62 New STG Ankle Arthritis 2024 PDF

Ankle Arthritis Sean T. Grambart DPM, FACFAS, D.ABFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Director of Research, DMU-CPMS Attending, IMMC Foot and Ankle Surgical Residency AO Fellow Dresden, Germany Past-President, American College of Foot and Ankle Surgeons...

Ankle Arthritis Sean T. Grambart DPM, FACFAS, D.ABFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Director of Research, DMU-CPMS Attending, IMMC Foot and Ankle Surgical Residency AO Fellow Dresden, Germany Past-President, American College of Foot and Ankle Surgeons 1 Knee Arthritis: Primary OA Most is primary OA: Post traumatic OA – 9.8% Non-PTOA – 90.2% Brown et al, JOT 2006 Primary OA – 94% CJRR 2006-7 2 A Unique Disease Etiology of arthritis Adjacent deformity Surrounding joint disease Age of the patient Expectations of treatment 3 Ankle Arthritis: Secondary Arthritis Most is post traumatic: PTOA – 79.5% Non-PTOA – 20.5% Brown et al, JOT 2006 PTOA – 78% Non-PTOA – 22% Valderrabano et al, CORR 2008 4 Ankle PTOA: Time to Develop Injury Type Percentage of PTOA Years from injury to ankle reconstruction Malleolar fracture 49.5% ~ 25 (10-40) Ligament instability 20.4% ~ 35 (25-45) Pilon & Talus fractures 21.0% ~ 4 (1-10) Other 9.1% 5 Ankle Arthritis is a Disease of the Young Mean age at time of ankle fusion (1995-2004): 55* Mean age at THA: 67.6 Mean age at TKA: 68.0 6 Deformity & Complexity Only 37% of ESAA cases have normal alignment Major adjunct procedures required in 35-40% of cases Rarely ever required in 1° TKA or THA This makes Rx of ESAA more specialized More difficult for pts to access Less predictable outcomes 7 Conservative Treatment Bracing NSAIDs Steroid Injections 8 Picking the Right Option Ankle Arthritis Treatment Options: Scope Fusion Open Ankle Fusion TTC Fusion Ankle Arthroplasty 9 Ankle Arthrodesis Indications Post traumatic arthritis Rheumatoid arthritis Neuromuscular disorders Diabetic neuroarthropathy Failed TAR 10 Ankle Arthrodesis Goals 1. Plantigrade foot 2. Sound arthrodesis 3. Decrease pain 4. Maintain length 5. Avoid wide ankle 6. Function on flat terrain 11 Glissan’s Four Requirements For A Successful Arthrodesis 1. Adequate joint debridement and preparation 2. Accurate coaptation of surfaces 3. Optimal position 4. Maintain position until arthrodesis is sound Glissan,Aust NZ J Surg, 19:64, 1949 12 Ankle Arthrodesis Pre-Operative Considerations Osteopenia Special radiographs Advanced imaging Adjacent joints Suprastructural considerations BMI? 13 Surgical Approaches Arthroscopic Approach Mini-Arthrotomy Approach Anterior Approach Transfibular with Medial Utility Incision Posterior Approach 14 Open Ankle Fusion Techniques Transfibular with two cross screws +/- use fibula as bone graft 15 Incision / Dissection Medial medial gutter saphenous vein, nerve Transfibular Approach 16 17 Ankle Arthrodesis Medial Malleolus Avoid resection (vascular,positioning and fixation implications) Provides buttress Debulk only when surfaces won’t coapt Protect during resection of tibial articular surface 18 Lateral Incision Syndesmotic Approach Superficial Peroneal N. Distal Anterior Tibiofibular Tibiofibular Syndesmosis 19 20 Lateral Joint Resections 21 22 23 Close Contact Fit 24 Arthrodesis Fixation Large Compression Screws Medial Directed posterior (talar body) Lateral Directed anterior (talar neck) 25 Medial Screw Insertion 26 Anterior Approach 27 Anterior Incision - Access Advantage is access Both malleoli visible Better joint take down than lateral If congruent deformity tibial osteotomy easier 28 Flat Cut with Deformity Correction 29 Posterior Approach 30 Arthroscopic Approach 31 Little to no deformity Good approach if there are soft tissue concerns Potential for quicker recovery Not typically for revision cases Mini-Arthrotomy Approach Good for soft tissue concerns