Imaging of the foot and ankle should consist of weight-bearing films unless absolutely impossible. Weishaupt D, Schweitzer ME, Alam F, et al: MR imaging of inflammatory diseases of the ankle and foot.
HISTORY/INTRODUCTION/SCOPE OF THE PROBLEM
CHAPTER SYNOPSIS: Ankle arthritis is less common than that of the other major lower limb joints. Most ankle arthritis is related to previous trauma; with the increasing prevalence of obesity, there may be more primary osteoarthritis of the ankle.
CHARACTERIZATION OF ANKLE OSTEOARTHRITIS
This finding suggests that the bony structures of the ankle can resist degeneration better than other joints throughout the body. III Prominent exostosis with or without fragmentation, with secondary formation of spurs on the posterior side of the thallus.
EPIDEMIOLOGY
CAUSES OF ANKLE ARTHRITIS
It is also known that MMP-13 transcription is activated by fibronectin exposure and thus becomes pathological when chondrocytes are exposed to the rest of the joint via matrix damage. Genes responsible for the formation of the collagen matrix are subject to some degree of variability and mutation.
PRIOR TRAUMA IN ANKLE OSTEOARTHRITIS
Limiting the configuration of the ankle creates a stable environment that can protect against the development of arthritis. This can result in structural weakening of the cartilage matrix that can predispose it to further injury.
RHEUMATOID ARTHRITIS
Fractures of the malleoli, plafond and talus can be accompanied by deep degenerative changes in the ankle joint. The mechanics of the ankle are at risk when the bearing surfaces of the joint are misaligned.
MEDICATION INDUCED
The pathogenesis of RA involves a complex autoimmune cell-mediated inflammation and subsequent tissue degeneration. In these patients, ligamentous laxity rather than posterior tibialis tendon dysfunction appears to be the main cause.58 This deformity causes a lateral shift of the talus relative to the tibia and compensatory leg external rotation in gait.
GOUT
SEPTIC ARTHRITIS
PREVENTION
Therefore, several studies have focused their efforts on identifying molecular targets to reduce chondrocyte dysfunction immediately at the time of injury. Taking steps to reduce inflammation as it occurs is important, but efforts should focus on education and prevention.
SUMMARY/CONCLUSION
McGuire MR, Kyle RF, Gustilo RB, et al: Comparative analysis of ankle arthroplasty versus ankle arthrodesis. Bouysset M, Bonvoisin B, Lejeune E, et al: Flattening of rheumatoid arthritis in tarsal arthritis on radiograph.
CONSERVATIVE (NONOPERATIVE) TREATMENT
When there is swelling, limitation of ankle movement or local warmth, the pain is likely due to joint pathology.
MEDICATION
The NSAIDs can cause upper gastrointestinal ulceration, hypertension, peripheral edema, renal failure, and difficulty in adjusting warfarin anticoagulation. When prescribing medications or performing injections, it is important to educate and warn the patient about the potential adverse effects of the drug or procedure, and to have the patient communicate with the surgeon immediately if any problems arise.
PHYSICAL THERAPY AND EXERCISE
Corticosteroids over a long period of time can cause Addisonian adrenal suppression, myopathy, moon facies, and osteopenia, in addition to many of the problems associated with NSAIDs.
IMMOBILIZATION AND BRACING
It is important when prescribing drugs or performing injections to educate and warn the patient about the potential adverse effects of the substance or procedure and for the patient to communicate immediately with the surgeon if problems arise. described for patients undergoing ankle arthrodesis for the same reason) (Fig. 3-2). Such devices may be painful, may reduce overall walking distance due to increased energy demand during walking, or may cause skin irritation/breakdown.
MECHANICAL AIDS TO AMBULATION
Of the available options, the SF-36, the SF-12, the visual analog scale, and the AOS are the only validated patient assessment instruments. These differences in procedure volumes reflect the relative immaturity in the field of ankle arthritis, including the tools used to assess the patient with ankle OA.
ASSESSMENT TOOLS Visual Analog Scale
To administer the SF-36, a patient should be provided with a paper copy of the 36-question survey (Table 4–1). To administer the ankle osteoarthritis scale, the patient should be provided with a paper copy of the questionnaire (Table 4-6).
SURGICAL TECHNIQUE
The visualization of the ankle joint will be greatly improved by the use of a high-pressure inflow. Posterior portals must be created to access the posterior aspect of the ankle joint.
INDICATIONS
Arthroscopic debridement is performed through the standard anteromedial and anterolateral ankle portals. OCL of the talus can occur on the medial or lateral side of the talar dome.
INTRODUCTION
The CORA of a wedge osteotomy is not in the center of the stem but at the top of the wedge.). Theta determines the angle of the cut relative to the transverse plane of the tibia.
