Total ankle replacement feasible/lucrative?

[Podicus]

Hello everyone, I wanted to ask for your opinions and perhaps gain some insight on this topic.

I was recently speaking with the podiatrist I have been shadowing about the prospect of total ankle replacements, a procedure that I find to be very interesting and downright cool.

I was surprised when he let me know he does not offer ankle replacement surgery as he feels he is not compensated well enough for the procedure, he instead refers to an foot and ankle ortho.

I was surprised to hear this as you would expect a total ankle replacement to be quite the rewarding procedure. I'm aware of the post surgical implications and the global billing period, but is it really best to leave the TAR's to the orthopods and stick more with the bread and butter procedures?

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[dyk343]

Many chose not to because
1) You have to have the absolute "perfect" patient for the implant which is hard to find.
2) The complication rate is very high
3) Once it fails (estimate ~10 years) you have to fuse the ankle joint with shambles for bone (Need a donor bone block)
4) They are hard to get certified in
5) They do not pay well for the amount of work and headache.
6) Patients, when indicated, usually do well with a primary ankle fusion.

I'm sure there are more reasons why people are not putting them in but that is a start.

And as a side note I've scrubbed with a lot of ortho F&A surgeons and they also are not putting them in due to what is listed above.

The implants are getting much better but they still have a ways to go engineering wise.

For some reason VA pods seem to put A LOT of ankle implants in....

 

[janV88]

Main problem with TAR is that not enough are done to perfect the implant and the technique. ~6000 are done annually in tha US vs ~700,000 knees. Orthopedists at my hospital are doing ~5-10+ knees and hips per week. Very few if any surgeons out there are doing that many ankles. Without the numbers we can't fine tune technique, we can't figure out which implants do well, and industry doesn't want to invest in R&D without the return.

Plus with TARs so few surgeons are doing them that you are married to that patient forever. If there are any complications or need of revision/salvage then you have to take care of it whereas our knee and hip collegues can just refer the pt to someone else who specializes in revisions.

 

[MarquetteGuy]

I think this depends on your practice setting. Being in an orthopaedic group, I see a lot of arthritic ankles. I perform many TAR's and have great success with them. These are some of my happiest patients, with a very low complication rate. I am very happy with my TARs. I am a promoter of TARs, but when used in the correct patient population only.

 

[dyk343]

I thought the cutoff age was 55 for a TAR...? Meaning, if you are 54 you have to wait a year before you meet the criteria to put one in. Is this a loose rule?

 

[ldsrmdude]

I thought the cutoff age was 55 for a TAR...? Meaning, if you are 54 you have to wait a year before you meet the criteria to put one in. Is this a loose rule?

Very loose for some people. If you listen to some of the guys doing them a lot they'll put them in a patient who is in their 40's or possibly earlier. I looked ahead at the surgery schedule for my residency (even though I already finished last week) and we have a TAR in a patient in their early 40's next month. Not saying it's common but 55 isn't a hard and fast rule by any means.

 

[janV88]

The indications for ankle vs hip/knee implants are totally different. Most TARs are done in pts with post-traumatic arthritis. These pts are younger, more active, trying to work, typically in the most productive years of their lives. Therefore attaining adequate pt satisfaction is much tougher in comparison to the pts who get knee/hip implants. Those pts are a lot older and already have another comorbidity. They are simply looking for pain relief. The primary indication for hip/knee replacement is due to osteoarthritis (primary arthritis). Primary ankle DJD (osteoarthritis) is extremely rare in comparison to knee/hip. Almost 9-fold less than hip/knee arthritis.

Agreed. The typical patient populations that require total joints with ankles vs knees/hips are different. Ankle arthritis is typically post traumatic and require intervention at a younger age.

But knees and hips are still done on younger patients and they face the similar issues ankles do. I saw a patient in ortho clinic who was in his 40's, ex football/basketball player, easy 250lb range. He had a total hip a few months ago. He was doing well and wanted his knee done next. My attending had a thorough discussion with him, and continued to do so at this follow up visit, that his hip is not meant for high impact / activity. He was warned of the likelihood of revision/poly exchange in the future. The patient acknowledged that his days of playing ball were over. He said that the pain was gone but his hip did not feel natural. Most of the hips I've seen thus far have been very low activity, nursing home, old females who sustained femoral neck fractures. It was an interesting conversation to see.

That made me wonder about the young, post traumatic ankle arthritis pt. With fusion they are likely going to have a lifetime of decreased function imposed by the nature of the surgery where as with TAR the decreased activity level is imposed by surgeon recommendations. Also, what about in-situ fusions -> TAR 10-20yrs later.

 

[Podicus]

In the meetings I have been in on, I have heard rumors that the average revision time for TAR's is around ten years. Wouldn't it be redundant to place a TAR in a patient whom is in their 40's?

 

[ldsrmdude]

In the meetings I have been in on, I have heard rumors that the average revision time for TAR's is around ten years. Wouldn't it be redundant to place a TAR in a patient whom is in their 40's?

I guess it depends on what you mean by redundant. I certainly don't have the experience to comment on the average revision time from personal experience. I'm told exchanging the poly spacer on a TAR (which is often what is needed in the revision) is pretty quick and easy, so I wouldn't be too concerned about that. There are definite advantages to total ankles opposed to fusions, such as avoiding adjacent joint arthritis, so I don't think that doing a TAR in a 40-something year old appropriate patient is wrong (or redundant) per se, so long as they understand that they will likely need a poly exchange at some point in the future. But like I said, I'm basing this off conjecture and not experience.

 

[JR2011]

I think this depends on your practice setting. Being in an orthopaedic group, I see a lot of arthritic ankles. I perform many TAR's and have great success with them. These are some of my happiest patients, with a very low complication rate. I am very happy with my TARs. I am a promoter of TARs, but when used in the correct patient population only.

I completely agree. Performing total ankle arthroplasty should be strictly reserved for those who are highly trained in performing this procedure, understanding the indications, dealing with revisions as well as complications, and keeping a consistent volume to stay sharp.

I do not believe that if an ankle fails you need a fusion in every case, nor do I believe there is a strict or loose age limit for TAR. The implants are made to be used and with time will wear out. As such they will require ongoing maintenance and this should be discussed with patients.

Today's implants offer a lot of room for revision surgery with cement. You have to keep a close eye on your implants and don't shy away from revision surgery when its necessary before failure occurs. This last sentence is IMHO after my experience.

Also important is for those who do not wish to perform this procedure to at least understand the technology and embrace it rather than giving false information to patients. I find it very frustrating with my patients tell me that their previous doctor (who does not perform this procedure) says it should never be performed. TAR is a fantastic procedure when applied and performed correctly.

 

[MarquetteGuy]

I completely agree. Performing total ankle arthroplasty should be strictly reserved for those who are highly trained in performing this procedure, understanding the indications, dealing with revisions as well as complications, and keeping a consistent volume to stay sharp.

I do not believe that if an ankle fails you need a fusion in every case, nor do I believe there is a strict or loose age limit for TAR. The implants are made to be used and with time will wear out. As such they will require ongoing maintenance and this should be discussed with patients.

Today's implants offer a lot of room for revision surgery with cement. You have to keep a close eye on your implants and don't shy away from revision surgery when its necessary before failure occurs. This last sentence is IMHO after my experience.

Also important is for those who do not wish to perform this procedure to at least understand the technology and embrace it rather than giving false information to patients. I find it very frustrating with my patients tell me that their previous doctor (who does not perform this procedure) says it should never be performed. TAR is a fantastic procedure when applied and performed correctly.

Completely agree with this post. The same holds true in my practice as well.