IN THIS ISSUE...

The Fortius Clinic Lecture Series - November Issue

JOINT REPLACEMENT OF THE LOWER LIMB

Total Knee Replacement - where are we now? Mr Giles Heilpern - see page 4

Ankle Arthritis in different age groups Mr Pete Rosenfeld - see page 10

Infection - Salvaging a Disaster - see page 8 to read more

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November’s lecture was the last of the 2014 series, as we have a break in December during the busy Christmas period. The topic was ‘Lower Limb Joint Replacement, and the evening’s speakers were Mr Giles Heilpern, consultant Knee Surgeon and Mr Pete Rosenfeld Foot & Ankle Surgeon. Mr Jonathon Lavelle chaired the meeting, kicking off proceedings and fielding the Q&A session. Unfortunately Dr Glyn Towlerton was called up as an Expert Medical Witness so was unable to give his presentation on pain management in joint replacement.Orthopaedic Knee Surgeon Mr Giles Heilpern spoke first on knee replacements. His key points were that knee replacement is primarily used for degenerative disease – a total knee replacement for widespread disease, and a partial knee replacement for compartment disease. He gave us a quick run through of the history of these replacements, demonstrating that very little has changed in the past 35 years, aside from various smaller evolutions. Then onto the results – often a brilliant operation but success rates are still only at 80-85% so for that reason the knee replacement is considered complex and difficult so used as a last resort.Next up was Mr Pete Rosenfeld, Orthopaedic Foot & Ankle Surgeon, who spoke on ankle replacements in relation to ankle arthritis. Mr Rosenfeld ran us through his decision making process with regards to three case studies, of three different age groups. For each of the arthritic patients he recommended a different treatment; from realignment to fusion and total ankle replacement.We have found that our new multidisciplinary format has worked really well so far and we look forward to continuing in this style in 2015. Topics we will be tackling include Skiing Injuries in January, February is not yet confirmed, The Adolescent Athlete in March, Barefoot Running in April and Hyperlaxity & Joint Instability in May. If you do have any suggested topics that you would like to see included within the programme, or interesting and challenging case studies that you’d like to discuss, please contact marketing@fortiusclinic.com and we’ll do our best to facilitate their inclusion.

The Fortius Lecture EveningEvery month the Fortius Clinic hosts a lecture evening for physiotherapists, Sports and Exercise Medicine professionals, led by a different team of specialists. The evening event is held in central London. If you would like to be added to our invitation list, please email RSVP@ fortiusclinic.com.]

Mary Jones MSc MCSP Director of Research and Outcomes

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FEATURE | Knee Replacements

So I’m going to briefly run through the indications for knee replacement, the many different types of surgery available and give you a flavour of the latest advances in techniques and prostheses. Most importantly I’m going to finish by touching on results, which are interesting, and as knee surgeons they generally temper which patients we offer knee replacements to…

The classic indication for TKR is advanced degenerative disease. This X Ray shows end stage lateral compartment osteoarthritis with an obvious valgus deformity of both legs. The only thing we can offer here is a knee replacement. When we see patients like that it’s an obvious knee replacement and generally patients will do pretty well.

One of the problems is that we tend to see patients with earlier and earlier osteoarthritis. We want to do something to make them better but a knee replacement is not always solution.

Sometimes knee replacements are useful in the trauma setting and they’re useful in the case of tumours as well. But the main indication by far is osteoarthritis.

TYPES• Total – widespread degenerative disease• Partial – single compartment degenerative disease but

controversial

In simple terms there are two different types of knee replacement – the total knee replacement and the partial knee replacement.In this case the patient is in her late 40s. She had a big hockey injury a few years ago and ruptured her ACL. She had an ACL reconstruction but the knee was never really stable afterwards and over time she went on to get bone on bone osteoarthritis in her medial compartment. An MRI scan showed a fair bit of wear and tear laterally and also in her patellofemoral compartment so despite her being in her 40s she went ahead and had a total knee replacement from which she is recovering very well.Partial knee replacements can be brilliant they can also be quite controversial. They are used for isolated single compartment disease.

MEDIAL UNICOMPARTMENTALSo here you see isolated medial compartment osteoarthritis, the rest of the knee is fine. So what we do in this situation is just resurface the damaged arthritic medial compartment and leave the rest. The advantages of that are that we leave the ligaments, we leave more of their own knee and theoretically it’s a quicker recovery. A good unicompartmental knee replacement gives a better functional outcome than a total knee replacement.

