Lecture 39 parekh tar
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Lecture 39 parekh tar
- 1. Total Ankle Replacement Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
- 2. Why a Total Ankle Arthroplasty? Severe painful post-traumatic osteoarthritis
- 3. Comparison of Health-Related Quality of Life Between Patients with End-Stage Ankle & Hip Arthrosis JBJS Mar 2008; 90:499-505 • End stage ankle arthritis is as severe, if not worse, than end stage hip disease.
- 4. Why a Total Ankle Arthroplasty? • The Need for Other Surgical Options: » Debilitating pain » Patients with large bone loss » Subtalar and/or midtarsal arthrosis » Bilateral involvement • Other Advantages: » Provides pain relief » Preserves joint motion & stability
- 7. Varus Ankle
- 8. Valgus Ankle
- 9. Total Ankle Replacement • USA Data • 2,300 – 4,000 TAA done in 2010 • 20,000 – 23,000 Fusions in 2010 • 96 % limp • 15% < 4 yrs. develop subtalar arthritis • 77 % satisfaction
- 10. Evaluation • History • Reason for DJD • Prior treatments • NSAIDS • Bracing • PT • CST injections • Prior surgeries • Open injuries • Infection
- 11. Examination • Gait • Alignment • Hip knee ankle foot • Varus/valgus • Areas of tenderness • Associated pathologies • NV status • Sensory status • Prior incisions
- 12. Radiographic Evaluation • Weightbearing • AP/lat/oblique
- 13. Radiographic Evaluation • Weightbearing • Saltzman • Foot films • AP/lat/oblique
- 15. TAR: What Went Wrong? • 1st generation problems • Did not respect • Anatomy • Kinematics • Alignment • Stability
- 16. TAR: What Went Wrong? • 1st generation problems • Excessive bone resections • Changed in level of the ankle axis • Constrained design • Poor cement fixation in fatty bone marrow • Multi-axial design relied on ligaments
- 17. TAR: What Went Wrong? MAYO prosthesis (1974) IRVINE arthroplasty
- 18. TAR: What Went Wrong? • High incidence of complications » Delayed wound healing » Fibular impingement » Loosening (radiologic and clinical) » Malleolar fractures
- 19. TAR: What Went Wrong? Conaxial ankle replacement medial malleolar fracture Ankle is in Varus and Tibial Component is Loose
- 20. What Went Wrong? Constrained •Treated the ankle as a hinge joint - transfer stresses to bone-cement interface »TPR »ICLH »Conaxial »Mayo Clinic (1976) ICLH arthroplasty
- 21. What Went Wrong? Unconstrained •Unstable, malleolar impingement »Mayo (1989) »Buckholz »Smith »Newton »Irvine SMITH arthroplasty
- 22. TAR: History/Development • Next Generation Ankle Replacements » Preserve bone stock » Respect rotational axis » Respect tibiopedal alignment » Semiconstrained » Biological fixation
- 23. Questions Outstanding • Should the bearing be fixed or mobile? • Fixed Bearings • Track record in knee and hip • One sided wear • More difficult exchange • Mobile bearings • Good congruency Easier ligament tensioning • Incidence of medial joint pain secondary to tight tensioning • Subluxation induced wear concerning
- 24. Questions Outstanding • Approach • Anterior • Coronal balance • Wound complications 10-34% • Lateral • Fibular osteotomy • More difficult to balance ankle
- 25. Questions Outstanding • What Surfaces Need Resurfacing? »Superior tibiotalar joint (BP, Zimmer) »Superior and medial (TNK) »Superior and lateral (Salto) »Complete superior, partial medial/lateral (STAR, Hintegra, Inbone) »Superior, medial, lateral (Agility)
- 28. FDA approved TAA Salto-Talaris with cement S.T.A.R. without cement INBONE with cement Zimmer with cement Prophecy without cement Infinity without cement Hintegra Agility with cement Eclipse with cement Mobility Exactech Integra
- 29. Salto Total Ankle • Next Generation…….. • Instrumentation to Find “Sweet Spot” in Fixed Bearing Prosthesis
- 30. Salto Data • FB better than MB • 98% survivorship @ 3.5 yrs • 85% survivorship @ 7-11 yrs • Significant improvement in gait • Survivorship lower in low volume centers
- 32. INBONE
- 34. Intra-Medullary Guidance (Need C-Arm) Just anterior to posterior facet Intra- Medullary Guidance Intra-Medullary Guidance (C-Arm)
- 38. 25 ° valgus Problem: Soft tissue imbalance
- 39. Works: Soft tissue tensioning.
- 42. Inbone Results • 3.9yr f/u survivorship 89% • Clinical experiences and anecdotes
- 43. STAR
- 44. 2nd Generation Designs • S.T.A.R prosthesis (Waldemar Link, Germany) » 3-component design » Free-gliding polyethylene meniscus » Rotation/gliding between tibia and meniscus » Flexion/extension between talar component
- 46. STAR Outcomes 9/79 (11%) Painful Impingement Against Malleoli
- 47. STAR Outcomes 2/79 Subtalar Subsidence requiring Fusion
- 48. STAR Outcomes
- 49. STAR Results • ? Concern on effect on talar blood supply • Survivorship 96% @ 5 yrs • Survivorship 90 - 70.7% @ 10yrs • Survivorship 45.6% @ 14yrs • Significant improvement in quality of life, pain, function • Better function, = pain relief to fusion
- 50. Zimmer TAR • Lateral approach • Minimal bone resection • Trabecular metal • ? Difficulty with balancing • Available only 1yr
- 51. Zimmer Results • None to date
- 52. Selection of Implant • Under 40yo • Mobile bearing – STAR, Salto, Hintegra • ? Zimmer • Over 40yo • Mobile bearing • Fixed – Salto • ? Zimmer • Over 300lb (136kg), revision, big deformity • Intramedullary device – InBone
- 53. Indications for TAA •Optimal Patient • Less excessive demands » Rheumatoid arthritic patients » Post-traumatic arthritis • Older • Multiple joint arthrosis to slow them down
- 54. Indications for TAR • Relative indication: » Youthful, active individuals • Contraindications: » Talar AVN, Charcot Joint, neurologically compromised foot, chronic infection
- 55. Outcomes • TAR better than AA walking upstairs, downstairs, uphill • TAR high rate of satisfaction & biomechanics of the gait similar to a healthy ankle • Bilateral gait mechanics • Altered in fusion patients • Relatively recovered TAR patients • Gait patterns in 3component, mobile-bearing TAR more closely resembled normal gait compared to fusion
- 56. Outcomes • TAR & fusion significant improvements in various parameters of gait • Neither group functioned as well as normal control subjects • Fusion relieves pain and improves overall function • Persistent alterations in gait • TAR - improvements in pain and gait up to 2 years
- 57. Conclusions • Both ankle design and technique dictate what works to obtain a good result • Expanding capability of ankle replacements • Offer opportunity to do ankle replacements in all patients, regardless of deformity or previous surgery