Are you ready to unravel the mysteries of ankle arthritis? What if you could gain a comprehensive understanding of this often misunderstood condition from one of the field's top experts? Dr Chad W. Rappaport, the Chief of the Foot & Ankle Service at Kayal Orthopaedic Center, is here to guide you through the labyrinth of ankle health. Learn how this unique three-bone joint functions and why it's less likely to succumb to arthritis than the hip or knee. You'll also uncover the most common causes and symptoms of ankle arthritis, providing you with the knowledge to manage this painful condition.
If you've ever wondered about the wizardry behind modern medical treatments for ankle arthritis, you're in for a treat. From ankle arthroscopy, with its impressive capability to alleviate pain, to the gold standard of end-stage ankle arthritis treatment - ankle arthrodesis, or fusion, Dr. Rappaport reveals all. You'll be fascinated as we dissect the role of screws and rods in post-operative healing and examine the technique of arthroscopic lavage for maintaining joint health.
The grand finale of our journey is a deep dive into the latest advancements in total ankle replacement surgery. Picture patient-specific implants, designed with the precision of preoperative planning, and the remarkable benefits of press-fit implants. You'll hear how 3D-printing technology is catapulting the field into the future and even glimpse how these innovations could transform revision surgeries. This enlightening conversation with Dr. Rappaport is a treasure trove of information for anyone seeking to understand the complexities of ankle arthritis and the cutting-edge therapies available. Tune in and unlock a wealth of knowledge.
Are you ready to unravel the mysteries of ankle arthritis? What if you could gain a comprehensive understanding of this often misunderstood condition from one of the field's top experts? Dr Chad W. Rappaport, the Chief of the Foot & Ankle Service at Kayal Orthopaedic Center, is here to guide you through the labyrinth of ankle health. Learn how this unique three-bone joint functions and why it's less likely to succumb to arthritis than the hip or knee. You'll also uncover the most common causes and symptoms of ankle arthritis, providing you with the knowledge to manage this painful condition.
If you've ever wondered about the wizardry behind modern medical treatments for ankle arthritis, you're in for a treat. From ankle arthroscopy, with its impressive capability to alleviate pain, to the gold standard of end-stage ankle arthritis treatment - ankle arthrodesis, or fusion, Dr. Rappaport reveals all. You'll be fascinated as we dissect the role of screws and rods in post-operative healing and examine the technique of arthroscopic lavage for maintaining joint health.
The grand finale of our journey is a deep dive into the latest advancements in total ankle replacement surgery. Picture patient-specific implants, designed with the precision of preoperative planning, and the remarkable benefits of press-fit implants. You'll hear how 3D-printing technology is catapulting the field into the future and even glimpse how these innovations could transform revision surgeries. This enlightening conversation with Dr. Rappaport is a treasure trove of information for anyone seeking to understand the complexities of ankle arthritis and the cutting-edge therapies available. Tune in and unlock a wealth of knowledge.
Hello and welcome to another edition of the Kale Ortho podcast. Today is June 29th 2023, and we're very fortunate to have with us today Dr Chad Rappaport, the chief of the Foot and Ankle Service. He has been with us for about 13 years now at the Kale Orthopedic Center. We're so privileged to have him with us today, as he is an expert in the field of foot and ankle surgery, And today's topic is going to be current concepts in the management of ankle arthritis. Welcome to the podcast, Dr Rappaport. Thank you, Dr Kale. It's such a pleasure to have you with us today.
Speaker 2:Thanks for having me.
Speaker 1:Yeah, it's our pleasure. So why don't you first start out and tell us a little bit about yourself, Dr Rappaport?
Speaker 2:My name is Chad Rappaport. I, as Dr Kale alluded, have been with the group for about 13 years now. Originally from Northern New Jersey, i was actually born in Middletown, new York, but my family moved down here into Northern New Jersey when I was three and lived here my entire life, with the exclusion, obviously, of college. I went to college in Arizona at Arizona State for a couple of years and finished up my undergraduate studies at University of Bridgeport in Connecticut before going to Padaetry School at Des Moines University Medical Center. After spending four years in Des Moines, i came back to New Jersey to complete a rigorous surgical three-year residency program in podiatric surgery, before leaving New Jersey and joining an orthopedic group in Pennsylvania for a few years before coming back home to New Jersey.
Speaker 1:Great, great Well. we've been certainly blessed to have you for the last 13 years or so and you've taken care of thousands and thousands of patients in Northern New Jersey who have really had fantastic results with your care. Thank you for that. Thank you. This topic, as we alluded to before, is the current management of ankle arthritis. Before we jump right into that, why don't we just explain for our viewing audience what exactly is ankle arthritis?
Speaker 2:Ankle arthritis is a source of pain that, in the ankle, can affect people in their early 20s to 30s, to their 70s and 80s. It, like arthritis in the hip and the knee, can cause the bilitating decrease of function and pain and really affect one's quality of life. In the ankle, the most common form of arthritis unlike the hip and the knee, wherein, of course, osteoarthritis or wear and tear arthritis or old-timers arthritis, whatever you want to deem it is most common In the ankle, the form of arthritis that we see most frequently is post-traumatic arthritis, which is arthritis that occurs as a result of a trauma or an insult to the ankle joint, which is fairly resilient with regards to the development of osteoarthritis, but very sensitive to the changes that occur after an injury.
