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Arthritic Ankle Replacement

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CLEVELAND, Ohio (Ivanhoe Newswire) - Lightning bolts striking your foot; pain so intense you feel you may never walk again; that's how people describe severe arthritis in their ankles. But now, new technology is helping arthritis sufferers.

Twenty three years ago, arthritis sufferer Jacqueline Devine dislocated her ankle during a bad car wreck. She lived in constant pain for two decades.

"It would feel like somebody hitting you with a ball bat all the time, in the ankle," she told Ivanhoe.

Severe arthritis set in and she could barely walk.

"I was getting to where I wanted to use a chair and wheel down the hall." Orthopedic surgeon Dr. Brian Donley from the Cleveland Clinic combined two breakthrough foot surgeries to fix her foot: a foot fusion and a total ankle replacement.

"These are two separate bones and we fused those now into one bone," Dr. Donley told Ivanhoe.

The foot fusion works in conjunction with the ankle replacement to give Jacqueline a stronger base.

"What we see here is the metal piece that replaced her ankle bone. The metal piece that replaced her tibia bone here. And in between those two is a piece of plastic that's replaced her cartilage."

An ankle replacement is not for everyone. An ideal candidate is a non-smoker non-diabetic of reasonable weight who's 60 or older.

Twelve weeks after her surgery, Jacqueline said she was up walking on her own, even tying her shoes. That is something she hasn't been able to do without pain in years.

"I feel brand new," she said.

Thanks to the surgical combo, she's kicked her ankle arthritis to the curb.

An interesting note: before the doctor would perform the total ankle replacement on Jacqueline, he told her all her dental work needed to be up to date. Major dental work can potentially affect the healing process of the ankle. Bacteria from your mouth goes into your blood stream and could affect the new joint.

RESEARCH SUMMARY

BACKGROUND: Arthritis is the leading cause of disability in the United States. It can occur at any age, and literally means "pain within a joint." As a result, arthritis is a term used broadly to refer to a number of different conditions. Although there is no cure for arthritis, there are many treatment options available. It is important to seek help early so that treatment can begin as soon as possible. With treatment, people with arthritis are able to manage pain, stay active, and live fulfilling lives, often without surgery.

TREATMENT: Depending on the type, location, and severity of the arthritis, there are many types of treatment available. There are non surgical options including pain relievers and anti-inflammatory medications to reduce swelling, shoe inserts (orthotics), such as pads or arch supports, custom-made shoe, such as a stiff-soled shoe with a rocker bottom, an ankle-foot orthosis (AFO), a brace or a cane, physical therapy and exercises, weight control or nutritional supplements, and medications, such as a steroid medication injected into the joint. There are also several surgical treatments such as arthroscopic debridement, arthrodesis (or fusion of the joints), and arthroplasty (replacement of the affected joint). (Source: http://orthoinfo.aaos.org)

WALKING AGAIN: The Salto Talaris Total Ankle Prosthesis is a member of Tornier`s Salto family of ankle arthroplasty systems which have been designed for the treatment of patients as an alternative to ankle fusion for patients with intractable ankle pain. The original Salto Total Ankle Prosthesis, a three part mobile-bearing implant, has been in use in Europe since 1997. The Salto Talaris Total Ankle Prosthesis was first implanted in the United States in December 2006 and has since established a leadership position in the total ankle prosthesis market. As with the entire Salto product line, the Salto Talaris was designed to simulate the anatomy and motion of the normal ankle, while also facilitating the surgical procedure and minimizing bone loss. The Salto Talaris is a precision-bearing design that is implanted utilizing instrumentation that has been designed to maximize the anatomic placement of device components. (Source: http://www.reuters.com)

"The ankle replacement works similar to a hip or a knee replacement, although the anatomy is different. The ankle replacement has to restore the exact anatomy that you remove in order to replace the ankle," Brian Donley, MD, an Orthopedic Surgeon at Cleveland Clinic told Ivanhoe. "An ankle replacement works by taking away the end of the tibia bone, which is the top of the ankle and taking away the top of the talus bone, which is the ankle bone and then replacing those with two metal parts."

Complications can include slow healing, as well as infection. Severe complications are rare, but they can result in amputation. The new models require that less bone be removed, so the bone to which the device is affixed is stronger. In addition, instruments used to guide surgeons in aligning the artificial joint have improved. (Source: http://www.nytimes.com)

INTERVIEW

Brian Donley, MD, an Orthopedic Surgeon at Cleveland Clinic, talks about new technology is helping arthritis sufferers.

