July 1, 2023 • 53 mins
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.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello and welcome to another edition of the Kale
Ortho podcast.
Today is June 29th 2023, andwe'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 about13 years now at the Kale
Orthopedic Center.
We're so privileged to have himwith us today, as he is an
expert in the field of foot andankle surgery, And today's topic
(00:24):
is going to be current conceptsin the management of ankle
arthritis.
Welcome to the podcast, DrRappaport.
Thank you, Dr Kale.
It's such a pleasure to haveyou with us today.
Speaker 2 (00:33):
Thanks for having me.
Speaker 1 (00:33):
Yeah, it's our pleasure.
So why don't you first startout and tell us a little bit
about yourself, Dr Rappaport?
Speaker 2 (00:40):
My name is Chad Rappaport.
I, as Dr Kale alluded, havebeen with the group for about 13
years now.
Originally from Northern NewJersey, i was actually born in
Middletown, new York, but myfamily moved down here into
Northern New Jersey when I wasthree and lived here my entire
life, with the exclusion,obviously, of college.
(01:02):
I went to college in Arizona atArizona State for a couple of
years and finished up myundergraduate studies at
University of Bridgeport inConnecticut before going to
Padaetry School at Des MoinesUniversity Medical Center.
After spending four years inDes Moines, i came back to New
Jersey to complete a rigoroussurgical three-year residency
(01:25):
program in podiatric surgery,before leaving New Jersey and
joining an orthopedic group inPennsylvania for a few years
before coming back home to NewJersey.
Speaker 1 (01:38):
Great, great Well.
we've been certainly blessed tohave you for the last 13 years
or so and you've taken care ofthousands and thousands of
patients in Northern New Jerseywho have really had fantastic
results with your care.
Thank you for that.
Thank you.
This topic, as we alluded tobefore, is the current
management of ankle arthritis.
Before we jump right into that,why don't we just explain for
(02:01):
our viewing audience whatexactly is ankle arthritis?
Speaker 2 (02:06):
Ankle arthritis is a source of pain that, in the
ankle, can affect people intheir early 20s to 30s, to their
70s and 80s.
It, like arthritis in the hipand the knee, can cause the
bilitating decrease of functionand pain and really affect one's
quality of life.
(02:26):
In the ankle, the most commonform of arthritis unlike the hip
and the knee, wherein, ofcourse, osteoarthritis or wear
and tear arthritis or old-timersarthritis, whatever you want to
deem it is most common In theankle, the form of arthritis
that we see most frequently ispost-traumatic arthritis, which
(02:47):
is arthritis that occurs as aresult of a trauma or an insult
to the ankle joint, which isfairly resilient with regards to
the development ofosteoarthritis, but very
sensitive to the changes thatoccur after an injury.
Speaker 1 (03:01):
For instance, a very common injury would be an ankle
fracture, right?
Yes, Such a ubiquitous problem.
If that ankle fracture is notproperly managed, patients can
develop this diagnosis of whatwe call post-traumatic arthritis
.
Right, That's correct.
It's more common than the hipand knee, where the most common
forms of arthritis in the hipand knee are degenerative wear
and tear osteoarthritis.
(03:22):
What Dr Rappaport is suggestingis that in the ankle the most
common cause is post-traumaticarthritis.
Is it as common to getarthritis in the ankle as it is
in the hip and knee and shoulder, for instance?
Speaker 2 (03:34):
No, it's not as common again, not to be
redundant, but it's because ofthe etiology.
The most common etiology ofarthritis in the ankle is
certainly post-traumaticarthritis.
Many individuals mostindividuals in fact, go through
their entire lives withoutdeveloping arthritis to any
significant degree in theirankle, wherein most of us, if we
(03:56):
leave an act of life, willdevelop some degree of arthritis
from wear and tear in age andour knee and our hip.
So it's much more uncommon inthe ankle than it is.
Speaker 1 (04:05):
It's somewhat counterintuitive, isn't it?
Such a small joint, relativelyspeaking, and our entire body
weight goes through that ankle.
Why do you think it is soresistant to arthritis?
Speaker 2 (04:15):
Yeah, it is counterintuitive.
I tell patients all the time ascommon, as ubiquitous as
osteoarthritis is and arthritisis in the knee and hip, it's
really quite uncommon in theankle joint.
You would think, for all thereasons that you've said, that
it would be at least as common,if not more common.
But fortunately for us thecomposition of the cartilaginic
(04:37):
ankle is different to kinematicsand the way the joint is loaded
is different in the ankle Andfortunately it spares most of us
from developing arthritisduring our lifetime Interesting.
Speaker 1 (04:47):
So, before we get any further, why don't we just
clarify for our viewing audienceexactly what part of the body
we're talking about, what bonesactually make up the ankle joint
per se?
Speaker 2 (04:57):
So the ankle joint is comprised of three bones.
The two stationary bones, as Ilike to refer to them, are
contributed to the ankle jointfrom the leg, and those are your
tibia, or your shin bone, andthe fibula, which is the
skinnier bone that lies withinthe outside part of your leg.
The dynamic bone that'scontributed to the ankle joint
(05:19):
is called the talus, and I'dlike to explain to patients that
.
Imagine the ankle is a garage.
So the stationary garage iscomprised by the tibia and the
fibula.
The car that moves in and outof the garage and has to be able
to move in and out of thegarage thousands of times per
day, perfectly without rubbingup against either sidewall, is
(05:40):
in fact the talus.
So it's a three bone joint, twocontributed by the leg, one
contributed to by the foot.
Speaker 1 (05:47):
I love that analogy.
I've never thought of thatbefore, but yeah, that's a
perfect analogy, i'm going touse that one.
So arthritis occurs whenthere's inflammation and
subsequently destruction in thejoint, and that can occur from a
myriad of different reasons, aswe have alluded to.
In this particular case,post-traumatic arthritis is the
(06:10):
number one source, but we'vealso talked about degenerative
wear and tear arthritis, whichis the most common in other
parts of the body.
What other types of arthritiscan develop in the ankle joint?
Speaker 2 (06:22):
So probably the second most common type of
arthritis that we see in theankle that can cause dysfunction
and pain would be aninflammatory related arthritis
like rheumatoid arthritis.
So rheumatoid arthritis isfairly common when we're talking
specifically about anklearthritis compared to
(06:43):
osteoarthritis.
Speaker 1 (06:44):
Yeah, It falls into the category of what we call an
autoimmune inflammatoryarthritis right where the body's
immune system can attack itselfand destroy the lining and the
cartilage and destroy the jointultimately as well.
You can also get septicarthritis right, where sometimes
people can get an infection inthe joint which ultimately can
destroy the joint and lead tothe need for some type of
(07:07):
surgery for that type ofarthritis.
What are some of the mostcommon symptoms that patients
will experience when they'reexperiencing ankle arthritis,
and how would they even knowPatients?
Speaker 2 (07:18):
will typically start to develop, obviously, pain,
chronic swelling that they can'tget to go away with icing and
non-steroidalanti-inflammatories.
They'll start to experience, inmany instances, functional
deficits such as stiffness orlack of range of motion, in
addition to pain, And manypatients will start to develop
(07:40):
over time, mechanical symptomssuch as catching, clicking,
locking, popping, things likethat.
Speaker 1 (07:46):
And probably ultimately deformity.
Right when it becomes verysevere, they'll ultimately
appreciate significantdeformities in the ankle as well
, but it can be a very, verydebilitating condition, right?
Just so patients understandthat the first line of care of
ankle arthritis is not surgery.
What are some of the things wecan do non-operatively, as you
(08:08):
alluded?
Speaker 2 (08:08):
to before.
Most patients who developarthritis can be managed quite
successfully non-operatively.
Non-operatively, non-invasivelywe treat the arthritis much
like we would in the knee andthe hip.
Oral anti-inflammatories can bevery effective, injectable
steroids, certain types ofbraces, physiotherapy,
(08:32):
arthroscopy although it has alimited role, can help, and the
ever-flourishing subspecialty oforthobiologic.
So the use of platelet-richplasma, bone marrow aspect
concentrate or stem cells can beeffective.
Speaker 1 (08:47):
Yeah, and how about functional bracing?
Speaker 2 (08:50):
Is that helpful?
Yeah, functional bracing can behelpful.
It's typically more successfulin patients that are a little
bit older and more sedentary anddon't have the expectations
that maybe a 35 or 40-year-olddoes.
And that's really where thedifficult issues come into play
with ankle arthritis, with itbeing most often as a result of
(09:14):
post-traumatic arthritis,because the trauma does not
discern or differentiate ordiscriminate with regards to age
.
So there are many patients whosuffer a severe ankle injury in
their teens or 20s or 30s, whoare trying to live with
debilitating arthritis at reallya young age, at 35 or 40.
And it's difficult for thosepatients, given the period of
(09:37):
life that they're in and whatmost of their contemporaries are
doing, to treat them withbracing.
But it is an option for usuallymore sedentary, older
population.
Speaker 1 (09:49):
Right Well, with arthritis.
We talked about arthritis inthe past as inflammation of the
joint and inflammation oftenassociated with redness, warmth,
pain and swelling.
So it's clear whyanti-inflammatories would work.
Motrin, advil, aleve, ibuprofenhelp with that inflammation And
by addressing the inflammationyou're addressing the redness,
warmth, swelling and pain.
(10:11):
Cortisone injections would helpin that regard as well.
For the same reasons Physicaltherapy why is that helpful?
Speaker 2 (10:19):
Physical therapy can help keep the joint mobile and
as functional as possible.
Some of the modalities thatpatients can receive while
they're in therapy, such aselectrical stimulation,
ultrasound, things like that,certainly have some palliative
merit And patients report thatthey feel better when they're at
therapy or for some hours or afew days afterwards.
(10:41):
But primarily, physical therapyfor most of my patients plays
more of a role in maintainingwhat little functionality they
may have left and stabilizingthe structures around the ankle
to ensure as best as we can thatthe joint doesn't continue to
deteriorate.
Speaker 1 (10:59):
Yeah, i would think that strengthening the muscles
around the joint, the dynamicstabilizers, will help provide
some of the stability thatthey've lost from the arthritis
right, and I assume that bracingworks for the same reasons.
Speaker 2 (11:12):
That's right.
So if we can control some ofthe 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'regetting better as time goes on
but some of them can be prettybulky and hard to use with
conventional shoes And so again,in my opinion, in most of my
(11:32):
patient population it's meantfor older, more sedentary
patients.
Speaker 1 (11:38):
Let's now hone in and focus our attention for the
rest of the podcast on thesurgical management of ankle
arthritis, because that's reallyyour area of expertise.
So let's begin educating ourviewing audience about the
surgical treatment alternativesfor arthritis.
And why don't we start fromleast invasive to probably the
(11:59):
most invasive?
