Ankle Replacement Surgery

[DrYES]

Just out of curiousity, do many of the practicing podiatric surgeons or podiatric surgery residents perform an ankle replacement procedure. I recently saw a youtube video of an orthopedic surgeon performing such a procedure, and from what I have read this procedure is rather new. Knee, hip, and should replacements are very common, could ankle replacements become common such as the said procedures above?

The procedure seemed pretty intensive, which is rather exciting. I saw a thread from 2008 over the same topic, I wondered if anything had changed!

Thank You,

Applied 2011:

Temple, Scholl, OCPM, Des Moines

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[G0dFather]

The geometry of the ankle joint is designed to be as efficient as possible thus it is one of those joints in the body that is less susceptible to degenerative joint disease ( we are talking about a natural course of events here btw excluding trauma, etc,).Thus there isn't great demand for replacement as opposed to say the knee or hip.

 

[Podfather]

Just out of curiousity, do many of the practicing podiatric surgeons or podiatric surgery residents perform an ankle replacement procedure. I recently saw a youtube video of an orthopedic surgeon performing such a procedure, and from what I have read this procedure is rather new. Knee, hip, and should replacements are very common, could ankle replacements become common such as the said procedures above?

The procedure seemed pretty intensive, which is rather exciting. I saw a thread from 2008 over the same topic, I wondered if anything had changed!

Thank You,

Applied 2011:

Temple, Scholl, OCPM, Des Moines

I have performed ankle replacement surgery (TAR). The newer generation implants have fared better than those several decades ago. Ankle fusion has (and some including me believe it still is) been the procedure for chronic pain caused by degenerative joint disease in the ankle. However, if the strict indications are followed for TAR they are a viable option. The procedure is not anymore "intense" than any other major reconstructive procedure of the lower extremity and to be frank easier than many.

 

[densmore22]

As a resident who's scrubbed and seen many (Inbone/II and STAR), I believe in them. Maybe because I'm getting trained in them from the beginning of my training, but I think they're the real deal, especially the STAR. There are better, more biomechanically and anatomically correct, TAR's out there (in Europe --> BOX is the one that comes to mind off the top of my head), but IF they're allowed in the US, it won't be for another 10-15 years at the earliest. That being said, they're not the come all, end all. If a surgeon is offering them to you saying it's a miracle cure, etc, etc, I'd run. You want the guy that has done 100 of them, but only on people that need them. If they tell you all the complications involved, the rehab, that very little ACTUAL ankle motion is acheived after the surgery, etc, then they're probably legit. I have every intention of putting them in when I'm done and out practicing. The data is not lying, the results are looking pretty good for long term results. I think within the next 15 years, you'll see the gold standard change for the treatment of end stage ankle arthritis from fusion to TAR, IMHO. Unlike ankle fusions, not every Joe Blow, DPM or MD should be putting them in (and you can even make the same case for fusions). But that's a whole other can of worms...

And BTW, the ankle is just as prone to degenerative arthritic changes as any other major joint in the body. One could argue that a higher proportion of people actually have ankle arthritis than what's reported compared to knee or hip. Data has shown that even a single ankle sprain in your life can result in ankle arthritis years down the road (albeit much less likely than chronic/repeated ankle sprains/instability). And it's been shown in several studies that the impact of ankle arthritis has a much more detrimental effect on people and their daily lives than having knee or hip arthritis alone, respectively. But yes, post-traumatic arthritis remains the number 1 cause of end stage ankle arthritis. Like any surgery, any technology, anything in general, there's pro's and con's. As a foot and ankle surgeon, if you're not willing and able and have the training and have the understanding and capacity to deal with any and all of the complications of a TAR (and even though the newer 3 component's have fewer complications OVERALL, but when it goes bad, it can be disastrous), then you really have no business putting them in. You shouldn't "dabble" in TAR's, you need to do them or don't do them. 1 every 2 months is not sufficient. More like 1 every week to 2 weeks or more is sufficient (and yes, I have attendings that do that legitimately).

