Is a patient with major ankle deformity amenable to successful total ankle arthroplasty?
Click Here to Manage Email Alerts
Click here to read the Cover Story, "Ankle replacement: A new gold standard for arthritis."
Ankle arthroplasty continues to advance
Total ankle arthroplasty has advanced significantly during the last decade and continues to progress as our understanding of ankle kinematics improves.
In an arthritic ankle with severe deformity, the gold-standard treatment used to be an ankle fusion. Now, that treatment option is being challenged and certain deformities may be amenable to replacement, which used to be a relative contraindication.
Ankle replacement technology has allowed us, as surgeons, to offer improved range of motion while improving angular deformity of the ankle relative to the leg and foot. This solution for degenerative arthritis of the tibiotalar joint remains under significant investigation as no consensus exists in the setting of severe coronal plane deformity.
Correction of valgus and varus deformities can be challenging. The arthroplasty surgeon must recognize the type of deformities involved in the degenerative changes of the ankle and implement appropriate adjunct procedures to obtain ligamentous stability and dynamic stability of the ankle. Achieving soft tissue balancing is paramount to having a successful outcome.
Although replacement in the setting of a deformed ankle remains controversial, we continue to push the envelope and challenge the previous standards.
Research advancements involving ankle arthritis treatment may contest the norm and bring about a new gold standard and consensus.
Adam D. Bitterman, DO, FAAOS, is an orthopedic foot and ankle surgeon and chair of orthopedics at Northwell Health Huntington Hospital and assistant professor at Zucker School of Medicine at Hofstra/Northwell in Huntington, New York.
No hard cut off for ankle deformity
Ankle arthritis is largely a post traumatic condition which often brings with it considerable challenges on both the soft tissue side and the bone deformity side. My total ankle arthroplasty practice has evolved considerably during the past 20 years to where I have no hard cut off for deformity that precludes a total ankle arthroplasty.
The innovations that have allowed these expanded indications, which encompass large deformities, include a stemmed prosthesis and preoperative patient-specific planning. In my practice, any coronal deformity that exceeds 15° is managed with a stemmed, fixed-bearing total ankle arthroplasty prosthesis. I believe this allows for more secure tibial fixation and less risk of edge loading on the polyethylene. Preoperative planning helps me plan for the bone cut orientation to achieve my desired alignment and to see the impact of the stem position on the tibial canal. In the rare situation in which my implant cannot be appropriately positioned in the tibia due to deformity, I will do a staged osteotomy followed by total ankle arthroplasty.
On the soft tissue side, my medial and lateral ligament reconstructions are largely facilitated by a prosthetic augment, which has increased my confidence in the initial strength of the repair and facilitated an earlier rehabilitation. Medial reconstructions that include hindfoot fusions are usually staged, with the total ankle arthroplasty procedure performed 3 to 4 months afterward.
Gregory C. Berlet, MD, FRCS(C), FAOA, is an orthopedic surgeon at the Orthopedic Foot & Ankle Center in Worthington, Ohio, and Foot & Ankle Section Editor for Healio/Orthopedics Today.
Collapse
Read more about
Click Here to Manage Email Alerts