ankle replacement evolution
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This document discusses total ankle replacement (TAR). It begins with the anatomy of the ankle joint and causes of ankle arthritis. Symptoms of ankle arthritis are described. The physical exam and tests to assess ankle stability are outlined. Treatment options for ankle arthritis include nonsurgical methods as well as different types of surgical procedures like arthrodesis (ankle fusion) and TAR. The history of TAR is summarized, including early constrained and unconstrained designs that had high failure rates. Modern TAR designs are classified and various implant systems currently in use are described, including their characteristics. The surgical approach and postoperative protocol for TAR are also summarized.
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ankle replacement evolution
- 1. TOTAL ANKLE REPLACEMENT CHAIRPERSON – DR. M. Y. PATIL PRESENTER – DR. SRINATH GUPTA
- 2. Anatomy of the Ankle • Hinge Joint • Made up of 3 bones • Lower end of the tibia (shinbone), • Fibula (the small bone of the lower leg) • Talus, the bone that fits into the socket formed by the tibia and the fibula v203 2 5/10/2015
- 6. Ankle-FOOT COMPLEX • Stability demands- 1.Providing a stable base of support for the body in a variety of weight bearing postures without undue muscular activity and energy expenditure. 2.Acting as a lever for effective push-off during gait.
- 7. Mobility demands- 1.Dampening of rotations imposed by more proximal joints of LL. 2.Being flexible enough as a shock absorber 3.Permitting the foot to conform to the changing and varied terrain on which foot is placed.
- 9. Ankle Anatomy 9 Ankle Anatomy Function Flexion And Extension 5/10/2015
- 10. Ankle Anatomy 10 Ankle Anatomy Subtalar Function 5/10/2015
- 11. Capsule • Is attached just beyond the articular margin • Except anterior-inferiorly and postero-superiorly • Attached to the neck of the talus and the inferior part of tibiofibular ligament. 11 5/10/2015
- 12. Ankle Biomechanics• Tri-plane motion • The load bearing force in stance phase of gait is 4 times the body weight • Normal ROM: • At least 10 degrees of dorsiflexion (extension) is needed for normal gait
- 13. CAUSES OF ANKLE ARTHRITIS • Primary Osteoarthritis of the Ankle • Post traumatic Osteoarthritis • Secondary Osteoarthritis • Rheumatoid • Hemochromatosis • Hemophilia 13 5/10/2015
- 14. SYMPTOMS • Pain • During activity • At rest or sleeping • Swelling and Tightness • Squeaking or grinding sound when ankle is moved. • Stiffness and decreased movement v206 14 5/10/2015
- 16. Physical Exam • Note obvious deformities • Neurovascular exam • Pain to palpation of malleoli and ligaments • Pain at the ankle with compression • syndesmotic injury • Examine the hindfoot and forefoot for associated injuries
- 17. Stability Tests • Anterior Drawer Test:- Used to evaluate tibiofibular ligament. Perform in both plantar flexion(test ATFL) & dorsiflexion(test CFL)
- 18. Continued… • Talar Tilt Test :- With the patient relaxed & knee flexed, stabilize the leg with one hand & grasp the heel with other.Then foot 1st dorsiflexed & plantar flexed, invert the hindfoot. Excessive motion may indicate instability of tibio talar joint, subtalar joint or both.
- 19. Continued… • External rotation test:- Foot should be in neutral position with the lower leg stabilized. Examiner should then externally rotate the foot. If this causes pain then must consider a tear of the anterior tibiofibular ligament. Depending on severity the interosseous membrane may be involved. Pain will be at site of the anterior tibiofibular ligament.
