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

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

3. Symptoms Pain Joint effusion Stiffness Deformity Altered gain
Achilles contracture

4. 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

5. 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

6. 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

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

8. 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

9. 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”

10. 1:43

11. 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 Mar-Apr;54(2):188-91
Plate and compression screw construct strongest
Dissection
Vascular disruption

12. Tzeitel/Motel 3:50 – 6:43

13. 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 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

14. Hodel/Perchik 2:39 – 4:30

15. Complications

16. Replacement Fusions are great but… Enter Total Ankle Arthroplasty
J Bone Joint Surg Am 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

17. The Players

18. Chava 0:50 end

19. Outcomes Gait analysis Durability Adjacent joint preservation
Foot Ankle Int Oct;34(10): 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 Nov;38(11):
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

20. Complications

21. Complications

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

23. Epilogue