ISSUE ANKLE JOINT REPLACEMENT 01 TECHNIQUE Ankle Joint Replacement 2012 UPDATE Adam D. Perler, DPM, FACFAS www.adamperler.com

Total Ankle this issue Replacement Ankle Joint Arthritis Overview P.1 Solutions for End- Joint Replacement Update P.2 stage Ankle Am I a Candidate? P.3 Arthritis Ankle Replacement Recovery P.3

1. The Salto Talaris (shown in picture to the right) Ankle Joint Arthritis Overview 2. The InBone Total Ankle System (page 3) In the past, ankle fusion was the gold Another indication that ankle joint 3. The S.T.A.R. Ankle standard technique for the treatment of end- replacement is becoming a more acceptable (page 2) stage arthritis of the ankle joint. While the treatment of end-stage ankle arthritis is the 4. The Agility Total Ankle idea of ankle joint replacement has been fact that many insurances are now creating System (page 3) around for many years, the initial devices and policies that include coverage for them.

implantation techniques were extremely

Ankle Arthritis by flawed and eventually abandoned. Many recent studies have demonstrated that the Numbers although ankle joint replacement surgery still In more recent years, however, ankle joint has a higher risk for complication compared  9 to 1 ratio of knee to replacement has come a long way and is now to ankle fusion, patient satisfaction rates ankle arthritis cases considered to be a very good alternative to remain higher in the replacement groups. On are diagnosed each ankle joint fusions. This is primarily due to average, most ankle joint replacement year. both the increased knowledge and patients are able to do low impact exercise  50,000 cases per year activities such as walking, golfing, hiking, of end-stage ankle understanding of how the ankle joint functions arthritis are diagnosed and the advancement of technology. Six cycling, swimming, and downhill skiing.  Last year, there were years ago, there was only one option for about 4,000 ankle joint ankle joint replacement that was FDA While ankle joint replacement is increasing in

implantations approved, the DePuy Agility ankle. Now, popularity, not every patient is a good performed in the US. there are several new devices that have candidate. A careful evaluation must be done This figure will likely come to the market, each offering a unique in order to determine if you are a good triple over the next advantage or improvement. There are several years. several more designs being developed, Page | 1 including one that I have designed and foot & ankle patented myself. S.T.A.R. Ankle The S.T.A.R. Ankle The Small Bone Innovations (SBI) S.T.A.R. The first FDA approved mobile Ankle was the first (and bearing ankle replacement. currently the only) mobile bearing ankle joint Designed to give a more natural replacement available in the motion at the ankle joint. US markets. The STAR was FDA approved in 2009. a good candidate. Also, in ankle joint replacement, one may will be exposed to wear and tear The mobile bearing many cases, other need to have a “fine-tuning” over time. This could lead to component allows for a reconstructive surgical procedure done to their ankle multiple revision surgeries and more natural motion procedures may need to be several years after their initial potentially increase the risk of between the tibial and talus. performed in order to prepare replacement in order to ensure the complications over the life of the It is also considered to be a the foot and ankle for an ankle proper function of the joint implant. lesser invasive implant with joint replacement. replacement. The Surgical Procedure minimal bone resection compared to some of the While the current literature The key to any successful ankle Total ankle replacement is other designs on the discusses who the ideal joint replacement is not only performed in an in-patient setting market. candidate is for an ankle joint dependent on good technique of at Riverview Hospital in replacement, each patient’s the surgeon, but also the selection Noblesville, IN. Your age, medical Salto Talaris Total health history, deformity, and of the best implant to suit the conditions, whether Ankle medical condition must be patient’s needs. Each Each patient's health you live locally or at carefully be reviewed by an device presented has history, deformity, a distance, as well The Tornier Salto Talaris experienced ankle joint unique strengths and and medical condition as several other implant was introduced to replacement surgeon to weaknesses. Each must be carefully be factors usually the US market in 2007. It determine if they are a good patient must be reviewed. determines how was developed in Europe candidate for surgery. As with a s s e s s e d long you may need as a mobile bearing, any mechanical device, an independently in order to stay in the however, the US version of ankle joint replacement is to determine which device would hospital. Typically a 36 – 48 hour this implant is actually a subject to wear and tear over lead to the most optimal result. stay is routine. fixed bearing, meaning the time. This could mean that Once implanted, the patient must white bearing seen below despite having a successful also have a realistic expectation of The procedure is performed in the is actually fixed to the tibial the types of activities that they can operating room under general plate that sits above it. The resume, as the joint replacement anesthetic. The procedure Salto Talaris is also is not capable of withstanding high typically takes less than 2.5 hours considered to be physically demanding activities to perform. Sometimes added minimalistic in regards to such as running, jumping, or procedures accompany the total the amount of bone cutting and can fail if put under too ankle replacement such as resected for implantation. much stress. While there is no lengthening of a tight calf muscle, clear definition in age criteria, the hardware removal, or fixation of younger a patient is, the more weak bone. their ankle joint replacement Page | 2 Wright Medical The InBone Total Ankle InBone Total Ankle The InBone Total Ankle was designed from the ground up as a modular system that allows the surgeon the flexibility to custom build the device based on the individual

