Ankle Replacement Surgery for Patients with Severe Ankle Arthritis

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Ankle Replacement Surgery for Patients with Severe Ankle Arthritis

Encouraging trends in the long term success of total ankle replacement were

reported in a study presented at the American Orthopaedic Foot and Ankle

Society¹s (AOFAS) annual summer meeting today.

This study, conducted by Saltzman MD, a Professor of Orthopaedic

Surgery and Engineering from the University of Iowa, found total ankle

replacement to be an option for patients with severe arthritis. Similar to

hip and knee replacement surgeries, total ankle replacement involves

removing the arthritic ankle joint and replacing it with an implant. Total

ankle replacement was developed in the 1970¹s but initially was plagued with

high long term failure rates. The older prosthetics implants loosened or

malfunctioned and frequently needed to be removed. Newer implants were

developed in the late 1990¹s that have made the surgery a more viable

option.

In the study, Dr. Saltzman reported long term results with the use of the

new Agility Total Ankle ( Depuy, Inc) implant developed by Dr. Alvine.

The Agility ankle consists of a bearing joint made of a highly mobile and

refined polyethylene plastic and mimics the motion of a real ankle. The

polyethylene meets with a polished metal surface acting as a hinge giving

the patient a range of motion of 20 degrees. Dr. Alvine¹s invention is

currently the only FDA approved total ankle implant in use in the United

States.

Prior to total ankle replacement surgery, the only surgical option for

patients with disabling arthritis was fusion. This procedure involves fusing

the bones together completely restricting ankle motion.

To measure the success of total ankle replacement surgery Dr. Saltzman

initially studied the patients of Dr. Alvine four and a half years after

they received their ankle implants. His new study re-examines those patients

nine years after their surgery.

³The results of total ankle replacement are encouraging,² said Dr. Saltzman.

³The new failure rate is 11% an improvement from previous reports in the

past. This suggests that the newer designs are having good mid-term

outcomes.² He warns that a failure rate of 11% still exceeds those of total

knee and hip replacement. Although the procedure still needs improvement the

implant is arguably better than joint fusion for selected patients according

to Dr. Saltzman.

Future improvements will depend upon further training of doctors on how to

use and properly implant the prosthetic device. The surgery should be done

by surgeons with a background in total knee and total hip replacement who

possess an extensive understanding of the foot and ankle.

Success also depends on the proper selection of patients. In Dr Saltzman¹s

study, the average age of the patients at the time of surgery studied by Dr.

Saltzman was 63. To receive a total ankle replacement, a patient must have

debilitating, end-stage arthritis.. End-stage arthritis can be

intermittently extremely painful and leaves patients incapacitated. They

find it difficult to stand and have a hard time maintaining employment.

Furthermore, some ankle arthritic conditions are so severe that patients are

unable to continue walking, even with the aid of a brace or cane. Most have

been treated with anti-inflammatory medicine for many years without

substantial relief. For these patients, surgery becomes the only option.

The short term complications associated with total ankle surgery are rare,

but can be devastating. A deep infection can lead to removal of the implant

and an extensive reconstructive surgery of the foot and ankle.

Long term problems include implants loosening and plastic irritation to the

bone liner from deformation or wear. Sometimes the bone crumbles underneath

the metal implant in a process known as subsidence. This type of situation

will require revision surgery to strengthen the bone and reattach the

implant. If the plastic liner frays, the small particles released can induce

damage to the surrounding bone, accelerating the process of subsidence. This

type of situation will require revision surgery to strengthen the bone and

reattach or replace the implant.

Dr. Saltzman cautions that the implant is made of mechanical parts. ³All

mechanical parts wear out, so patients with long term use will sometimes

require maintenance,² he said. Ideal candidates are elderly, inactive people

with end stage arthritis simply because they are low demand and usually

realistic about the capabilities of their implant.

³Patients need to be realistic about the limitations and expectations with

use of an ankle replacement,² Dr. Saltzman says, ³but it is a viable option

to treat people with debilitating end-stage ankle arthritis.²

The AOFAS is the leading professional organization for orthopaedic surgeons

specializing in disorders of the foot and ankle. Orthopaedic surgeons are

medical doctors with extensive training in the diagnosis and treatment of

the musculoskeletal system that includes bones, joints, ligaments, tendons,

muscles, and nerves.

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