Do DPM's do ankle replacement surgery? Or is this only ortho surg?

[capo]

Or is this the sole domain of ortho surgeons? I'm just curious, as I was asked this the other day about podiatrists by a friend about his grandfather and I didn't exactly know myself.

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[jonwill]

I just spoke with a DPM that was doing an ankle replacement tomorrow. I'm aware of various DPM's that perform the procedure. I'm sure that foot and ankle orthopods do them as well.

 

[capo]

Thanks for the info. I'm not surprised but I didn't know for sure. How often are these procedures performed and is ankle replacement going to become more prevalent, with baby boomers aging? Is it almost as frequent as are knee replacements? I would think the ankle, being a complex joint, will fail and degenerate in many people over time due to wear and tear of aging.

 

[dpmgrad]

Or is this the sole domain of ortho surgeons? I'm just curious, as I was asked this the other day about podiatrists by a friend about his grandfather and I didn't exactly know myself.

There are several DPMs that do Total Ankle Replacements (TAR). In fact, the DePuy Agility Total Ankle Replacement Implant course is open to both Orthopods and DPMs.

In my opinion, the current total ankle implants that we have available in US are not the best. There are a great deal of total ankle implant failure reported in literature. There are several total ankle implants out in Europe, especially in Germany, that are far more superior than what we have available in the US. In the US, we currently have the DePuy Agility (which is currently the only FDA approved implant in US) and STAR Implant (which is currently in FDA trials and is available in selected clinical trial sites in the US). There is the Hintegra Implant, which is not FDA approved yet in the US. The Buechel Pappas implant is also currently under FDA trials and does not have FDA approval in the US. In one of the Orthopedic Foot and Ankle conferences that I attended, Dr. Hansen basically said that the Total Ankle Implant is for an arthritic ankle that HAS NO DEFORMITY (varus or valgus). I agree with him on this.

There is still a lot of debate whether to perform an ankle arthrodesis (fusion) or total ankle replacement for ankle arthritis in the US.

 

[capo]

Thanks again. So can DPM's do this as a regular part of their practice if they want to specialize in these? It seems it's still possible for a DPM to do ALL surgical type duties and evals and consults of surgical nature? This is a main component of my interest in podiatry.

 

[dpmgrad]

Thanks again. So can DPM's do this as a regular part of their practice if they want to specialize in these? It seems it's still possible for a DPM to do ALL surgical type duties and evals and consults of surgical nature? This is a main component of my interest in podiarty.

Not all DPMs will be allowed to perform total ankle replacement surgery. Only DPM who have Board certification in Reconstructive Rearfoot Surgery will be able to perform this procedure. In addition, the DPM will also need to attend a training course and apply for priviledges at the hospital to do such surgical procedures. Currently, the DePuy Agility is the only implant available for qualified DPMs to perform. The STAR and Buechel Pappas Implants are available for selected DPMs around the country that are involved in the FDA clinical trial centers. Once these two implants have their FDA approval, they will be available for qualified DPMs to utilize.

As for the second part of your question, I am not sure what you are trying to ask. If you are implying that if it would be possible for you to only do foot and ankle surgery and almost no conservative / routine foot care as a DPM, I think that you need take a second look at the Podiatric profession. Remember, we are Foot and Ankle Specialists that offer comprehensive foot and ankle care. This includes providing routine foot care. There are a few established DPMs that have a huge surgical volumes. Also, please do not be misguided by the fact that if you join an Orthopedic group that you will not be doing any routine foot care. Remember, you are a DPM and no matter what group you join, patients will come to you for routine foot care.

 

[jonwill]

Not all DPMs will be allowed to perform total ankle replacement surgery. Only DPM who have Board certification in Reconstructive Rearfoot Surgery will be able to perform this procedure. In addition, the DPM will also need to attend a training course and apply for priviledges at the hospital to do such surgical procedures. Currently, the DePuy Agility is the only implant available for qualified DPMs to perform. The STAR and Buechel Pappas Implants are available for selected DPMs around the country that are involved in the FDA clinical trial centers. Once these two implants have their FDA approval, they will be available for qualified DPMs to utilize.