And, just like anything else,you tend to get the most bang
for the buck with the moreinvasive procedures, but clearly
those are associated with ahigher risk.
Typically the less invasiveprocedures low risk, lower yield
.
More invasive proceduresslightly higher risk, but pretty
(12:20):
much almost guarantee thatyou're going to fix the problem.
So, on that note, why don't youjust discuss the surgical
treatment alternatives?
Speaker 2 (12:28):
Okay, thank you.
So the surgical alternatives interms of least invasive to most
invasive, would start out withankle arthroscopy.
Ankle arthroscopy is aminimally invasive procedure
that usually takes less than 35or 45 minutes to perform.
It's almost always performed asan outpatient in a surgical
(12:48):
center setting, and the goal ofthe arthroscopy is essentially
to clean out the joint.
Many of these patients, most ofthese patients, have significant
amounts of intraarticularscarring or scar tissue inside
of the joint.
They may have, as a result oftheir initial trauma, loose
(13:10):
bodies in the form of bone orcartilage that are floating
around in the joint.
That can cause pain andmechanical symptoms, as I
mentioned before, like catching,walking, locking, popping, and
so the arthroscopy, which isdone through two very, very
small incisions in the frontpart of the ankle, can be
utilized not only to diagnosethe severity of the underlying
(13:32):
arthritis, but it can help quitea bit in terms of cleaning out
the joint So that, postarthroscopy, the joint may, and
the patient may, get betteryield from some of the other
nonoperative measures that wediscussed earlier, like
cortisone injections.
If a patient has a tremendousamount of loose bodies of scar
(13:55):
tissue, of what we callimpingement bands in the ankle,
noninvasive measures such asintraarticular cortisone
injections or injections intothe joint may have limited yield
or improvement and may not lastvery much.
If those things are eliminatedfrom inside of the joint, the
(14:17):
patient is much more likely tohave greater relief from an
injection and it's likely tolast longer.
Speaker 1 (14:26):
Over the years we've treated many patients that had
arthritis in the ankle right Andthe arthritis wasn't bad enough
to warrant a very invasiveprocedure.
But I know over the yearsyou've offered them this
minimally invasive arthroscopicprocedure.
Through two little puncturesites cleaned out the ankle
joint.
Very often, like all otherjoints, whenever there's
(14:48):
arthritis It's often associatedwith some loose bodies, some
wear and tear and floatingdebris inside the joint, a lot
of scar tissue, and very oftenyou've very successfully treated
them with what we call anarthroscopic lavage and debris
month removing loose bodies,cleaning up the arthritis as
much as you can.
And certainly while you're inthere, i know you've offered
(15:09):
them cortisone injections underarthroscopic evaluation and
often some other biologicaltherapies as well Regenerative
medicine therapies like bonemarrow aspirate and
platelet-rich plasma injectiontherapy at the time of
arthroscopy And I know that'sworked very well for a lot of
patients at least to buy themsome time.
(15:32):
Certainly in the younger patientwhere you want to try to buy
some time before doing aninvasive procedure, sometimes
there's a very good treatmentalternative.
I know also over the yearswe've seen patients where
they've had a mechanical blockto motion because of small
little spurs that have developedaround the joint.
So when that hinge joint istrying to go through range of
(15:54):
motion, the two spurs arehitting one another and causing
that mechanical block to rangeof motion.
And you've showed me onnumerous occasions where you
sculpt these patients and excisethose spurs arthroscopically
and restore patients' range ofmotion.
I thought that was fantasticAnd I just know that that's a
(16:14):
very viable treatmentalternative for patients that
don't have arthritis severeenough to warrant the other
procedures that Dr Rapaport isabout to discuss.
So next, in line afterarthroscopic lavage and debris
month, what would be the nexttreatment alternative for a
patient with arthritis?
What has been the standard ofcare for the definitive
(16:38):
treatment of ankle arthritis formany, many years?
Speaker 2 (16:41):
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-traumaticarthritis has been ankle
arthrodesis or ankle fusion,which entails essentially
(17:02):
surgically binding the threebones that I mentioned prior
together to eliminate oil motioninside of the joint, and for
decades it's been a workhorse.
It does a very, very good jobof eliminating pain, but it
obviously comes at a fairlysignificant functional price.
You can't move your ankle upand down anymore, but it's still
(17:25):
today, in some patients, thebest option for a number of
different reasons that we'llprobably get into a little bit
later, but for years and yearsthat has been the gold standard.
Speaker 1 (17:36):
And how does assertion perform in ankle
fusion?
Speaker 2 (17:39):
I know there's different techniques, so
basically, the techniques aredivided into open or
arthroscopic techniques.
Most ankle fusions areperformed in an open manner,
where an actual incision is made.
The joint is prepared byremoving any scar tissue and
loose, morselized bone andcartilage and any remaining
(18:02):
cartilage that remains on thearticular part of the tibium and
the pailus, and then, of course, we put the joint into a
neutral position that's asfunctional as we possibly can
get it for that patient And then, with the use of rods or screws
or more in more recent historyplates that we put on top of the
(18:25):
joint, the joint is essentiallysqueezed together and fused
over the course of eight to 12weeks after the surgery.
In some instances, however, wecan perform an arthroscopically
assisted ankle fusion, which isan ankle fusion that is done
through the two small incisionsthat we spoke about earlier that
(18:48):
you would use for anyprototypical ankle arthroscopy.
But in this particular situationthe arthroscopy is used to
prepare the joint, as I justdescribed, in a similar manner
that it's done in an openfashion, but the fixation,
meaning the tools or theinstruments that we use to fuse
(19:10):
the joints, are inserted what wecall percutaneously.
So once the joint is preparedthrough these two small
incisions on the front part ofthe joint.
Other small incisions are madeabout the ankle and lower leg to
introduce screws that areplaced across the joint,
essentially compressing allthose bones together, and that's
(19:32):
a good option for patients whomight have little to no
deformity.
Patients who have significantdeformity require an open
procedure so that deformity canbe corrected before we actually
apply the fixation pins orscrews or plates.
But arthroscopic assisted anklefusion can also be a good
(19:53):
choice, and perhaps the onlychoice, in patients who have
severely compromised tissues onthe front part of their lower
leg or ankle, wherein you'd bevery concerned about making an
incision for fear of woundissues and infection and things
like that.
So generally speaking, it'sdone through an open manner or
technique, but there's someindications and instances where
(20:15):
we would perform thisarthroscopically.
Speaker 1 (20:18):
So why does ankle fusion work for ankle arthritis?
Speaker 2 (20:21):
So ankle fusion works because it eliminates all
motion in the joint And when apain, when a arthritic, painful
joint moves, it causes pain.
So if we stop the joint frombeing able to move, it
eliminates the pain.
You mentioned earlier about theability for arthroscopy to
(20:43):
remove spurs and that can limitmotion around the joint.
And I think, organically ornaturally, as a joint becomes
more and more arthritic,particularly around the ankle,
it's very common to developspurs around the ankle And it's
really your body's attempt attrying to fuse itself.
It realizes that the placementand growth of these spurs
(21:04):
minimizes the movement inside ofthe joint.
It doesn't do a very effectivejob in the long run of doing
that, but it underscores theregion or the rationale why we
fuse joints.
We're carrying out much moreefficaciously what the body will
try and do over time, which isdevelop spurs around the joint
to try and minimize motion.
(21:26):
So we eliminate not minimize,eliminate motion with a fusion
And that's how it eliminatespain.
Speaker 1 (21:33):
So aren't these patients upset now that you've
eliminated the motion of thejoint?
Speaker 2 (21:38):
Well, most of these patients don't have very much
motion left anyways, and themotion that they do have causes
terrible pain.
So the two or three to fivedegrees, let's say, for example,
of additional loss in terms ofrange of motion, when it's
coupled with near completerelief of their pain, they're
very willing to make that tradeoff.
Speaker 1 (22:00):
Exactly my point.
So, dr Rappaport, you explainedto us that ankle fusion is a
viable option in the treatmentof ankle arthritis and has been,
up till today, considered thegold standard of care for the
treatment of ankle arthritis.
Can you help our viewingaudience understand what exactly
(22:22):
you mean by performing an anklefusion with this model?
Speaker 2 (22:25):
Sure This is a model of a lower extremity ankle and
foot.
This is the ankle joint minusthe smaller bone that runs down
the outer aspect of the leg, andyou can see the articulation of
the joint between the tibia andthe tail.
Again, the tibia is astationary bone that comprises
(22:46):
one third of the ankle joint.
It doesn't move.
The tail is, which iscontributed, as you can see, to
the ankle joint by the foot, isreally the dynamic bone in the
joint.
That's the one that I analogizeto being the car that moves in
and out of the garage.
So when we fuse an ankle joint,whether we do it open or
arthroscopically, essentiallywhat we're doing, as you can see
in this model, is prohibitingany motion from occurring in
(23:09):
this very painful, inflamed,dysfunctional joint, and we can
do that by applying a plate overthe top of the ankle joint that
essentially squeezes thesebones together and causes them
to unite into one large bonymass, in the excluding the ankle
joint.
There are instances wherein thejoint one floor below the ankle
(23:33):
joint to the subtailer joint,has also become arthritic
because of changes in the anklejoint above it, and in that
instance we might performsomething called the tibiotelo
calcaneal fusion, which isusually done through the
application of a rod that'sdelivered from the bottom of the
foot, past the subtailer joint,through the ankle joint and up
(23:57):
into the lower aspect of thetibia.
And this is a surgery that'sdone for patients who not only
have debilitating and painfularthritis of the ankle joint,
but who also have similarchanges within the joint.
That's one floor below theankle joint, which is the
subtailer joint.
Speaker 1 (24:13):
So although you're fusing the ankle joint for an
ankle fusion, there's stillmotion right in the foot below
the fusion, in the subtailerjoint.
Typically, the motion is inwhat plane?
Speaker 2 (24:26):
So the motion in the subtailer joint is variable, but
it's the joint essentially thatallows the foot to become a
mobile adapter to the terrainthat's underneath it.
So I like to explain topatients when you're walking on
the sand at the beach, it'sreally the subtailer joint that
allows your foot to adapt to allthe undulations within the sand
(24:46):
underneath it.
Or, for example, if you'rewalking sideways up a hill, it's
really the subtailer joint thatallows the foot to go into
varying degrees of what we callsupination or pronation.
That again allows the foot toadapt to the terrain that's
underneath it.
Speaker 1 (25:01):
So that helps to explain why ankle fusions are
well tolerated.
That's correct.
Speaker 2 (25:06):
Yeah, the fusion of the ankle joint does not
eliminate, unless we've done atibiotailor cacanial fusion,
like I explained earlier.
it does not take away from themotion and functionality of the
foot.
Speaker 1 (25:21):
Right.
So what percent of times whenyou would do an ankle fusion do
you tend to incorporate thesubtailer joint?