OUTCOMES/RESULTS
The fixator is relatively bulky and inconvenient for a patient and introduces additional frustrations (pin tract problems) that do not occur with internal fixation. The fixator also offers the possibility to extend the limbs longer than is possible with internal fixation.
SUMMARY/CONCLUSIONS
Inflammation, synovitis and other pathological conditions, such as rheumatoid arthritis, can lead to destruction of the ankle joint. Custom-made osteochondral allografts are obtained from regional tissue banks using anteroposterior (AP) weight-bearing radiographs of the host and allograft specimen.
INDICATIONS/CONTRAINDICATIONS
Distally, the feet now rest on the tibia, and an appropriately sized blade is placed in the center of the ankle joint. An approximately 3- to 4-mm articular portion of the medial malleolus is also removed.
RESULTS
Meehan et al.7 reported on 11 patients with fresh osteochondral allograft transplantation of the tibiotalar joint. Kitaoka HB, Patzer GL, Ilstrup DM, et al: Survival analysis of Mayo total ankle arthroplasty.
CLASSIFICATION SYSTEM
However, a rabbit study by Karadam et al.5 showed no beneficial effects of joint distraction, although early microscopic change after joint distraction was the only parameter examined. It must be recognized that we do not fully understand the mechanisms by which joint distraction may be beneficial, and therefore the indications for treatment are still being elucidated.
TECHNIQUE
On an AP radiograph of the distal tibia, the frontal plane joint angle (varus, normal or valgus) is measured between the anatomical axis of the tibia and the line parallel to the distal tibial ceiling, defined as the lateral distal tibial angle (LDTA) ). Tibial or ankle deformities may be associated with either cavovarus or planovalgus deformity of the foot.
POSTOPERATIVE CARE, RESTRICTIONS, AND REHABILITATION
Next, the first forefoot wire is placed from the head of the fifth metatarsal bone to engage the fifth, fourth, and third metatarsals, or the fifth and first metatarsals. A second forefoot wire is placed medially to engage the first and second and occasionally the third metatarsal bones.
OUTCOMES
This is started in the hospital and continued during the in-frame period and after frame removal. Assistive devices are used for the first several weeks after removing the frame for comfort with weight bearing allowed.
COMPLICATIONS
The key to a successful fusion is the health of the bone and the position where the tibiotalar joint is located. Both positional deformity of the ankle and poor bone stock are relative contraindications to arthroscopic arthrodesis.
GENERAL CONSIDERATIONS IN SURGICAL TECHNIQUE
The patient must be kept strictly non-weight bearing on the affected extremity for at least 6 weeks while the arthrodesis heals. This should be done with a boot or brace to minimize overloading of the anterior ankle as the patient adjusts his gait.
ARTHROSCOPIC TECHNIQUE
Postoperatively, the surgical incisions are bandaged and the lower leg should be immobilized in a well-padded short-leg cast. This cast should be applied anteriorly with one flap, spread approximately 5 mm, and padding should be placed in this interval and then wrapped with fiberglass in the immediate postoperative period.
OPEN TECHNIQUE
This chapter will provide the reader with a thorough overview of the ankle joint and the etiologies of ankle osteoarthritis. The surgeon's learning curve in ankle replacement is considerably long and flat.
CURRENT KNOWLEDGE
However, many of the complications associated with mobile bearings are not inherent in the design. Finally, critical in the design of an ankle replacement is the size of the prosthesis.
TIBIAL COMPONENT
TALAR DESIGN
Of course, we are limited with the use of metal projections below because the subtalar joint is so close. While some manufacturers will build calcaneal fixation into custom implants, only the INBONE ankle has an off-the-shelf modular stem that can be used to provide good fixation through the subtalar joint to the calcaneus.
POLYETHYLENE COMPONENT
This means that all talar components, regardless of the shape of the talar prosthesis, have additional fixation in addition to their replacement shape. Obviously, this seems to be appropriate only in cases where the subtalar joint is already so arthritic that a combined ankle replacement and subtalar fusion is considered necessary simultaneously or where only a minimal amount of talus remains, such as in revisions of previous TAA, avascular necrosis or severe trauma and when the subtalar joint has previously been fused.
POSTOPERATIVE RESTRICTIONS/
REHABILITATION
SUMMARY/FUTURE CONSIDERATIONS
Assal M, Al-Shaikh R, Reiber BH, et al: Fracture of a polyethylene component in ankle arthroplasty: a case report. The final stability of the ligament is mandatory if the ankle is to function properly after joint insertion.
