ANATOMY - STRUCTURES OF THE FOOT AND ANKLE

The foot is made up of many bones and soft tissues such as muscles, ligaments and
tendons. The bones of the foot are often divided into 3 regions: hindfoot, midfoot and
forefoot.

A joint is the area where two bones come together and it includes all of the soft
tissue structures inbetween the two bones.

Cartilage is a thick tissue and is found on the ends of the bones. It acts as a
protective cushion and a sliding surface on which the bones move.

Using your computer mouse, very carefully move over the foot diagram directly
to the right of this text. The individual names of each bone will appear as you do
so. The calcaneus bone, which is not seen to the diagram on the right, can be seen
on the diagram to the bottom right. You must have the Flash Player© installed
on your computer to effectively view the names. You can download it here.

Ligaments and tendons are "soft tissue" structures that are very strong. A ligament
joins two bones together.

A tendon is a thick, cord-like structure that joins muscle to bone. One of the most
well known tendons is the Achilles tendon. The Achilles joins the calf muscle to the
heel (calcaneus). Again, the calcaneus bone can be seen directly below and also on
the bottom right picture.

 
Total Ankle Replacement

Thirty or so years ago when total ankle replacement surgery was begun it was soon realized that the
implant or the prosthesis that was used at that time was not successful. Almost all of the total ankle
replacements implanted at that time ultimately failed. The design of the prosthesis implant began to
improve in the late 1980's. Because of these changes, total ankle joint replacement again became part of
the treatment that a surgeon had available to correct ankle arthritis. Within the past seven years ankle
replacement has again been taken seriously by orthopedic ankle reconstructive surgeons.

The results of ankle replacement today are good and the outcome of ankle replacement from a functional
standpoint is better than that of arthrodesis. What does this mean? In an ankle arthrodesis, the joint is
fused or glued together, limiting the up and down movement. An ankle replacement, however, allows a
more normal "function," though the movement may not be perfect.

Unfortunately, not all ankle replacement surgery goes smoothly. Many experienced surgeons have found
that it takes time for them to learn how to put in the ankle prosthesis. It may take many years for a
surgeon to gain sufficient experience to perform the surgery predictably without considerable
complications. Recent scientific reports (from my own institution as well as those of others) have outlined
this problem in more detail. Surgeons refer to this problem as the "learning curve." Fortunately, Dr.
Myerson has extensive experience with this surgery and has performed well over 350 ankle
replacements.

The main advantage of total ankle replacement is the return of some freedom of movement in
the ankle. This movement is important for walking, exercise and climbing type activities. Full
movement of the ankle joint is never regained even with total ankle replacement. The
movement that is present, however, is far preferable to the lack of movement in the fused
ankle. There is another very important aspect to ankle replacement in that it avoids the stresses
that occur following ankle fusion or arthrodesis. When an ankle joint is fused, there is of course no up
and down movement in the ankle. There does however remain for some patients a limited amount of up
and down movement which occur in the adjacent joints. The problem is that in later years these joints
begin to take the brunt of the force in the foot, and they too begin to develop changes of arthritis. This
can be a serious dilemma, since almost 100% of patients will after a prolonged time demonstrate
changes of arthritis in these joints next to the ankle. Not all of these patients have symptoms of arthritis,
but for many it can become debilitating, since the only option remaining is to fuse these joints as well.
What then happens is a gradual need for further fusion of adjacent joints in the foot, resulting in
considerable incapacity.

The recovery following the total ankle replacement is very carefully monitored. Rehabilitation and
exercise are essential. Dr. Myerson's approach to rehabilitation includes an exercise bicycle and therapy
in a swimming pool. This begins as soon as the stitches are removed and the incision is healed. These
exercises facilitate the range of motion and ultimately improve the final outcome of the joint replacement
procedure.

These are XR's after total ankle replacement. The XR on the right shows
the prosthesis with the plate and screws on the outside anklebone
called the fibula.
 In these two pictures, we are looking at an XR from the side of the
ankle after a total ankle has been inserted. The XR's demonstrate the
movement that is possible after total ankle replacement. The XR on the
left shows the foot moving downward and that on the right, with the
foot moving upwards.

This is the up and down movement of the ankle that one would expect
following a total ankle replacement.

Ankle Fusion (Arthrodesis)

An ankle arthrodesis is an operation that glues together or fuses the ankle joint. The ankle joint is
responsible for more than 75% of the up and down movement of the ankle. With the ankle fused, no
further upward movement is present but a limited amount of downward movement is possible. The in
and out movement of the heel joint is not affected by an ankle fusion.

