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

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

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 • T 1. Pic k the rig ht AA 34 ys F o llo w up 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 IP #1: PAT IE NT SE L E CT ION • >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

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 • 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.

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 • 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

ANKLE WB X RAYS – LONG LEG FILMS

Pre-op C.T. cysts ? dimensions

T IP #2 : SURGICAL APPROACH • Spina l a ne sthe sia • Ra dio luc e nt ta b le • Supine po sitio n • F o o t a t the E dg e : Surg e o n dista l • Bump: E psila te ra l hip. T o e s to the Ce iling • T hig h T o urniq ue t • C-Arm F luo ro sc o py – Ankle Mo rtise vie w

SURGICAL ANAT OMY: ANT E RIOR ANKL E • 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 • 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

ANT E RIOR APPROACH • 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

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

PE ARL S AND PIT F AL L S • 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

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

WOUND CL OSURE . POST OP CARE • 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

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 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 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 o 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

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