LATERAL UNICOMPARTMENTALAnd you can do a lateral unicompartmental knee replacement. This is much less common however because most people get medial OA.

PATELLOFEMORAL REPLACEMENTAs you will all know, most patellofemoral disease is treated most effectively with physiotherapy. Personally I try to resist doing anything surgical to the patellofemoral joint. In end stage patellofemoral osteoarthritisbone however replacing the patellofemoral joint can be highly effective.

DEVICESThere are lots of new innovative implants on the market today… and we have to be careful. There is a lot we know about knee replacement but also an awful lot we do not fully understand. There is always temptation to innovate but we must ensure that the evidence base supports any new technique that we adopt.

HISTORYThe history of Knee replacement is quite interesting.Modern condylar knee replacement started in the 1960s/1970s, with lots of people trying lots of things. Unicompartmental knee replacement initially didn’t work very well with a high failure rate, a high revision rate, poor fixation or even no fixation of the devices. As a result its use declined a lot.Various people looked at those results, including John Insall, one of the founders of the total knee replacement. He found a 28% revision rate at 2 years, which by anybody’s standards is less than ideal. The game changer for unicompartmental knee replacement was when the Oxford knee replacement came in from the Oxford Group. It was first implanted in the mid ‘70s and still has fantastic results. The Oxford group report a 91% 20 year survival rate which is excellent. Other units have struggled slightly to reproduce those results.Modern total knee replacement started in the 1970s as well. And it’s interesting that actually not that much has changed. So in the ‘70s they were made of metal, with a polyethylene insert and cemented

in. Both the cruciate ligaments were taken out. And if you compare these two pictures, the first one from the 1970’s is one of John Insall’s early knee replacements from the Hospital for Special Surgery in New York in the early ‘80s, and the second image shows a state of the art PFC sigma TKR available today. If you look at them, they are remarkably similar and that’s a good 35 years of evolution, and really not much has changed in terms of design.

Things have evolved, but remain fundamentally unchanged today.

This is one of the knee replacements that I use now, which has been the same since 1994. But it started life as a cylindrical implant with no attention whatsoever paid to the patellofemoral joint. And over time a patellofemoral joint was brought in along with a patella button.

WHAT HAS EVOLVEDSo the fundamental implants remain similar, but there is nonetheless a great deal at which we have got better.

The things that have changed are the things that are not necessarily directly related to the implant, the things that surround knee surgery. We know that putting in a knee replacement accurately is fundamental not only for its function but also for its longevity. So we now resurface the patella when we didn’t to start with; the instruments have got much better; we’re much better at putting them in, and there’s less for the hospital to sterilise. POLYETHYLENE On the Polyethylene side the plastic insert has changed. Led mainly by the Hip surgeons and the problems they were having with the plastic wearing out, we too have adopted this highly cross linked polyethelene which potentially will last for much longer than the original.

DESIGNSOver the years, we have developed a vast array of patella components.In 1974, Peter Walker developed the first dome-shaped patella resurfacing component. Most of the designs introduced during the nineties has incorporated multiple changes in the geometry of the trochlear groove, which have been shown to have a positive impact on the patellar complication rate (Bindelglass & Dorr, 1998; Kavolus et al., 2008; Mont et al., 1999). The two devices that were compared are highlighted here:The PFC has a standard dome-shaped cemented patellar component and a trochlea that terminates distally at the centre.The MRK had the medially placed, inset cementless patella button and a trochlea that terminates distally lateral to the midline.

Write-up from Giles Halpern’s talk on Knee replacements Mr Giles Heilpern MA (Cantab) MB BS FRCSEd (Tr & Orth) Consultant Orthopaedic Knee Surgeon

IT’S WORTH STARTING WITH A VIEW OF JUST HOW MANY KNEE REPLACEMENTS ARE DONE IN THE UK EVERY YEAR – SOMEWHERE IN THE REGION OF 70,000. THAT’S A MASSIVE AMOUNT OF SURGERY AND A MASSIVE COST BURDEN FOR THE COUNTRY.