An ankle fusion is a good operation for certain selected individuals who are not good candidates for a
total ankle replacement. The success rate of ankle fusion is good provided techniques are used which use
small incisions. It is possible to do the ankle fusion through two tiny incisions, referred to as the mini-
arthrotomy procedure for ankle fusion. This procedure was pioneered and developed by Dr. Myerson.
Exercise is possible following an ankle fusion but very few running type activities, ball or racquet sports
are going to be possible.

Left: Specialized instruments inside the ankle

joint during surgery for an ankle fusion. The
incisions on the side of the ankle are each 2cm in
length.
 This is the side and front view of an ankle fusion. Three screws are
routinely used for fusion. They are buried in the bone and do not need to
be removed.

Total Ankle Allograft Transplant Replacement

The procedure which will be discussed below is an ankle allograft transplant replacement using a fresh
graft of the ankle harvested from a cadaver. Although there are other alternative surgical choices, each
operation has clear advantages and disadvantages and the success rates of these various operations are
different. These decisions are not always easy for the patient to make. The final decision should be made
with an orthopedic surgeon who has considerable experience in the management of ankle arthritis. This
experience is very important. Studies have shown that the successful results of surgery increase and
complication rates decrease with greater surgical experience.

The results of ankle allograft replacement are good but not always predictable. With an ankle
arthrodesis, the joint is fused or glued together, limiting the up and down movement. An ankle allograft
replacement, however, allows a more normal “function,” though the movement may not be perfect. The
main advantage of the allograft ankle replacement is the return of some freedom of movement in the
ankle. This movement is important for walking, exercise and climbing type activities. Full movement of
the ankle joint is not likely regained, however, is far preferable to the lack of movement in the fused
ankle. The success rate of the allograft replacement has been good. There are potential for complications
like any other operation including skin healing problems, changes in the nerves on the skin with numb
patches, and continued arthritis. Perhaps the specific problem of the allograft replacement is that the
bone and cartilage which is transplanted does not heal, and further arthritis develops. If this happens,
another allograft replacement may be performed, or one can convert this to a more traditional total
ankle replacement, or even an ankle fusion.

The recovery following the allograft ankle replacement is very carefully monitored. Rehabilitation and
exercise are essential. Dr. Myerson’s approach to rehabilitation includes an exercise bicycle and therapy
in a swimming pool. This begins as soon as the stitches are removed and the incision is healed. These
exercises facilitate the range of motion and ultimately improve the final outcome of the allograft joint
replacement procedure.

This is the up and down movement of the ankle that one would expect following an ankle allograft
replacement.

In an ankle allograft replacement, an entirely new joint surface (made of bone and cartilage from a fresh
cadaver) is implanted instead of replacing the ankle joint with a replacement made of metal and plastic.
This procedure offers a unique alternative to the management of ankle arthritis without “burning any
bridges.” Although we have not been performing this procedure for more than a few years, the short
term results are very encouraging.

The main advantage of this type of procedure is the potential for replacement of the entire ankle joint
with viable living cartilage cells. In the cases we have performed so far there does not appear to be any
immune response or rejection of the implanted material. It seems that unlike other transplanted tissue,
there is not sufficient bone or cartilage for this to be recognized as foreign and then rejected. The most
important aspect of the transplant is the correct sizing to perfectly match the ankle.

The operation involves removal of a segment of bone and cartilage from the arthritic ankle, and then the
identical bone cuts are made on the ankle cadaver graft using specialized instruments which cut the graft
in the exact size and shape. This operation involves a very specialized team of ankle reconstructive
surgeons as well as a good working bone bank to provide the donor graft required for implantation. Once
you have been accepted as a candidate for the allograft ankle replacement, you will be put on a waiting
list. It may take anything from one week to one year to find the exact donor for your ankle. This does
not depend on tissue matching as for example must be done with other organ transplants. Instead, we
have to obtain a perfect size match for your ankle. This takes a lot of work on the part of the bone graft
company with which we work.

Once you are put on the waiting list for the allograft ankle replacement, we ask that you are available at
all times to have your surgery. This may inconvenience you, but it takes a lot of work on the part of the
bone graft company to find the perfect match for you, and we do not want this to be wasted. Once a
graft size match has been identified we are notified by the company, and then the graft is subjected to
very stringent infection testing. This is extremely important, and neither we nor the company will
perform any graft unless this has been completely cleared medically. This may take up to three weeks to
clear infection control adequately. We try not to involve you in this process until the graft has been
released, but this can be difficult, since you will need to make travel, family and work arrangements. For
this reason, we will often inform you of the availability of a size match early on, but you will have to
understand that the majority of grafts do not pass through infection control. This can be very frustrating,
but is better than finding out at the last moment, when you are unable to arrive in time for the surgery.
Once the graft has been released to us, we must implant it immediately, since the success of the
allograft replacement depends upon the presence of living cartilage cells. These have a limited life span,
and for this reason, we want to perform the surgery as soon as possible once the graft is released to us.
We therefore ask that once you are on the list, that you inform us immediately if your home or work
circumstances change such that you will not be able to go through with the surgery in the near future.

