Current Concepts in Ankle Arthritis: Fuse it or lose it? Vytautas M. Ringus MD Orthopaedic and Sports Medicine Center of Norman, PC

Types of Ankle Arthritis Primary Less common than hip/knee Congruent Incongruent Post Traumatic Recurrent injuries Intraarticular damage Inflammatory markers Autoimmune Infectious Avascular

Symptoms Pain Joint effusion Stiffness Deformity Altered gain Achilles contracture

Nonoperative management Rest/Activity Modification Therapy Injections Steroid PRP Fukawa et al 2017 FAI 20 pts, 3 injections at 2 week intervals Maximal effect at 12 weeks Safe and effective Worse arthritis did worse Viscosupplementation Safe But does it work? Other BMA Stem Cells Arizona Brace

Operative Options Location and extent of arthritis Deformity through ankle Hindfoot and Forefoot status Past medical history Activity level Vascular status Concomitant medical issues Active infection BMI Current needs Age Outcomes

Arthroscopy Role Indications Expectations Outcomes Often times a delay tactic Indications Isolated lesions/spurs Expectations Improve ROM Limited term relief Outcomes Osti et al J Orthop Surg Res. 2016 15 former pro soccer players, 7.5 yr f/u Early changes with impingement Improved pain scores with good to excellent scores in 11

Osteotomies Single Double TRIPLE??? Plafondoplasty Opening vs closing wedges Double Rotation through mid tibia and malleolus TRIPLE??? What What!?

Motion Preserving Alternatives – the “weirdos” Distraction arthroplasty External fixator Relieve joint pressure Common complications from pins Roughly 50% improvement over 2-3 years with deterioration over time Resurfacing Biologic Metallic Not widely available – FDA approval experimental only Allograft Unipolar Rankin JBJS Dec 2009 15 patients avg 54 mo f/u 11 good to excellent results Bipolar Giannini et al Injury July 2017 The AOFAS score improved from 31 ± 11 pre operatively, to 65 ± 25 at the last (p < 0.0005). Fourteen failures occurred, with 70.8% allograft rate of survival. All the surviving allografts showed a reduction of the ankle joint movement, still associated with a satisfactory clinical result

Weirdos Total Talus Replacement Angthong Orthop Rev (Pavia). 2014 One patient 7.6 month followup Improved pain scores Harnroongroj et al, JBJS 2014 16 patients Outcomes followed loosely Did “Ok”

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Fusion Gold standard (still, but…) Arthroscopic Open Single vs double smaller incisions Single allows future options Exposure Union rates between 90-95% Reliable pain relief Plate vs screws Strength J Foot Ankle Surg. 2015 Mar-Apr;54(2):188-91 Plate and compression screw construct strongest Dissection Vascular disruption

Tzeitel/Motel 3:50 – 6:43

Arthroscopic Fusion J Bone Joint Surg Am. 2013 Jan 16;95(2):98-102 Townshend et al “Arthroscopic arthrodesis resulted in a shorter hospital stay and showed better outcomes at one and two years.” In a review by: Cottino et al Curr Rev Musculoskelet Med. 2012 Jun Fusion rates between 85-97% Earlier discharge Cost effective Possible earlier rate of union (undetermined) Complications similar to open: deep infection (0.85%), superficial infection (2.5%), nonunion (3-15%), hardware pain (18-30%), malunion (0.85%). adjacent joint arthritis Controversies exist regarding body mass index and cigarette smoke as risk factors. No association between age, diabetes mellitus, peripheral neuropathy, and nonunion has been found

Hodel/Perchik 2:39 – 4:30

Complications

Replacement Fusions are great but… Enter Total Ankle Arthroplasty J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28 At 22 years, 98% had adjacent joint arthritis radiographically, and 1/3 were symptomatic Enter Total Ankle Arthroplasty Indications Have evolved over time Age Deformity Weight Approaches Anterior vs lateral Wound healing and blood supply issue Adjunct procedures Correct surrounding malalignment Two stage vs one stage

The Players

Chava 0:50 end

Outcomes Gait analysis Durability Adjacent joint preservation Foot Ankle Int. 2013 Oct;34(10):1340-8 Brodsky et al. Total ankle arthroplasty produced a more symmetrical vertical ground reaction force curve, which was closer to that of the controls than was the curve of the ankle arthrodesis group. Durability Multiple studies of 3rd generation replacements 5 yr survival at 90-95%, 10 year at 80% Fact? Adjacent joint preservation Foot Ankle Int. 2017 Nov;38(11):1183-1187 Dekker et al – 140 TAR (3 types), min 5 year f/u, 27% STJ, 31% TN DJD progression, 16 STJ fusions (11%), 2 TN fusions (1%) Pain relief Satisfaction

Complications

Complications

The Future Revision replacements New designs Subtalar Replacements Invision Upside down implants? New designs Anatomic distal tibia/talus – “Vantage”? Subtalar Replacements Growing new ankles?

Epilogue