 

[Podfather]

As a resident who's scrubbed and seen many (Inbone/II and STAR), I believe in them. Maybe because I'm getting trained in them from the beginning of my training, but I think they're the real deal, especially the STAR. There are better, more biomechanically and anatomically correct, TAR's out there (in Europe --> BOX is the one that comes to mind off the top of my head), but IF they're allowed in the US, it won't be for another 10-15 years at the earliest. That being said, they're not the come all, end all. If a surgeon is offering them to you saying it's a miracle cure, etc, etc, I'd run. You want the guy that has done 100 of them, but only on people that need them. If they tell you all the complications involved, the rehab, that very little ACTUAL ankle motion is acheived after the surgery, etc, then they're probably legit. I have every intention of putting them in when I'm done and out practicing. The data is not lying, the results are looking pretty good for long term results. I think within the next 15 years, you'll see the gold standard change for the treatment of end stage ankle arthritis from fusion to TAR, IMHO. Unlike ankle fusions, not every Joe Blow, DPM or MD should be putting them in (and you can even make the same case for fusions). But that's a whole other can of worms...

And BTW, the ankle is just as prone to degenerative arthritic changes as any other major joint in the body. One could argue that a higher proportion of people actually have ankle arthritis than what's reported compared to knee or hip. Data has shown that even a single ankle sprain in your life can result in ankle arthritis years down the road (albeit much less likely than chronic/repeated ankle sprains/instability). And it's been shown in several studies that the impact of ankle arthritis has a much more detrimental effect on people and their daily lives than having knee or hip arthritis alone, respectively. But yes, post-traumatic arthritis remains the number 1 cause of end stage ankle arthritis. Like any surgery, any technology, anything in general, there's pro's and con's. As a foot and ankle surgeon, if you're not willing and able and have the training and have the understanding and capacity to deal with any and all of the complications of a TAR (and even though the newer 3 component's have fewer complications OVERALL, but when it goes bad, it can be disastrous), then you really have no business putting them in. You shouldn't "dabble" in TAR's, you need to do them or don't do them. 1 every 2 months is not sufficient. More like 1 every week to 2 weeks or more is sufficient (and yes, I have attendings that do that legitimately).

I agree with everything you said except: 1-2 ankle replacements each week (50-100 year) translates into a practice that must see 1,000 DJD of the ankle patients each year. Unless that's all you do I find that hard to believe. Also I have done the reconstruct on failed TARs not pretty. Usually a fresh femoral head with a nail. Not a good result for a patient who didn't want a fusion.

I know some of the busier TAR DPMs and orthopods in the country and they may get to 1-2 a week. They are referred all from a surrounding area but most of the people I know in orthopedics or podiatry do them monthly or bi-monthly. Steck, Schuberth come to mind as regional gurus. Perhaps you are a resident with them.

 

[PADPM]

I agree with everything you said except: 1-2 ankle replacements each week (50-100 year) translates into a practice that must see 1,000 DJD of the ankle patients each year. Unless that's all you do I find that hard to believe. Also I have done the reconstruct on failed TARs not pretty. Usually a fresh femoral head with a nail. Not a good result for a patient who didn't want a fusion.

I know some of the busier TAR DPMs and orthopods in the country and they may get to 1-2 a week. They are referred all from a surrounding area but most of the people I know in orthopedics or podiatry do them monthly or bi-monthly. Steck, Schuberth come to mind as regional gurus. Perhaps you are a resident with them.

I agree with Podfather. Unless a practice is extremely, extremely busy (and I know busy) and happens to see major pathology in a majority of it's patients, it's unlikely a doctor is going to perform 1-2 TARs weekly. Unless that office is a referral source strictly for this pathology/treatment OR the doctor is over-utilizing this procedure.

I am NOT stating that any attending at your hospital is over utilizing this procedure, but you must always be careful and keep your eyes open when some doctors are performing a high number of a specific type of surgery.

A rep was in our office the other day telling a few of the docs in our practice about a local DPM who did about "150" first MTPJ joint replacements last year. Rather than be impressed, I was staggered.

I know this doctor and she has a pretty small practice. I would estimate she treats about 100 or less patients weekly. In our one office, we treat about 700 patients a week and we have a "few" offices. With all the docs in our practice, I don't think we've done that many joint replacements cumulatively in the past several years.