Less technically demanding than arthroscopy Adequate visualization Anterolateral incision Anteromedial incision Not typically for revision cases 32 Incision Anterior-Medial Anterior-Lateral 33 34 Screw Fixation 35 Alignment Neutral flexion 36 Alignment 5 degrees of valgus 37 Alignment 5-10 degrees of external rotation Look at contralateral side 38 Optimal Position Frontal plane = “slight” valgus Sagittal plane = right angle (90 degrees) Transverse plane = 5-10 degrees external rotation Buck et al,JBJS, Vol 69-A,#7, Nov 1987 39 Post-op Management Recommendations Jones Splint BK Cast NWB (8-12 wks) Protected WTB (8 wks) Close Clinical and Radiographic Evaluation Physical Therapy / Rehabilitation 40 Recognized Complications * Nonunion Mal-union, Mal-position Infection Pain Adjacent Arthrosis Functional Limitations 41 Surrounding Joint Disease 42 TAR…Is Motion Really Salvaged? The primary purpose of ankle replacement surgery is to relieve pain. Post op motion dependent on the amount of stiffness before surgery. Generally, ankle motion after surgery will be similar to that before surgery. 43 History: More than 40 years in the making Inverted hip stem as 1st implant 1973 Initial designs had 50% or greater failure rate Multiple generations each with improved design 44 First Generation: Too much bone resection Use of PMMA cement causes osteolysis and loosening Constrained implants unable to dissipate rotational forces leading to loosening 45 Second Generation: 46 2 component fixed bearing systems with polyethylene bearing surfaced More conservative bone cuts Eliminated use of cement Added porous coating for press fit and boney ingrowth **subsidence osteolysis Third Generation: 3 component mobile bearing Semi- constrained fixed bearing Lateral resurfacing approach Modular stem fixed bearing 47 Implant Design: Mobile Bearing Fixed Bearing 2 components Stable articulation Decreased risk of subluxation Higher risk of loosening at tibial component due to high shear forces and bone-implant interface 48 3 components More flexible articulation Lower shear forces at bone implant interface Susceptible to excessive anterior/posterior or lateral subluxation of poly Increased risk of malleolar impingement Mobile Bearing Design 49 Best for petite patients, with minimal deformity and low physical demand Fixed Bearing Modular Intramedullary Guidance CT guidance available Vertical stem can bypass cystic bone and metaphyseal defects Allows for greater force distribution Good for large patients with greater demand, significant deformity in frontal plane, or for revisions or fusion take downs 50 Fourth Generation: Similar to 3rd generation Continued decrease in bone resection 2 major improvements: Notch to prevent fibular impingement Poly made of HXLPE Stronger creating less debris 51 CT Planning/Referencing 52 53 Total Ankle Replacement Ideal Patient? > 50 yrs. Old Low physical demands Reasonable weight Good bone stock Good hindfoot alignment Normal vascularity 54 Who is NOT the ideal patient? Neuroarthropathy Charcot Ischemia AVN of the talus Previous infection Neuropathy Neuromuscular disorders 55 Who is NOT the ideal patient? Contraindications Relative Gross Obesity Poor Skin Circulation Certain Occupations Compliance Age Severe deformity Tobacco Abuse 56 Total Ankle Replacements Pros ROM closer to the normal ankle Provides a painless, plantigrade , stable foot Decreased chance of adjacent joint arthritis Viable intermediate solution prior to fusion Cons Polyethylene wear Talar subsidence Early failure rates Hindfoot alignment critical Ancillary procedures can be staged. 57 Cases 58 59 60 61 62 63 64 Things to Consider Don’t go gray Pre-op plan Intra-op precision Soft Tissue balancing Implant selection Post-op reenforcement Revise when necessary Understand complications – will happen TRAINING!! 65 Summary 66