As for the second part of your question, I am not sure what you are trying to ask. If you are implying that if it would be possible for you to only do foot and ankle surgery and almost no conservative / routine foot care as a DPM, I think that you need take a second look at the Podiatric profession. Remember, we are Foot and Ankle Specialists that offer comprehensive foot and ankle care. This includes providing routine foot care. There are a few established DPMs that have a huge surgical volumes. Also, please do not be misguided by the fact that if you join an Orthopedic group that you will not be doing any routine foot care. Remember, you are a DPM and no matter what group you join, patients will come to you for routine foot care.

 

[capo]

Not all DPMs will be allowed to perform total ankle replacement surgery. Only DPM who have Board certification in Reconstructive Rearfoot Surgery will be able to perform this procedure. In addition, the DPM will also need to attend a training course and apply for priviledges at the hospital to do such surgical procedures. Currently, the DePuy Agility is the only implant available for qualified DPMs to perform. The STAR and Buechel Pappas Implants are available for selected DPMs around the country that are involved in the FDA clinical trial centers. Once these two implants have their FDA approval, they will be available for qualified DPMs to utilize.

As for the second part of your question, I am not sure what you are trying to ask. If you are implying that if it would be possible for you to only do foot and ankle surgery and almost no conservative / routine foot care as a DPM, I think that you need take a second look at the Podiatric profession. Remember, we are Foot and Ankle Specialists that offer comprehensive foot and ankle care. This includes providing routine foot care. There are a few established DPMs that have a huge surgical volumes. Also, please do not be misguided by the fact that if you join an Orthopedic group that you will not be doing any routine foot care. Remember, you are a DPM and no matter what group you join, patients will come to you for routine foot care.

No, I agree that whether you do ortho surgery or podiatric surgery, I assume most of your patient base is non surgical or rouitine care. I'm not only interested in the surgical aspect of pods but I would like to attempt to go as far as one can in the profession. This siad, I am a long way from being in a position to do this. I've yet to take my 1st class in pod school.

But I do hope more doors will open for DPM's, by the time I arrive at the level of residency. I appreciate the candid advice and rest assured, I am interested in the totality of the profession not just select aspects of it.

I see you graduated from Temple's program. Where did you do/doing your residency? Is it heavily surgical based? How during school years did you, or can I, get exposure to the surgical side of pods? Thanks alot.

 

[dpmgrad]

No, I agree that whether you do ortho surgery or podiatric surgery, I assume most of your patient base is non surgical or rouitine care. I'm not only interested in the surgical aspect of pods but I would like to attempt to go as far as one can in the profession. This siad, I am a long way from being in a position to do this. I've yet to take my 1st class in pod school.

But I do hope more doors will open for DPM's, by the time I arrive at the level of residency. I appreciate the candid advice and rest assured, I am interested in the totality of the profession not just select aspects of it.

I see you graduated from Temple's program. Where did you do/doing your residency? Is it heavily surgical based? How during school years did you, or can I, get exposure to the surgical side of pods? Thanks alot.

I am finishing up my third year in one of the PM&S-36 programs in the greater Philadelphia area. In my program, we get a well rounded exposure to various forefoot and reconstructive rearfoot procedures. However, we are not one of those super high surgical volume programs. But, each graduating resident will have done adequate amount of cases that would enable him or her to comfortably perform the forefoot or rearfoot procedure and be good at it. I am fortunate to be in one of those hospitals where Podiatry has a great relationship with the Orthopedic Surgeons. In fact, if the Orthopedic Surgeons have a foot or ankle case, they expect the Podiatry resident to scrub in and pretty much do the entire case. It is great that I get training from both Podiatric Surgeons and Orthopedic Surgeons.