Speaker 2 (25:28):
A minimum, probably less than 20% of the time Great.
Speaker 1 (25:32):
The other thing that I think is important to mention
with respect to performing anankle fusion is, as you can see
from this model, the fusionallows correction of deformity
in all planes.
So, like we discussed earlier,when there is ankle arthritis,
there's often deformityassociated with that ankle
arthritis.
It's either an ankle that hasfallen into what we call varus
(25:54):
or valgus, or even in this plane, in the sagittal plane, there
can also be deformity as well.
When Dr Rappaport performs anankle fusion, he is able to
correct the deformity in allplanes.
He gets the ankle well alignedin all planes and he will
typically fuse the ankle in thisposition.
What we call plantigrate, andyou can see this is a functional
(26:17):
foot.
This foot and ankle is in avery good position and should be
able to participate in mostactivities of daily living.
So, in your experience, drRappaport, how have these
patients that have undergoneankle fusion done traditionally?
Speaker 2 (26:31):
So they do very well.
Patients are quite pleased themajority of times with their
ankle fusion.
As I said, the ankle fusiondoes a great job of eliminating
pain and it's typically employedin a patient who has already
experienced quite a bit offunctional loss in terms of
their ankle.
One of the benefits, to thisday, of performing an ankle
(26:53):
replacement is that it is very,very durable.
So even when a patient may be apotential candidate for a more
functional operative treatmentfor ankle arthritis, if they
have a certain body habitus, ifthey enjoy certain activities or
their vacation is very rough ontheir ankle, these are patients
(27:15):
that may be better off with anankle fusion because of the
durability of the procedure.
Speaker 1 (27:21):
Hmm, i see, it seems like this surgical technique of
ankle fusion checks off all theboxes that we're looking to
check off with respect tomanaging ankle arthritis right.
It helps to manage pain, itcorrects deformity, it provides
stability, but are there anyboxes that it fails to check?
Speaker 2 (27:43):
Well, the biggest box , of course, would be the
functional loss of your anklejoint, which in some patients is
absolutely unacceptable, And inthose patients we have to have
a long, hard discussion aboutwhat the best option is for them
.
Speaker 1 (28:01):
Exactly So what other treatment alternatives do you
offer your patients that arelooking to check off that fourth
box too, that are justabsolutely against fusing their
ankle, whether because of age orbecause of function or quality
of life or potentially certainrestrictions that the ankle
fusion may impose upon them?
(28:22):
Do you offer any treatmentalternatives in your practice
that maybe other foot and anklesurgeons do not?
Speaker 2 (28:29):
Yes, As you know, at the Kaila Orthopedic Center we
always strive to be on thecutting edge of technology And
in the world of ankle arthritis,that is total ankle replacement
, which I'm proud to offer mostof my patients who have
debilitating ankle arthritis.
You know, five or 10 years agoprobably closer to 10 years ago,
(28:50):
70% of my patients would betreated with ankle fusion And
30% would be treated withreplacement.
And because of the rapidimprovements in technology and
instrumentation and preoperativeplanning, there's now the exact
opposite, wherein the majorityof patients I treat with total
(29:11):
ankle replacement.
Speaker 1 (29:12):
That's so exciting.
I remember when I was intraining almost 30 years ago,
ankle replacements for poo pooedvery much like even shoulder
replacements were really juststarting to become a relatively
successful long term.
But clearly technology hasevolved over the last 30 years
tremendously.
I know that ankle replacementsstarted in the 70s and have gone
(29:35):
through numerous iterationsover the past 40, 50 years.
I believe in our fourthgeneration of ankle replacements
right now.
Right, What are some of thosetechnological advancements that
have made ankle replacementsurgery much more successful now
?
Speaker 2 (29:51):
Starting from the instrumentation to the
preoperative planning, to usingadvances in cross sectional
imaging all have improved theoutcomes of total ankle
replacement.
You know, total anklereplacement first came about in
the 70s and it really hadsobering results and was largely
abandoned for 20 or 30 years orso before the quote unquote
(30:15):
second generation of implantscame into play in the 80s and
90s.
We are now on our fourthgeneration of implants and with
each turn the implants havebecome more reliable, easier to
use and have increasing amountsof longevity, which has been
(30:35):
very exciting to see.
Speaker 1 (30:36):
Yeah, I mean, obviously, there's a couple of
factors that come into successof total joint replacement
surgery in general.
extrapolating from the hip andknee replacement literature,
it's, i'm sure, the same in thearea of ankle replacement
surgery.
Number one alignment.
right Alignment of the implantshas to be perfect in order to
(30:57):
properly load the construct.
Number two fixation Theimplants have to be adequately
fixed to bone, whether by cementor in a press fit manner.
And then, thirdly, and probablyequally as important, is the
concept that ankle replacementsurgery, very much like knee
replacement and hip replacementsurgery, is a soft tissue
(31:17):
operation right Balancing thesoft tissues to make sure that
the tension on the ligamentsurrounding the joints is
isometric throughout the arc ofmotion so that implants are not
improperly loaded.
Would you agree with all thoseconcepts?
Speaker 2 (31:33):
Yes, absolutely, and I think what has made total
ankle replacement mostsuccessful, which contributed
most to the improvements in oursuccess rates, have been the
understanding that the formityhas on the ankle joint, both
above the ankle joint and belowthe ankle joint, which was, i
(31:54):
think, poorly understood to alarge degree in years past.
In 2023, we know that you cannotexpect to implant a ankle
prosthesis and have it besuccessful and have it last long
if there's deformity eitherabove or below the ankle, in the
(32:19):
lower leg or in the foot, and Ithink that's one of the things
that makes total anklereplacement unique when compared
to total knee and total hipreplacement is because of the
underlying etiology or clause,which is trauma.
There is very frequentlydeformity within the lower leg,
above the ankle.
That needs to be aligned eitherat the same time or many times
(32:42):
before the ankle replacement.
And even more common isdeformity within the foot, and
that also requires sometimes astaged approach where we address
the malignment in the foot Andthen, once that heals come back
a few months later, to do theankle replacement.
We now know without any shadowof a doubt in 2023, that if you
(33:06):
put an ankle replacement on topof a foot, that's not mutually
aligned, it's going to failprematurely.
Speaker 1 (33:12):
Interesting.
So that's important forpatients to know, because they
then have two options Eitherproceed with a fusion or you
have to correct the deformityabove or below the ankle joint
first, or at least very shortlyafter the ankle replacement, to
make sure that that ankle isproperly loaded during that
patient's lifetime.
Otherwise it will lead topremature failure.
Speaker 2 (33:35):
That's correct.
Some patients have mild amountsof deformity, either above or
below the ankle joint, which wecan correct at the same time
that we're doing their anklereplacements.
Other patients have deformitieswhich really require a staged
approach, where the deformityeither above or, more commonly,
below the ankle is addressedfirst And then we come back a
few months later and perform theankle replacement.
Speaker 1 (33:57):
How has cross-sectional imaging impacted
your ability to do anklereplacements well, either by
utilizing high-resolutioncross-sectional MRI or CAT scan
imaging.
Speaker 2 (34:08):
Yeah, it's made a tremendous difference in the
outcomes and patient-reportedoutcomes in total ankle
replacement.
Currently there are severalsystems on the market that use
cross-sectional imaging to helpin preoperative planning and
what we call patient-specificinstrumentation.
So, for example, the systemthat I prefer uses a CT scan of
(34:33):
the knee and of the ankle.
That information from those CTscans are analyzed by engineers
who essentially establish apreliminary prosthesis And, by
way of a software program thatwe share, they will send that
prototype to me and I will, inthe comfort of my own home,
(34:53):
under no stress or duress,essentially perform a mock ankle
replacement on the computer AndI may change the size of the
implant, I may change thealignment of the implant
slightly and I send it back tothe engineers who make those
changes for me.
And then they'll send back thenew quote-unquote design
(35:17):
prosthesis And, once again inthe comfort of my own home, i
play with it using the softwareprogram until I get to a point
where I'm very happy with thesize, the rotation, the
alignment.
And then the company willactually manufacture these
patient-specific instrumentguides which allow the surgeon
(35:40):
at the time of the surgery toperform the surgery without
really having to make anydifficult decisions
interoperatively For the adventof patient-specific
instrumentation.
While the patient was underanesthesia, while they had a
tourniquet around their leg, thejoint was approached and all
(36:01):
these difficult questions beganto be addressed one by one.
What size do we want the tibialcomponent?
What size do we want the tailorcomponent?
What size do we want theplastic polyethylene splacer in
between them?
Do we want to rotate it twodegrees this way or three
degrees that way?
And it could be very, verystressful to do interoperatively
(36:22):
again while the patient's underanesthesia, while you're trying
to work against time.
With regards to the tourniquet,the cross-sectional imaging and
patient-specificinstrumentation has really made
the the procedure itself fairlystraightforward.
So, for example, at the time ofthe surgery, the manufacturer
(36:43):
will have sent to the hospitalthese patient-specific
instruments.
This is a carbon copy, prototypeof a patient whom I've already
performed a procedure on oftheir distal tibia, which is
this part of the lower leg herethat articulates or forms part
of the ankle joint, and alongwith this they will manufacture
(37:08):
this cutting jig.
And this cutting jig, as youcan see, fits perfectly on the
front part of this tibia.
It will not fit on anyone elsein the entire world's tibia like
it fits on this tibia.
So, as you can see from theside or the sagittal view, it's
an absolute, exact duplicate ofthis patient's distal tibia And
(37:32):
it will not move out of place.
But if you move it onemillimeter in any direction, it
will not slide into properposition.
But once if you can hear thatsnap once it finds its sweet
spot, it will not move and itwill again, will not fit on
anybody else's tibia.
And so, from this point forward,this is pinned with some pins
onto the front part of thepatient's tibia.
(37:53):
This slides off and a cuttingjig slides on those pins that
preliminarily held this in placeAnd that guide has cutting
slots in it and that's where westart to make our initial cuts.
And so we can get to that partof the procedure in 30 or 45
(38:14):
minutes, wherein you wouldn'tmake your initial cuts with the
old technique, perhaps an hourand a half or two hours into the
surgery, because you're tryingto align everything and make
decisions with regards to wherethe cuts go and what degree of
alignment, and so on and soforth.
Speaker 1 (38:30):
Wow, so that's fascinating.
Dr Rapaport, as you know, weall love technology at the Kaila
Orthopedic Center.
Everyone's skeletons aredifferent sizes and shapes,
right, so we love to customizeour implants, whether it's in
the area of the shoulderreplacement or the ankle
replacement, or hip or kneereplacement.
We like to do customized,patient-specific total joint
(38:53):
replacement surgery, so it's aperfect fit each and every time.
How are these implants fixed tothe bone?
