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A Case Study on the Conversion of a Painful Arthritic Ankle with Previous Triple
Arthrodesis to Total Ankle Arthroplasty using the Wright Medical In-Bone System
Stefano Militello DPM, Victor Nwosu DPM
Intro
Results
Total ankle arthroplasty was developed to provide an alternative
to ankle arthrodesis for the treatment of severe arthrosis, with
the inherent advantage of preserving joint motion. Initially
introduced in the 1970’s first-generation ankle arthroplasties
were plagued with unacceptably high complication rates.
The purpose of this case study is to show the inevitable
evolution of the Total Ankle implant, and the surgical placement
of the Wright INBONE total ankle system on a 54 year old male.
We found extremely favorable post operative results with the
INBONE system. Results, although only based on this one
case, showed the INBONE total ankle implant system is a viable
option for patients that are candidates for an ankle arthrodesis
but want to keep their range of motion and continue a lifestyle
which requires unhindered motion.
Case Presentation & Method
A 54 y/o NIDDM male presented to the Benenati Foot & Ankle
Care Center seeking a second opinion for diffuse, aching and
shooting pain of 3 years duration to the medial and lateral sides
of his left ankle, as well as the heel. Pt rated his pain to be 9/10.
Pt narrates to numerous unsuccessful conservative attempts by
a previous Foot & Ankle Surgeon to alleviate his left ankle joint
pain. According to the Pt, conservative treatment over a 3 year
period consisted of custom-molded orthotics such as Ankle Foot
Orthoses (AFO) and a Swedo brace, intra articular steroid
injections, NSAIDs and a removable walking boot.
He,
however, admits to successful fusion of his rearfoot joints by the
same Surgeon.
Past medical history is significant for
osteoarthritis of the knees, hips, shoulders, wrists and ankles,
leg cramps and hyperlipidemia.
Pt relates that a surgical
history includes operations to the aforementioned joints.
Operative procedures to both knees in excess of 10, including
left Total Knee Replacement. The pt was taking Oxycontin for
his arthritis.
Physical exam revealed a painful left ankle joint with crepitus
and little to no motion upon active dorsiflexion and
plantarflexion. Pt’s rearfoot was noted to be in proper & correct
alignment from the previous fusion. Biomechanical exam
revealed an ankle joint without the required 10 degrees of
dorsiflexion. Neurovascular status was noted to be intact. Initial
radiographs of the left ankle revealed moderate to severe
osteoarthritic and degenerative changes to the dorsal anterior
aspect, as well as, medial gutter of ankle joint. There was also
noted to be complete fusion of the subtalar, calcaneocuboid and
talonavicular joints from previous surgery.
Being that conservative measures had been exhausted, surgical
approach was considered the best option at juncture. The pt
was given the option of an ankle fusion, which would mimic his
current condition, however, without the pain. The alternative
would be an ankle replacement, which would provide motion
and alleviate pain. The decision was made to use the FDA
approved Wright Medical INBONE Total Ankle System. Surgery
was scheduled and the INBONE Total Ankle System was
placed with the aid of the intramedullary guidance system. The
pt was placed in a BK NWB cast postoperatively
The patients pain went from a
12/10 pre-operatively, to a 3/10
post-operatively,
and
an
intermitant 1/10 4 months postoperatively. The patient was
able to regain most of his
motion.
b
Radiographically, the tibial
component was stable and the
talar component showed no
loosening. Increased motion
was also noted to radiographs
upon
dorsiflexion
and
plantarflexion as compared to
pre-operative radiographs.
The patient was able to
resume
his
professional
bowling career and recreational
golfing. His return to activity
was sooner than expected as it
began 1 month postoperatively.
The patient is now completely
satisfied
and
pleasantly
surprised at the activity level
that he has been able to attain.
The Thompson-Richard prosthesis (TPR) was a two component semiconstrained system which allowed only plantar-and dorsiflexion. This
caused shear forces to only be transmitted to the bone cement interface
and thus a high rate of radiolucency on radiographic evaluation.15
Modern implants consist of metallic tibial and talar components with or
without cement, and a meniscus-like polyethylene component that is
either fixed to the tibial component or mobile articulating with both. In
this case the INBONE (Wright Medical) replacement system was used
in order to revert a painful previous triple arthrodesis. We used this
implant with the hopes of regaining motion to a once painful joint. The
advantages of the INBONE Total Ankle System were as follows: First,
both the tibial and talar components are well supported by stems of
adjustable lengths for superior fixation. Secondly, vertical fixation allows
less bone removal of the tibia and leaves the fibula intact and most of
the medial malleolus. Third, the talar component matches the natural
anatomy to minimize talar subsidence, minimize poly wear, and create
natural and stable ankle motion. Fourth, the polyethylene has been
thickened and the surface area maximized to lessen wear. Fifth, a fixed
bearing system is better suited for the ankle especially if an accurate
method is used to implant the total ankle. And finally an intramedullary
guidance system has been developed for this ankle system to help
insure reproducible and accurate bony cuts for proper alignment of the
prosthesis.16
In conclusion, the INBONE total ankle implant system is a viable option
for patients that are candidates for an ankle arthrodesis but want to keep
their range of motion and continue a lifestyle which requires unhindered
motion, although further research with an increase in study size is
recommended. The result of the conversion to total ankle arthroplasty
with use of the INBONE system are promising after intermediate follow
up. Appropriate patient selection, however, remains a cornerstone to a
successful implant. At some point extension of the indications to a
younger age group with a more active lifestyle, and to ankle deformities
remains the outlook for the future.