When I was at TUSPM, I helped set up a program at TUSPM through the Student Chapter of ACFAS (Surgery Club), where students can go observe surgery cases (and possibly scrub in on them) at various hospitals during the time when there are very little student externs at those hospitals. However, after I graduated from TUSPM, I think that the Surgery Club no longer offer this option. During your free time, you can shadow some of the Podiatrists in the local area and you might be able to tag along for the surgery cases that the Podiatrist is doing. I would highly recommend you wait until you do your OR Protocol course before scrubbing into cases because if you don't know how to scrub or you contaminate yourself or anything in the OR, they might throw you out of the OR. I had some second year TUSPM students that visit my residency program and they all got to scrub into cases since they had their OR Protocol course. If you are going to be a TUSPM student, during your third year, you will be rotating through the surgery module at the TUSPM Foot and Ankle Institute. If you got a chance to work up a patient for surgery in the surgery module, you can always ask the resident or the attending if you can scrub in or observe the surgery case when it is scheduled for the patient. Lastly, if you are going to scrub in on some cases, try to find out what those cases are ahead of time and READ UP on the cases and review the anatomy.

If you have any additional questions, feel free to ask. Good luck.

 

[oncogene]

I am finishing up my third year in one of the PM&S-36 programs in the greater Philadelphia area. In my program, we get a well rounded exposure to various forefoot and reconstructive rearfoot procedures. However, we are not one of those super high surgical volume programs. But, each graduating resident will have done adequate amount of cases that would enable him or her to comfortably perform the forefoot or rearfoot procedure and be good at it. I am fortunate to be in one of those hospitals where Podiatry has a great relationship with the Orthopedic Surgeons. In fact, if the Orthopedic Surgeons have a foot or ankle case, they expect the Podiatry resident to scrub in and pretty much do the entire case. It is great that I get training from both Podiatric Surgeons and Orthopedic Surgeons.

When I was at TUSPM, I helped set up a program at TUSPM through the Student Chapter of ACFAS (Surgery Club), where students can go observe surgery cases (and possibly scrub in on them) at various hospitals during the time when there are very little student externs at those hospitals. However, after I graduated from TUSPM, I think that the Surgery Club no longer offer this option. During your free time, you can shadow some of the Podiatrists in the local area and you might be able to tag along for the surgery cases that the Podiatrist is doing. I would highly recommend you wait until you do your OR Protocol course before scrubbing into cases because if you don't know how to scrub or you contaminate yourself or anything in the OR, they might throw you out of the OR. I had some second year TUSPM students that visit my residency program and they all got to scrub into cases since they had their OR Protocol course. If you are going to be a TUSPM student, during your third year, you will be rotating through the surgery module at the TUSPM Foot and Ankle Institute. If you got a chance to work up a patient for surgery in the surgery module, you can always ask the resident or the attending if you can scrub in or observe the surgery case when it is scheduled for the patient. Lastly, if you are going to scrub in on some cases, try to find out what those cases are ahead of time and READ UP on the cases and review the anatomy.

If you have any additional questions, feel free to ask. Good luck.

dpmgrad,
What programs offer high surgical volume?

oncogene

 

[JohnfootDr]

DPMgrad:

I thought only 2 states (TN and one other) actually required RR & A certification to do rearfoot work (PSR-24 or PM & S 36 Residency). I have seen lots of places with PSR-12 trained attendings (or less, if they have been in practice for decades) doing complex rearfoot work. Eventually that is likely to change in some other states.

A lot depends on hospital priviledges and showing the training as you mentioned--some hosptials are very restrictive, some are very open. Depends on the amount of Pod work being done (and, to some extent the amount of Orthopods and how they view Podiatrists at the hospital).

I'll agree on the availablity and functionality of the Agility (which many don't like) being a big stumbling point in Pods not doing TAR/TAA (Total Ankle Arthroplasties). If something a bit more functional came along, more than a few of the attendings I know would be interested in putting them in.

John

PS--Still looking!!

 

[dpmgrad]

DPMgrad:

I thought only 2 states (TN and one other) actually required RR & A certification to do rearfoot work (PSR-24 or PM & S 36 Residency). I have seen lots of places with PSR-12 trained attendings (or less, if they have been in practice for decades) doing complex rearfoot work. Eventually that is likely to change in some other states.