Speaker 2 (39:02):
So these implants are implanted in a press-fit manner
, So the implant is usually madeof a porous type of metal that
allows for rapid and significantingrowth of the bone around it,
and so that's really what holdsit in place, whereas in the
(39:23):
past these devices have beenimplanted with cement, which is
not favorable.
Speaker 1 (39:29):
Yeah, i love it.
I love it.
I love the fact that more andmore of us are using press-fit
implants, where the implantsactually, as I discussed with my
patients, become part of theirskeleton.
The bone actually grows intothat implant and fixes it in
place and, at leasttheoretically speaking, that
fixation should be permanent innature.
(39:50):
Gone are the days,theoretically at least, where we
have to worry about looseningbecause of failure of the cement
mantle.
That's been the rate-limitingstep in so many joint
replacement surgeries in theshoulder, in the knee, certainly
in the hip and probably in theankle as well.
The cement over time canoxidize, become brittle and come
(40:14):
loose and fail or crack andcause an implant to fail.
But if the patient's own bonegrows into the implant because
of these advanced surfaces thatthese implants are now being
made out of, a lot of them arebeing 3D-printed with porosities
(40:35):
to allow this biologicalincorporation and in-growth.
Our hope is that these implantswill last forever And certainly
in the field of anklereplacement surgery, where the
results have not been asfavorable over the years as hip
and knee replacement surgery,this may be a game-changing
event.
The fact that you're doingmechanically neutral positioned
(40:56):
implants with biologicalincorporation and fixation from
bone in-growth may negate theneed for any future surgery.
Speaker 2 (41:04):
That's correct, And additionally, I would add that
if a revision is required downthe road, if you are revising a
prosthesis that was press-fitversus one that was fixed with
cement, you're going to be leftwith a lot more real estate to
use.
When we talk about revision andankle replacement which is
(41:26):
perhaps for another day one ofthe rate-limiting factors is
bone stock, And when you usecement to fix a total ankle
replacement, for whatever reason, that needs to be removed
because of the presence ofcement, it typically means that
getting that implant out isgoing to require removing more
(41:47):
bone, and bone And real estatearound the ankle is minimal and
very important, And the morethat you can save or salvage the
better.
Speaker 1 (42:00):
When you compare and contrast outcome studies from
the traditional ankle fusionsurgical techniques to total
ankle replacement surgeries.
What do you say to yourpatients?
Speaker 2 (42:11):
I say that the outcomes are very similar in
terms of pain reduction, andfunctional outcomes are much
more favorable, obviously withankle replacement, because
you're salvaging thefunctionality of the joint, and
with regards to revisionprocedures, although we know at
(42:32):
least in 2023, to the best ofour ability that 10 to 15 years
out, 90% of these prostheses arehealthy and functioning well
and in patients that are happy,there are instances where
revisions are required, but Ithink people think that if they
(42:53):
have a fusion, it's a one anddone procedure.
They're never going to have tohave a revision never again And
it is very likely that they willnever require a revision of
their ankle fusion ever again.
But when you fuse the anklejoint, it puts a tremendous
amount of strain on neighboringjoints, and so it's not uncommon
at all for patients, forexample, to require a fusion of
(43:13):
a joint adjacent to their anklejoint after they've had a fusion
and as little as five or six orseven years after the surgery.
So, across the board, theresults are very comparable,
with one distinct advantage inthe corner of ankle replacement,
which, of course, isfunctionality.
Speaker 1 (43:30):
It's amazing how much overlap there is in the field
of orthopedics with respect towhat we tell our patients.
In different body parts, Thesame thing applies in other
areas of the body.
When you fuse a joint, clearlythere's no motion at that joint
And therefore typically thejoints above and below bear more
of the brunt of the load andare more easily worn out over
(43:54):
time because they're bearing thebrunt of the load from the
joint that has just been fused.
So, Dr Rappapoor, what do youtypically tell the patient
securely after the surgery ofankle replacement surgery, both
short and long term?
Are they able to weight bearimmediately after the surgery?
Do they need to be partialweight bearing or non-weight
bearing, and for how long?
And then, ultimately, withrespect to return to quality of
(44:16):
life, in sports, for instance,what do you tell your patients?
Speaker 2 (44:20):
So typically the weight bearing status after the
surgery depends entirely on anyadjunctive procedures that the
patient may have had.
As we talked earlier, many ofthese patients need procedures
done at the same time to addressdeformity either above or below
the ankle joint, to ensuremaximal longevity to the ankle
(44:41):
replacement.
And so many times thoseancillary procedures dictate
when the patients can weightbear.
But for patients who are luckyenough to just be able to have
the ankle replacement done in myhands, they're non-weight
bearing for three weeks And thereason for that primarily is to
allow the incision to mature tothe point where they're over the
(45:04):
hump or past the hurdle ofpotentially developing any wound
, incision issues or infectionor things along those lines.
So in patients who just have atotal ankle replacement, they're
usually weight bearing in awalking cast after their
searches are removed at threeweeks, and I keep them in a
walking cast for about threeweeks to four weeks, depending
(45:26):
on the patient and how theirx-rays look, obviously, and how
they're feeling, beforeadvancing them out of their
walking cast and back into shoes.
So some patients are back intotheir normal shoes or at least
given the green light to go backinto the normal shoes at six or
eight weeks.
But patients who've had aplethora of other procedures
done at the same time to addressdeformity are usually unable to
(45:47):
bear weight for six to eightweeks.
In terms of postoperatively, iusually will tell patients that
it's going to be a full yearbefore they realize all the
benefits of the procedure interms of pain relief.
Swelling Swelling is a bigthing in lower extremity surgery
, particularly total anklereplacement, because of the
(46:09):
location of the ankle relativeto the heart, because of gravity
, because we spend most of ourtime with our foot below the
level of the heart and becauseof the problem that poses upon
our bodies with regards togetting the swelling to go back
up the leg, against the grain oragainst the stream, if you will
.
So I usually tell patients it'sgoing to take a full year
(46:31):
before we can really sit downand have a conversation about
exactly how much theirfunctionality improved, exactly
how much of their pain went away.
So it's a marathon, it's not asprint, but most patients will
already realize a significantreduction in their pain in the
first few weeks after we do theprocedure.
(46:51):
And in terms of what they canand can't do after the surgery,
it's fairly similar, i think, toother joint replacements.
We ask them to respect thereplacement.
We prefer non-weight bearing,athletic or recreational
vocational habits over ones thatemploy continual recruitment
and pounding of the ankle.
(47:12):
So we would rather a patientswim, for example, than run on a
treadmill.
We'd rather a patient playdoubles tennis than play singles
tennis.
We'd rather a patient have amore 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 (47:34):
I think that before we leave Dr Rappaport, it's
important to poo poo the myththat a lot of doctors and even
patients may have aboutcommunications that they've had,
possibly with other doctors,that ankle replacements don't do
well And perhaps they won'teven offer them as a viable
(47:55):
treatment alternative.
I know that I've emphasizedover and over again how
important it is that patientsseek out high volume surgeons.
It's like any other thing inlife.
You know, people that areexperienced tend to have the
best outcomes, and the AmericanCatering Orthopedic Surgeon
emphasizes that high volumesurgeons have the best outcomes.
(48:16):
And nothing could be more true,i think, than in the area of
ankle replacement surgery, atleast in the field of hip
replacement and knee replacementsurgery, a lot of surgeons are
doing those procedures And evenwith those procedures high
volume surgeons have the bestoutcomes.
The average orthopedic surgeonin a year will do 20 joint
(48:36):
replacements, which is not a lotof joint replacements.
Patients are often puttingtheir lives in the hands of a
surgeon that doesn't do thatmany joint replacements And you
know it's not the standard jointreplacement they have to worry
about.
It's the situation wherepotentially they may run into
problems intraoperatively and nosurgical techniques to really
(48:57):
get them out of a bad situationthat they may be in for whatever
reason, and only high volumesurgeons, experienced surgeons,
have that knowledge andexperience to be able to do that
.
But in the area of anklereplacement surgery, such few
surgeons actually perform anklereplacement surgery And so it's
rarely, if ever, offered topatients.
(49:17):
And when patients are seen inmany other offices with ankle
arthritis, they're just treatednonoperatively for a very long
time and told to live with it,or they may be referred to a
foot and ankle surgeon that onlydoes fusions, because the vast
majority of foot and anklesurgeons do not do ankle
replacement surgery.
So I think it's important.
(49:38):
One of the reasons I reallywanted to have this podcast was
to make patients aware that thistechnology exists And it's gone
through four differentiterations since the 1970s.
And now outcome studies arereporting fantastic results at
over 10 year follow up withexcellent functional scores,
(49:59):
elimination of pain, fantasticalignment, stability to the
construct and functional rangeof motion And I think that's
very, very important toemphasize.
And now, with these cuttingedge technologies that you're
employing the patient specificinstrumentation to ensure a
perfect fit and alignment eachand every time, and with these
(50:22):
biological fixation implants,the vendors are certainly doing
their job to provide us with thelatest and greatest
technologies to use on ourpatients.
Where the patient's bone is nowgrowing into the implant,
fixing it in place theoretically, permanently, where we no
longer even have to worry aboutloosening, potentially for
(50:42):
failure of the cement mantle.
Theoretically, outcome studiesmay be 90% at 20 years in the
future And I think it'simportant that our patients are
aware that this technologyexists and high volume total
ankle replacement surgeons likeDr Rappaport exist And it
certainly would benefit them toget an opinion from a high
(51:04):
volume surgeon like Dr RappaportAnything along those lines.
You want to elaborate on DrRappaport?
Speaker 2 (51:11):
Yes, i agree with everything you said.
Just like any other surgicalprocedure, there's a learning
curve.
I think that in my neck of thewoods and foot and ankle, the
procedure that has the steepestlearning curve by far is total
ankle replacement.
You have to have a healthyamount of respect for the
procedure because of a number ofdifferent things, but the soft
(51:36):
tissue envelope, for example,around the ankle, is very thin
and unforgiving, And total anklereplacement is a procedure that
is a wonderful experience forboth the surgeon and the patient
.
But you have to have a healthydose of respect for it And that
shouldn't be done by someone ordone in an instance where
someone did a weekend course ora week conference.
(51:57):
I spent a good three or fouryears going to multiple
different cadaver labs andworkshops and sought out
training on my own before I evenattempted my first total ankle
replacement because of theamount of respect that I have
for it.
But if it's done by someone whois confident and experienced,
it can be a great procedure.
Speaker 1 (52:19):
Well, let's end on that note.
It's been a very enlighteningexperience, fantastic
conversation with you, drRappaport.
I've always appreciated yourcomplete passion for the field
of foot and ankle surgery.
We're so proud to have you headup our foot and ankle service
at Kale Orthopedic Center And wehope that our viewing audience
(52:39):
found this to be veryinformative, and I just want to
thank you for your time, drRappaport.
Thank you so much.
Thanks, dr Kale.
