SAM A. L ABI B, MD F AOA E mo ry Unive rsity. Atla nta , GA e - - PowerPoint PPT Presentation

e mo ryhe a lthc a re .o rg / o rtho

T OT AL ANKL E RE PL ACE ME NT : 5 T IPS F OR A SUCCE SSF UL OUT COME

SAM A. L ABI B, MD F AOA E mo ry Unive rsity. Atla nta , GA

DISCLOSURES

• Re se a rc h/ F

e llo wshi p F unding : Arthre x, Ossur, L inva te c

• Co nsulta nt:

Arthre x, Me dsha pe , Stryke r

JOINT REPLACEMENT SURVIVORSHIP

• HIP REPLACEMENT

91% @ 10 YRS 73% @ 20 YRS 70% @ 30 YRS

• KNEE REPLACEMENT

98% @ 10 YRS 90% @ 15 YRS

• ANKLE REPLACEMENT

80-90% @ 10 YRS

ANKL E RE PL ACE ME NT 5 T IPS F OR A SUCCE SSF UL OUT COME

• 1. Pic k the rig ht

pa tie nt

• 2. Surg ic a l Appro a c h
• 3. Ac c ura te Bo ne

Cuts

• 4. So ft T

issue Ba la nc ing

• 5. Po st o pe ra tive

c a re .

• T

AA 34 ys F

• llo w up

• >50 ys o ld/ < 35 BMI
• Dia b e te s? A1C <8
• Mo tiva te d,

Co mplia nt

• Ne uro -Va sc ula r

inta c t (Ne uro pa thy)

• Bo ne : T

a lus inta c t

• Sub ta la r F

usio n +De fo rmity: 2 sta g e Sx

T IP #1: PAT IE NT SE L E CT ION

• 23,029 pa tie nts we re ide ntifie d fro m 2005 to 2011,

inc luding 5361 with T AA a nd 17,668 with AA. Ob e se T AA pa tie nts ha d a sig nific a ntly inc re a se d risk o f 90-da y ma jo r, mino r, lo c a l, syste mic , ve no us thro mb o e mb o lic , infe c tio us, a nd me dic a l c o mplic a tio ns c o mpa re d with no no b e se pa tie nts.

• T

he inc ide nc e o f re visio n T AA wa s a lso sig nific a ntly hig he r in o b e se pa tie nts c o mpa re d with no no b e se pa tie nts.

• F

inding s we re simila r fo r AA, a s a ll type s o f c o mplic a tio ns we re sig nific a ntly hig he r in o b e se pa tie nts c o mpa re d with no no b e se pa tie nts.

OBE SIT Y IS ASSOCIAT E D WIT H INCRE ASE D COMPL ICAT IONS AF T E R OPE RAT IVE MANAGE ME NT OF E ND- ST AGE ANKL E ART HRIT IS WE RNE R E T AL . F OOT AND ANKL E INT . MARCH 2015

• L

e ve l I V, Re tro spe c tive Ca se Se rie s

• 57 c o nse c utive prima ry T

AA re vie we d

• 16 pa tie nts (28%) with wo und b re a kdo wn
• All invo lve d the c e ntra l third o f the wo und

– 15 o f 16 = a nte ro -me dia l ne c ro sis o ve r the

tib ia lis a nte rio r te ndo n

– 1 o f 15 = a nte ro -la te ra l ne c ro sis

• Sta tistic a lly sig nific a nt risk fa c to rs =

– Smo king >12 pa c k ye a rs, PVD, a nd CAD

WOUND BRE AKDOWN AF T E R T OT AL ANKL E ART HOPL AST Y WHAL E N E T AL , F OOT ANKL E INT 2010

ANKLE WB X RAYS – LONG LEG FILMS

Pre-op C.T.

cysts ? dimensions

• Spina l a ne sthe sia
• Ra dio luc e nt ta b le
• Supine po sitio n
• F
• o t a t the E

dg e : Surg e o n dista l

• Bump: E

psila te ra l hip. T

• e s to the Ce iling
• T

hig h T

• urniq ue t
• C-Arm F

luo ro sc o py – Ankle Mo rtise vie w

T IP #2 : SURGICAL APPROACH

• T

a ylo r, G. I a n, a nd We i Re n Pa n. "Ang io so me s o f the le g : a na to mic study a nd c linic a l implic a tio ns." Pla stic a nd re c o nstruc tive surg e ry 102.3 (1998): 599-616.