A lot depends on hospital priviledges and showing the training as you mentioned--some hosptials are very restrictive, some are very open. Depends on the amount of Pod work being done (and, to some extent the amount of Orthopods and how they view Podiatrists at the hospital).

I'll agree on the availablity and functionality of the Agility (which many don't like) being a big stumbling point in Pods not doing TAR/TAA (Total Ankle Arthroplasties). If something a bit more functional came along, more than a few of the attendings I know would be interested in putting them in.

John

PS--Still looking!!

John, you are correct in that there are many PSR-12 trained podiatrists who are doing rearfoot procedures. Of course, these podiatrists have been in practice a long time. However, as you pointed out, it is the hospitals that would limit what the surgeon can or can not do based on the surgical priviledges granted to them. Thanks for pointing out about the states that required RRA board certification to do rearfoot surgery.

 

[dpmgrad]

dpmgrad,
What programs offer high surgical volume?

oncogene

The best way to determine if program has high surgical volume is to take a look at the surgical logs of the current residents. The only problem with looking at the resident's surgical volume is that some residency program have their residents unbundle procedures so that they can have a high surgical volume. One other note about high surgical volume programs is that sometimes a high surgical volume may not provide the best surgical training. If there are so many cases that residents need to scrub on, the residents are often thrown into the surgical case without having the opportunity to review the case preoperatively with the attending or get to follow the patient postoperatively. I personally think that preoperative planning and postoperative follow up are rather important.

Some programs with higher surgical volumes include Grant Medical Center, Southeast Michigan Hospital (former Kern), Northern Virginia. There are others but those are the ones that come to mind.

 

[JohnfootDr]

A bit late coming back here, but a couple of other pointers.

Look at the logs carefully. An 'A' level case means they observed. A 'B' level case means they did less than 50% of the work, and a 'C' level case means they did the majority of the work.

In a lot of larger programs, you might have 3 residents and 1 attending scrubbed around one foot. That means that 2 of the 4 probably don't have a very good view of what is going on--yet they can log the case as a 'B' if they just occasionally retract--if it was a complicated case, it can make their logs look good, but they really didn't learn much.

Beware of the Surgery mills--extremely high volume places. As DPMgrad pointed out, you don't get any pre and post surgery exposure. You also don't get a grasp on basic office practice skills--which can greatly hurt your early years in practice. Very, Very few Podiatrists can make a good living by ONLY doing surgery. The best earners have a good mix of palliation, trauma/normal aches and pains (plantar fascitiis, tendinitis, ingrowns, etc.), and surgery. As a guy who has been in practice for years if he would rather do a Triple Arthrodesis, or 5 P & A's (the P & A's take 1/4 the time overall as a triple and it's follow up visits)--and the P & A's pay better.

As one of the attendings in school pointed out--if you just do surgery, ALL your patients are new--and if you don't get anyone needing surgery for a couple of weeks, you don't have any income for that period of time. The guys with a good mix can at least count on the older folks coming back in every 3 months for routine care. Much as I hate C & C, it does bring in a regular income to a practice.

 

[dpmgrad]

A bit late coming back here, but a couple of other pointers.

Look at the logs carefully. An 'A' level case means they observed. A 'B' level case means they did less than 50% of the work, and a 'C' level case means they did the majority of the work.

In a lot of larger programs, you might have 3 residents and 1 attending scrubbed around one foot. That means that 2 of the 4 probably don't have a very good view of what is going on--yet they can log the case as a 'B' if they just occasionally retract--if it was a complicated case, it can make their logs look good, but they really didn't learn much.

Beware of the Surgery mills--extremely high volume places. As DPMgrad pointed out, you don't get any pre and post surgery exposure. You also don't get a grasp on basic office practice skills--which can greatly hurt your early years in practice. Very, Very few Podiatrists can make a good living by ONLY doing surgery. The best earners have a good mix of palliation, trauma/normal aches and pains (plantar fascitiis, tendinitis, ingrowns, etc.), and surgery. As a guy who has been in practice for years if he would rather do a Triple Arthrodesis, or 5 P & A's (the P & A's take 1/4 the time overall as a triple and it's follow up visits)--and the P & A's pay better.

