Data is scant on the critical question of whether patients with endstage ankle arthritis are better served by a fusion or a replacement. The STAR trial, a prospective case control study, comparing safety and efficacy of STAR ankle replacement at 24 months for 158 replacements and 66 fusions: This FDA trial showed the STAR ankle replacement had better function, equivalent pain relief and a higher rate of complications and secondary procedures as ankles treated with fusion. A separate prospective cohort comparison of 200 ankle replacements vs. 94 ankle fusions performed by the collaborative consortium of Canadian Orthopaedic Foot and Ankle Surgeons (COFAS) suggests similar patient oriented outcomes at 24 months. Patients' self-assessment questionnaires do not show significant differences between the two groups. The main medium/long-term concerns with ankle replacement remain component subsidence (especially talar subsidence) and polyethylene wear. Forces across the ankle are considerable, and the orientation of those forces to the underlying trabecular structure are a concern. Whether 2 or 3 part ankles will provide better bearing wear results remains unknown. With older designs, at 10 years the Swedish registry found approximately 60% survivorship. This registry has also shown better survivorship in patients with rheumatoid disease and with increased surgeon experience. More recent results related to the Hintegra and AES components show better midterm (5 year) revision rates in selected surgeons hands, than seen with older designs. A large meta-analysis of ankle fusion and replacement published data by Haddad et al reported a mean nonunion rate of 10%. The main long-term concerns with ankle fusion are limitations of motion, and the development of premature arthritis in adjacent foot joints. In a study of an average of 9 year outcome of the Agility ankle replacement suggested that the incidence secondary arthritis is halved by replacement as compared to fusion.
Fusion remains the standard of care and is associated with a high satisfaction rate. But.… fusion generally requires 6 weeks of restricted weight bearing or immobilization. Potential problems include 1) nonunion, 2) malunion, 3) sesamoid pain (from DJD), 4) late onset IP1 DJD. Complete joint replacement has been performed with a number of different designs since the early 1970's. The metal and poly designed implants are associated with a high failure rate, presumably from high shear loads, eccentric axial loads, poor fixation and bone stock problems. Resurfacing of both sides of the joint with a one piece silicone based crosslinked rubber {“silastic”} in rheumatoid patients appears to function better with use of metal grommets to reduce generation of particle debris and foreign body reaction. These silastic implants are still used by surgeons in select low-demand rheumatoid patients. Salvage after failure of any of these total joint replacements can be challenging because of loss of bone stock. 3 other methods are used to resurface the joint in severe OA: 1) resurfacing the proximal phalangeal side only, 2) resurfacing the metatarsal head only and 3) resurfacing the joint with and interposition arthroplasty. 1) advantage of the proximal phalangeal side resurfacing is simplicity of geometry; the disadvantage is disruption of the FHB attachment and the relative scarcity of severe cartilage damage at that side of the joint. 2) Advantage of the metatarsal head side for resurfacing is that is the typical location of the arthritic change; the disadvantage is potential interference with the sesamoid complex and bulkiness of fixation could lead to a more difficult salvage. 3) The advantage of interposition arthroplasty is the maintenance of bone stock; disadvantages include inconsistent local tissue and somewhat less predictable outcomes. In this talk I will focus primarily on the technique and results of a proximal phalangeal resurfacing approach for OA of the MTP1 joint.
Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type
sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of
information on optimal conservative and operative management.
Because of the spectrum of injury, there is a spectrum of treatment. if there is mortise widening, operative stabilization is required if the mortise is normal, even with external rotation stress test positive,
conservative treatment has been employed. staged conservative regimen directed at reducing pain and swelling
acutely, at regaining range of motion and strength subacutely, and then
progressed to functional training and finally return to sport. The
timeframe for these was in the range of 2 to 6 weeks without very specific
progression criteria. In the athlete, pain with rotational stress, greater severity of sprain,
may treat operatively to stabilize the syndesmosis and aggressive rehab
with earlier return to sport Tightrope vs screw fixation vs both Use of arthroscopy Chronic sprains with recalcitrant pain and functional instability usually
require operative treatment. very poor evidence exists as to the timing or type of procedure.
Arthroscopy is required to confirm the diagnosis, treat intraarticular
problems, and provide fixation of the distal tibiofibular syndesmosis. The
postoperative regimen used is generally the same as the one used when
treating an acute syndesmosis disruption.
clinical studies tightrope fixation has been acceptable and comparable to screw
fixation laboratory studies demonstrate comparable construct stability in the
laboratory/cadaveric setting indications for tightrope fixation are becoming more clear with more
experience my indications: syndesmotic sprains with complete or incomplete disruption fractures with syndesmotic disruption augment with screws, leave in place
following screw removalTreatment
Tight rope vs Screw Fixation
Clubfoot deformity is the most common congenital musculoskeletal disorder Dr. Ignacio Ponseti first performed his non-invasive treatment in 1949, but didn't publish his results until 1963. Two more papers, published in 1979 and 1995 described the long-term outcomes of treatment. In 1996 Oxford Press published a book detailing his approach. Although the treatment has always had high success rates, a lack of publicity prevented it from becoming more widely used until the late 1990s. Its basic mechanism consists of a series of plaster casts and manipulations that gradually reshape the foot around a fixed talus to obtain correction. Generally, between five and seven casts are required. The casts extend from the toes to the upper thigh and hold the knees at a right angle. One of the most important aspects of this method is timing: infants can be given treatment starting at seven days old and ideally should begin treatment before reaching eight months of age. Brazil, Uganda, Malawi and Chile now have official national programs, which are sponsored by each country's Ministries of Health, in which clinics in each country treat clubfoot disorder using the Ponseti Method. China set up a national program in 2005, but with a population of 1.3 billion people, it will take several years to complete the training. The prevalence of the Ponseti Method varies in the sixty other countries with healthcare workers trained in the treatment. This talk will review the principles of treatment and focus on results of recurrence after initial treatment with the Ponseti Method.
