Download - ankle replacement evolution
TOTAL ANKLE REPLACEMENT
CHAIRPERSON – DR. M. Y. PATIL
PRESENTER – DR. SRINATH GUPTA
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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
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3Ankle Anatomy
LATERAL LIGAMENTS
MEDIAL LIGAMENTS
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.
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.
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Ankle Anatomy
Ankle Anatomy Function Flexion And Extension
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10Ankle Anatomy
Ankle Anatomy Subtalar Function
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.
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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
CAUSES OF ANKLE ARTHRITIS
• Primary Osteoarthritis of the Ankle
• Post traumatic Osteoarthritis
• Secondary Osteoarthritis• Rheumatoid• Hemochromatosis• Hemophilia
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14SYMPTOMS
• Pain • During activity• At rest or sleeping
• Swelling and Tightness• Squeaking or grinding sound when ankle is moved.• Stiffness and decreased movement
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15Examination
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
Stability Tests
• Anterior Drawer Test:- Used to evaluate tibiofibular ligament. Perform in both plantar flexion(test ATFL) & dorsiflexion(test CFL)
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.
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.
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20TREATMENT
• Nonsurgical and
• Surgical
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21NONSURGICAL
• 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
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22SURGICAL
• Arthroscopic debridement is helpful in early cases of Arthritis.
• Arthrodesis
• Total Ankle Replacement
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23ARTHROPLASTY
• Recommended in patients with Advanced arthritis• Destroyed ankle joint surfaces• An ankle condition that interferes with daily activities
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Classification of Total Ankle Replacement
• Surgical approach• Bearing type• External surface• Bearing surface• Sulcus type• Surface morphology
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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 )
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26HISTORY
• First ankle replacement was performed in 1970s
• Two types of designs were developed Constrained Unconstrained
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• 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
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• 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
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‘Old generation’ ankle replacements consisted of a polyethylene tibial component and a metallic talar component.
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Modern ankle replacement consists of metallic tibial and talar components, stabilized with or without cement.
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• 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
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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.
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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.
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The ESKA ankle prosthesis (Germany)
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The ESKA prosthesis consists of two components.
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TNK prosthesis
• FIRST CERAMIC PROSTHESIS
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Three-component designs
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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.
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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.
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The Scandinavian Total Ankle Replacement (STAR)
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The STAR prosthesis uses two bars for tibial component fixation.
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The HINTEGRA TAA
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Screw fixation is a characteristic element of the HINTEGRA prosthesis.
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The SALTO Talaris™ anatomic ankle (Tornier)
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The SALTO ankle prosthesis ‘fixed-bearing’ version is used in the USA, whereas the original ‘mobile-bearing’ design is used in Europe.
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The Agility total ankle replacement
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The Agility prosthesis, a two-component design, requires tibio-fibular fixation.
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• 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.
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The Mobility ankle system (DePuy)
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ZIMMER TAR WITH TRABECULAR METAL
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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
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55Common approach
• Patient is taken in supine. position and incision is taken
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56Intermuscular pain
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Superficial dissection
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58Deep dissection
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61Structures at risk
• Cutaneous branches of the superficial peroneal nerve• Neurovascular bundle consisting of
• Deep peroneal nerve and• Anterior tibial artery
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• video
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63POST-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
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THANK YOU