- 20. TREATMENT • Nonsurgical and • Surgical 20 5/10/2015
- 21. NONSURGICAL • Pain relievers and anti – inflammatory meds • Orthotics such as Soft pads or arch supports • Custom made shoes – Stiff soled shoe with a rocker bottom • An Ankle – Foot – Orthosis • Physical therapy and exercises • Steroid medications injected into the joint 21 5/10/2015
- 22. SURGICAL • Arthroscopic debridement is helpful in early cases of Arthritis. • Arthrodesis • Total Ankle Replacement 22 5/10/2015
- 23. ARTHROPLASTY • Recommended in patients with Advanced arthritis • Destroyed ankle joint surfaces • An ankle condition that interferes with daily activities 23 5/10/2015
- 24. Classification of Total Ankle Replacement 5/10/2015 24 • Surgical approach • Bearing type • External surface • Bearing surface • Sulcus type • Surface morphology
- 25. ABSOLUTE CONTRAINDICATION • Neuropathy ( Charcot foot) • Non – manageable hind foot malalignment • Massive joint laxity (Eg: Marfan disease) • Highly compromised periarticular soft tissue • Severe senomotoric dysfunction of foot and ankle • Advanced soft tissue or bony infection • AVN of talus ( needs custom made implants ) 25 5/10/2015
- 26. HISTORY • First ankle replacement was performed in 1970s • Two types of designs were developed Constrained Unconstrained 26 5/10/2015
- 27. • Constrained • Greater stability but with reduced motion • Increased stresses at the bone – cement – implant interfaces leading to early loosening and failure Ex – St. George/Buchholz, Imperial College London Hospital, Conaxial and Mayo designs 27 5/10/2015
- 28. • Unconstrained • Improved ROM in multiple planes but with reduced stability. • Less stress at the bone – cement – implant interface Ex – Waugh / Irvine, Smith and Newton Prostheses 5/10/2015 28
- 29. ‘Old generation’ ankle replacements consisted of a polyethylene tibial component and a metallic talar component. 29 5/10/2015
- 30. Modern ankle replacement consists of metallic tibial and talar components, stabilized with or without cement. 30 5/10/2015
- 31. • In 1970, study was done by Lord and Marotte and was concluded with the current implants, Arthrodesis is a better option than Arthroplasty. • Inverted hip stem was used for tibia, talus was completely removed and then a cemented acetabular cup was inserted in the calcaneum 31 5/10/2015
- 32. 32 5/10/2015
- 33. NEW GEN IMPLANTS • The new generation implants presently in use can be classified • (a) as two- or three-component designs and • (b) as fixed or mobile-bearing designs. 33 5/10/2015
- 34. The INBONE™ ankle (Boulder, USA) • This is the only TAA with an intramedullary alignment system design. • Over 200 INBONE™ ankle replacements have been performed in the USA. 34 5/10/2015
- 35. The ESKA ankle prosthesis (Germany) 35 5/10/2015
- 36. The ESKA prosthesis consists of two components. 36 5/10/2015
- 37. TNK prosthesis • FIRST CERAMIC PROSTHESIS 37 5/10/2015
- 39. The BP total ankle replacement • Its upper surface is flat, whereas its lower surface conforms to the trochlear surface, thereby providing unconstrained, sliding cylindrical motion with LCS on the bearing surfaces, allowing inversion, eversion motion. 39 5/10/2015
- 40. The tibial stem and the deep sulcus of the talar component accommodating a matching polyethylene surface, allowing inversion/eversion motion, are characteristic features of the Buechel– Pappas ankle replacement. 40 5/10/2015
- 41. The Scandinavian Total Ankle Replacement (STAR) 41 5/10/2015
- 42. The STAR prosthesis uses two bars for tibial component fixation. 42 5/10/2015
- 44. Screw fixation is a characteristic element of the HINTEGRA prosthesis. 44 5/10/2015
- 45. The SALTO Talaris™ anatomic ankle (Tornier) 45 5/10/2015
- 46. The SALTO ankle prosthesis ‘fixed-bearing’ version is used in the USA, whereas the original ‘mobile-bearing’ design is used in Europe. 46 5/10/2015
- 47. 47 5/10/2015
- 48. The Agility total ankle replacement 48 5/10/2015
- 49. 49 5/10/2015
- 50. The Agility prosthesis, a two-component design, requires tibio-fibular fixation. 50 5/10/2015
- 51. • Benefits of Agility implant • Greater ankle support and longer-term stability than earlier implants • Multiple sizes for a more precise fit • More natural joint movement than is possible with ankle fusion surgery • A unique feature of the Agility is the addition of a syndesmotic fusion to allow load transfer from the tibial component to both bones of the leg. 51 5/10/2015
- 52. The Mobility ankle system (DePuy) 52 5/10/2015
- 53. ZIMMER TAR WITH TRABECULAR METAL 53 5/10/2015
- 54. OTHER NEW IMPLANTS • BOX Total Ankle Replacement • The German Ankle System • The ZENITH total ankle replacement system (Corin, UK) • The Alphanorm total ankle replacement • The TARIC prosthesis • The CCI evolution total ankle prosthesis 54 5/10/2015
- 55. Common approach 5/10/2015 55 • Patient is taken in supine. position and incision is taken
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- 61. Structures at risk • Cutaneous branches of the superficial peroneal nerve • Neurovascular bundle consisting of • Deep peroneal nerve and • Anterior tibial artery 5/10/2015 61
- 63. POST-OP Protocol • ROM within first week. Non weight bearing walking. • 6 weeks (with Doctors Instruction) • Gradually put weight on the leg • Use of a cane or walker. • Begin Driving • 6 to 8 weeks - automatic shift • 12 weeks – manual shift • 12 weeks - low-impact activities, such as walking. • Up to 1 year - may require the use of an ankle support 63 5/10/2015