Appreciate it, my pleasure.
Hello and welcome to another edition of the Kale
Ortho podcast.
Today is June 29th 2023, andwe'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 about13 years now at the Kale
Orthopedic Center.
We're so privileged to have himwith us today, as he is an
expert in the field of foot andankle surgery, And today's topic
(00:24):
is going to be current conceptsin the management of ankle
arthritis.
Welcome to the podcast, DrRappaport.
Thank you, Dr Kale.
It's such a pleasure to haveyou with us today.
Speaker 2 (00:33):
Thanks for having me.
Speaker 1 (00:33):
Yeah, it's our pleasure.
So why don't you first startout and tell us a little bit
about yourself, Dr Rappaport?
Speaker 2 (00:40):
My name is Chad Rappaport.
I, as Dr Kale alluded, havebeen with the group for about 13
years now.
Originally from Northern NewJersey, i was actually born in
Middletown, new York, but myfamily moved down here into
Northern New Jersey when I wasthree and lived here my entire
life, with the exclusion,obviously, of college.
(01:02):
I went to college in Arizona atArizona State for a couple of
years and finished up myundergraduate studies at
University of Bridgeport inConnecticut before going to
Padaetry School at Des MoinesUniversity Medical Center.
After spending four years inDes Moines, i came back to New
Jersey to complete a rigoroussurgical three-year residency
(01:25):
program in podiatric surgery,before leaving New Jersey and
joining an orthopedic group inPennsylvania for a few years
before coming back home to NewJersey.
Speaker 1 (01:38):
Great, great Well.
we've been certainly blessed tohave you for the last 13 years
or so and you've taken care ofthousands and thousands of
patients in Northern New Jerseywho have really had fantastic
results with your care.
Thank you for that.
Thank you.
This topic, as we alluded tobefore, is the current
management of ankle arthritis.
Before we jump right into that,why don't we just explain for
(02:01):
our viewing audience whatexactly is ankle arthritis?
Speaker 2 (02:06):
Ankle arthritis is a source of pain that, in the
ankle, can affect people intheir early 20s to 30s, to their
70s and 80s.
It, like arthritis in the hipand the knee, can cause the
bilitating decrease of functionand pain and really affect one's
quality of life.
(02:26):
In the ankle, the most commonform of arthritis unlike the hip
and the knee, wherein, ofcourse, osteoarthritis or wear
and tear arthritis or old-timersarthritis, whatever you want to
deem it is most common In theankle, the form of arthritis
that we see most frequently ispost-traumatic arthritis, which
(02:47):
is arthritis that occurs as aresult of a trauma or an insult
to the ankle joint, which isfairly resilient with regards to
the development ofosteoarthritis, but very
sensitive to the changes thatoccur after an injury.
Speaker 1 (03:01):
For instance, a very common injury would be an ankle
fracture, right?
Yes, Such a ubiquitous problem.
If that ankle fracture is notproperly managed, patients can
develop this diagnosis of whatwe call post-traumatic arthritis
.
Right, That's correct.
It's more common than the hipand knee, where the most common
forms of arthritis in the hipand knee are degenerative wear
and tear osteoarthritis.
(03:22):
What Dr Rappaport is suggestingis that in the ankle the most
common cause is post-traumaticarthritis.
Is it as common to getarthritis in the ankle as it is
in the hip and knee and shoulder, for instance?
Speaker 2 (03:34):
No, it's not as common again, not to be
redundant, but it's because ofthe etiology.
The most common etiology ofarthritis in the ankle is
certainly post-traumaticarthritis.
Many individuals mostindividuals in fact, go through
their entire lives withoutdeveloping arthritis to any
significant degree in theirankle, wherein most of us, if we
(03:56):
leave an act of life, willdevelop some degree of arthritis
from wear and tear in age andour knee and our hip.
So it's much more uncommon inthe ankle than it is.
Speaker 1 (04:05):
It's somewhat counterintuitive, isn't it?
Such a small joint, relativelyspeaking, and our entire body
weight goes through that ankle.
Why do you think it is soresistant to arthritis?
Speaker 2 (04:15):
Yeah, it is counterintuitive.
I tell patients all the time ascommon, as ubiquitous as
osteoarthritis is and arthritisis in the knee and hip, it's
really quite uncommon in theankle joint.
You would think, for all thereasons that you've said, that
it would be at least as common,if not more common.
But fortunately for us thecomposition of the cartilaginic
(04:37):
ankle is different to kinematicsand the way the joint is loaded
is different in the ankle Andfortunately it spares most of us
from developing arthritisduring our lifetime Interesting.
Speaker 1 (04:47):
So, before we get any further, why don't we just
clarify for our viewing audienceexactly what part of the body
we're talking about, what bonesactually make up the ankle joint
per se?
Speaker 2 (04:57):
So the ankle joint is comprised of three bones.
The two stationary bones, as Ilike to refer to them, are
contributed to the ankle jointfrom the leg, and those are your
tibia, or your shin bone, andthe fibula, which is the
skinnier bone that lies withinthe outside part of your leg.
The dynamic bone that'scontributed to the ankle joint
(05:19):
is called the talus, and I'dlike to explain to patients that
.
Imagine the ankle is a garage.
So the stationary garage iscomprised by the tibia and the
fibula.
The car that moves in and outof the garage and has to be able
to move in and out of thegarage thousands of times per
day, perfectly without rubbingup against either sidewall, is
(05:40):
in fact the talus.
So it's a three bone joint, twocontributed by the leg, one
contributed to by the foot.
Speaker 1 (05:47):
I love that analogy.
I've never thought of thatbefore, but yeah, that's a
perfect analogy, i'm going touse that one.
So arthritis occurs whenthere's inflammation and
subsequently destruction in thejoint, and that can occur from a
myriad of different reasons, aswe have alluded to.
In this particular case,post-traumatic arthritis is the
(06:10):
number one source, but we'vealso talked about degenerative
wear and tear arthritis, whichis the most common in other
parts of the body.
What other types of arthritiscan develop in the ankle joint?
Speaker 2 (06:22):
So probably the second most common type of
arthritis that we see in theankle that can cause dysfunction
and pain would be aninflammatory related arthritis
like rheumatoid arthritis.
So rheumatoid arthritis isfairly common when we're talking
specifically about anklearthritis compared to
(06:43):
osteoarthritis.
Speaker 1 (06:44):
Yeah, It falls into the category of what we call an
autoimmune inflammatoryarthritis right where the body's
immune system can attack itselfand destroy the lining and the
cartilage and destroy the jointultimately as well.
You can also get septicarthritis right, where sometimes
people can get an infection inthe joint which ultimately can
destroy the joint and lead tothe need for some type of
(07:07):
surgery for that type ofarthritis.
What are some of the mostcommon symptoms that patients
will experience when they'reexperiencing ankle arthritis,
and how would they even knowPatients?
Speaker 2 (07:18):
will typically start to develop, obviously, pain,
chronic swelling that they can'tget to go away with icing and
non-steroidalanti-inflammatories.
They'll start to experience, inmany instances, functional
deficits such as stiffness orlack of range of motion, in
addition to pain, And manypatients will start to develop
(07:40):
over time, mechanical symptomssuch as catching, clicking,
locking, popping, things likethat.
Speaker 1 (07:46):
And probably ultimately deformity.
Right when it becomes verysevere, they'll ultimately
appreciate significantdeformities in the ankle as well
, but it can be a very, verydebilitating condition, right?
Just so patients understandthat the first line of care of
ankle arthritis is not surgery.
What are some of the things wecan do non-operatively, as you
(08:08):
alluded?
Speaker 2 (08:08):
to before.
Most patients who developarthritis can be managed quite
successfully non-operatively.
Non-operatively, non-invasivelywe treat the arthritis much
like we would in the knee andthe hip.
Oral anti-inflammatories can bevery effective, injectable
steroids, certain types ofbraces, physiotherapy,
(08:32):
arthroscopy although it has alimited role, can help, and the
ever-flourishing subspecialty oforthobiologic.
So the use of platelet-richplasma, bone marrow aspect
concentrate or stem cells can beeffective.
Speaker 1 (08:47):
Yeah, and how about functional bracing?
Speaker 2 (08:50):
Is that helpful?
Yeah, functional bracing can behelpful.
It's typically more successfulin patients that are a little
bit older and more sedentary anddon't have the expectations
that maybe a 35 or 40-year-olddoes.
And that's really where thedifficult issues come into play
with ankle arthritis, with itbeing most often as a result of
(09:14):
post-traumatic arthritis,because the trauma does not
discern or differentiate ordiscriminate with regards to age
.
So there are many patients whosuffer a severe ankle injury in
their teens or 20s or 30s, whoare trying to live with
debilitating arthritis at reallya young age, at 35 or 40.
And it's difficult for thosepatients, given the period of
(09:37):
life that they're in and whatmost of their contemporaries are
doing, to treat them withbracing.
But it is an option for usuallymore sedentary, older
population.
Speaker 1 (09:49):
Right Well, with arthritis.
We talked about arthritis inthe past as inflammation of the
joint and inflammation oftenassociated with redness, warmth,
pain and swelling.
So it's clear whyanti-inflammatories would work.
Motrin, advil, aleve, ibuprofenhelp with that inflammation And
by addressing the inflammationyou're addressing the redness,
warmth, swelling and pain.
(10:11):
Cortisone injections would helpin that regard as well.
For the same reasons Physicaltherapy why is that helpful?
Speaker 2 (10:19):
Physical therapy can help keep the joint mobile and
as functional as possible.
Some of the modalities thatpatients can receive while
they're in therapy, such aselectrical stimulation,
ultrasound, things like that,certainly have some palliative
merit And patients report thatthey feel better when they're at
therapy or for some hours or afew days afterwards.
(10:41):
But primarily, physical therapyfor most of my patients plays
more of a role in maintainingwhat little functionality they
may have left and stabilizingthe structures around the ankle
to ensure as best as we can thatthe joint doesn't continue to
deteriorate.
Speaker 1 (10:59):
Yeah, i would think that strengthening the muscles
around the joint, the dynamicstabilizers, will help provide
some of the stability thatthey've lost from the arthritis
right, and I assume that bracingworks for the same reasons.
Speaker 2 (11:12):
That's right.
So if we can control some ofthe 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'regetting better as time goes on
but some of them can be prettybulky and hard to use with
conventional shoes And so again,in my opinion, in most of my
(11:32):
patient population it's meantfor older, more sedentary
patients.
Speaker 1 (11:38):
Let's now hone in and focus our attention for the
rest of the podcast on thesurgical management of ankle
arthritis, because that's reallyyour area of expertise.
So let's begin educating ourviewing audience about the
surgical treatment alternativesfor arthritis.
And why don't we start fromleast invasive to probably the
(11:59):
most invasive?
And, just like anything else,you tend to get the most bang
for the buck with the moreinvasive procedures, but clearly
those are associated with ahigher risk.