• So urc e Arte ry: Ante rio r

T ib ia l

• T

he b lo o d supply is sho wn to b e a c o ntinuo us thre e - dime nsio na l ne two rk o f ve sse ls no t o nly in the skin b ut in a ll tissue la ye rs

SURGICAL ANAT OMY: ANT E RIOR ANKL E

• SPN
• E

xte nso r Re tina c ulum

• T

ib ia lis Ante rio r/ E HL inte rva l

• Ante rio r T

ib ia l Ang io so me

• Pre se rve c uta ne o us

ve sse ls

• Pre se rve Ca psule

SURGICAL ANAT OMY

• Pro te c t the Bundle :

Va sc ula r Clips Me dia l Ma lle o la r Bra nc h.

• Pe rio ste a l Disse c tio n
• T

a lus Blo o d Supply

• Ma nua l Re tra c tio n
• Re mo ve

Oste o phyte s

ANT E RIOR APPROACH

T IP #3 : ACCURAT E BONE CUT S

• K

no w yo ur T AR ste ps

• F

L UOROSCOPY

• Avo id Va rus Cuts
• Ac c ura te Ro ta tio n
• Pre se rve Me d Ma l
• Pro te c t the F

ib ula

• Co nse rve b o ne

(Dista l T ib ia =5 mm)

• Gutte r De b ride me nt

• Re mo ve Ha rdwa re

fro m Ma lle o li AF T E R b o ny c uts

• Pro phyla c tic

Me dia l Ma lle o lus Sc re w

• Avo id Multiple Ho le s
• Re mo ve Bo ne

po ste rio r tib ia

• Avo id NV b undle

PE ARL S AND PIT F AL L S

T IP #4 : SOF T T ISSUE BAL ANCING

• Afte r b o ne c uts
• Jo int Spa c e r/ T

ria l re duc tio n

• Va rus Ankle .

De lto id Re le a se

• Va lg us Ankle .

Bro stro m re pa ir

• Ac hille s o r

Ga sto c Re le a se

• Go o d He mo sta sis
• Co pio us I

rrig a tio n

• Va nc o myc in

po wde r

• No te nsio n- 4 la ye r

c lo sure

• No dra in
• Ca st splint. NWB x 2

we e ks

WOUND CL OSURE . POST OP CARE

• T

he o ve ra ll like liho o d o f SSI wa s de c re a se d b y 73% in pa tie nts who re c e ive d to pic a lly a pplie d va nc o myc in (o dds ra tio [OR], 0.267; 95% CI , 0.089- 0.803; P = .0188). T he ra te o f supe rfic ia l infe c tio n wa s no t sig nific a ntly diffe re nt b e twe e n the 2 g ro ups (OR, 0.400; 95% CI , 0.078-2.062; P = .2734); ho we ve r, de e p infe c tio ns we re 80% le ss like ly in pa tie nts who re c e ive d va nc o myc in po wde r (OR, 0.200; 95% CI , 0.044-0.913; P = .0377).

T OPICAL L Y APPL IE D VANCOMYCIN POWDE R RE DUCE S T HE RAT E OF SURGICAL SIT E INF E CT ION IN DIABE T IC PAT IE NT S UNDE RGOING F OOT AND ANKL E SURGE

• RY. WUKICH E

T AL . F OOT AND ANKL E INT . MAY 2015

T IP #5 : POST OP RE HAB

• Disc ha rg e a fte r 23

ho urs.

• Multi- Mo da l Pa in
• ASA po BI

D X 6 we e ks

• NWB X 2 we e ks
• Wo und Che c k a nd

Bo o t X 6 we e ks

• PWB to F

WB o ve r 8 we e ks

• F
• llo w up a t 6,12, 24

mo s.

33 YR FOLLOW UP OF TAR

• Atlanta 1974
• Small Lady
• BMI =21.5
• Low Impact
• Cemented
• Well Aligned
• Thick Poly

TAR 2017 CONCLUSIONS

• SIGNIFICANT IMROVMENT IN TAR TECHNOLOGY
• BETTER DESIGNS/ LESS BONE CUTS
• MODULARITY
• SOFT TISSUE BALANCING/ DEFORMITY

CORRECTION

• REPRODUCEABLE RESULTS
• LONG TERM.

TOTAL AL AN ANKL KLE E REP EPLACEM EMENT I IS HER ERE T E TO STAY

e mo ryhe a lthc a re .o rg / o rtho

T HANK YOU

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