Do you think maybe this other doctor is over utilizing this procedure? Do you think maybe some of these patients could have used an arthrodesis? Do you think some of these patients could have had a joint sparring procedure such as a decompression osteotomy? Do you think that all of those 150 patients REALLY needed joint replacements? Statistically, I would doubt that very much.

When you get into practice, please do what's best for your patient, not necessarily what's best for you or what is in your comfort zone. If you get in a groove and make every patient fit YOUR criteria, it's a dis-service to your patients. If a procedure is out of your comfort zone, hone up on your skills or refer the patient out....it's the right thing.

 

[Podfather]

I agree with Podfather. Unless a practice is extremely, extremely busy (and I know busy) and happens to see major pathology in a majority of it's patients, it's unlikely a doctor is going to perform 1-2 TARs weekly. Unless that office is a referral source strictly for this pathology/treatment OR the doctor is over-utilizing this procedure.

I am NOT stating that any attending at your hospital is over utilizing this procedure, but you must always be careful and keep your eyes open when some doctors are performing a high number of a specific type of surgery.

A rep was in our office the other day telling a few of the docs in our practice about a local DPM who did about "150" first MTPJ joint replacements last year. Rather than be impressed, I was staggered.

I know this doctor and she has a pretty small practice. I would estimate she treats about 100 or less patients weekly. In our one office, we treat about 700 patients a week and we have a "few" offices. With all the docs in our practice, I don't think we've done that many joint replacements cumulatively in the past several years.

Do you think maybe this other doctor is over utilizing this procedure? Do you think maybe some of these patients could have used an arthrodesis? Do you think some of these patients could have had a joint sparring procedure such as a decompression osteotomy? Do you think that all of those 150 patients REALLY needed joint replacements? Statistically, I would doubt that very much.

When you get into practice, please do what's best for your patient, not necessarily what's best for you or what is in your comfort zone. If you get in a groove and make every patient fit YOUR criteria, it's a dis-service to your patients. If a procedure is out of your comfort zone, hone up on your skills or refer the patient out....it's the right thing.

Like I said a regional referral source could do it. But when you exclude patients with neuropathy/charcot, osteoporosis, a history of AVN, previous bone loss, complex deformity, too young, vascular issues, potential wound healing issues, people too sick for surgery, and those who prefer a fusion after hearing the consult a surgeon would need to see ALOT of people with DJD of the ankle to get to 1-2 TARs per week. I know some high volume guys who are legit and I know a few (who the residents love because they get the case) who do them on anyone they can talk into it.

 

[densmore22]

I agree with everything you said except: 1-2 ankle replacements each week (50-100 year) translates into a practice that must see 1,000 DJD of the ankle patients each year. Unless that's all you do I find that hard to believe. Also I have done the reconstruct on failed TARs not pretty. Usually a fresh femoral head with a nail. Not a good result for a patient who didn't want a fusion.

I know some of the busier TAR DPMs and orthopods in the country and they may get to 1-2 a week. They are referred all from a surrounding area but most of the people I know in orthopedics or podiatry do them monthly or bi-monthly. Steck, Schuberth come to mind as regional gurus. Perhaps you are a resident with them.

I'm not a resident with them and my attending puts in 3-6/month, depending if said attending is on vacation/lecturing/etc. They are evolving their clinic into a total ankle clinic so yes, they get referred many arthritic ankles from all over the world.

I have not done a reconstruct per se, I've done redo's using Inbone, but not a TAR to fusion...yet. Take downs to TAR's, which are always fun.

 

[Podfather]

I'm not a resident with them and my attending puts in 3-6/month, depending if said attending is on vacation/lecturing/etc. They are evolving their clinic into a total ankle clinic so yes, they get referred many arthritic ankles from all over the world.

I have not done a reconstruct per se, I've done redo's using Inbone, but not a TAR to fusion...yet. Take downs to TAR's, which are always fun.

Enjoy and learn. 👍

 

[PADPM]

I'm not a resident with them and my attending puts in 3-6/month, depending if said attending is on vacation/lecturing/etc. They are evolving their clinic into a total ankle clinic so yes, they get referred many arthritic ankles from all over the world.

I have not done a reconstruct per se, I've done redo's using Inbone, but not a TAR to fusion...yet. Take downs to TAR's, which are always fun.

Sounds like you're in a great program and are fortunate to have the ability to learn from great mentors.