Typically the less invasiveprocedures low risk, lower yield
.
More invasive proceduresslightly higher risk, but pretty
(12:20):
much almost guarantee thatyou're going to fix the problem.
So, on that note, why don't youjust discuss the surgical
treatment alternatives?
Speaker 2 (12:28):
Okay, thank you.
So the surgical alternatives interms of least invasive to most
invasive, would start out withankle arthroscopy.
Ankle arthroscopy is aminimally invasive procedure
that usually takes less than 35or 45 minutes to perform.
It's almost always performed asan outpatient in a surgical
(12:48):
center setting, and the goal ofthe arthroscopy is essentially
to clean out the joint.
Many of these patients, most ofthese patients, have significant
amounts of intraarticularscarring or scar tissue inside
of the joint.
They may have, as a result oftheir initial trauma, loose
(13:10):
bodies in the form of bone orcartilage that are floating
around in the joint.
That can cause pain andmechanical symptoms, as I
mentioned before, like catching,walking, locking, popping, and
so the arthroscopy, which isdone through two very, very
small incisions in the frontpart of the ankle, can be
utilized not only to diagnosethe severity of the underlying
(13:32):
arthritis, but it can help quitea bit in terms of cleaning out
the joint So that, postarthroscopy, the joint may, and
the patient may, get betteryield from some of the other
nonoperative measures that wediscussed earlier, like
cortisone injections.
If a patient has a tremendousamount of loose bodies of scar
(13:55):
tissue, of what we callimpingement bands in the ankle,
noninvasive measures such asintraarticular cortisone
injections or injections intothe joint may have limited yield
or improvement and may not lastvery much.
If those things are eliminatedfrom inside of the joint, the
(14:17):
patient is much more likely tohave greater relief from an
injection and it's likely tolast longer.
Speaker 1 (14:26):
Over the years we've treated many patients that had
arthritis in the ankle right Andthe arthritis wasn't bad enough
to warrant a very invasiveprocedure.
But I know over the yearsyou've offered them this
minimally invasive arthroscopicprocedure.
Through two little puncturesites cleaned out the ankle
joint.
Very often, like all otherjoints, whenever there's
(14:48):
arthritis It's often associatedwith some loose bodies, some
wear and tear and floatingdebris inside the joint, a lot
of scar tissue, and very oftenyou've very successfully treated
them with what we call anarthroscopic lavage and debris
month removing loose bodies,cleaning up the arthritis as
much as you can.
And certainly while you're inthere, i know you've offered
(15:09):
them cortisone injections underarthroscopic evaluation and
often some other biologicaltherapies as well Regenerative
medicine therapies like bonemarrow aspirate and
platelet-rich plasma injectiontherapy at the time of
arthroscopy And I know that'sworked very well for a lot of
patients at least to buy themsome time.
(15:32):
Certainly in the younger patientwhere you want to try to buy
some time before doing aninvasive procedure, sometimes
there's a very good treatmentalternative.
I know also over the yearswe've seen patients where
they've had a mechanical blockto motion because of small
little spurs that have developedaround the joint.
So when that hinge joint istrying to go through range of
(15:54):
motion, the two spurs arehitting one another and causing
that mechanical block to rangeof motion.
And you've showed me onnumerous occasions where you
sculpt these patients and excisethose spurs arthroscopically
and restore patients' range ofmotion.
I thought that was fantasticAnd I just know that that's a
(16:14):
very viable treatmentalternative for patients that
don't have arthritis severeenough to warrant the other
procedures that Dr Rapaport isabout to discuss.
So next, in line afterarthroscopic lavage and debris
month, what would be the nexttreatment alternative for a
patient with arthritis?
What has been the standard ofcare for the definitive
(16:38):
treatment of ankle arthritis formany, many years?
Speaker 2 (16:41):
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-traumaticarthritis has been ankle
arthrodesis or ankle fusion,which entails essentially
(17:02):
surgically binding the threebones that I mentioned prior
together to eliminate oil motioninside of the joint, and for
decades it's been a workhorse.
It does a very, very good jobof eliminating pain, but it
obviously comes at a fairlysignificant functional price.
You can't move your ankle upand down anymore, but it's still
(17:25):
today, in some patients, thebest option for a number of
different reasons that we'llprobably get into a little bit
later, but for years and yearsthat has been the gold standard.
Speaker 1 (17:36):
And how does assertion perform in ankle
fusion?
Speaker 2 (17:39):
I know there's different techniques, so
basically, the techniques aredivided into open or
arthroscopic techniques.
Most ankle fusions areperformed in an open manner,
where an actual incision is made.
The joint is prepared byremoving any scar tissue and
loose, morselized bone andcartilage and any remaining
(18:02):
cartilage that remains on thearticular part of the tibium and
the pailus, and then, of course, we put the joint into a
neutral position that's asfunctional as we possibly can
get it for that patient And then, with the use of rods or screws
or more in more recent historyplates that we put on top of the
(18:25):
joint, the joint is essentiallysqueezed together and fused
over the course of eight to 12weeks after the surgery.
In some instances, however, wecan perform an arthroscopically
assisted ankle fusion, which isan ankle fusion that is done
through the two small incisionsthat we spoke about earlier that
(18:48):
you would use for anyprototypical ankle arthroscopy.
But in this particular situationthe arthroscopy is used to
prepare the joint, as I justdescribed, in a similar manner
that it's done in an openfashion, but the fixation,
meaning the tools or theinstruments that we use to fuse
(19:10):
the joints, are inserted what wecall percutaneously.
So once the joint is preparedthrough these two small
incisions on the front part ofthe joint.
Other small incisions are madeabout the ankle and lower leg to
introduce screws that areplaced across the joint,
essentially compressing allthose bones together, and that's
(19:32):
a good option for patients whomight have little to no
deformity.
Patients who have significantdeformity require an open
procedure so that deformity canbe corrected before we actually
apply the fixation pins orscrews or plates.
But arthroscopic assisted anklefusion can also be a good
(19:53):
choice, and perhaps the onlychoice, in patients who have
severely compromised tissues onthe front part of their lower
leg or ankle, wherein you'd bevery concerned about making an
incision for fear of woundissues and infection and things
like that.
So generally speaking, it'sdone through an open manner or
technique, but there's someindications and instances where
(20:15):
we would perform thisarthroscopically.
Speaker 1 (20:18):
So why does ankle fusion work for ankle arthritis?
Speaker 2 (20:21):
So ankle fusion works because it eliminates all
motion in the joint And when apain, when a arthritic, painful
joint moves, it causes pain.
So if we stop the joint frombeing able to move, it
eliminates the pain.
You mentioned earlier about theability for arthroscopy to
(20:43):
remove spurs and that can limitmotion around the joint.
And I think, organically ornaturally, as a joint becomes
more and more arthritic,particularly around the ankle,
it's very common to developspurs around the ankle And it's
really your body's attempt attrying to fuse itself.
It realizes that the placementand growth of these spurs
(21:04):
minimizes the movement inside ofthe joint.
It doesn't do a very effectivejob in the long run of doing
that, but it underscores theregion or the rationale why we
fuse joints.
We're carrying out much moreefficaciously what the body will
try and do over time, which isdevelop spurs around the joint
to try and minimize motion.
(21:26):
So we eliminate not minimize,eliminate motion with a fusion
And that's how it eliminatespain.
Speaker 1 (21:33):
So aren't these patients upset now that you've
eliminated the motion of thejoint?
Speaker 2 (21:38):
Well, most of these patients don't have very much
motion left anyways, and themotion that they do have causes
terrible pain.
So the two or three to fivedegrees, let's say, for example,
of additional loss in terms ofrange of motion, when it's
coupled with near completerelief of their pain, they're
very willing to make that tradeoff.
Speaker 1 (22:00):
Exactly my point.
So, dr Rappaport, you explainedto us that ankle fusion is a
viable option in the treatmentof ankle arthritis and has been,
up till today, considered thegold standard of care for the
treatment of ankle arthritis.
Can you help our viewingaudience understand what exactly
(22:22):
you mean by performing an anklefusion with this model?
Speaker 2 (22:25):
Sure This is a model of a lower extremity ankle and
foot.
This is the ankle joint minusthe smaller bone that runs down
the outer aspect of the leg, andyou can see the articulation of
the joint between the tibia andthe tail.
Again, the tibia is astationary bone that comprises
(22:46):
one third of the ankle joint.
It doesn't move.
The tail is, which iscontributed, as you can see, to
the ankle joint by the foot, isreally the dynamic bone in the
joint.
That's the one that I analogizeto being the car that moves in
and out of the garage.
So when we fuse an ankle joint,whether we do it open or
arthroscopically, essentiallywhat we're doing, as you can see
in this model, is prohibitingany motion from occurring in
(23:09):
this very painful, inflamed,dysfunctional joint, and we can
do that by applying a plate overthe top of the ankle joint that
essentially squeezes thesebones together and causes them
to unite into one large bonymass, in the excluding the ankle
joint.
There are instances wherein thejoint one floor below the ankle
(23:33):
joint to the subtailer joint,has also become arthritic
because of changes in the anklejoint above it, and in that
instance we might performsomething called the tibiotelo
calcaneal fusion, which isusually done through the
application of a rod that'sdelivered from the bottom of the
foot, past the subtailer joint,through the ankle joint and up
(23:57):
into the lower aspect of thetibia.
And this is a surgery that'sdone for patients who not only
have debilitating and painfularthritis of the ankle joint,
but who also have similarchanges within the joint.
That's one floor below theankle joint, which is the
subtailer joint.
Speaker 1 (24:13):
So although you're fusing the ankle joint for an
ankle fusion, there's stillmotion right in the foot below
the fusion, in the subtailerjoint.
Typically, the motion is inwhat plane?
Speaker 2 (24:26):
So the motion in the subtailer joint is variable, but
it's the joint essentially thatallows the foot to become a
mobile adapter to the terrainthat's underneath it.
So I like to explain topatients when you're walking on
the sand at the beach, it'sreally the subtailer joint that
allows your foot to adapt to allthe undulations within the sand
(24:46):
underneath it.
Or, for example, if you'rewalking sideways up a hill, it's
really the subtailer joint thatallows the foot to go into
varying degrees of what we callsupination or pronation.
That again allows the foot toadapt to the terrain that's
underneath it.
Speaker 1 (25:01):
So that helps to explain why ankle fusions are
well tolerated.
That's correct.
Speaker 2 (25:06):
Yeah, the fusion of the ankle joint does not
eliminate, unless we've done atibiotailor cacanial fusion,
like I explained earlier.
it does not take away from themotion and functionality of the
foot.
Speaker 1 (25:21):
Right.
So what percent of times whenyou would do an ankle fusion do
you tend to incorporate thesubtailer joint?
Speaker 2 (25:28):
A minimum, probably less than 20% of the time Great.