Acknowledgments
Analysis & Discussion
Special Thanks to Dr. Benenati, Dr. Shaw, The Benenati foot care staff, St. John
Macomb Hospital, and The St. John Macomb Hospital Staff.
Primary osteoarthritis is less common in the ankle when compared to
knee and hip joints, but arthritis secondary to trauma occurs frequently.1
Non-operative management includes analgesics and anti-inflammatory
medications, activity modification, physiotherapy, orthotics, and intraarticular injections. Traditionally, end stage arthritis of the ankle joint
has been surgically managed by arthrodesis. Ankle replacement is an
alternative to arthrodesis for selected patients, with the advantage being
the preservation of movement and function. In turn this can result in
improvements in gait including reduction of limp and protection of other
joints. 4--8
Total
Ankle arthroplasty does not come without its complications;
infections and loosening can produce failure.
Contraindications for
ankle arthroplasty include acute and chronic foot infections, an
insensate foot, Charcot arthropathy, avascular necrosis of the talus,
inadequate foot and leg musculature, paralysis, and lower limb
deformities.2 The ideal candidate is a reasonably mobile middle-to-old
aged patient, with normal or low body mass index, good bone stock,
with multiple joint arthritis.
During
the past 30 years , initial attempts at Total Ankle Arthrodesis
(TAA) have largely failed. The stimulus for TAA derives from the partial
dissatisfaction that comes with ankle arthrodesis.10-13 Arthrodesis also
comes with an increased association with high complication and
reoperation rates.
Historically, old generation ankle implants such as the Imperial College
of London Hospital (ICLH) implant consisted of a polyethylene tibial
component that was cemented for stability and a metallic talar
component. Pain when walking with this implant was common, along
with talar collapse, and loosening of the components. The Mayo Total
Ankle Replacement was another such implant that was designed as a
constrained design. Only 19% of patients were considered to have good
results. 14
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Rhys TH, Daniels TR. Ankle arthritis. Current concepts review. J Bone
Joint Surg Am (2003) 85A:923–936.[Free Full Text]
Jackson MP, Singh D. Total ankle replacement. Curr Orthop (2003)
17:292–298.[CrossRef][Web of Science]
Gougoulias NE, Aggathangelidis F, Parsons SW. Arthroscopic ankle
arthrodesis. Foot Ankle Int (2007) 28:695–706.[CrossRef][Web of
Science][Medline]
Piriou P, Culpan P, Mullins M. Ankle replacement versus arthrodesis: a
comparative gait analysis study. Foot Ankle Int (2008) 29:3–
9.[CrossRef][Web of Science][Medline]
Doets HC, van Middelkoop M, Houdijk H, Nelissen RG, Veeger HE. Gait
analysis after successful mobile bearing total ankle replacement. Foot
Ankle Int (2007) 28:313–322.[CrossRef][Web of Science][Medline]
Valderrabano V, Hintermann B, Nigg B, Stefanyshyn D. Kinematic
changes after fusion and total replacement of the ankle—part1: range
of motion. Foot Ankle Int (2003) 24:881–887.[Web of Science][Medline]
Valderrabano V, Hintermann B, Nigg B, Stefanyshyn D, Stergiou P.
Kinematic changes after fusion and total replacement of the ankle—
part 2: movement transfer. Foot Ankle Int (2003) 24:889–896.
Valderrabano V, Hintermann B, Nigg B, Stefanyshyn D, Stergiou P.
Kinematic changes after fusion and total replacement of the ankle—
part 3: talar movement. Foot Ankle Int (2003) 24:897–900.[Web of
Science][Medline]
Abidi NA, Gruen GS, Conti S. Ankle arthrodesis. Indications and
techniques. J Am Acad Orthop Surg (2000) 8:200–
209.[Abstract/Free Full Text]
Haddad SL, Coetzee JC, Estok R, Fajrbach K, Banel D, Nalysnyk L.
Intermediate and long-term outcomes of total ankle arthroplasty and
ankle arthrodesis. A systemic review of the literature. J Bone Joint Surg
(2007) 89A:1899–1905.[Abstract/Free Full Text]
Coester LM, Saltzmann CL, Leupold J, Pontarelli W. Long-term results
following ankle arthrodesis for posttraumatic arthritis. J Bone Joint Surg
(2001) 83A:219–228.[Abstract/Free Full Text]
Guyer AJ, Richardson EG. Current concepts review: total ankle
arthroplasty. Foot Ankle Int (2008) 29:256–264.[CrossRef][Web of
Science][Medline]
Chou LB, Coughlin MT, Hansen S Jr, et al. Osteoarthritis of the ankle:
the role of arthroplasty. J Am Acad Orthop Surg (2008) 16:249–
259.[Abstract/Free Full Text]
Kitaoka HB, Patzer GL, Strup DMI, et al. Survivorship analysis of the
Mayo total ankle arthroplasty. J Bone Joint Surg (1994) 76A:974–
979.[Abstract/Free Full Text]
Jensen NC, Kroner K. Total ankle joint replacement: a clinical follow-up.