BIOMECHANICS
This then allows the surgeon to correct any varus, valgus or equine deformity and allows the ankle to extend, thereby identifying the deltoid endpoint. The angular deformity of the ankle must be considered with other adjacent joints, particularly the knee and the foot, and is addressed in Chapter 12.
OPERATIVE TECHNIQUE
Biomechanical aspects of the ankle are extremely important if we want to assess how the ankle deformity has occurred and apply the necessary procedures to correct the deformity. Often there may be severe ankle valgus with an intact deltoid ligament, all secondary to erosion of the talar into the lateral subchondral plate of the ankle joint and into the fibula.
PREOPERATIVE CONSIDERATIONS
If there are skin problems in the area of the lateral aspect of the ankle, stage II and stage III deformities should be treated with extreme caution. If both are unusable, a segment of the tendon can be used as a free graft to reconstruct the lateral collateral structures, achieving lateral stability.
OPERATIVE PROCEDURE VARUS AND VALGUS DEFORMITY
At the end of the procedure, the subtalar joint can be placed anywhere the surgeon desires to provide gentle valgus to the hindfoot. The talonavicular joint fusion can be transferred to the reconstruction.
LONG-TERM PROBLEMS IN TREATING THE VARUS OR VALGUS ANKLE
The closer the location of the angulation, the greater the displacement of the ankle and foot from their functional position directly below the weight bearing line of the foot. The closer the location of the angulation, the greater the displacement of the ankle and foot from their function.
INDICATIONS FOR OSTEOTOMY AND ANGULATORY OSTEOTOMIES
Another little recognized problem is external tibial torsion, which indirectly exacerbates varus ankle problems and can be very disabling.
PLANNING OF A SINGLE-PLANE OSTEOTOMY
In this way, the surgeon can determine the incision plane necessary to correct the deformity (Figure 12–3) (see Chapter 6). This mimics normal anatomy and biomechanics by stressing the stability of the medial knee ligament and the deltoid at the ankle.
RESULTS OF OSTEOTOMIES
A well-separated second fixation point at the lateral hinge was sufficient to provide comfort and stability even with ankle plaster casts. X-rays are not taken until after seven to eight weeks, unless the patient has fallen or there is some other reason to think there may be a problem.
FUTURE CONSIDERATIONS
The heel must be in slight valgus with adequate tension in the deltoid ligament to achieve good balance. The valgus foot needs restoration of alignment in the rear foot and in the medial column.
CLASSIFICATION
The medial column of the foot (including the talonavicular, naviculocuneiform, and metatatarsocuneiform joints) must be sufficiently stable to support the ankle. The most reliable technique is to restore the medial column of the foot and to regain appropriate tension in the deltoid.
VARUS ANKLE
If using the Agility ankle implant, the talar component obliquity must be considered. A groove cut into the talus for insertion of the talar component runs from anterolateral to posteromedial.
POSTOPERATIVE CARE
Wynn AH, Wilde AH: Long-term follow-up of the Conaxial (Beck-Steffee) total ankle arthroplasty. Greisberg J, Sangerozan B: Deformity and degeneration in the smaller joints of the adult acquired flatfoot.
SURGICAL TECHNIQUES
If the patient has suffered a previous fracture of the tibia with valgus deformity (or if they have congenital genu valgum), extension of the hip–. Note the position of the endobuttons in the sagittal plane, anterior to the fibula and trans-talar (E).
SUMMARY
It is common for the fibula to scallop around the lateral aspect of the tibial component. FIGURE 16–8. With nonunion of the syndesmosis, bulging lyses around the fibula are a common and concerning finding.
OUTCOMES/RESULTS FOR TECHNIQUE(S)
An adequate autologous and, if necessary, allograft is packed behind the anterolateral corner of the tibial component. Periprosthetic fractures can be classified by the time of fracture (intraoperative or postoperative) or by the location of the fracture.
REVIEW
We discuss them in terms of both the time at which the fracture occurs (intraoperative or postoperative) and the location of the fractures. If fractures are not identified at the time of surgery, they should be carefully sought at the time of the first postoperative visit.
DISCUSSION
Most reports in the literature suggest that malleolar fractures not associated with varus or valgus alignment of the implanted ankle are benign complications and do not affect the overall outcome of the ankle replacement. Late fractures may be due to subsidence or loosening of the components.10 If this is the case, the underlying cause of the fracture should be addressed.
TREATMENT OF TOTAL ANKLE ARTHROSCOPY PERIPROSTHETIC
Vertical steep fractures of the medial malleolus should be covered with an anti-slip plate (see Fig. 17–1), especially if the medial malleolus has not been partially replaced, as in the Agility TAA. It's never easier to repair a fracture than on your first trip to the operating room.