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FIXATIONFixation changed and has changed back again. As with Hip replacements you can put these things in cemented or uncemented. There’s no doubt that there are advantages to uncemented, not least in terms of surgical time, but if you look at the National Joint register in the UK there’s no question but that favours cemented implants. So there has been a shift back again and most surgeons would now use a cemented in TKR, as they used to do 35 years ago. Instrumentation has improved with better ergonomics and lower profiles. It is more accurate, with less trays for sterilisation, but still Internal Medicine/Emergency Medicine referencing.

PARTIAL KNEE REPLACEMENT OR TOTAL KNEE REPLACEMENT And then we come on to this debate about unis and totals and who should have what and when they should have it. And it’s an ongoing debate really, if you have ten knee surgeons in a room you’ll have a pretty fiery discussion.I personally think that a good partial knee replacement gives a good functional result and I think that a good partial knee replacement gives a better functional result than a good total knee replacement. But it’s difficult evidence to find. Most of the scoring systems that we use to look at these replacements are fairly crude and to pick up those subtle differences is very difficult.In young people a partial knee replacement preserves bone so if you’re going back for revision surgery probably in 15 or 20 years you’ve got much more to work with. People also talk about quicker post op recovery, less blood loss and all those aspects around the surgery itself. As attractive as that might sound, for me and my patients, and certainly if I were the patient, what I’d actually want is a knee replacement that would last me 20 years, I wouldn’t really mind if my incision was 5 or 8 centimetres long or if I were in hospital for 1 day or 4 days. So I think we have to be very careful about that.If we look at the UK National Joint registry unicompartmental knee replacement has some very high revision rates, so 10 to 15 % at 10 years. Which is potentially a problem. It either means that we’re putting them in the wrong people or that we’re not putting them in properly. But when you look into it more, it’s complicated and there’s far more to it. One of the factors is that with a partial knee replacement it’s relatively easy to revise. So if someone comes to you with a PKR that they’ve had done elsewhere and which is giving them problems, it’s relatively straightforward to change it for a TKR, whereas if someone has issues with a TKR they will often be told that to change it is a very big deal and they may well choose not to undergo the revision. So it is multifactorial.

INNOVATIONSThere are some more innovations that have come in during the last few years and all these things relate to our ability to implant prostheses in the correct alignment.Computer navigation was introduced about 15 years ago and there’s lots about computer navigation that is really attractive. It enables you to align the knee replacement according to the patient’s anatomy. It sounds fantastic, but there are a few flaws with it: the first of which is that before you start you have to tell the computer where various anatomical landmarks are. This sounds easy but in practice it is often not. If you put your marker in the wrong place the computer is registering things that are not where they’re meant to be. So you think you’re putting it in perfectly and you may not be.

So that’s the first thing, and the second thing is all the cost of the equipment and the fact that there’s quite a big learning curve in terms of learning how to do it.More exciting for us I think is patient specific instrumentation. What we can do now, using a CT scan or an MRI scan, is manufacture the blocks through which we cut the bone to be entirely patient specific or bespoke.These are attractive surgically particularly in challenging cases, but attractive also from the hospital perspective as it reduces significantly the amount of instruments you need to put a knee replacement in. The bespoke blocks are not always completely accurate however. There is also a significant implication for training the knee surgeons of the future that we must be aware of.

The other thing that has changed around knee replacement is enhanced recovery programmes. We’ve all seen patients after a knee replacement - it’s a painful experience and the first few weeks can be quite difficult. There are lots of things we do now to help. We try to get people home sooner, we deliver lots of care at home with physiotherapists and nurses. We also infiltrate lots of local anaesthetic around the knee joint before we close up the knee. So we do lots of things to try to modify those first few days, because it can have quite a significant impact on patient’s outcome. What you want is a knee that the patient can move without pain early, so they can get into the flow of it. If it’s painful for too long it can be a real problem. I believe there is a golden window of opportunity following a knee replacement. It is critical to achieve as much movement as possible as quickly as possible which is where we rely on the expertise that physiotherapists bring – without good postoperative physiotherapy our results without question suffer.

BUT THEN WE COME ON TO THE RESULTS…Patient satisfaction for TKR hovers around the 80% mark – not great when you consider that it is 95% for total hip replacement. In real terms that means as many as 1 in 5 patients might go through this big, painful operation and expose themselves to all the risk that that it entails and still end up not much better than they were before. This certainly tempers my view of knee replacement and makes me think very carefully before I replace someone’s knee. Patient selection for knee replacement is fundamental and sometimes you’re faced with someone who has proven osteoarthritis but you just know that if you replace their knee they are not going to do very well. That can be quite a difficult conversation.But although it may be a last resort, as we all know it can be brilliant. You’ll all have seen patients that fly through their knee replacements and are delighted with the result, with a 90% replacement survival rate to 20 years.And for partial knee replacements, as I’ve alluded to before, it’s controversial and there are some knee surgeons that won’t do it. I think it’s brilliant in the right people, but you have to be careful who you select.