Speaker 1:For instance, a very common injury would be an ankle fracture, right? Yes, Such a ubiquitous problem. If that ankle fracture is not properly managed, patients can develop this diagnosis of what we call post-traumatic arthritis. Right, That's correct. It's more common than the hip and knee, where the most common forms of arthritis in the hip and knee are degenerative wear and tear osteoarthritis. What Dr Rappaport is suggesting is that in the ankle the most common cause is post-traumatic arthritis. Is it as common to get arthritis in the ankle as it is in the hip and knee and shoulder, for instance?
Speaker 2:No, it's not as common again, not to be redundant, but it's because of the etiology. The most common etiology of arthritis in the ankle is certainly post-traumatic arthritis. Many individuals most individuals in fact, go through their entire lives without developing arthritis to any significant degree in their ankle, wherein most of us, if we leave an act of life, will develop some degree of arthritis from wear and tear in age and our knee and our hip. So it's much more uncommon in the ankle than it is.
Speaker 1:It's somewhat counterintuitive, isn't it? Such a small joint, relatively speaking, and our entire body weight goes through that ankle. Why do you think it is so resistant to arthritis?
Speaker 2:Yeah, it is counterintuitive. I tell patients all the time as common, as ubiquitous as osteoarthritis is and arthritis is in the knee and hip, it's really quite uncommon in the ankle joint. You would think, for all the reasons that you've said, that it would be at least as common, if not more common. But fortunately for us the composition of the cartilaginic ankle is different to kinematics and the way the joint is loaded is different in the ankle And fortunately it spares most of us from developing arthritis during our lifetime Interesting.
Speaker 1:So, before we get any further, why don't we just clarify for our viewing audience exactly what part of the body we're talking about, what bones actually make up the ankle joint per se?
Speaker 2:So the ankle joint is comprised of three bones. The two stationary bones, as I like to refer to them, are contributed to the ankle joint from the leg, and those are your tibia, or your shin bone, and the fibula, which is the skinnier bone that lies within the outside part of your leg. The dynamic bone that's contributed to the ankle joint is called the talus, and I'd like to explain to patients that. Imagine the ankle is a garage. So the stationary garage is comprised by the tibia and the fibula. The car that moves in and out of the garage and has to be able to move in and out of the garage thousands of times per day, perfectly without rubbing up against either sidewall, is in fact the talus. So it's a three bone joint, two contributed by the leg, one contributed to by the foot.
Speaker 1:I love that analogy. I've never thought of that before, but yeah, that's a perfect analogy, i'm going to use that one. So arthritis occurs when there's inflammation and subsequently destruction in the joint, and that can occur from a myriad of different reasons, as we have alluded to. In this particular case, post-traumatic arthritis is the number one source, but we've also talked about degenerative wear and tear arthritis, which is the most common in other parts of the body. What other types of arthritis can develop in the ankle joint?
Speaker 2:So probably the second most common type of arthritis that we see in the ankle that can cause dysfunction and pain would be an inflammatory related arthritis like rheumatoid arthritis. So rheumatoid arthritis is fairly common when we're talking specifically about ankle arthritis compared to osteoarthritis.
Speaker 1:Yeah, It falls into the category of what we call an autoimmune inflammatory arthritis right where the body's immune system can attack itself and destroy the lining and the cartilage and destroy the joint ultimately as well. You can also get septic arthritis right, where sometimes people can get an infection in the joint which ultimately can destroy the joint and lead to the need for some type of surgery for that type of arthritis. What are some of the most common symptoms that patients will experience when they're experiencing ankle arthritis, and how would they even know Patients?
Speaker 2:will typically start to develop, obviously, pain, chronic swelling that they can't get to go away with icing and non-steroidal anti-inflammatories. They'll start to experience, in many instances, functional deficits such as stiffness or lack of range of motion, in addition to pain, And many patients will start to develop over time, mechanical symptoms such as catching, clicking, locking, popping, things like that.
Speaker 1:And probably ultimately deformity. Right when it becomes very severe, they'll ultimately appreciate significant deformities in the ankle as well, but it can be a very, very debilitating condition, right? Just so patients understand that the first line of care of ankle arthritis is not surgery. What are some of the things we can do non-operatively, as you alluded?
Speaker 2:to before. Most patients who develop arthritis can be managed quite successfully non-operatively. Non-operatively, non-invasively we treat the arthritis much like we would in the knee and the hip. Oral anti-inflammatories can be very effective, injectable steroids, certain types of braces, physiotherapy, arthroscopy although it has a limited role, can help, and the ever-flourishing subspecialty of orthobiologic. So the use of platelet-rich plasma, bone marrow aspect concentrate or stem cells can be effective.
Speaker 1:Yeah, and how about functional bracing?
