Ankle Arthritis Treatment 2022 PDF

Ankle Arthritis Sean T. Grambart DPM, FACFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Past-President, American College of Foot and Ankle Surgeons Knee Arthritis: 10 OA Most is primary OA: Post traumatic OA – 9.8% Non-PTOA – 90.2% Brown et al, JOT 2006 Primary OA...

Ankle Arthritis Sean T. Grambart DPM, FACFAS Assistant Dean of Clinical Affairs, College of Podiatric Medicine and Surgery Past-President, American College of Foot and Ankle Surgeons Knee Arthritis: 10 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% Valderrabano et al, CORR 2008 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 Soohoo et al, JBJSA 2007 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 Valderrabano et al, CORR 2009 7 Bracing Conservative Treatment NSAIDs Steroid Injections 8 Picking the Right Option Ankle Arthritis Treatment Options: Scope Fusion Open Ankle Fusion Fusion TTC Fusion Ankle Arthroplasty TAR 9 The Challenge: Optimizing Fusion & Outcome Emphasis has been on mechanical stabilization…. Modern techniques demand biologic augmentation as well US Hindfoot & Ankle Arthrodesis Procedures Continue to Grow 6%-7% Annually *Frey et al, FAI 1994 *Myerson et al, JBJS 2000 *Easley et al, JBJS 2000 *Thordarson et al, FAI 2003 *Haddad et al, JBJS 2007 *Easley et al, JBJS 2008 10 Ankle Arthrodesis Indications Post traumatic arthritis Rheumatoid arthritis Neuromuscular disorders Diabetic neuroarthropathy Failed TAR 11 Ankle Arthrodesis Goals 1. Plantigrade foot 2. Sound arthrodesis 3. Decrease pain 4. Maintain length 5. Avoid wide ankle 6. Function on flat terrain 12 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 13 Ankle Arthrodesis Pre-Operative Considerations Osteopenia Special radiographs Advanced imaging Adjacent joints Suprastructural considerations BMI? 14 Surgical Approaches Arthroscopic Approach Mini-Arthrotomy Approach Anterior Approach Transfibular with Medial Utility Incision Posterior Approach 15 Open Ankle Fusion Techniques Transfibular with two cross screws +/- use fibula as bone graft 16 Incision / Dissection Medial medial gutter saphenous vein, nerve Transfibular Approach 17 18 Ankle Arthrodesis Medial Malleolus 1. Avoid resection (vascular,positioning and fixation implications) 2. Provides buttress 3. Debulk only when surfaces won’t coapt 4. Protect during resection of tibial articular surface 19 Lateral Incision Syndesmotic Approach Superficial Peroneal N. Distal Anterior Tibiofibular L. Tibiofibular Syndesmosis 20 21 22 23 Lateral Joint Resections 24 25 26 Medial Joint Resection 27 28 Close Contact Fit 29 Arthrodesis Fixation Large Compression Screws Medial directed posterior (talar body) Lateral directed anterior (talar neck) 30 Medial Screw Insertion 31 Lateral Screw Insertion 32 33 Anterior Approach 34 Anterior Incision Access Advantage is access Both malleoli visible Better joint take down than lateral If congruent deformity tibial osteotomy easier 35 Flat Cut with Deformity Correction 36 Posterior Approach 37 Arthroscopic Approach Little to no deformity Good approach if there are soft tissue concerns Potential for quicker recovery Not typically for revision cases 38 Mini-Arthrotomy Approach Good for soft tissue concerns Less technically demanding than arthroscopy Adequate visualization Anterolateral incision Anteromedial incision Not typically for revision cases 39 Incision Anterior-Medial Anterior-Lateral 1.5-2.0cm 40 41 What do you do with the Posterior Talus 42 Screw Fixation 43 Alignment Neutral flexion 44 Alignment 5 degrees of valgus 45 Alignment 5-10 degrees of external rotation Look at contralateral side 46 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 47 Post-op Management Recommendations Jones Splint BK Cast NWB (8-12 wks) Protected WTB (8 wks) Close Clinical and Radiographic Evaluation Physical Therapy / Rehabilitation 48 Recognized Complications * Nonunion Mal-union, Mal-position Infection Pain Adjacent Arthrosis Functional Limitations 49 Causes of Non-union Inadequate Resection Inadequate Fixation Lack of Post-op Compliance Previous Insult (infection, surgery, trauma) Debilitated Patient * Smoking 50 Surrounding Joint Disease 51 Picking the Right Option Ankle Arthritis Treatment Options: Scope Fusion Open Ankle Fusion Fusion TTC Fusion Ankle Arthroplasty TAR 52 How did we get here? Google Search not happy with loss of motion Ankle Non-union up to 41% Frey et al. FAI, 1994 Increased juxta-articular arthritis long term 53 Current State of Practice TAR gaining in popularity with improved outcomes and techniques 1971 1879 - ??? 2009 Ankle Fusion remains the “Gold Standard” for ankle joint arthritis 54 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 55 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. 56 First Generation: Too much bone resection Decreased bone density and strength Use of PMMA cement causes osteolysis and loosening Constrained implants unable to dissipate rotational forces leading to loosening 57 Second Generation: 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 58 Third Generation: 3 component mobile bearing Semi- constrained fixed bearing Lateral resurfacing approach Modular stem fixed bearing 59 Pre-Op CT Guidance Increased survivorship and durability Decrease learning curve in ankle replacement 60 Implant Design: 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 Mobile Bearing 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 Most important: Proper fit. -complete sagittal plane and axial rotation for even wear on the poly. 61 Mobile Bearing Design Best for petite patients, with minimal deformity and low physical demand 62 Fixed Bearing Modular Stem FDA Clearance in 2005 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 63 Fixed Bearing Models: Best for low demand patient small to medium size ankle Little to no frontal plane deformity 64 Lateral trans-fibular approach: Lateral approach Resurfacing with curved bone cuts Shown to have a biomechanical advantage Reported decrease in OR time 65 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 66 Where are we now? CT Planning/Referencing 67 68 Total Ankle Replacement Ideal Patient? > 50 yrs. Old Low physical demands Reasonable weight Good bone stock Good hindfoot alignment Normal vascularity 69 Who is NOT the ideal patient? Neuroarthropathy Charcot Ischemia AVN of the talus Previous infection Neuropathy Neuromuscular disorders 70 Who is NOT the ideal patient? Contraindications Relative Gross Obesity Poor Skin Circulation Certain Occupations Compliance Age Severe deformity Tobacco Abuse 71 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 Insurance reimbursement (implant) Hindfoot alignment critical Ancillary procedures can be staged. 72 Cases 73 74 75 76 77 78 79 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!! 80 Questions?