SUMMARYSo in summary, has anything really changed? The simple answer to that is no, BUT the designs have evolved, there have been some design modifications, we’re much better at putting them in accurately, we’re much better at getting patients through their recovery, and most importantly, we have a better understanding of who needs what type, where and when. But it’s still something that needs more work.And to my mind it is still very much a last resort. That’s why we all spend so much time trying to avoid people getting to the osteoarthritis situation. That’s why we think people should have muscle strengthening and rebalancing physiotherapy; why we do everything we can to preserve the meniscus; why we reconstruct ligaments and opt for cartilage regeneration techniques and osteotomy. So whilst a knee replacement is a very good pain relieving operation for end stage osteoarthritis I think it is important that we all remember that it is NOT a new knee.

Mr Giles Heilpern MA (Cantab) MB BS FRCSEd (Tr & Orth) Consultant Orthopaedic Knee SurgeonMr Heilpern’s surgical practice encompasses all aspects of knee surgery but with a particular interest in meniscal injuries, ligament reconstruction and partial and total knee replacement.

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Stiffness of the knee following surgery is a debilitating complication of knee surgery and a common cause of complaint for patients. While it may occur unexpectedly after almost any knee procedure, it is not an infrequent problem following total knee replacement. It is a more common complication than infection, thromboembolism or early mechanical failure. (Reports suggest between 5%-7%)The definition of stiff TKR has changed over time to reflect patient and physician’s high expectations for function and range of motion (ROM) after surgery. Typical flexion requirements might be:

Walking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65° Lifting an object from the ground . . . . . . . . . . . . . . . 70° Climbing stairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85° comfortable sitting and standing . . . . . . . . . . . . . . . . 95° Tying shoelaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105° Squatting and picking up an object . . . . . . . . . . . . 115°

It is important to manage expectations – patients that have not bent their knee in 20 years cannot expect to bend their knee on day 1 post-op. They will need to work hard to regain their extension following an operation. Loss of extension is significantly more debilitating than loss of flexion. “ It’s far easier to get a straight knee bent, than it is to get a bent knee to straighten after one month post-op.” There are many different causes of stiffness. These may be patient related, such as pre-operative knee stiffness, multiple scarring, previous infection, fibrosis or ossifications, poor rehabilitation and compliance, or depression. They may be due to the Anaesthetist providing inadequate post-op pain control or aggressive anticoagulation therapy which may result in the development of intra-articular hematomas with secondary stiffness or to technical error by the surgeon, such as Inadequate bone resection, too tight a Flexion gap, or improper alignment. Or they may be down to the improperly sized components and inaccurate patellofemoral joint reconstruction.

NORMAL EXTENSION AND FLEXIONNormal extension is limited by static factors, antero medial impingement of femur on tibial plateau, tension within the posterior capsule and the fat pad which is compressed and pushed forward. The fat pad is the largest soft tissue structure within the knee.

Even in starvation its volume remains the same. It is full of stem cells and is highly sensitive to touch and pressure. The fat pad sits behind the patella tendon superior to the intermeniscal ligament and in the interval between the patella tendon and anterior tibia, the so called “anterior interval”. During normal flexion and extension the fat pad “flows” over the bony structures at the front of the knee. Dynamic limitation is provided by tension within the hamstrings and gastrocnemii. Normal flexion static limitation is by the bone contours and the extensor mechanism tension. Dynamic limitation is quadriceps muscle tone.

BONE AND SOFT TISSUE CAUSES OF FIXED FLEXION DEFORMITYPost-operative flexion is even more challenging now, with the ‘high-flex’ implants. Poor flexion in the knee may be due to bone or soft tissue problems.Bone blocks may be:• Articular incongruity secondary to intra-articular fracture malunion.• Bone osteophytes, especially in the arch of the notch or the

anteromedial tibial spine osteophyte, the “anvil”.