Speaker 2:Is that helpful? Yeah, functional bracing can be helpful. It's typically more successful in patients that are a little bit older and more sedentary and don't have the expectations that maybe a 35 or 40-year-old does. And that's really where the difficult issues come into play with ankle arthritis, with it being most often as a result of post-traumatic arthritis, because the trauma does not discern or differentiate or discriminate with regards to age. So there are many patients who suffer a severe ankle injury in their teens or 20s or 30s, who are trying to live with debilitating arthritis at really a young age, at 35 or 40. And it's difficult for those patients, given the period of life that they're in and what most of their contemporaries are doing, to treat them with bracing. But it is an option for usually more sedentary, older population.
Speaker 1:Right Well, with arthritis. We talked about arthritis in the past as inflammation of the joint and inflammation often associated with redness, warmth, pain and swelling. So it's clear why anti-inflammatories would work. Motrin, advil, aleve, ibuprofen help with that inflammation And by addressing the inflammation you're addressing the redness, warmth, swelling and pain. Cortisone injections would help in that regard as well. For the same reasons Physical therapy why is that helpful?
Speaker 2:Physical therapy can help keep the joint mobile and as functional as possible. Some of the modalities that patients can receive while they're in therapy, such as electrical stimulation, ultrasound, things like that, certainly have some palliative merit And patients report that they feel better when they're at therapy or for some hours or a few days afterwards. But primarily, physical therapy for most of my patients plays more of a role in maintaining what little functionality they may have left and stabilizing the structures around the ankle to ensure as best as we can that the joint doesn't continue to deteriorate.
Speaker 1:Yeah, i would think that strengthening the muscles around the joint, the dynamic stabilizers, will help provide some of the stability that they've lost from the arthritis right, and I assume that bracing works for the same reasons.
Speaker 2:That's right. So if we can control some of the motion around a joint that's very painful when it moves, there'll be some palliative benefit and pain relief to that. But these braces and they're getting better as time goes on but some of them can be pretty bulky and hard to use with conventional shoes And so again, in my opinion, in most of my patient population it's meant for older, more sedentary patients.
Speaker 1:Let's now hone in and focus our attention for the rest of the podcast on the surgical management of ankle arthritis, because that's really your area of expertise. So let's begin educating our viewing audience about the surgical treatment alternatives for arthritis. And why don't we start from least invasive to probably the most invasive? And, just like anything else, you tend to get the most bang for the buck with the more invasive procedures, but clearly those are associated with a higher risk. Typically the less invasive procedures low risk, lower yield. More invasive procedures slightly higher risk, but pretty much almost guarantee that you're going to fix the problem. So, on that note, why don't you just discuss the surgical treatment alternatives?
Speaker 2:Okay, thank you. So the surgical alternatives in terms of least invasive to most invasive, would start out with ankle arthroscopy. Ankle arthroscopy is a minimally invasive procedure that usually takes less than 35 or 45 minutes to perform. It's almost always performed as an outpatient in a surgical center setting, and the goal of the arthroscopy is essentially to clean out the joint.
Speaker 2:Many of these patients, most of these patients, have significant amounts of intraarticular scarring or scar tissue inside of the joint.
Speaker 2:They may have, as a result of their initial trauma, loose bodies in the form of bone or cartilage that are floating around in the joint. That can cause pain and mechanical symptoms, as I mentioned before, like catching, walking, locking, popping, and so the arthroscopy, which is done through two very, very small incisions in the front part of the ankle, can be utilized not only to diagnose the severity of the underlying arthritis, but it can help quite a bit in terms of cleaning out the joint So that, post arthroscopy, the joint may, and the patient may, get better yield from some of the other nonoperative measures that we discussed earlier, like cortisone injections. If a patient has a tremendous amount of loose bodies of scar tissue, of what we call impingement bands in the ankle, noninvasive measures such as intraarticular cortisone injections or injections into the joint may have limited yield or improvement and may not last very much. If those things are eliminated from inside of the joint, the patient is much more likely to have greater relief from an injection and it's likely to last longer.
Speaker 1:Over the years we've treated many patients that had arthritis in the ankle right And the arthritis wasn't bad enough to warrant a very invasive procedure. But I know over the years you've offered them this minimally invasive arthroscopic procedure. Through two little puncture sites cleaned out the ankle joint. Very often, like all other joints, whenever there's arthritis It's often associated with some loose bodies, some wear and tear and floating debris inside the joint, a lot of scar tissue, and very often you've very successfully treated them with what we call an arthroscopic lavage and debris month removing loose bodies, cleaning up the arthritis as much as you can. And certainly while you're in there, i know you've offered them cortisone injections under arthroscopic evaluation and often some other biological therapies as well Regenerative medicine therapies like bone marrow aspirate and platelet-rich plasma injection therapy at the time of arthroscopy And I know that's worked very well for a lot of patients at least to buy them some time.
Speaker 1:Certainly in the younger patient where you want to try to buy some time before doing an invasive procedure, sometimes there's a very good treatment alternative. I know also over the years we've seen patients where they've had a mechanical block to motion because of small little spurs that have developed around the joint. So when that hinge joint is trying to go through range of motion, the two spurs are hitting one another and causing that mechanical block to range of motion. And you've showed me on numerous occasions where you sculpt these patients and excise those spurs arthroscopically and restore patients' range of motion. I thought that was fantastic And I just know that that's a very viable treatment alternative for patients that don't have arthritis severe enough to warrant the other procedures that Dr Rapaport is about to discuss. So next, in line after arthroscopic lavage and debris month, what would be the next treatment alternative for a patient with arthritis? What has been the standard of care for the definitive treatment of ankle arthritis for many, many years?
