Fig.2) impingement (Fig.3), loose bodies and hypertrophic scar tissue (Fig.4) in the joint. Thorough physical examination, including range of motion and limb alignment, maximum point of tenderness was performed before arthroscopy. Three views of the ankle weight bearing radiographs were obtained to investigate the possible pathological condition, such as malpositioned prosthesis, subsidence, gutter impingement (Fig. 5), aseptic loosening of prosthesis, anterior impingement and intraarticular loose bodies. 10/18 patients underwent metal reduction CT scan to confirm the diagnosis and to rule out pathology in surrounding joints and soft tissue envelope. 1 patient with anterior impingement underwent dynamic ultrasound study to check the extent of impingement and confirmation of the diagnosis. All patients underwent preoperative blood work to rule out the possibility of infection.

6 Figure 1: Arthroscopic picture showing visualization of the TAR Figure 2: Arthroscopic picture showing synovitis in front of the TAR Figure 4: Arthroscopic picture showing hypertrophic scar tissue and loose body in the total ankle replacement Figure 3: Arthroscopic picture showing medial Gutter impingement in the TAR joint

7 Figure 5: Preoperative anteroposterior x ray(a) of patient with lateral gutter impingement and loose body (arrow) and postoperative anteroposterior x ray(b) of patient after arthroscopic debridement of lateral gutter impingement(arrow)

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9 We suggest that an arthroscopy can be a valuable tool to evaluate a painful TAR, and can be used to diagnose and treat certain conditions that would otherwise require an arthrotomy. In this series, it appears to a relatively benign procedure with minimum morbidity, and it does not compromise any future procedures that may need to be performed, such as revision TAR or Arthrodesis. This is a preliminary evidence of role of ankle arthroscopy in TAA patients in managing the complications like synovitis, impingement and loose bodies. There is a learning curve in arthroscopy technique of the problematic TAR and remains a technically demanding procedure. Further studies are needed to further define the indications, classification systems and expected results. Weaknesses : Chart review & there is no control group of patients operated by open arthrotomy or mini open procedure Limited number of patients and relatively very short follow up period time- results may be short term. We did not use any approved functional scoring system. non availability of pre operative scores

10 1. Haddad,S.L., Coetzee,J.C., Estok,R., Fahrbach,K., Banel,D., and Nalysnyk,L.: Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am, 89: , Glazebrook,M.A., Arsenault,K., and Dunbar,M.: Evidence-based classification of complications in total ankle arthroplasty. Foot Ankle Int, 30: , Kopp,F.J., Patel,M.M., Deland,J.T., and O'Malley,M.J.: Total ankle arthroplasty with the Agility prosthesis: clinical and radiographic evaluation. Foot Ankle Int, 27:97-103, Kurup,H.V. and Taylor,G.R.: Medial impingement after ankle replacement. Int Orthop, 32: , Saltzman,C.L., Kadoko,R.G., and Suh,J.S.: Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop Surg, 2:1-7, Diduch,D.R., Scuderi,G.R., Scott,W.N., Insall,J.N., and Kelly,M.A.: The efficacy of arthroscopy following total knee replacement. Arthroscopy, 13: , Shirzad,K., Viens,N.A., and Deorio,J.K.: Arthroscopic treatment of impingement after total ankle arthroplasty: technique tip. Foot Ankle Int, 32: , 2011.