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Update on Total Ankle Replacements (and other cool foot & ankle - - PowerPoint PPT Presentation

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Update on Total Ankle Replacements (and other cool foot & ankle stuff) Carter Kiesau, MD Foot & Ankle Specialist PeaceHealth Orthopedics & Sports Medicine March 6, 2015 Objectives What does an orthopedic foot & ankle

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Update on Total Ankle Replacements

Carter Kiesau, MD

Foot & Ankle Specialist

PeaceHealth Orthopedics & Sports Medicine March 6, 2015

(and other cool foot & ankle stuff)

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Objectives

  • What does an orthopedic foot & ankle specialist do?
  • Review ankle arthritis
  • Cover treatment options

– Nonoperative (meds, pt, brace, injection, etc) – Surgical (joint-sparing, replacement, fusion)

  • Learn about total ankle replacement

– Preop optimization – Surgery – Postop care – Long-term maintenance – Interesting cases

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My Background

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Audience Response Question

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Audience Response Question

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My Practice

  • Foot & Ankle

– Ankle Arthritis: replacement, fusions, arthroscopy, osteotomies – Sports: ligament/tendon repairs, Achilles repair, cartilage lesions – Trauma: Lisfranc midfoot, fractures (ankle, pilon, calcaneus, talus, metatarsal) – Deformity: flatfoot, cavus foot, varus, valgus, bunions, hammertoes – Diabetes: Charcot arthritis, ulcers, osteomyelitis, amputations – Rheumatoid: fusions, deformity corrections – Nerves: Morton’s neuroma, Tarsal tunnel syndrome

  • General Orthopedic Trauma

– Adult: fractures (hip, wrist, elbow, shoulder, ankle, knee, etc), infections – Pediatric: fractures (wrist/forearm, ankle, elbow, femur, tibia), infections

  • Knee

– Meniscal Tears: arthroscopic partial meniscectomy

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Metatarsal Collapse (Freibergs)

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Bunions

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Supersized Bunions

Would you like hammertoes with that?

(Rhuematoid Forefoot)

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Rhuematoid Forefoot

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Rhuematoid Forefoot

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A night on call…

(or a weekend)

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Gifts from Galbraith Mountain

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Open, Comminuted, Segmental (with a prior ACL screw)

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Day Care “Oopsie Daisy”

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Type III Pediatric Elbow Fracture

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Mossy rooftops are slippery…

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Comminuted, Intra-articular Calcaneus Fracture

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“This year I’m going to put Christmas lights on the big tree…”

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Open Comminuted Pilon Fracture

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Ankle Arthritis

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Ankle Arthritis

  • Less common than hip/knee arthritis
  • Types:

– Post-Traumatic Arthritis (65%) – Primary Osteoarthritis (10%) – Inflammatory Arthritis

  • Rhuematoid, Psoriatic, Gout, Pseudogout

– Neuropathic – Osteonecrosis – Septic Arthritis – Hemophilia

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Ankle Arthritis

  • Radiographs:

– Weightbearing 3 views ankle

  • AP, Lateral, and Oblique
  • Weightbearing shows us true cartilage wear and how

close the bones get with functional loading

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Ankle Arthritis

  • Nonoperative Treatment Options

– Activity Modification

  • Avoid hills, uneven ground, impact
  • Try unloaded exercise (pool, bike, kayak, rower)

– Weight loss – Rocker sole shoe – Orthotics – Immobilization/Bracing (ASO, boot, SMAFO, Arizona) – PT – NSAIDs – Injections – Alternative (accupuncture, Willow Curve?, Australian Dream?)

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Ankle Arthritis

  • Ankle Injection

– Antero-Medial (my first choice)

  • Soft spot between medial malleolus,

medial talar dome, and anterior tibial tendon

– Antero-Lateral

  • Soft spot between lateral malleolus, lateral

talar dome, latearal tibia, and extensor digitorum longus tendons

– Go where the spurs aren’t

  • Find the wide open space
  • Range the ankle to help
  • Ankle distraction can help get needle in
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Ankle Arthritis

  • Operative Treatment Options

– Debridement, Excision spurs – Distraction Arthroplasty – Supramalleolar Osteotomy – Ankle Fusion – Total Ankle Allograft Replacement – Total Ankle Replacement

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Ankle Arthritis

  • Outcome Issues:

– Debridement, Excision spurs

  • Possible faster progression of arthritis

– Supramalleolar Osteotomy

  • Short term success, nonunions

– Distraction Arthroplasty

  • Short lived, if it works

– Allograft Arthroplasty

  • Less than 50/50 chance of success
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Ankle Arthritis

  • Fusion or Replacement?
  • Fusion:

– Nonunion rate 10% – Subtalar arthritis rate 90% at 10 years

  • Replacement:

– Range of motion increase of 11 degrees – Lucency rate 23% at 4.5 years – Total reoperation rate 11% (impingement, cysts, loosening, failure) – Implant survival 90% at 10 years

  • Both patients are generally happy
  • Replacement patients score higher due to motion
  • Does replacement protect against adjacent joint arthritis?

– Yes, compared to fusion.