Speaker 2:The gold standard, if you will, for end stage arthritis of the ankle, irrespective of its etiology whether it's inflammatory, rheumatoid arthritis or osteoarthritis or post-traumatic arthritis has been ankle arthrodesis or ankle fusion, which entails essentially surgically binding the three bones that I mentioned prior together to eliminate oil motion inside of the joint, and for decades it's been a workhorse. It does a very, very good job of eliminating pain, but it obviously comes at a fairly significant functional price. You can't move your ankle up and down anymore, but it's still today, in some patients, the best option for a number of different reasons that we'll probably get into a little bit later, but for years and years that has been the gold standard.
Speaker 1:And how does assertion perform in ankle fusion?
Speaker 2:I know there's different techniques, so basically, the techniques are divided into open or arthroscopic techniques. Most ankle fusions are performed in an open manner, where an actual incision is made. The joint is prepared by removing any scar tissue and loose, morselized bone and cartilage and any remaining cartilage that remains on the articular part of the tibium and the pailus, and then, of course, we put the joint into a neutral position that's as functional as we possibly can get it for that patient And then, with the use of rods or screws or more in more recent history plates that we put on top of the joint, the joint is essentially squeezed together and fused over the course of eight to 12 weeks after the surgery. In some instances, however, we can perform an arthroscopically assisted ankle fusion, which is an ankle fusion that is done through the two small incisions that we spoke about earlier that you would use for any prototypical ankle arthroscopy.
Speaker 2:But in this particular situation the arthroscopy is used to prepare the joint, as I just described, in a similar manner that it's done in an open fashion, but the fixation, meaning the tools or the instruments that we use to fuse the joints, are inserted what we call percutaneously.
Speaker 2:So once the joint is prepared through these two small incisions on the front part of the joint. Other small incisions are made about the ankle and lower leg to introduce screws that are placed across the joint, essentially compressing all those bones together, and that's a good option for patients who might have little to no deformity. Patients who have significant deformity require an open procedure so that deformity can be corrected before we actually apply the fixation pins or screws or plates. But arthroscopic assisted ankle fusion can also be a good choice, and perhaps the only choice, in patients who have severely compromised tissues on the front part of their lower leg or ankle, wherein you'd be very concerned about making an incision for fear of wound issues and infection and things like that. So generally speaking, it's done through an open manner or technique, but there's some indications and instances where we would perform this arthroscopically.
Speaker 1:So why does ankle fusion work for ankle arthritis?
Speaker 2:So ankle fusion works because it eliminates all motion in the joint And when a pain, when a arthritic, painful joint moves, it causes pain. So if we stop the joint from being able to move, it eliminates the pain. You mentioned earlier about the ability for arthroscopy to remove spurs and that can limit motion around the joint. And I think, organically or naturally, as a joint becomes more and more arthritic, particularly around the ankle, it's very common to develop spurs around the ankle And it's really your body's attempt at trying to fuse itself. It realizes that the placement and growth of these spurs minimizes the movement inside of the joint. It doesn't do a very effective job in the long run of doing that, but it underscores the region or the rationale why we fuse joints. We're carrying out much more efficaciously what the body will try and do over time, which is develop spurs around the joint to try and minimize motion. So we eliminate not minimize, eliminate motion with a fusion And that's how it eliminates pain.
Speaker 1:So aren't these patients upset now that you've eliminated the motion of the joint?
Speaker 2:Well, most of these patients don't have very much motion left anyways, and the motion that they do have causes terrible pain. So the two or three to five degrees, let's say, for example, of additional loss in terms of range of motion, when it's coupled with near complete relief of their pain, they're very willing to make that trade off.
Speaker 1:Exactly my point. So, dr Rappaport, you explained to us that ankle fusion is a viable option in the treatment of ankle arthritis and has been, up till today, considered the gold standard of care for the treatment of ankle arthritis. Can you help our viewing audience understand what exactly you mean by performing an ankle fusion with this model?
Speaker 2:Sure This is a model of a lower extremity ankle and foot. This is the ankle joint minus the smaller bone that runs down the outer aspect of the leg, and you can see the articulation of the joint between the tibia and the tail. Again, the tibia is a stationary bone that comprises one third of the ankle joint. It doesn't move. The tail is, which is contributed, as you can see, to the ankle joint by the foot, is really the dynamic bone in the joint. That's the one that I analogize to being the car that moves in and out of the garage.