When you saw Jacqueline what was her problem?

Dr. Donley: Jacqueline had a difficult problem, she had a lot of arthritis not just in her ankle but she also had a lot of arthritis in her foot. Jacqueline required two different operations in order to reconstruct her and allow her to regain mobility without pain.

She needed a fusion and an ankle replacement?

Dr. Donley: In her first stage of reconstruction she needed an operation to take away the pain and stabilize the foot and that consisted of a fusion. We call that a triple arthrodesis, where we take three joints, fuse those three joints together by putting in screws and plates and hardware. Once she healed from that operation then that allowed us to address her ankle and she had a lot of arthritis in her ankle. Because she had such a stiff foot, she was a great candidate then for an ankle replacement to take away her pain in the ankle but allow her to continue with motion.

Where was the fusion?

Dr. Donley: The fusion was in the foot in the joints below the ankle. So we call that the subtalar joint and the transverse tarsal joint.

You hear of problems with back fusion, is that similar with the foot?

Dr. Donley: The fusions in the foot actually work really well. They take away some motion, which a patient misses, but you trade it in for great pain relief. A fusion in the foot is still a pretty standard operation. The challenge is that if you fuse the foot you can't also fuse the ankle because they end up really stiff. If you do a foot fusion those patients usually are best with an ankle replacement if they need an operation on their ankle for arthritis.

How long have you been doing ankle replacements?

Dr. Donley: I have been doing ankle replacements since 2006 when newer generation designs became available.

Tell me how the ankle replacement works.

Dr. Donley: The ankle replacement works similar to a hip or a knee replacement, although the anatomy is different. The ankle replacement has to restore the exact anatomy that you remove in order to replace the ankle. An ankle replacement works by taking away the end of the tibia bone, which is the top of the ankle and taking away the top of the talus bone, which is the ankle bone and then replacing those with two metal parts.

Are they metal?

Dr. Donley: The ankle components are made up of different types of metal, which replace the top of the talus bone and replace the bottom of the tibia bone. Then in between there's a piece of plastic which we call polyethylene.

What's the biggest challenge?

Dr. Donley: The challenges of the ankle replacement are that the ankle is a much smaller joint and there are actually three different joints in a very close area there. You have your ankle joint and then you also have what we call your syndesmotic joint, which is your connection between your tibia bone and your fibula bone and then right below there you have your subtalar joint, which is a connection between your talus and your calcaneus. There's a lot of motion and a lot of complex anatomy going on, which does make the ankle replacement a challenge.

Do you have to replace all three of those?

Dr. Donley: You don't have to replace all three of those. You just replace the ankle joint, but you have to respect and understand the anatomy that's close by so that you can preserve the motion in those joints.

You would think if someone had arthritis in the ankle joint, they would have arthritis in the other two joints, is that usually not the case?

Dr. Donley: Not necessarily. The other joints, specifically the subtalar joint, which is the joint below the ankle, there is no option for replacement of that joint. When that joint becomes arthritic, that's when you need a fusion, which is what Jacqueline had.

With the hip they said the metal and the plastic was a bad option after a while because it would rub metal on metal and just become more painful, is that true with the ankle?

Dr. Donley: With all joint replacements whether it's an ankle, whether it's a hip, whether it's a knee, you worry about wearing out of that plastic piece. The way you decrease that wear is by technically putting the components in a perfect anatomic position, which helps reduce that and also with design considerations to try to lessen the wear of that metal against the plastic. But it's something we worry about in all joint replacements.

Is this for everybody?

Dr. Donley: The ankle replacement is a newer technology and because of that we're still learning a lot about ankle replacement. We're learning about who's a good candidate, who's not a good candidate. So this really is not for everybody. It's kind of a select population that will do very well with a well done ankle replacement.

Who is that select population?

Dr. Donley: I think for me the ideal population is someone who is sixty years of age or over, someone who is of a reasonable body weight and someone who doesn't have a lot of different illnesses such as diabetes or smoking.

How does dental work affect the healing?

Dr. Donley: The concern about dental work with all joint replacement is whenever you have dental work done you get a bacteriemia. Bacteria from your mouth go in to your bloodstream and you worry about whether that bacteria could infect a joint that you already have. She was going to get dental work around that time so we preferred that she do it beforehand instead of after just to try to lessen that risk.

FOR MORE INFORMATION, PLEASE CONTACT:

Mary Vasil
Cleveland Clinic's Lutheran Hospital
(216) 363-5789
vasilm@ccf.org

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