POSSIBLE SOFT TISSUE CAUSES:• “Cyclops lesion”; the stump of torn ACL.• Bucket handle meniscal tears.• Capsule/ligament contracture.• Fat Pad Contracture. This cause is relatively poorly understood and

often not recognised. The fat pad contracture effectively obliterates the anterior interval space creating a patella baja and limiting full extension. This results in pain, limitation of patello femoral excursion and increased patello femoral contact pressures.

TREATMENTSome patients who develop post-operative stiffness require manipulation under anesthesia to address this issue. The best candidate for maninpulation is a motivated patient with a restricted ROM detected within 3 months of surgery. Treatment of fixed FFD involves recognition of the pathology and then removal of bone blocks to give more or less release of soft tissue contractures as appropriate. Stiff knees caused by technical error can be improved after revision surgery, but the degree of improvement is difficult to predict. It’s a difficult surgery and the best treatment is prevention.

Notes on the Stiff KneeBased on previous presentations from Mr Guy Bellier and Mr Jonathan Webb.

Extracts from previous presentation from Mr Andrew Davies on the management of infection. Post operative Intra-articular infection in Arthroscopic procedures and infection in Arthroplasty is a common cause of stiffness, pain and poor function. Infectious complications of arthroscopy are rare but result in significant morbidity for the patient when they occur, usually requiring readmission to the hospital, at least 1 additional operation, and prolonged antibiotic therapy, both intravenous and oral. They can interfere with a patient’s recovery, often resulting in suboptimal joint function.The incidence of infection requiring reoperation after knee arthroscopy has been established at about 0.15%. Incidence of infection for an ACL is 0.5%-1%, and for total knee arthroplasty (TKA) it is 1.55% in the first 2 years, falling to 0.46% over the next 8 years.

Aspects to consider in diagnosing post operative ACL infections are: the Patient reporting pain which is unexpected or prolonged, signs of fever, swelling and stiffness of the knee; increased levels of white cell count (WCC) greater than 60% neutrophilia, levels of C-reactive protein (CRP) above 30 and levels of erythocyte sedimentation rate (ESR) above 30. In the case of suspected infection, it is very important that no antibiotics are given until after Biopsies. Management then includes Aspirate / gram stain followed by aggressive arthroscopic debridement and biopsy with intravenous antibiotic, repeated at 48 hours. Inflammatory markers should be monitored and the patient should rest the limb.Study findings suggest that ACL grafts may be retained with prompt, thorough arthroscopic lavage and debridement; correct antibiotics according to cultures; and repeated arthroscopy if necessary. The use of a single-stage revision is gaining popularity, used in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no

radiological evidence of component loosening or osteitis. The overall self-reported complication rate for arthroscopic knee procedures was 4.7%. Knee arthroscopy is not a benign procedure, and patients should be aware of the risk of complications.

The “Vancy Blanky” is a surgical technique using presoaked vancomycin hamstring grafts to decrease the risk of infection after anterior cruciate ligament reconstruction. In the case of TKA acute joint infection occurring within less than 72 hours, with no evidence of a loosening prosthesis, these have been shown to respond well to open debridement and polyethylene exchange.Preoperative precautions to bear in mind are a Healthy patient; Diabetic control; Immunosuppressives management; HIV well controlled; Clean and Preoperative Chlorhexidine wash; No skin lesions; Preoperative antibiotics Diabetes and BMI have an influence on relative Risk • DM 3x • BMI > 50 21x • BMI – 40-49 3.3x

Operative precautions include: Laminar flow; Chlorhexidine prep; Ioban drapes; Pulse Lavage; Antibiotic Cement, and Efficient surgery, as operative time is also one of many factors that may increase infection risk.

Salvaging a DisasterBased on a previous presentation from Mr Andrew Davies.

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WHY IS ANKLE OSTEOARTHRITIS LESS COMMON?We don’t know the answer but is has several features that may answer that question.

THE SHAPEThe contours of the ankle are very closely matching (high congruency) and also have contours that allow more laxity. The hip has a high congruency in the form of a ball and socket, but no ability to allow laxity or angulation.The ankle joint is also rolling joint, with high congruency and contact throughout its range, unlike the knee which has less contact throughout its range and tends towards point loading.The talus is a truncated cone, which means it is wider at the front and narrower at the back. Because it is wider at the front, it has got most contact when it is in dorsal flexion and beyond.- the positions used during maximal weight bearing. This “squeeze” effect may act as a bumper against high forces.Unlike the hip or knee, the ankle has malleoli either side. The lateral malleolus (fibula) moves and rotates with ankle movement, as the width of the truncated talus changes. This fibula movement may act as another buffer against pressure.These features can also work against the ankle and if disturbed there is a huge increase in contact pressures with only a small change - a 1mm shift in talar position

causes a 42% decrease in contact area. This talar shift requires a rupture to the deltoid ligament or medial malleolus and requires a significant injury. So big ankle injuries will lead to arthritis, but the little injuries won’t.