SUMMARY AND RECOMMENDATIONS
Schuberth JM, Patel S, Zarutsky E: Perioperative complications of the Agility total ankle replacement in 50 initial, consecutive cases. Total ankle arthroplasty (TAA) continues to emerge and refine itself as a viable treatment for end-stage ankle arthritis.
INCIDENCE AND PREDISPOSING FACTORS
Therefore, to reduce bacterial contamination in the environment, the number of staff in the operating room and movement in and out of the room should be limited. This should be avoided as it can put pressure on the front part of the ankle, causing skin damage.
DIAGNOSIS
A normal ankle aspirate with a white blood cell count of 50,000 cells/ml and 75% polymorphonuclear neutrophils is considered diagnostic of an infection.63 These values are too high and have no value in infected total joints.60 In a study of revision total knee arthroplasties, an aspirate with 2500 cells/ml and 60%. A specificity of 98% is obtained using the criteria of more than 10 polymorphonuclear leukocytes per high power field in more than 5 high power fields.
MANAGEMENT
Treatment should be thorough irrigation and debridement of the joint with retention of the prosthesis. Current data have shown that the use of antibiotic-impregnated cement spacers has improved the results of the treatment of infection associated with total joint arthroplasty.
ACKNOWLEDGMENTS
Fitzgerald RH Jr, Nolan DR, Ilstrup DM, et al.: Deep wound sepsis after total hip arthroplasty. Durbhakula SM, Czajka J, Fuchs MD, et al: Spacer endoprosthesis for the treatment of infected total hip arthroplasty.
DIAGNOSIS Clinical
A comprehensive description of the radiographic assessment of total ankle arthroplasty from the musculoskeletal imaging literature. An excellent and comprehensive review of the complications associated with total ankle arthroplasty, including bone loss.
PHYSICAL EXAMINATION
This chapter describes my treatment of the compromised or outright failed total ankle replacement, developed over a period of 15 years. If the prosthesis is unevenly adjusted, varus or valgus of the hindfoot will be clinically apparent, with the patient complaining of uneven shoe wear and loss of balance.
TREATMENT OPTIONS
FIGURE 20–4. Impact of the cut surface of the talus on the tibial component as a result of settling of the talus component. Finally, the surgeon must always be aware of the possibility of a FIGURE 20–8. Syndesmotic nonunion.
RADIOGRAPHS AND DEFINITIONS OF LOOSENING
Infection should always be expected in secondary procedures, and tissue samples and swabs should always be taken for bacteriological cultures.
REVISION
PREOPERATIVE CLINICAL ASSESSMENT
Looking at the foot with the patient standing will tell if it is aligned or in varus/valgus. If there is very little or no motion in a painfully replaced joint, a revision may not work and a conversion to a fusion should be considered.
RADIOGRAPHIC PREOPERATIVE ASSESSMENT
With a normal tibialis posterior tendon, the patient can perform a heel raise test and the heel is inverted as the patient steps up with the toes. Painful movements in a TAR suggest that the cause of the pain has a mechanical reason and can be corrected with surgery.
MALPOSITION
Muscle testing is mandatory and will tell if imbalance is due to weak or non-existent muscle function (ie mainly the tibialis posterior or peroneus brevis muscles for inversion and eversion respectively). Painful movements in other joints, such as the subtalar joints, suggest that the cause of the pain should be sought in those joints.
INFECTION PROBLEMS IN DECISION-MAKING
Further examination will show swelling, erythema, or warmth around the malleoli or around the entire ankle joint. The function of the peroneus is also valued in heel elevation and if the function is poor, varus deformity can occur.
SURGERY (REVISION)
CLOSURE OF THE WOUND AND POSTOPERATIVE TREATMENT
A revision as such may resist weight-bearing, whereas major osteotomies or subtalar fusions would usually benefit from a 6-week non-weight-bearing period. Because multiple incisions and prolonged operative time will increase the risk of infection, it is the surgeon's choice whether to perform the necessary additional surgery preoperatively, intraoperatively, or postoperatively.
FUSION
Some surgeons prefer to perform alignment and stabilization procedures such as heel osteotomy, subtalar fusion, or collateral ligament reinforcement 2 to 3 months before the actual revision procedure to reduce the risk of infection.
REOPERATIONS
Peroneal muscle function can be difficult to diagnose when the ankle is stiff. The distal portion of the flexor hallucis longus tendon may attach to the flexor digitorum longus tendon.
INDICATION/CONTRAINDICATIONS
CLASSIFICATION OF MODES OF FAILURE OF TOTAL ANKLE REPLACEMENTS
Transfibular lateral or posterolateral approach with blade plate fixation Type 4 Any mode of failure including subtalar joint Intramuscular rod fixation with component removal through an. The fibula is removed or turned away to allow access to the components.