Speaker 2:So when we fuse an ankle joint, whether we do it open or arthroscopically, essentially what we're doing, as you can see in this model, is prohibiting any motion from occurring in this very painful, inflamed, dysfunctional joint, and we can do that by applying a plate over the top of the ankle joint that essentially squeezes these bones together and causes them to unite into one large bony mass, in the excluding the ankle joint. There are instances wherein the joint one floor below the ankle joint to the subtailer joint, has also become arthritic because of changes in the ankle joint above it, and in that instance we might perform something called the tibiotelo calcaneal fusion, which is usually done through the application of a rod that's delivered from the bottom of the foot, past the subtailer joint, through the ankle joint and up into the lower aspect of the tibia. And this is a surgery that's done for patients who not only have debilitating and painful arthritis of the ankle joint, but who also have similar changes within the joint. That's one floor below the ankle joint, which is the subtailer joint.
Speaker 1:So although you're fusing the ankle joint for an ankle fusion, there's still motion right in the foot below the fusion, in the subtailer joint. Typically, the motion is in what plane?
Speaker 2:So the motion in the subtailer joint is variable, but it's the joint essentially that allows the foot to become a mobile adapter to the terrain that's underneath it. So I like to explain to patients when you're walking on the sand at the beach, it's really the subtailer joint that allows your foot to adapt to all the undulations within the sand underneath it. Or, for example, if you're walking sideways up a hill, it's really the subtailer joint that allows the foot to go into varying degrees of what we call supination or pronation. That again allows the foot to adapt to the terrain that's underneath it.
Speaker 1:So that helps to explain why ankle fusions are well tolerated. That's correct.
Speaker 2:Yeah, the fusion of the ankle joint does not eliminate, unless we've done a tibiotailor cacanial fusion, like I explained earlier. it does not take away from the motion and functionality of the foot.
Speaker 1:Right. So what percent of times when you would do an ankle fusion do you tend to incorporate the subtailer joint?
Speaker 2:A minimum, probably less than 20% of the time Great.
Speaker 1:The other thing that I think is important to mention with respect to performing an ankle fusion is, as you can see from this model, the fusion allows correction of deformity in all planes. So, like we discussed earlier, when there is ankle arthritis, there's often deformity associated with that ankle arthritis. It's either an ankle that has fallen into what we call varus or valgus, or even in this plane, in the sagittal plane, there can also be deformity as well. When Dr Rappaport performs an ankle fusion, he is able to correct the deformity in all planes. He gets the ankle well aligned in all planes and he will typically fuse the ankle in this position. What we call plantigrate, and you can see this is a functional foot. This foot and ankle is in a very good position and should be able to participate in most activities of daily living. So, in your experience, dr Rappaport, how have these patients that have undergone ankle fusion done traditionally?
Speaker 2:So they do very well. Patients are quite pleased the majority of times with their ankle fusion. As I said, the ankle fusion does a great job of eliminating pain and it's typically employed in a patient who has already experienced quite a bit of functional loss in terms of their ankle. One of the benefits, to this day, of performing an ankle replacement is that it is very, very durable. So even when a patient may be a potential candidate for a more functional operative treatment for ankle arthritis, if they have a certain body habitus, if they enjoy certain activities or their vacation is very rough on their ankle, these are patients that may be better off with an ankle fusion because of the durability of the procedure.
Speaker 1:Hmm, i see, it seems like this surgical technique of ankle fusion checks off all the boxes that we're looking to check off with respect to managing ankle arthritis right. It helps to manage pain, it corrects deformity, it provides stability, but are there any boxes that it fails to check?
Speaker 2:Well, the biggest box, of course, would be the functional loss of your ankle joint, which in some patients is absolutely unacceptable, And in those patients we have to have a long, hard discussion about what the best option is for them.
Speaker 1:Exactly So what other treatment alternatives do you offer your patients that are looking to check off that fourth box too, that are just absolutely against fusing their ankle, whether because of age or because of function or quality of life or potentially certain restrictions that the ankle fusion may impose upon them? Do you offer any treatment alternatives in your practice that maybe other foot and ankle surgeons do not?
Speaker 2:Yes, As you know, at the Kaila Orthopedic Center we always strive to be on the cutting edge of technology And in the world of ankle arthritis, that is total ankle replacement, which I'm proud to offer most of my patients who have debilitating ankle arthritis. You know, five or 10 years ago probably closer to 10 years ago, 70% of my patients would be treated with ankle fusion And 30% would be treated with replacement. And because of the rapid improvements in technology and instrumentation and preoperative planning, there's now the exact opposite, wherein the majority of patients I treat with total ankle replacement.
Speaker 1:That's so exciting. I remember when I was in training almost 30 years ago, ankle replacements for poo pooed very much like even shoulder replacements were really just starting to become a relatively successful long term. But clearly technology has evolved over the last 30 years tremendously. I know that ankle replacements started in the 70s and have gone through numerous iterations over the past 40, 50 years. I believe in our fourth generation of ankle replacements right now. Right, What are some of those technological advancements that have made ankle replacement surgery much more successful now?
Speaker 2:Starting from the instrumentation to the preoperative planning, to using advances in cross sectional imaging all have improved the outcomes of total ankle replacement. You know, total ankle replacement first came about in the 70s and it really had sobering results and was largely abandoned for 20 or 30 years or so before the quote unquote second generation of implants came into play in the 80s and 90s. We are now on our fourth generation of implants and with each turn the implants have become more reliable, easier to use and have increasing amounts of longevity, which has been very exciting to see.
