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