As one of the attendings in school pointed out--if you just do surgery, ALL your patients are new--and if you don't get anyone needing surgery for a couple of weeks, you don't have any income for that period of time. The guys with a good mix can at least count on the older folks coming back in every 3 months for routine care. Much as I hate C & C, it does bring in a regular income to a practice.

well said.

 

[IlizaRob]

I know that this thread was pulled from the archives but I stumbled across this website and thought it was relevant to the OP. Its about a DPM doing ankle replacements.

http://www.anklejoint.com/

 

[capo]

I know that this thread was pulled from the archives but I stumbled across this website and thought it was relevant to the OP. Its about a DPM doing ankle replacements.

http://www.anklejoint.com/

Thanks for this link.

 

[dpmgrad]

Thanks for this link.

Here is another link to a Podiatrist doing Total Ankle Replacement:

http://www.totalankle.com/

 

[MD2b20004]

I know that this thread was pulled from the archives but I stumbled across this website and thought it was relevant to the OP. Its about a DPM doing ankle replacements.

http://www.anklejoint.com/

For a professional website, from a doctor, that website sure does have crap loads of spelling and grammer errors that if I was an educated patient I wont even email the dude to ask him about a corn on my foot.

 

[jonwill]

For a professional website, from a doctor, that website sure does have crap loads of spelling and grammer errors that if I was an educated patient I wont even email the dude to ask him about a corn on my foot.

"Jim, I'm a doctor, not an english teacher!!!" (Star Trek)

I read a small portion of the website and found no shocking errors. However, in your short post of two sentences, I found two or three!

You seem to be posting on our forum an awful lot. Are you interested in podiatric medicine?

 

[coastalfaa]

qualified podiatric surgeons are currently and have been for some time inserting total ankle replacements in patients.

 

[Stafocker]

qualified podiatric surgeons are currently and have been for some time inserting total ankle replacements in patients.

Welcome Coastalfaa! thanks for posting, but that forum hasn't been posted for over a year now!

 

[Dr_Feelgood]

"Jim, I'm a doctor, not an english teacher!!!" (Star Trek)

I read a small portion of the website and found no shocking errors. However, in your short post of two sentences, I found two or three!

You seem to be posting on our forum an awful lot. Are you interested in podiatric medicine?

One error that I found (I think) is this guy is claiming to have used BP since 1998. I have been under the impression that until last year the Depuy Agility was the only FDA approved implant in the US. Am I wrong?

 

[jonwill]

One error that I found (I think) is this guy is claiming to have used BP since 1998. I have been under the impression that until last year the Depuy Agility was the only FDA approved implant in the US. Am I wrong?

HE LIVES!

 

[OSUDDS]

welcome back feelgood

 

[dpmgrad]

One error that I found (I think) is this guy is claiming to have used BP since 1998. I have been under the impression that until last year the Depuy Agility was the only FDA approved implant in the US. Am I wrong?

Actually BP was suppose to be FDA approved. However, it loss its FDA approval a few years back. This is what I was told by one of the podiatric surgeons that used to do TAR with BP ankle implants in Ohio. BP implant was available in the US before DePuy Agility was in the US market. Welcome back!

 

[dawg44]

Total Ankles in my opinion is just a bunch of implant manufacturing marketing BS. They've tried to extrapolate the success of total knees to ankle.
1) We already have a very good, proven permanent surgery for ankle arthritis.
2) They never had such a surgery for the knee, a knee fusion is a horrible situation.
3) The situations where you think it might be an option (i.e. the patient wants it not you) are precisely the patients that are going to fail early and need a revision to an ankle fusion now you are trying to make up length and are hoping to God the implant hasn't subsided into the subtalar joint.
4) I've never done one and don't plan on it. You always look better trying to revise someone's poor surgical decision into a better situation, than you do taking care of your own poor decision.