Speaker 1:Yeah, I mean, obviously, there's a couple of factors that come into success of total joint replacement surgery in general. extrapolating from the hip and knee replacement literature, it's, i'm sure, the same in the area of ankle replacement surgery. Number one alignment. right Alignment of the implants has to be perfect in order to properly load the construct. Number two fixation The implants have to be adequately fixed to bone, whether by cement or in a press fit manner. And then, thirdly, and probably equally as important, is the concept that ankle replacement surgery, very much like knee replacement and hip replacement surgery, is a soft tissue operation right Balancing the soft tissues to make sure that the tension on the ligament surrounding the joints is isometric throughout the arc of motion so that implants are not improperly loaded. Would you agree with all those concepts?
Speaker 2:Yes, absolutely, and I think what has made total ankle replacement most successful, which contributed most to the improvements in our success rates, have been the understanding that the formity has on the ankle joint, both above the ankle joint and below the ankle joint, which was, i think, poorly understood to a large degree in years past.
Speaker 2:In 2023, we know that you cannot expect to implant a ankle prosthesis and have it be successful and have it last long if there's deformity either above or below the ankle, in the lower leg or in the foot, and I think that's one of the things that makes total ankle replacement unique when compared to total knee and total hip replacement is because of the underlying etiology or clause, which is trauma. There is very frequently deformity within the lower leg, above the ankle. That needs to be aligned either at the same time or many times before the ankle replacement. And even more common is deformity within the foot, and that also requires sometimes a staged approach where we address the malignment in the foot And then, once that heals come back a few months later, to do the ankle replacement. We now know without any shadow of a doubt in 2023, that if you put an ankle replacement on top of a foot, that's not mutually aligned, it's going to fail prematurely.
Speaker 1:Interesting. So that's important for patients to know, because they then have two options Either proceed with a fusion or you have to correct the deformity above or below the ankle joint first, or at least very shortly after the ankle replacement, to make sure that that ankle is properly loaded during that patient's lifetime. Otherwise it will lead to premature failure.
Speaker 2:That's correct. Some patients have mild amounts of deformity, either above or below the ankle joint, which we can correct at the same time that we're doing their ankle replacements. Other patients have deformities which really require a staged approach, where the deformity either above or, more commonly, below the ankle is addressed first And then we come back a few months later and perform the ankle replacement.
Speaker 1:How has cross-sectional imaging impacted your ability to do ankle replacements well, either by utilizing high-resolution cross-sectional MRI or CAT scan imaging.
Speaker 2:Yeah, it's made a tremendous difference in the outcomes and patient-reported outcomes in total ankle replacement. Currently there are several systems on the market that use cross-sectional imaging to help in preoperative planning and what we call patient-specific instrumentation. So, for example, the system that I prefer uses a CT scan of the knee and of the ankle. That information from those CT scans are analyzed by engineers who essentially establish a preliminary prosthesis And, by way of a software program that we share, they will send that prototype to me and I will, in the comfort of my own home, under no stress or duress, essentially perform a mock ankle replacement on the computer And I may change the size of the implant, I may change the alignment of the implant slightly and I send it back to the engineers who make those changes for me. And then they'll send back the new quote-unquote design prosthesis And, once again in the comfort of my own home, i play with it using the software program until I get to a point where I'm very happy with the size, the rotation, the alignment. And then the company will actually manufacture these patient-specific instrument guides which allow the surgeon at the time of the surgery to perform the surgery without really having to make any difficult decisions interoperatively For the advent of patient-specific instrumentation. While the patient was under anesthesia, while they had a tourniquet around their leg, the joint was approached and all these difficult questions began to be addressed one by one. What size do we want the tibial component? What size do we want the tailor component? What size do we want the plastic polyethylene splacer in between them? Do we want to rotate it two degrees this way or three degrees that way? And it could be very, very stressful to do interoperatively again while the patient's under anesthesia, while you're trying to work against time. With regards to the tourniquet, the cross-sectional imaging and patient-specific instrumentation has really made the the procedure itself fairly straightforward. So, for example, at the time of the surgery, the manufacturer will have sent to the hospital these patient-specific instruments.
Speaker 2:This is a carbon copy, prototype of a patient whom I've already performed a procedure on of their distal tibia, which is this part of the lower leg here that articulates or forms part of the ankle joint, and along with this they will manufacture this cutting jig. And this cutting jig, as you can see, fits perfectly on the front part of this tibia. It will not fit on anyone else in the entire world's tibia like it fits on this tibia. So, as you can see from the side or the sagittal view, it's an absolute, exact duplicate of this patient's distal tibia And it will not move out of place. But if you move it one millimeter in any direction, it will not slide into proper position. But once if you can hear that snap once it finds its sweet spot, it will not move and it will again, will not fit on anybody else's tibia.
Speaker 2:And so, from this point forward, this is pinned with some pins onto the front part of the patient's tibia. This slides off and a cutting jig slides on those pins that preliminarily held this in place And that guide has cutting slots in it and that's where we start to make our initial cuts. And so we can get to that part of the procedure in 30 or 45 minutes, wherein you wouldn't make your initial cuts with the old technique, perhaps an hour and a half or two hours into the surgery, because you're trying to align everything and make decisions with regards to where the cuts go and what degree of alignment, and so on and so forth.