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Ankle Fusion, Subtalar Arthritis

  • 52 y.o. healthy woman
  • MVA 30 years ago, tibia fx
  • Ankle and knee arthritis
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Ankle fusion 3 years ago

  • Presents to me with subtalar arthritis
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Her Theoretical Timelines

Ankle Fusion

  • Year 0: ankle fusion
  • Year 3: subtalar fusion
  • Year 4: total knee
  • Year 5: convert to total ankle
  • Year 7: doing well
  • 4 surgeries
  • 5 years of pain needing

surgeries

Ankle Replacement

  • Year 0: Total Ankle
  • No need for subtalar fusion?
  • No need for total knee yet?
  • Would total ankle need

revision? Hopefully not for 10+ years.

  • 1 surgery?
  • = less than a year of pain?
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Total Ankles: Our Series

  • My Training:

– 75 total ankles during fellowship year at Duke

  • 3 surgeons, large academic center
  • 4 Years at PeaceHealth in Bellingham

– Now over 60 total ankles (Taranow combined) – Only 3 re-operations = 5%, (compared to 11%)

  • 2 spur debridements, 1 cyst grafting
  • No failures, no infections, no wound problems
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Patient Selection & Pre-op Optimization

  • Diabetics

– HbA1C < 7 – Tight perioperative glucose control

  • Smokers

– Must quit prior to surgery

  • Rheumatoid Arthritis

– Consult with rheumatologist, many meds can be taken

  • Lymphedema controlled
  • Hypovitaminosis D

– Correct to > 30

  • Dental Infections resolved
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Contraindications

  • Absolute:

– Neuropathic Joint

  • Charcot Arthropathy, severe peripheral neuropathy

– Severe ankle or foot deformity – Severely scarred soft tissues, plastics flaps – Open Ulcer or active infection – Extreme laxity (Marfan’s) – Motor functional weakness/paralysis – High functional demand patients (contact sports, construction)

  • Relative:

– Osteonecrosis – Previous ankle infection – Uncontrolled diabetes – Severe Lymphedema – Severe vascular insufficiency – Young age?

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Total Ankle Surgical Team

In The Room:

  • Dr. Kiesau
  • Dr. Taranow
  • Ortho PA Assist
  • Anesthesiologist
  • Scrub Technician
  • Nurse Circulator
  • Radiology Technician
  • Device Representative
  • The patient, too!

Peri-operative:

  • many clinic/hospital

providers & staff

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Anesthesia

  • Popliteal Block

– Intra- and Post-operative pain control – Lasts about 16 hours

  • Combined with general

anesthesia

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Total Ankle Surgery Info

  • 2-3 hours if straightforward
  • 4-8 hours if complex

– Additional procedures to correct other deformities

  • 1 night admission
  • Can usually bear weight at 2 weeks postop
  • Reimburses only 70% of a total knee or hip

– takes twice as long to perform – Typically uses two surgeons

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Typical Postop Care

  • 1 night admission
  • Splint, nonweightbearing, elevation, scooter
  • Stitches out at 10-14 days
  • Start walking in a boot
  • Work on range of motion
  • Wean to ASO brace at 6 weeks
  • Can do PT if needed
  • Regular activities at 3 - 4 months
  • Gradual improvements over the year
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Maintenance

  • Similar to arthritis management:

– Weight loss – Activity modification

  • Low impact exercise/sports ok (hiking, biking,

groomers)

  • High impact are not (running, soccer, moguls)

– Radiographs every 1 – 2 years

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A Few Cases

  • The awesome ones, of course!
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Post-traumatic Ankle Arthritis

  • 64 y.o. lady
  • Prior tibial shaft fracture
  • Healed in valgus angulation deformity
  • Developed knee, ankle and subtalar arthritis
  • Total knee replacement
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Post-traumatic valgus arthritis

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CT

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After osteotomy, subtalar fusion

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After osteotomy, subtalar fusion

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STAR

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Total Ankle Bone Cuts

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STAR after Osteotomies

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1 Year Postop

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Disaster Strikes!

  • But, it’s not her.
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Failed Buechal-Pappas Ankle

  • 70 y.o. male, healthy
  • Ankle replacement 14 years ago in NYC
  • Previous triple arthrodesis
  • Wears SMAFO brace
  • Constant pain, instability
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OR Plan

  • Fusion hardware in room
  • Ex-plant
  • Ankle reduction
  • Inbone total ankle
  • Bone grafting tibia and fibula
  • ORIF fibula
  • Allograft tendon lateral

ligament repair

  • Say a prayer
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INBONE

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1 Year

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1 Year

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1 Year

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1 Year

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Not everyone gets a total ankle

  • 28 y.o. female, healthy
  • Open ankle fracture, ORIF
  • 1 year later: Tibial AVN, equinus, pain
  • Infectious workup negative
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1 Year later

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6 Weeks

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STAR

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Speaking of disasters…

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Severe Varus

  • 58 y.o. male, no medical problems
  • Post-traumatic arthrtitis, MVA, multiple

surgeries

  • Uses Arizona brace daily
  • 22 degree varus deformity
  • equinus
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Preop Video

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OR Plan

  • Inbone Total

Ankle

  • Medial Malleolar

Osteotomy

  • Lateral Ligament

Reconstruction

  • 1st MT

Dorsiflexion Osteotomy

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Walking Videos

Pre-Op 3 Months

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Walking Videos

Pre-Op 6 Months

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1 ½ Years Postop

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1 ½ Years Postop

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1 ½ Years Postop

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Photos

Pre-Op Post-Op

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Photos

Pre-Op Post-Op

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Photos

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Sydney, Aus

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Thank You

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Pre Post Comparison

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Pre Post Comparison