 

[jays2cool4u]

Total Ankles in my opinion is just a bunch of implant manufacturing marketing BS. They've tried to extrapolate the success of total knees to ankle.
1) We already have a very good, proven permanent surgery for ankle arthritis.
2) They never had such a surgery for the knee, a knee fusion is a horrible situation.
3) The situations where you think it might be an option (i.e. the patient wants it not you) are precisely the patients that are going to fail early and need a revision to an ankle fusion now you are trying to make up length and are hoping to God the implant hasn't subsided into the subtalar joint.
4) I've never done one and don't plan on it. You always look better trying to revise someone's poor surgical decision into a better situation, than you do taking care of your own poor decision.

What is the proven permanent surgery for ankle arthritis?

 

[Stafocker]

What is the proven permanent surgery for ankle arthritis?

Fusion of the ankle

 

[Dr_Feelgood]

Total Ankles in my opinion is just a bunch of implant manufacturing marketing BS. They've tried to extrapolate the success of total knees to ankle.
1) We already have a very good, proven permanent surgery for ankle arthritis.
2) They never had such a surgery for the knee, a knee fusion is a horrible situation.
3) The situations where you think it might be an option (i.e. the patient wants it not you) are precisely the patients that are going to fail early and need a revision to an ankle fusion now you are trying to make up length and are hoping to God the implant hasn't subsided into the subtalar joint.
4) I've never done one and don't plan on it. You always look better trying to revise someone's poor surgical decision into a better situation, than you do taking care of your own poor decision.

I have been in a number of implants (about 6-7 not a ton but a lot for a 4th year student) and the patients are doing very well.

The group is also placing them in young patients b/c they don't see any logic is waiting to implant a half dead patient. Now we do not have any patients that are more the a few years out but they are very successful so far.

You do not need to go onto a fusion and can replace components of the implant if they fail. But if try an implant you have not lost anything and can go onto a fusion with a bone graft.

While subsidence is a problem they usually subside or loosen from the tibial component, that is why you must fuse the syndesmosis.

 

[dawg44]

I have been in a number of implants (about 6-7 not a ton but a lot for a 4th year student) and the patients are doing very well.

The group is also placing them in young patients b/c they don't see any logic is waiting to implant a half dead patient. Now we do not have any patients that are more the a few years out but they are very successful so far.

You do not need to go onto a fusion and can replace components of the implant if they fail. But if try an implant you have not lost anything and can go onto a fusion with a bone graft.

While subsidence is a problem they usually subside or loosen from the tibial component, that is why you must fuse the syndesmosis.

I hope they last for you but you said the key words "few years out" The young ones are precisely the ones who are going to beat the crap out of them.
I've revised about a dozen to a fusions and I disagree (respectfully) about not losing anything. Making up length with an allograft or whatever is a difficult problem. The worst problem I've seen is subsidence into the subtalar joint, basically dooming them to a TTC fusion. If it's me give me a solid ankle fusion and a good subtalar joint and I'm fine.

Good Debate going here.

 

[IlizaRob]

I hope they last for you but you said the key words "few years out" The young ones are precisely the ones who are going to beat the crap out of them.
I've revised about a dozen to a fusions and I disagree (respectfully) about not losing anything. Making up length with an allograft or whatever is a difficult problem. The worst problem I've seen is subsidence into the subtalar joint, basically dooming them to a TTC fusion. If it's me give me a solid ankle fusion and a good subtalar joint and I'm fine.

Good Debate going here.

Its good to see you back dawg. Its always nice to have an ortho viewpoint on these topics. I have nothing to contribute because I have not seen many implants done but I hope to see many in the coming months when I will be spending some time with a surgeon who does a good amount. I hope to have a better viewpoint after that rotation.

Feelgood, good to see you back as well. I hope you didnt ruin the Lawns before the new shipment comes in.

 

[Feli]

One error that I found (I think) is this guy is claiming to have used BP since 1998. I have been under the impression that until last year the Depuy Agility was the only FDA approved implant in the US. Am I wrong?

WB, man.

Agility is the only FDA approved to my knowledge.... as dpmgrad mentioned. I know a few DPMs here in Fla who do BP, tough. I know Feldman published his results on it recently; it was at least a poster.... don't know if it made a journal or not (and too lazy to search after a long day at my new anesthesia rotation ).