Speaker 1:Wow, so that's fascinating. Dr Rapaport, as you know, we all love technology at the Kaila Orthopedic Center. Everyone's skeletons are different sizes and shapes, right, so we love to customize our implants, whether it's in the area of the shoulder replacement or the ankle replacement, or hip or knee replacement. We like to do customized, patient-specific total joint replacement surgery, so it's a perfect fit each and every time. How are these implants fixed to the bone?
Speaker 2:So these implants are implanted in a press-fit manner, So the implant is usually made of a porous type of metal that allows for rapid and significant ingrowth of the bone around it, and so that's really what holds it in place, whereas in the past these devices have been implanted with cement, which is not favorable.
Speaker 1:Yeah, i love it. I love it. I love the fact that more and more of us are using press-fit implants, where the implants actually, as I discussed with my patients, become part of their skeleton. The bone actually grows into that implant and fixes it in place and, at least theoretically speaking, that fixation should be permanent in nature. Gone are the days, theoretically at least, where we have to worry about loosening because of failure of the cement mantle.
Speaker 1:That's been the rate-limiting step in so many joint replacement surgeries in the shoulder, in the knee, certainly in the hip and probably in the ankle as well. The cement over time can oxidize, become brittle and come loose and fail or crack and cause an implant to fail. But if the patient's own bone grows into the implant because of these advanced surfaces that these implants are now being made out of, a lot of them are being 3D-printed with porosities to allow this biological incorporation and in-growth. Our hope is that these implants will last forever And certainly in the field of ankle replacement surgery, where the results have not been as favorable over the years as hip and knee replacement surgery, this may be a game-changing event. The fact that you're doing mechanically neutral positioned implants with biological incorporation and fixation from bone in-growth may negate the need for any future surgery.
Speaker 2:That's correct, And additionally, I would add that if a revision is required down the road, if you are revising a prosthesis that was press-fit versus one that was fixed with cement, you're going to be left with a lot more real estate to use. When we talk about revision and ankle replacement which is perhaps for another day one of the rate-limiting factors is bone stock, And when you use cement to fix a total ankle replacement, for whatever reason, that needs to be removed because of the presence of cement, it typically means that getting that implant out is going to require removing more bone, and bone And real estate around the ankle is minimal and very important, And the more that you can save or salvage the better.
Speaker 1:When you compare and contrast outcome studies from the traditional ankle fusion surgical techniques to total ankle replacement surgeries. What do you say to your patients?
Speaker 2:I say that the outcomes are very similar in terms of pain reduction, and functional outcomes are much more favorable, obviously with ankle replacement, because you're salvaging the functionality of the joint, and with regards to revision procedures, although we know at least in 2023, to the best of our ability that 10 to 15 years out, 90% of these prostheses are healthy and functioning well and in patients that are happy, there are instances where revisions are required, but I think people think that if they have a fusion, it's a one and done procedure.
Speaker 2:They're never going to have to have a revision never again And it is very likely that they will never require a revision of their ankle fusion ever again. But when you fuse the ankle joint, it puts a tremendous amount of strain on neighboring joints, and so it's not uncommon at all for patients, for example, to require a fusion of a joint adjacent to their ankle joint after they've had a fusion and as little as five or six or seven years after the surgery. So, across the board, the results are very comparable, with one distinct advantage in the corner of ankle replacement, which, of course, is functionality.
Speaker 1:It's amazing how much overlap there is in the field of orthopedics with respect to what we tell our patients. In different body parts, The same thing applies in other areas of the body. When you fuse a joint, clearly there's no motion at that joint And therefore typically the joints above and below bear more of the brunt of the load and are more easily worn out over time because they're bearing the brunt of the load from the joint that has just been fused. So, Dr Rappapoor, what do you typically tell the patient securely after the surgery of ankle replacement surgery, both short and long term? Are they able to weight bear immediately after the surgery? Do they need to be partial weight bearing or non-weight bearing, and for how long? And then, ultimately, with respect to return to quality of life, in sports, for instance, what do you tell your patients?
Speaker 2:So typically the weight bearing status after the surgery depends entirely on any adjunctive procedures that the patient may have had.
Speaker 2:As we talked earlier, many of these patients need procedures done at the same time to address deformity either above or below the ankle joint, to ensure maximal longevity to the ankle replacement. And so many times those ancillary procedures dictate when the patients can weight bear. But for patients who are lucky enough to just be able to have the ankle replacement done in my hands, they're non-weight bearing for three weeks And the reason for that primarily is to allow the incision to mature to the point where they're over the hump or past the hurdle of potentially developing any wound, incision issues or infection or things along those lines. So in patients who just have a total ankle replacement, they're usually weight bearing in a walking cast after their searches are removed at three weeks, and I keep them in a walking cast for about three weeks to four weeks, depending on the patient and how their x-rays look, obviously, and how they're feeling, before advancing them out of their walking cast and back into shoes. So some patients are back into their normal shoes or at least given the green light to go back into the normal shoes at six or eight weeks. But patients who've had a plethora of other procedures done at the same time to address deformity are usually unable to bear weight for six to eight weeks.