Speaker 1 (25:32):
The other thing that I think is important to mention
with respect to performing anankle fusion is, as you can see
from this model, the fusionallows correction of deformity
in all planes.
So, like we discussed earlier,when there is ankle arthritis,
there's often deformityassociated with that ankle
arthritis.
It's either an ankle that hasfallen into what we call varus
(25:54):
or valgus, or even in this plane, in the sagittal plane, there
can also be deformity as well.
When Dr Rappaport performs anankle fusion, he is able to
correct the deformity in allplanes.
He gets the ankle well alignedin all planes and he will
typically fuse the ankle in thisposition.
What we call plantigrate, andyou can see this is a functional
(26:17):
foot.
This foot and ankle is in avery good position and should be
able to participate in mostactivities of daily living.
So, in your experience, drRappaport, how have these
patients that have undergoneankle fusion done traditionally?
Speaker 2 (26:31):
So they do very well.
Patients are quite pleased themajority of times with their
ankle fusion.
As I said, the ankle fusiondoes a great job of eliminating
pain and it's typically employedin a patient who has already
experienced quite a bit offunctional loss in terms of
their ankle.
One of the benefits, to thisday, of performing an ankle
(26:53):
replacement is that it is very,very durable.
So even when a patient may be apotential candidate for a more
functional operative treatmentfor ankle arthritis, if they
have a certain body habitus, ifthey enjoy certain activities or
their vacation is very rough ontheir ankle, these are patients
(27:15):
that may be better off with anankle fusion because of the
durability of the procedure.
Speaker 1 (27:21):
Hmm, i see, it seems like this surgical technique of
ankle fusion checks off all theboxes that we're looking to
check off with respect tomanaging ankle arthritis right.
It helps to manage pain, itcorrects deformity, it provides
stability, but are there anyboxes that it fails to check?
Speaker 2 (27:43):
Well, the biggest box , of course, would be the
functional loss of your anklejoint, which in some patients is
absolutely unacceptable, And inthose patients we have to have
a long, hard discussion aboutwhat the best option is for them
.
Speaker 1 (28:01):
Exactly So what other treatment alternatives do you
offer your patients that arelooking to check off that fourth
box too, that are justabsolutely against fusing their
ankle, whether because of age orbecause of function or quality
of life or potentially certainrestrictions that the ankle
fusion may impose upon them?
(28:22):
Do you offer any treatmentalternatives in your practice
that maybe other foot and anklesurgeons do not?
Speaker 2 (28:29):
Yes, As you know, at the Kaila Orthopedic Center we
always strive to be on thecutting edge of technology And
in the world of ankle arthritis,that is total ankle replacement
, which I'm proud to offer mostof my patients who have
debilitating ankle arthritis.
You know, five or 10 years agoprobably closer to 10 years ago,
(28:50):
70% of my patients would betreated with ankle fusion And
30% would be treated withreplacement.
And because of the rapidimprovements in technology and
instrumentation and preoperativeplanning, there's now the exact
opposite, wherein the majorityof patients I treat with total
(29:11):
ankle replacement.
Speaker 1 (29:12):
That's so exciting.
I remember when I was intraining almost 30 years ago,
ankle replacements for poo pooedvery much like even shoulder
replacements were really juststarting to become a relatively
successful long term.
But clearly technology hasevolved over the last 30 years
tremendously.
I know that ankle replacementsstarted in the 70s and have gone
(29:35):
through numerous iterationsover the past 40, 50 years.
I believe in our fourthgeneration of ankle replacements
right now.
Right, What are some of thosetechnological advancements that
have made ankle replacementsurgery much more successful now
?
Speaker 2 (29:51):
Starting from the instrumentation to the
preoperative planning, to usingadvances in cross sectional
imaging all have improved theoutcomes of total ankle
replacement.
You know, total anklereplacement first came about in
the 70s and it really hadsobering results and was largely
abandoned for 20 or 30 years orso before the quote unquote
(30:15):
second generation of implantscame into play in the 80s and
90s.
We are now on our fourthgeneration of implants and with
each turn the implants havebecome more reliable, easier to
use and have increasing amountsof longevity, which has been
(30:35):
very exciting to see.
Speaker 1 (30:36):
Yeah, I mean, obviously, there's a couple of
factors that come into successof total joint replacement
surgery in general.
extrapolating from the hip andknee replacement literature,
it's, i'm sure, the same in thearea of ankle replacement
surgery.
Number one alignment.
right Alignment of the implantshas to be perfect in order to
(30:57):
properly load the construct.
Number two fixation Theimplants have to be adequately
fixed to bone, whether by cementor in a press fit manner.
And then, thirdly, and probablyequally as important, is the
concept that ankle replacementsurgery, very much like knee
replacement and hip replacementsurgery, is a soft tissue
(31:17):
operation right Balancing thesoft tissues to make sure that
the tension on the ligamentsurrounding the joints is
isometric throughout the arc ofmotion so that implants are not
improperly loaded.
Would you agree with all thoseconcepts?
Speaker 2 (31:33):
Yes, absolutely, and I think what has made total
ankle replacement mostsuccessful, which contributed
most to the improvements in oursuccess rates, have been the
understanding that the formityhas on the ankle joint, both
above the ankle joint and belowthe ankle joint, which was, i
(31:54):
think, poorly understood to alarge degree in years past.
In 2023, we know that you cannotexpect to implant a ankle
prosthesis and have it besuccessful and have it last long
if there's deformity eitherabove or below the ankle, in the
(32:19):
lower leg or in the foot, and Ithink that's one of the things
that makes total anklereplacement unique when compared
to total knee and total hipreplacement is because of the
underlying etiology or clause,which is trauma.
There is very frequentlydeformity within the lower leg,
above the ankle.
That needs to be aligned eitherat the same time or many times
(32:42):
before the ankle replacement.
And even more common isdeformity within the foot, and
that also requires sometimes astaged approach where we address
the malignment in the foot Andthen, once that heals come back
a few months later, to do theankle replacement.
We now know without any shadowof a doubt in 2023, that if you
(33:06):
put an ankle replacement on topof a foot, that's not mutually
aligned, it's going to failprematurely.
Speaker 1 (33:12):
Interesting.
So that's important forpatients to know, because they
then have two options Eitherproceed with a fusion or you
have to correct the deformityabove or below the ankle joint
first, or at least very shortlyafter the ankle replacement, to
make sure that that ankle isproperly loaded during that
patient's lifetime.
Otherwise it will lead topremature failure.
Speaker 2 (33:35):
That's correct.
Some patients have mild amountsof deformity, either above or
below the ankle joint, which wecan correct at the same time
that we're doing their anklereplacements.
Other patients have deformitieswhich really require a staged
approach, where the deformityeither above or, more commonly,
below the ankle is addressedfirst And then we come back a
few months later and perform theankle replacement.
Speaker 1 (33:57):
How has cross-sectional imaging impacted
your ability to do anklereplacements well, either by
utilizing high-resolutioncross-sectional MRI or CAT scan
imaging.
Speaker 2 (34:08):
Yeah, it's made a tremendous difference in the
outcomes and patient-reportedoutcomes in total ankle
replacement.
Currently there are severalsystems on the market that use
cross-sectional imaging to helpin preoperative planning and
what we call patient-specificinstrumentation.
So, for example, the systemthat I prefer uses a CT scan of
(34:33):
the knee and of the ankle.
That information from those CTscans are analyzed by engineers
who essentially establish apreliminary prosthesis And, by
way of a software program thatwe share, they will send that
prototype to me and I will, inthe comfort of my own home,
(34:53):
under no stress or duress,essentially perform a mock ankle
replacement on the computer AndI may change the size of the
implant, I may change thealignment of the implant
slightly and I send it back tothe engineers who make those
changes for me.
And then they'll send back thenew quote-unquote design
(35:17):
prosthesis And, once again inthe comfort of my own home, i
play with it using the softwareprogram until I get to a point
where I'm very happy with thesize, the rotation, the
alignment.
And then the company willactually manufacture these
patient-specific instrumentguides which allow the surgeon
(35:40):
at the time of the surgery toperform the surgery without
really having to make anydifficult decisions
interoperatively For the adventof patient-specific
instrumentation.
While the patient was underanesthesia, while they had a
tourniquet around their leg, thejoint was approached and all
(36:01):
these difficult questions beganto be addressed one by one.
What size do we want the tibialcomponent?
What size do we want the tailorcomponent?
What size do we want theplastic polyethylene splacer in
between them?
Do we want to rotate it twodegrees this way or three
degrees that way?
And it could be very, verystressful to do interoperatively
(36:22):
again while the patient's underanesthesia, while you're trying
to work against time.
With regards to the tourniquet,the cross-sectional imaging and
patient-specificinstrumentation has really made
the the procedure itself fairlystraightforward.
So, for example, at the time ofthe surgery, the manufacturer
(36:43):
will have sent to the hospitalthese patient-specific
instruments.
This is a carbon copy, prototypeof a patient whom I've already
performed a procedure on oftheir distal tibia, which is
this part of the lower leg herethat articulates or forms part
of the ankle joint, and alongwith this they will manufacture
(37:08):
this cutting jig.
And this cutting jig, as youcan see, fits perfectly on the
front part of this tibia.
It will not fit on anyone elsein the entire world's tibia like
it fits on this tibia.
So, as you can see from theside or the sagittal view, it's
an absolute, exact duplicate ofthis patient's distal tibia And
(37:32):
it will not move out of place.
But if you move it onemillimeter in any direction, it
will not slide into properposition.
But once if you can hear thatsnap once it finds its sweet
spot, it will not move and itwill again, will not fit on
anybody else's tibia.
And so, from this point forward,this is pinned with some pins
onto the front part of thepatient's tibia.
(37:53):
This slides off and a cuttingjig slides on those pins that
preliminarily held this in placeAnd that guide has cutting
slots in it and that's where westart to make our initial cuts.
And so we can get to that partof the procedure in 30 or 45
(38:14):
minutes, wherein you wouldn'tmake your initial cuts with the
old technique, perhaps an hourand a half or two hours into the
surgery, because you're tryingto align everything and make
decisions with regards to wherethe cuts go and what degree of
alignment, and so on and soforth.
Speaker 1 (38:30):
Wow, so that's fascinating.
Dr Rapaport, as you know, weall love technology at the Kaila
Orthopedic Center.
Everyone's skeletons aredifferent sizes and shapes,
right, so we love to customizeour implants, whether it's in
the area of the shoulderreplacement or the ankle
replacement, or hip or kneereplacement.
We like to do customized,patient-specific total joint
(38:53):
replacement surgery, so it's aperfect fit each and every time.
How are these implants fixed tothe bone?