 

[whiskers]

I find it intersting to note that no ankle discussion in podiatry would be complete without the inclusion of the exclusion clause w/in the profession (of even the new 3yr residency) of who can and can not do this and that concerning the ankle. It is amazing that after all the talk about standardizing the profession there still is an "exclusion clause" protected by some group of key holders.

Personally, I think that this is absolutely absurd that Podiatry has "Fellowships" in anything relating to the foot or ankle esp when there are PSR12's doing reconstructive work demonstrating to the world that "12 months was long enough." In my opinion, what good is having 12 or even 100 specially trained pods in anything if the other 10988-10900 have to tell the rest of the world that they can't do that procedure and have to send it all out to an orthpod?

How can the MDs train their surgical residents on the entire body in 5 yrs but our profession takes 3yrs to only find out that we still are incomplete and need fellowships etc in order to become complete doctors of the foot and ankle that we all want to be known as?

Do MD foot and ankle specialists need to do a fellowship beyond their ~ 6 month foot and ankle fellowship in order to do ankle implants and reconstructive sx?

BTW, those without the fellowships, are they going to become the dinosaurs of tomorrow in the profession?

As long as the profession has what I consider in my opinion to be educational elitism and exclusionism, I can not and will not personally advocate for a scope of practice increase for my own profession out of fear of how it would be delegated.

 

[Dr_Feelgood]

I hope they last for you but you said the key words "few years out" The young ones are precisely the ones who are going to beat the crap out of them.
I've revised about a dozen to a fusions and I disagree (respectfully) about not losing anything. Making up length with an allograft or whatever is a difficult problem. The worst problem I've seen is subsidence into the subtalar joint, basically dooming them to a TTC fusion. If it's me give me a solid ankle fusion and a good subtalar joint and I'm fine.

Good Debate going here.

How many ankle fusions go onto subtalar fusions? Depuy also makes the long stem implant to complete the TTC fusion. Without getting too nerdy the subtalar joint is not that important (of course easy to say from a guy with a healthy STJ) i.e. Astion et al and most lateral ankle stabs that are non-anatomic

I understand the whole thing with youth wearing out the joints but the same was said for knee replacements in the 80s and 90s. Mobile-bearing implants should be out fairly soon (from some inside info) and we should see the implants doing even better.

I realize that an ankle fusion after an implant is not an easy task, but ankle fusions are not a benign procedure. The motion must come from somewhere else. If we give up on ankle implants than we will not get better components.

 

[Dr_Feelgood]

WB, man.

Agility is the only FDA approved to my knowledge.... as dpmgrad mentioned. I know a few DPMs here in Fla who do BP, tough. I know Feldman published his results on it recently; it was at least a poster.... don't know if it made a journal or not (and too lazy to search after a long day at my new anesthesia rotation ).

Inbone which was Topaz is approved. I had heard that BP was going to be last year. SBI is also coming out with an implant that may be around as early as March.

 

[Stafocker]

Do MD foot and ankle specialists need to do a fellowship beyond their ~ 6 month foot and ankle fellowship in order to do ankle implants and reconstructive sx?
.

12 month fellowships + 5 years (according to AOFAS) and yeah, they have to be approved (certified) by each of the vendors, just like pods.

fellowships are not for everyone in podiatry, just like not all orthos do foot & ankle. but its definitely a plus if you want to get that extra education, just like MD/DO's go further after 3 years of PCP, they can do fellowships to specialize in other stuff, too. But it's not for all MD/DO's, just like not all Pods should do fellowships.

Being associated with a fellowship, it's not really about increasing surgery, but more about research and grant writing. Basically, you want to be the "big bad" in your field and stand out from others.

Also, there are other fellowships not dealing with Foot & Ankle Reconstruction, some are Diabetic Liimb Salvage, AO fellowships, Illiazov, Paley's, etc.

