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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. 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