Speaker 2:In terms of postoperatively, i usually will tell patients that it's going to be a full year before they realize all the benefits of the procedure in terms of pain relief. Swelling Swelling is a big thing in lower extremity surgery, particularly total ankle replacement, because of the location of the ankle relative to the heart, because of gravity, because we spend most of our time with our foot below the level of the heart and because of the problem that poses upon our bodies with regards to getting the swelling to go back up the leg, against the grain or against the stream, if you will. So I usually tell patients it's going to take a full year before we can really sit down and have a conversation about exactly how much their functionality improved, exactly how much of their pain went away. So it's a marathon, it's not a sprint, but most patients will already realize a significant reduction in their pain in the first few weeks after we do the procedure. And in terms of what they can and can't do after the surgery, it's fairly similar, i think, to other joint replacements.
Speaker 2:We ask them to respect the replacement. We prefer non-weight bearing, athletic or recreational vocational habits over ones that employ continual recruitment and pounding of the ankle. So we would rather a patient swim, for example, than run on a treadmill. We'd rather a patient play doubles tennis than play singles tennis. We'd rather a patient have a more sedentary job than one that is very demanding on the ankle, going up and down ladders, walking over construction sites, things like that.
Speaker 1:I think that before we leave Dr Rappaport, it's important to poo poo the myth that a lot of doctors and even patients may have about communications that they've had, possibly with other doctors, that ankle replacements don't do well And perhaps they won't even offer them as a viable treatment alternative. I know that I've emphasized over and over again how important it is that patients seek out high volume surgeons. It's like any other thing in life. You know, people that are experienced tend to have the best outcomes, and the American Catering Orthopedic Surgeon emphasizes that high volume surgeons have the best outcomes. And nothing could be more true, i think, than in the area of ankle replacement surgery, at least in the field of hip replacement and knee replacement surgery, a lot of surgeons are doing those procedures And even with those procedures high volume surgeons have the best outcomes. The average orthopedic surgeon in a year will do 20 joint replacements, which is not a lot of joint replacements. Patients are often putting their lives in the hands of a surgeon that doesn't do that many joint replacements And you know it's not the standard joint replacement they have to worry about. It's the situation where potentially they may run into problems intraoperatively and no surgical techniques to really get them out of a bad situation that they may be in for whatever reason, and only high volume surgeons, experienced surgeons, have that knowledge and experience to be able to do that. But in the area of ankle replacement surgery, such few surgeons actually perform ankle replacement surgery And so it's rarely, if ever, offered to patients. And when patients are seen in many other offices with ankle arthritis, they're just treated nonoperatively for a very long time and told to live with it, or they may be referred to a foot and ankle surgeon that only does fusions, because the vast majority of foot and ankle surgeons do not do ankle replacement surgery. So I think it's important.
Speaker 1:One of the reasons I really wanted to have this podcast was to make patients aware that this technology exists And it's gone through four different iterations since the 1970s.
Speaker 1:And now outcome studies are reporting fantastic results at over 10 year follow up with excellent functional scores, elimination of pain, fantastic alignment, stability to the construct and functional range of motion And I think that's very, very important to emphasize. And now, with these cutting edge technologies that you're employing the patient specific instrumentation to ensure a perfect fit and alignment each and every time, and with these biological fixation implants, the vendors are certainly doing their job to provide us with the latest and greatest technologies to use on our patients. Where the patient's bone is now growing into the implant, fixing it in place theoretically, permanently, where we no longer even have to worry about loosening, potentially for failure of the cement mantle. Theoretically, outcome studies may be 90% at 20 years in the future And I think it's important that our patients are aware that this technology exists and high volume total ankle replacement surgeons like Dr Rappaport exist And it certainly would benefit them to get an opinion from a high volume surgeon like Dr Rappaport Anything along those lines. You want to elaborate on Dr Rappaport?
Speaker 2:Yes, i agree with everything you said. Just like any other surgical procedure, there's a learning curve. I think that in my neck of the woods and foot and ankle, the procedure that has the steepest learning curve by far is total ankle replacement. You have to have a healthy amount of respect for the procedure because of a number of different things, but the soft tissue envelope, for example, around the ankle, is very thin and unforgiving, And total ankle replacement is a procedure that is a wonderful experience for both the surgeon and the patient. But you have to have a healthy dose of respect for it And that shouldn't be done by someone or done in an instance where someone did a weekend course or a week conference. I spent a good three or four years going to multiple different cadaver labs and workshops and sought out training on my own before I even attempted my first total ankle replacement because of the amount of respect that I have for it. But if it's done by someone who is confident and experienced, it can be a great procedure.
Speaker 1:Well, let's end on that note. It's been a very enlightening experience, fantastic conversation with you, dr Rappaport. I've always appreciated your complete passion for the field of foot and ankle surgery. We're so proud to have you head up our foot and ankle service at Kale Orthopedic Center And we hope that our viewing audience found this to be very informative, and I just want to thank you for your time, dr Rappaport. Thank you so much. Thanks, dr Kale. Appreciate it, my pleasure.