 

[dawg44]

How many ankle fusions go onto subtalar fusions? Depuy also makes the long stem implant to complete the TTC fusion. Without getting too nerdy the subtalar joint is not that important (of course easy to say from a guy with a healthy STJ) i.e. Astion et al and most lateral ankle stabs that are non-anatomic

I understand the whole thing with youth wearing out the joints but the same was said for knee replacements in the 80s and 90s. Mobile-bearing implants should be out fairly soon (from some inside info) and we should see the implants doing even better.

I realize that an ankle fusion after an implant is not an easy task, but ankle fusions are not a benign procedure. The motion must come from somewhere else. If we give up on ankle implants than we will not get better components.

There are a few good nails out their now. I have tried Zimmer trabecular metal augments for these type of cases and they have helped alot with the bone loss and structural support problem. They give you instant structural support and you're not worried about them fading away like an allograft.

It's not that the subtalar joint is vitally important in and of itself, but if you take it away, you take away alot of motion at the TN joint. Add a fused ankle on top of that and a fused ankle with a good subtalar and TN joint is much better situation than a TTC fusion post arthroplasty. I've never been cavalier about getting rid of it (subtalar joint), I've done a few revisions of those damn subtalar implants that have gotten into the subtalar joint and forced me to do a subtalar fusion. Another surgery that I have not or will not do. That goes back to the old saying a easy answer for a complex problem is usually the wrong answer, but that's an entirely different debate.

Back on topic, Knee replacements like I said you can't extrapolate it to knee replacements. What is your option if you have severe knee arthritis
1) Live with it
2) Fuse it
3) Replace it
Knee fusion is a terrible operation, imagine getting in a car, sitting in a chair. Patients hate them with a passion. Most do not hate an ankle fusion

I'm not saying give up on them, I'm saying they are not there yet. Let them continue to figure it out it out in Europe. We have lots of John Edwards running around here, they don't.

Good to be back Rob

 

[dawg44]

This thread should be not be CAN you do them, but SHOULD you do them.

 

[Dr_Feelgood]

There are a few good nails out their now. I have tried Zimmer trabecular metal augments for these type of cases and they have helped alot with the bone loss and structural support problem. They give you instant structural support and you're not worried about them fading away like an allograft.

It's not that the subtalar joint is vitally important in and of itself, but if you take it away, you take away alot of motion at the TN joint. Add a fused ankle on top of that and a fused ankle with a good subtalar and TN joint is much better situation than a TTC fusion post arthroplasty. I've never been cavalier about getting rid of it (subtalar joint), I've done a few revisions of those damn subtalar implants that have gotten into the subtalar joint and forced me to do a subtalar fusion. Another surgery that I have not or will not do. That goes back to the old saying a easy answer for a complex problem is usually the wrong answer, but that's an entirely different debate.

Back on topic, Knee replacements like I said you can't extrapolate it to knee replacements. What is your option if you have severe knee arthritis
1) Live with it
2) Fuse it
3) Replace it
Knee fusion is a terrible operation, imagine getting in a car, sitting in a chair. Patients hate them with a passion. Most do not hate an ankle fusion

I'm not saying give up on them, I'm saying they are not there yet. Let them continue to figure it out it out in Europe. We have lots of John Edwards running around here, they don't.

Good to be back Rob

I love this line.

 

[Stafocker]

I love this line.

lol

 

[dpmgrad]

Inbone which was Topaz is approved. I had heard that BP was going to be last year. SBI is also coming out with an implant that may be around as early as March.

Tornier Salto Talaris Ankle Implant is suppose to be FDA approved as well. I like the Tornier implant. I got a chance to see a couple during my AO Fellowship in Switzerland. STAR implant is close to FDA approval.

 

[Dr_Feelgood]

Tornier Salto Talaris Ankle Implant is suppose to be FDA approved as well. I like the Tornier implant. I got a chance to see a couple during my AO Fellowship in Switzerland. STAR implant is close to FDA approval.

This is the new SBI implant I was alluding to.

 

[SportPOD]

Just came across this article. Thought I would add it to the current discusion.

http://www.orthosupersite.com/view.asp?rID=25464