CASE STUDYIntegra®

Cadence® Total Ankle System

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Integra®

Cadence® Total Ankle System

Case Presentation: Use of the Cadence® Total Ankle System in a 41-year-old Individual presenting with End Stage Ankle Arthritis without Deformity

Surgeon Profile

Selene G. Parekh, MD, MBA, FAOA

Co-Chief, Foot & Ankle Division

Partner, North Carolina Orthopaedic Clinic

Professor, Department of Orthopaedic Surgery

Adjunct Faculty, Fuqua Business School

Duke University Durham, NC

About the Author:

Dr. Parekh is a Professor of Orthopaedic Surgery at Duke Orthopaedics and North Carolina Orthopaedic Clinic. Prior to his tenure at Duke, Dr. Parekh was a Foot and Ankle Surgeon at the University of North Carolina (UNC). While there, he was integrally involved in the teaching of medical students and residents. Furthermore, he served as the foot and ankle consultant to the Athletic Department, treating many of the well-known UNC athletes. He is a graduate of the Boston University School of Medicine, Dr. Parekh completed his internship and residency at the Hospital of the University of Pennsylvania and his fellowship in foot and ankle surgery under the direction of some of the leading global authorities at the University of Pennsylvania. Dr. Parekh has been an active speaker at regional, national, and international meetings, helping to teach other orthopaedic surgeons about best practices and novel techniques for the care of foot and ankle patients. He has published in numerous journals and has served as editor for several textbooks.

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Integra®

Cadence® Total Ankle System

Use of the Cadence® Total Ankle System in a 41-year-old Individual presenting with End Stage Ankle Arthritis without Deformity

Figure 1. Preoperative X-rays of left ankle showing arthritic changes.

Patient Profile:

A 41-year-old female presented with a painful end stage ankle arthritis of the left ankle. She initially sustained a left ankle fracture when she was 18 years of age that was treated non-operatively. Nineteen years later she sustained another fracture of her left ankle and was treated with an ORIF. The plate became loose and was subsequently removed. A few years later she began to experience persistent pain and an ankle arthroscopy was performed. The patient was informed the talus was void of cartilage and since her arthroscopy she denies any significant relief. She rates her current pain at 8/10 and she has been on anti-inflammatories and pain-relievers and used multiple lace-up and strap-on braces. Preoperative AP and lateral X-rays [Figure 1] of the left ankle showed arthritic changes secondary to fracture.

After extensive discussion, the patient elected for a total ankle replacement. Given her age, and the possible need for a revision total ankle in her lifetime, I decided to select an implant system that was anatomic, retained bone (especially on the talus), and maximized cortical coverage on the tibia. These criteria led to the selection of the Cadence ankle replacement.

As the manufacturer of this device, Integra does not practice medicine and does not recommend this or any other surgical technique for use on a specific patient. The surgeon who performs any procedure is responsible for determining and using the appropriate techniques in each patient.

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Integra®

Cadence® Total Ankle System

Surgical Procedure:

The patient was brought to the operating room (OR) and following administration of general and regional anesthesia (popliteal block) was placed in a supine position. A pneumatic tourniquet at thigh level was placed and the Cadence Surgical Technique utilized. An anterior ankle incision was made two finger widths lateral to the anterior tibial crest with a 15 blade. Bleeders were cauterized. The incision was taken to the level of superficial peroneal nerve. This was marked and mobilized. The EHL tendon was identified and taken out of its sheath. The incision was taken all the way down to bone where subperiosteal dissection was performed on the medial and lateral aspects of the ankle and the external guide was placed.

The Cadence external guide was positioned, the slope estimated. The gap sizer was placed and the tibial cutting jig was attached to the distal block [Figure 2]. Next, the alignment was checked for varus/valgus, rotation, medial/lateral translation, and slope. Once this was placed appropriately, the guide was pinned. Drill holes, followed by guide pins were applied. The saw was used to resect the tibia followed by the talus.

Figure 2. The cutting jig was attached to the distal block and the alignment was checked for varus/valgus, rotation, medial/lateral translation, and slope

The 0.5 inch curved osteotome was used to remove the tibia that was cut and the ankle was held at neutral. The guide was distracted onto the talus, and was then pinned and cut. The posterior chamfer guide was then placed and pinned, and the cut then performed. The guides were then switched for anterior chamfer preparation and followed by the talar peg drill holes [Figure 3].

Figure 3. Resection of the talus articular surface was performed by placing the chamfer cutting guide on top of the talus.

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Next the trials were placed and the tibia measured medially and laterally for size determination. The tibia measured a size 2. The tibial pegs were then drilled [Figure 4]. A 6mm poly was trialed and found to give good stability. The ankle could be brought into 5 degrees of dorsiflexion. Achilles tendon lengthening was not performed. The tibia preparation was completed with the drill and pins. The talus was pinned and drilled. The wound was then thoroughly irrigated and the final implants placed [i.e., tibia size 2, talus size 2, and size 2 6mm neutral HXL Ultra High Molecular Weight Polyethylene (UHMWPE)].

Figure 4. After implant size determination, the tibial pegs were drilled and the final implants placed.

Intraoperative radiographs [Figure 5] of the ankle were obtained showing good position of the Cadence on AP and lateral views.

Figure 5. Immediate post op imaging demonstrates proper positon of the Cadence implant on antero-posterior and lateral views

The capsule was then closed with 0 Vicryl sutures followed by 2-0 Vicryl for the tendon sheath, and 2-0 Vicryl for the subcutaneous tissues. Staples were used to close the skin. A VAC dressing was applied. A soft tissue expander was then applied to remove tension from the skin. A sterile dressing was applied and staples used to close the skin [Figure 6]. The patient was placed in a Jones splint in neutral dorsiflexion-plantar flexion and neutral inversion and eversion. The patient was awakened and brought to the PACU in stable condition.

Figure 6. Immediate post op imaging demonstrates proper positon of the Cadence implant on antero-posterior and lateral views.

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Integra®

Cadence® Total Ankle System

Post-Operative Course:

One week post-surgery, the negative pressure wound therapy and soft tissue expansion devices were removed. The patient was then placed in a short leg non-weight bearing cast and at week 3, all stitches were removed. The patient was then outfitted with a boot, allowing her to walk on the extremity. At week 6, the boot was removed and physical therapy initiated [Figure 7]. Over the next three months, the patient worked on her range of motion, strength, balance, gait, and proprioception. Her follow-up continues to be uneventful and at the most recent follow-up, nine months after surgery, she is happy with a pain level of 0-1 out of 10.

Figure 7. 6 weeks’ post op imaging demonstrates proper positon of the Cadence implant on antero-posterior and lateral views.

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Figure 7. 6 weeks’ post op imaging demonstrates proper positon of the Cadence implant on antero-posterior and lateral views.

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Availability of these products might vary from a given country or region to another, as a result of specific local regulatory approval or clearance requirements for sale in such country or region. n Non contractual document. The manufacturer reserves the right, without prior notice, to modify the products in order to improve their quality.n Warning: Applicable laws restrict these products to sale by or on the order of a physician.n Consult product labels and inserts for any indication, contraindications, hazards, warnings, precautions, and instructions for use.

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Integra®

Cadence® Total Ankle System