Osteoarthritis (OA) is a disease of the joints stemming from a variety of factors, including joint injuries and abnormally high mechanical loading. Although the traditional treatment alternatives for end-stage OA are arthroplasty in the case of the hip and knee, and arthroplasty or arthrodesis in the case of the ankle, these options are not ideal for younger, more active patients. For these patients, joint prostheses would be expected to fail relatively quickly, and ankle fusion is not amenable to maintaining their active lifestyles. In these cases, joint distraction has attracted investigative attention as a conservative OA treatment for younger patients9-14. Based on the principle that decreasing the mechanical load on cartilage stimulates its regeneration15, distraction treatment calls for reduced loading of the joint during a period of typically 3 months, during which time the load customarily passing through the joint is taken up by an external fixator spanning the joint . By mounting the fixator components to the bone on each side of the joint, and then lengthening the rods connecting the proximal and distal portions of the fixator, the joint is distracted. Assuming the fixation is appropriately stiff, any load passes through the fixator instead of the joint, and the two articular surfaces will not be allowed to contact each other under physiologic loading. The exact mechanisms leading to cartilage regeneration during distraction are not yet understood. A possible negative consequence of joint fixation is cartilage degeneration due to immobilization during the treatment. It has been shown by Haapala et al. and others that long-term immobilization can be detrimental to articular cartilage16-18. Conversely, joint motion during fixation (even passive motion) is thought to stimulate or encourage cartilage regeneration19-22. Toward this end, considerable effort has been invested in the application of hinges to external fixation for joints Joint motion has also been suggested as a potentially beneficial factor in distraction treatment, as well10. This is borne out by data from an RCT comparing the use of a rigid vs motion external fixator. Change in joint biology due to resorption of cysts may be responsible for reversal of symptoms.
Diagnosis a. History and exam i. b. Midfoot sprains or subtle injuries i. - subtle x-ray findings with minimal displacement i) - TMT tenderness, swelling - inability to WB ii) - indirect twisting injury (athletic) - crush injury of the foot (trauma) - axial forefoot loading (dancers, jumpers) iii) - need to assess all 3 views in detail standing AP compare to the other side
- - -
a) Surgical Indications i) Any displacement/positive stress xrays/test ii) Surgical technique - open reduction or closed and percutaneus fixation - anatomic reduction essential - - WB with protection for another 4-6 weeks iii. Screw vs tightrope fixation iv. Hardware removal b) Non-operative i) Stable non-displaced sprain (need to make sure this is stable, ie stress views) - 6 to 8 weeks NWB - expect prolonged recovery up to 6 months with proper treatment
a. Do all injuries with mild displacement have to be fixed operatively? b. Arthrodesis vs fixation for soft tissue lisfranc with mild displacement? c. d. Hardware removal?
In developed nations Charcot arthropathy is most commonly caused by diabetes mellitus. Worldwide, leprosy remains the primary cause. All evidence points to a relationship between neurologic loss, continued loading activities and the development of unrecognized bone fragmentation. In type 2 diabetes, dysregulation of leptin biology causes bone loss and may be an important factor in precipitating Charcot events. Bone density studies show massive loss of bone in patients with ankle and hindfoot Charcot problems, but not midfoot problems. This suggests a different mechanism for collapse. Stable collapse with ulcer development in the midfoot can be treated with exostectomy. Realignment and fusion remain the mainstays of treatment for diabetic Charcot neuropathy, especially in the ankle and hindfoot. Bone mineralization deficiencies require special consideration of fixation techniques. Thin wire external fixation – either as primary fixation or to reinforce/neutralize other methods can be very helpful. Large bridging screws and carefully selected bridging plates are frequently also valuable to consider. Excessive immobilization periods (often double the normal amount of time) are generally required. The goal may be limited to a braceable, plantigrade foot.
A. ANKLE ARTHROSCOPY: Tips and Pearls on Avoiding Complications a. Introduction i. understanding of the anatomy of the foot and ankle is critical to safe performance of arthroscopic procedures and prevention of complications ii. understanding of the surface and intra-articular anatomy of the ankle/subtalaar region is essential iii. topographical anatomy serves as a guide to the successful placement of arthroscopic portals in the ankle iv. neurovascular and tendinous structures are most at risk b. Indications for Posterior/Subtalar Arthroscopy i. Posterior ankle/ST Impingement ii. OLT Ankle (usually posteromedial) iii. Assist operative reduction of calc or post mal fractures iv. Arthrodesis ankle/ST or both c. Portals i. Know the anatomy, use blunt dissection, minimize re-entry ii. Preoperative plan for access, pathology, visualization d. Prone Position a. Posteromedial b. Posterolateral c. Accessory posterolateral e. i. Positioning - ii. posterior, prone iii. iv. Equipment - general set-up/instruments - scopes (4.0 for outside joint or fusions; 2.7 otherwise) - irrigation/pump (run at lowest flow possible) f. i. Patient selection and education ii. Careful preoperative planning, evaluation iii. Know/respect your anatomy iv. Meticulous portal placement/care v. Limit operative time/distension/tissue damage vi. Use mini C-arm to monitor vii. Plan, plan and plan, if you are prepared, all will work out viii. Rehabilitation protocol and follow up.