CARTILAGEWithin the ankle joint is some of the thinnest cartilage in the body. The cartilage structure is formed differently: It is stiffer and harder and with a stronger matrix It is stiffer and more resistant to compression compared with hip and knee. There is a higher percentage of superficial layers, which are the main layer for load bearing. The tensile strength of Ankle cartilage decreases much less with ageing when compared with the femoral head and hip joint.The boney foundation to the cartilage – the subchondral bone of the ankle does not change density or sclerose with arthritis, unlike other joints. This may retain some of the shock absorbing functions of this boney layer.

HOW DOES ANKLE ARTHRITIS AFFECT GAIT?The gait changes in arthritis with “antalgic” features:- Decreased stride length- Decreased velocity (by a third)- Short single leg stance

- Altered ground reaction forces- Increased external rotation – patients do

this to reduce ankle movement and avoid pain.

THE FIRST QUESTION WE ASK OURSELVES – IS IT ACTUALLY ANKLE OA?There are so many things other than arthritis that it could be as there are many structures around the ankle that can cause pain. This can be at the front of the ankle or on the medial or lateral sides:• Arthritis in other joints – talonavicular or

subtalar or tibio-fibular• Tendonitis – posterior tibial tendon,

peroneal tendon, anterior tibial tendons.• Nerve injuries – from the spine or peripheral

nerve injuries• Synovitis of the other joints. • Stress, like talar navicular joint pain, do they

mean medial ankle or is it the lateral side, or is it the lower tibia?

If we’re looking for ankle arthritis, we are looking for typical features of :mechanical pain increasing with use, regularly occurring across the front of the ankle and only experiencing rest pain after prolonged use. Its also essential to consider the body either as a cause of the pain, and also to assess the effects that any proposed surgery on the ankle will affect the other joints or conditions in the body.

Case study 1Young adult case study:- 19 years old- Warehouse worker- Ankle pain - mainly lateral weight bearing pain - Walking on the side of his 5th metatarsal- He’s had a fracture several years before(a growth plate injury, so his medial physis fused early and the fibular and lateral physis continued to grow causing a varus deformity).

TREATMENT CHOICES:- Arthroscopy?- Distraction?- Fusion?- Realignment?- Replacement?Conservative Management: stop impact activities eg running , increased pain relief, support with better shoe wear. Custom made insoles and shoes may help reduce the symptoms.Surgical Options: arthroscopy could be done but it won’t help the lateral WB pain.

DOES ARTHROSCOPY WORK IN ARTH

WHAT ABOUT ANKLE FUSION?It will get his ankle straight, correct the WB alignment, relieve the ankle pain. But how well does it function and how long does it last?

BIOMECHANICS AFTER ANKLE FUSION- Normal ROM on flat ground- PF & DF reduced by 50-75%- Problems on hills and stairs- A fraction off a normal gait

COMPLICATIONS- 1-5% non union- 1-5% infection- 1-5% malunion- Arthritis develops in other joints

Results at 22years

Distraction?

Not appropriate in this case

REALIGNMENTThis is what I recommend – distal tibial realignment

REPLACEMENT He’s too young and it would wear out. In France they would do it now, to protect the other joints from becoming arthritic and then fuse him in 5-10 years when the replacement runs out.

FEATURE | ANKLE ARTHRITIS IN DIFFERENT AGE GROUPS

Lecture by Mr Pete Rosenfeld, Consultant Orthopaedic Foot and Ankle Surgeon

THE ANKLE IS INCREDIBLE – IT IS THE MOST COMMONLY INJURED JOINT AND YET IT IS RARELY AFFECTED BY OSTEOARTHRITIS (9 TIMES LESS THAN THE HIP OR KNEE). IT IS ONLY 1/3 THE SIZE OF A HIP/KNEE AND THEREFORE TAKES THE MOST WEIGHT BEARING FORCE OF ANY JOINT!.