Speaker 2 (39:02):
So these implants are implanted in a press-fit manner
, So the implant is usually madeof a porous type of metal that
allows for rapid and significantingrowth of the bone around it,
and so that's really what holdsit in place, whereas in the
(39:23):
past these devices have beenimplanted with cement, which is
not favorable.
Speaker 1 (39:29):
Yeah, i love it.
I love it.
I love the fact that more andmore of us are using press-fit
implants, where the implantsactually, as I discussed with my
patients, become part of theirskeleton.
The bone actually grows intothat implant and fixes it in
place and, at leasttheoretically speaking, that
fixation should be permanent innature.
(39:50):
Gone are the days,theoretically at least, where we
have to worry about looseningbecause of failure of the cement
mantle.
That's been the rate-limitingstep in so many joint
replacement surgeries in theshoulder, in the knee, certainly
in the hip and probably in theankle as well.
The cement over time canoxidize, become brittle and come
(40:14):
loose and fail or crack andcause an implant to fail.
But if the patient's own bonegrows into the implant because
of these advanced surfaces thatthese implants are now being
made out of, a lot of them arebeing 3D-printed with porosities
(40:35):
to allow this biologicalincorporation and in-growth.
Our hope is that these implantswill last forever And certainly
in the field of anklereplacement surgery, where the
results have not been asfavorable over the years as hip
and knee replacement surgery,this may be a game-changing
event.
The fact that you're doingmechanically neutral positioned
(40:56):
implants with biologicalincorporation and fixation from
bone in-growth may negate theneed for any future surgery.
Speaker 2 (41:04):
That's correct, And additionally, I would add that
if a revision is required downthe road, if you are revising a
prosthesis that was press-fitversus one that was fixed with
cement, you're going to be leftwith a lot more real estate to
use.
When we talk about revision andankle replacement which is
(41:26):
perhaps for another day one ofthe rate-limiting factors is
bone stock, And when you usecement to fix a total ankle
replacement, for whatever reason, that needs to be removed
because of the presence ofcement, it typically means that
getting that implant out isgoing to require removing more
(41:47):
bone, and bone And real estatearound the ankle is minimal and
very important, And the morethat you can save or salvage the
better.
Speaker 1 (42:00):
When you compare and contrast outcome studies from
the traditional ankle fusionsurgical techniques to total
ankle replacement surgeries.
What do you say to yourpatients?
Speaker 2 (42:11):
I say that the outcomes are very similar in
terms of pain reduction, andfunctional outcomes are much
more favorable, obviously withankle replacement, because
you're salvaging thefunctionality of the joint, and
with regards to revisionprocedures, although we know at
(42:32):
least in 2023, to the best ofour ability that 10 to 15 years
out, 90% of these prostheses arehealthy and functioning well
and in patients that are happy,there are instances where
revisions are required, but Ithink people think that if they
(42:53):
have a fusion, it's a one anddone procedure.
They're never going to have tohave a revision never again And
it is very likely that they willnever require a revision of
their ankle fusion ever again.
But when you fuse the anklejoint, it puts a tremendous
amount of strain on neighboringjoints, and so it's not uncommon
at all for patients, forexample, to require a fusion of
(43:13):
a joint adjacent to their anklejoint after they've had a fusion
and as little as five or six orseven years after the surgery.
So, across the board, theresults are very comparable,
with one distinct advantage inthe corner of ankle replacement,
which, of course, isfunctionality.
Speaker 1 (43:30):
It's amazing how much overlap there is in the field
of orthopedics with respect towhat we tell our patients.
In different body parts, Thesame thing applies in other
areas of the body.
When you fuse a joint, clearlythere's no motion at that joint
And therefore typically thejoints above and below bear more
of the brunt of the load andare more easily worn out over
(43:54):
time because they're bearing thebrunt of the load from the
joint that has just been fused.
So, Dr Rappapoor, what do youtypically tell the patient
securely after the surgery ofankle replacement surgery, both
short and long term?
Are they able to weight bearimmediately after the surgery?
Do they need to be partialweight bearing or non-weight
bearing, and for how long?
And then, ultimately, withrespect to return to quality of
(44:16):
life, in sports, for instance,what do you tell your patients?
Speaker 2 (44:20):
So typically the weight bearing status after the
surgery depends entirely on anyadjunctive procedures that the
patient may have had.
As we talked earlier, many ofthese patients need procedures
done at the same time to addressdeformity either above or below
the ankle joint, to ensuremaximal longevity to the ankle
(44:41):
replacement.
And so many times thoseancillary procedures dictate
when the patients can weightbear.
But for patients who are luckyenough to just be able to have
the ankle replacement done in myhands, they're non-weight
bearing for three weeks And thereason for that primarily is to
allow the incision to mature tothe point where they're over the
(45:04):
hump or past the hurdle ofpotentially developing any wound
, incision issues or infectionor things along those lines.
So in patients who just have atotal ankle replacement, they're
usually weight bearing in awalking cast after their
searches are removed at threeweeks, and I keep them in a
walking cast for about threeweeks to four weeks, depending
(45:26):
on the patient and how theirx-rays look, obviously, and how
they're feeling, beforeadvancing them out of their
walking cast and back into shoes.
So some patients are back intotheir normal shoes or at least
given the green light to go backinto the normal shoes at six or
eight weeks.
But patients who've had aplethora of other procedures
done at the same time to addressdeformity are usually unable to
(45:47):
bear weight for six to eightweeks.
In terms of postoperatively, iusually will tell patients that
it's going to be a full yearbefore they realize all the
benefits of the procedure interms of pain relief.
Swelling Swelling is a bigthing in lower extremity surgery
, particularly total anklereplacement, because of the
(46:09):
location of the ankle relativeto the heart, because of gravity
, because we spend most of ourtime with our foot below the
level of the heart and becauseof the problem that poses upon
our bodies with regards togetting the swelling to go back
up the leg, against the grain oragainst the stream, if you will
.
So I usually tell patients it'sgoing to take a full year
(46:31):
before we can really sit downand have a conversation about
exactly how much theirfunctionality improved, exactly
how much of their pain went away.
So it's a marathon, it's not asprint, but most patients will
already realize a significantreduction in their pain in the
first few weeks after we do theprocedure.
(46:51):
And in terms of what they canand can't do after the surgery,
it's fairly similar, i think, toother joint replacements.
We ask them to respect thereplacement.
We prefer non-weight bearing,athletic or recreational
vocational habits over ones thatemploy continual recruitment
and pounding of the ankle.
(47:12):
So we would rather a patientswim, for example, than run on a
treadmill.
We'd rather a patient playdoubles tennis than play singles
tennis.
We'd rather a patient have amore 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 (47:34):
I think that before we leave Dr Rappaport, it's
important to poo poo the myththat a lot of doctors and even
patients may have aboutcommunications that they've had,
possibly with other doctors,that ankle replacements don't do
well And perhaps they won'teven offer them as a viable
(47:55):
treatment alternative.
I know that I've emphasizedover and over again how
important it is that patientsseek out high volume surgeons.
It's like any other thing inlife.
You know, people that areexperienced tend to have the
best outcomes, and the AmericanCatering Orthopedic Surgeon
emphasizes that high volumesurgeons have the best outcomes.
(48:16):
And nothing could be more true,i think, than in the area of
ankle replacement surgery, atleast in the field of hip
replacement and knee replacementsurgery, a lot of surgeons are
doing those procedures And evenwith those procedures high
volume surgeons have the bestoutcomes.
The average orthopedic surgeonin a year will do 20 joint
(48:36):
replacements, which is not a lotof joint replacements.
Patients are often puttingtheir lives in the hands of a
surgeon that doesn't do thatmany joint replacements And you
know it's not the standard jointreplacement they have to worry
about.
It's the situation wherepotentially they may run into
problems intraoperatively and nosurgical techniques to really
(48:57):
get them out of a bad situationthat they may be in for whatever
reason, and only high volumesurgeons, experienced surgeons,
have that knowledge andexperience to be able to do that
.
But in the area of anklereplacement surgery, such few
surgeons actually perform anklereplacement surgery And so it's
rarely, if ever, offered topatients.
(49:17):
And when patients are seen inmany other offices with ankle
arthritis, they're just treatednonoperatively for a very long
time and told to live with it,or they may be referred to a
foot and ankle surgeon that onlydoes fusions, because the vast
majority of foot and anklesurgeons do not do ankle
replacement surgery.
So I think it's important.
(49:38):
One of the reasons I reallywanted to have this podcast was
to make patients aware that thistechnology exists And it's gone
through four differentiterations since the 1970s.
And now outcome studies arereporting fantastic results at
over 10 year follow up withexcellent functional scores,
(49:59):
elimination of pain, fantasticalignment, stability to the
construct and functional rangeof motion And I think that's
very, very important toemphasize.
And now, with these cuttingedge technologies that you're
employing the patient specificinstrumentation to ensure a
perfect fit and alignment eachand every time, and with these
(50:22):
biological fixation implants,the vendors are certainly doing
their job to provide us with thelatest and greatest
technologies to use on ourpatients.
Where the patient's bone is nowgrowing into the implant,
fixing it in place theoretically, permanently, where we no
longer even have to worry aboutloosening, potentially for
(50:42):
failure of the cement mantle.
Theoretically, outcome studiesmay be 90% at 20 years in the
future And I think it'simportant that our patients are
aware that this technologyexists and high volume total
ankle replacement surgeons likeDr Rappaport exist And it
certainly would benefit them toget an opinion from a high
(51:04):
volume surgeon like Dr RappaportAnything along those lines.
You want to elaborate on DrRappaport?
Speaker 2 (51:11):
Yes, i agree with everything you said.
Just like any other surgicalprocedure, there's a learning
curve.
I think that in my neck of thewoods and foot and ankle, the
procedure that has the steepestlearning curve by far is total
ankle replacement.
You have to have a healthyamount of respect for the
procedure because of a number ofdifferent things, but the soft
(51:36):
tissue envelope, for example,around the ankle, is very thin
and unforgiving, And total anklereplacement is a procedure that
is a wonderful experience forboth the surgeon and the patient
.
But you have to have a healthydose of respect for it And that
shouldn't be done by someone ordone in an instance where
someone did a weekend course ora week conference.
(51:57):
I spent a good three or fouryears going to multiple
different cadaver labs andworkshops and sought out
training on my own before I evenattempted my first total ankle
replacement because of theamount of respect that I have
for it.
But if it's done by someone whois confident and experienced,
it can be a great procedure.
Speaker 1 (52:19):
Well, let's end on that note.
It's been a very enlighteningexperience, fantastic
conversation with you, drRappaport.
I've always appreciated yourcomplete passion for the field
of foot and ankle surgery.
We're so proud to have you headup our foot and ankle service
at Kale Orthopedic Center And wehope that our viewing audience
(52:39):
found this to be veryinformative, and I just want to
thank you for your time, drRappaport.
Thank you so much.
Thanks, dr Kale.
Appreciate it, my pleasure.
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