After Surgery patient’s anatomy. It is an intramedullary (within the bone) Dr. Perler will see you at the Sutures are removed at week designs are due out over the system that consists of a hospital each day until you are three and a new cast is placed. next few years. Dr. Perler is locked bearing and utilizes a ready to be discharged home. You are then allowed to bear full committed to being able to specialized guidance jig During your hospital stay we will weight in this cast. At six weeks provide you access to all of the allowing for accurate placement control your pain and to teach you following surgery the cast is implants that are available, as when using Wright Medical’s to walk with crutches or a walker removed and you are placed in long as they continue to unique leg positioning device. while not bearing weight on the a Cam-boot walker and allowed demonstrate good outcomes. It is also perhaps the best ankle. Physical therapy is to start ankle motion exercises. As with any surgery, this device for a total ankle joint performed twice daily to make sure At this time, physical therapy is technique must be approved revision procedure currently on you can safely ambulate non- begun. Further follow-up after by your insurance to assure the market. weight bearing at the time of the six-week visit depends upon proper coverage. The world of

individual patients. Usually a six ankle replacement, at this point discharge. Your ankle is usually OnLine Videos immobilized for four to six weeks in month visit and a yearly visit are in time, is dynamic and Go to www.adamperler.com in a cast. You will not be able to bear recommended to check on exciting. There are newer and order to review information weight during the first two or three motion and to ensure no other better options available now for regarding the implants and to weeks and will need to use problems are developing. ankle arthritis than have ever w a t c h crutches, a walker, or a roll-a-bout. been in the past. If you have instructional Miscellaneous Information The cast immobilization is typically ankle arthritis or think you have videos for utilized to promote wound healing It should also be noted that ankle arthritis it may be time to each of the and to protect your wounds. several new ankle implant see what options you have for implants that pain relief. are available. The videos are listed under the Patient resection of bone than the DePuy Agility Education tab. Make sure you “newer” systems. It also write down any questions that requires the temporary use Total Ankle you may have before your of an external fixation appointment so Dr. Perler can system for implantation, as The Agility Total Ankle is the review them with you during well as the need to fuse the oldest implant design your workup. Also, there are a fibula to the tibia for optimal available in the U.S. market. lot of other resources listed results. Revision of this It is a locked bearing system there for your education about system can be more difficult that requires a larger your potential ankle joint than the other designs now replacement. available. Page | 3

Training Highlights

 Board certified in Foot and Reconstructive Rearfoot and Ankle Surgery (ABPS)

 Fellow of the American College of Foot and Ankle Surgeons (FACFAS)

 Fellow of the Association of Extremity Nerve Surgeons (FAENS)

 Fellowship in Advanced Deformity Correction of the Lower Extremity with External

Fixation—Kurgan, Russia

 Fellowship AO Lower Extremity Orthopedic Trauma —MHH, Hannover, Germany

 Peripheral Nerve Surgery Training — Union Memorial Hospital, Baltimore, MD T he k ey  Tornier Salto Talaris Total Ankle Training—Indianapolis, IN  Wright Medical InBone Total Ankle Training—Indianapolis, IN to life is  Wright Medical Prophecy Total Ankle Training—Columbus, Ohio m o t i o n!  SBI S.T.A.R. Total Ankle Training—San Francisco, CA & Indianapolis, IN  Developer of the PEARLtm total ankle joint replacement system  Total Ankle Replacement product development team—Biomet Orthopedics

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foot & ankle

Adam D. Perler, DPM, FACFAS www.adamperler.com www.ahni.com

American Health Network American Health Network 1080 N. Green St., Suite 200 18077 River Avenue, Suite 104 Brownsburg, IN 46112 Noblesville, IN 46062

Phone: (317) 852-5434 Fax: (317) 852-1516

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