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Case study 225- 60 YEARS OLD ADULTS- 38 year old female- Currently in-between jobs- Ankle pain only- Varus arthritis

TREATMENT CHOICES:- Arthroscopy?- Distraction?- Fusion?- Realignment?- Replacement?She was 127kg at 5 foot 3!!She’s been back to see me 2 weeks ago, no ankle pain having lost 41kilos.

TOTAL ANKLE REPLACEMENTAdvantages:- Maintain ankle ROM- Better function- Hindfoot joints protected- Rapid recovery- Gain in QALY makes it more cost effective than

arthrodesis

TAR – GAIT

DISADVANTAGES:- Failure due to loosening and Osteolysis- Complex revision- Infection rate similar to AF- Higher repeat surgeries than AF

Salto ankle replacement – the best results

Case study 3THE OLDER PATIENTTREATMENT CHOICES:- Arthroscopy?- Distraction?- Fusion?- Realignment?- Replacement?Arthroscopy can be very good for the older patient. Ankle replacement is my choice of treatment for the older patient. The recover is easier with only 2 weeks needed on crutches and in a plastercast.

CONTRAINDICATIONS- Soft tissues- Avascular- Infection- Severe deformity- Non compliance- Charcot- Absent deltoid?

JANUARY- The next lecture We don’t have a lecture in December but in January we will be back talking about Skiing Injuries.

Ski ServiceIn the meantime if you would like to refer a patient to the Ski Service please email skiinjuries@fortiusclinic.com.

The Ski Service offers urgent access to Consultant Orthopaedic Surgeons, Physicians and Radiologists, with specific expertise in ski injuries.

• Same day and next day urgent appointmetns• X-ray, MRI and Ultrasound scanning facilities• Post injury treatment, advice and rehabilitation plans.

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INTRODUCING...

Orthopaedic Shoulder, Elbow, Hand & Wrist SurgeonMr Ahmed is a Consultant Orthopaedic Surgeon, specialising in shoulder, elbow and hand surgery.

Orthopaedic Knee SurgeonMr Ball specialises in all aspects of knee surgery.

Contact the Fortius Clinic If you would like to refer a patient to one of our consultants, please get in touch:

17 Fitzhardinge Street, London, W1H 6EQ

Tel: 0203 195 2442 Fax: 0203 070 0106

Email: info@fortiusclinic.com Web: www.fortiusclinic.com

His clinical interests include arthroscopic shoulder and elbow surgery including management of complex shoulder injuries by arthroscopic and minimal invasive means.Mr Ahmed has pioneered keyhole techniques for fixation of complex shoulder fractures and has presented his technique both nationally and

internationally. Several scientific papers describe his technique. He has a keen interest in sports and has treated many professional sports persons including Premier league footballers and rugby players. In 2012, he was selected as a member of the shoulder and elbow specialist team by LOCOG for the London Olympic and Paralympic Games.

Mr Ball is an extremely keen sportsman. He captained Cambridge University Football Club and has played semi-professional football, thus understands the needs and

expectations of sports people. Mr Ball has a special interest in sports knee injuries, complex ligament reconstruction and re-alignment surgery.

Achilles and Patella Tendinopathy clinicThe monthly UTC Tendinopathy clinic is proving extremely popular and is now being expanded to cover Patella tendon as well as Achilles tendon. This is a unique opportunity as the service is not offered elsewhere in Europe or the US. The specialist insight delivered by the clinic is designed to support the patient’s ongoing physio care - following attendance at the clinic, patients return for physio locally with a detailed rehab plan based on the ultrasound tissue characterisation.

If you would like to book an appointment for a patient please call 0203 195 2442.

Mr Simon Ball

Booking for FISIC ‘15 is now open

and early bird ticket ticket rates apply.

For more information please visit the FISIC ‘15 website - www.fisic.co.uk or call Harriet Webb on 0203 195 2434 (harriet.webb@fortiusclinic.com)

Mr Hasan Ahmed

Don’t forget to follow us on Twitter @FortiusClinicUK. You will also find us on Facebook and LinkedIn

t: +44 (0) 203 195 2442 f: 0203 070 0106

e: appointments@fortiusclinic.com w: www.fortiusclinic.com

Fortius Clinic is situated in Central London, close to Selfridges, and just off Manchester Square.

17 Fitzhardinge Street London W1H 6EQ

For further information or to book an appointment, please contact us:

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