In a total ankle allograft replacement, an entirely new joint surface (made of bone and cartilage from a
fresh cadaver) is implanted instead of replacing the ankle joint with a replacement made of metal and
plastic. This essentially amounts to what can be considered a transplant of a new ankle, since the fresh
bone and cartilage is transplanted from a cadaver, replacing the arthritic ankle which is removed
completely. The advantage of this type of procedure is the potential for replacement of the entire ankle
joint with viable living cartilage cells. This procedure offers a unique alternative to the management of
ankle arthritis without “burning any bridges.” It is a procedure which is probably the most exciting of all
treatment options available for managing ankle arthritis, in that if it works, the patient has as normal an
ankle as possible under the circumstances.

Not everyone is a suitable candidate for this ankle transplant procedure. The patient who is ideally suited
for this operation is younger and much more active. Since the total ankle replacement works well,
particularly for the older individual, DR Myerson rarely uses the ankle transplant for the elderly more
sedentary individual. It is used more specifically for the younger patient who would normally require an
ankle fusion (arthrodesis), but for whom there are complicating features where an ankle fusion is not the
ideal operation. This is particularly the case in patients who have ankle arthritis in both ankles, where a
fusion of both ankles is really debilitating. The other scenario which is a problem is in the patient who
has arthritis of both the ankle and other additional joints in the back of the foot, so that if an arthrodesis
has to be performed, it would have to be more extensive.

The ankle allograft transplant operation requires a very specialized team of ankle reconstructive
surgeons as well as a good working bone bank to provide the donor graft required for implantation. What
happens with the patient who may be eligible for this procedure is that following a careful examination,
the size of the ankle is measured by computer analysis, and the measurements are then sent digitally to
a company which harvests the ankle from a cadaver. Extremely strict precautions are taken to ensure
that this process is completely sterile, and that there is no infection possibly present in the transplanted
tissue. The infection screening process is even more rigorous than that taken by companies which are
involved in blood transfusions.

Once the ankle has been measured, the data is sent to the tissue bank, which then begins a search for
the exact size. Unfortunately this can take some time, and patients may have to wait for more than six
months until the correct size has cleared the screening process. The recovery after the ankle allograft
transplant is very similar to that after total ankle replacement. Interestingly, there is no rejection of the
graft as may occur in other transplant cases, since the volume of tissue transplanted has little
immunogenic potential. In the cases performed thus far there has not been any immune response or
rejection of the implanted material. Below is an example of the surgical procedure.

Above on the left is a cutting jig which is used to harvest the ankle joint from the cadaver ankle. The
block is fixed on to the cadaver and the precise cuts are made to remove the ankle joint which is then
implanted as can be seen on the right hand picture, with a healthy new ankle in place.

In the above pictures, the ankle allograft transplant is being checked. The up and down movement of the
ankle is being tested, and one can see that normal motion of the ankle has been established for this
patient.

Distraction Ankle Arthroplasty

In this treatment for ankle arthritis, a small cage is put on the inside of the ankle and the ankle joint is
stretched apart. The arthritis in the ankle is then cleaned out and the joint is lined or resurfaced with a
membrane that is taken from cadaver tissue. The membrane is approximately 1.5 millimeters thick and
is implanted to cover the entire surface of the talus.
 These pictures show the appearance of an XR with
ankle arthritis on the left, and the open ankle after the
arthritis has been removed on the right. The ankle
joint is covered with a membrane obtained from the
tissue bank.

The concept behind this procedure is to stretch the ankle joint, rest the surface of the cartilage of the
tibia and resurface the talus with a membrane. Although the membrane is not living there is the potential
for growth of scar cells into this membrane that may then permit some gliding motion of the ankle. This
procedure is clearly not as satisfactory as either an ankle arthrodesis or a joint replacement. It is viewed
as an interim alternative before either of the other two operations is performed. Following surgery, the
fixator is left on for approximately eight weeks. Movement exercises of the ankle are initiated during this
recovery process to begin the return of movement to the ankle joint.

Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome is when the main nerve that goes to the foot gets squeezed. You may be
familiar with a similar condition in the wrist, Carpal Tunnel Syndrome. Tarsal tunnel syndrome is the
result of swelling and scarring on the back of the ankle, sometimes aggravated by the shape or deformity
of the foot. The symptoms include tingling, burning, numbness and vague aching and pain on the inside
of the ankle radiating down to the arch of the foot.

The diagnosis of this condition is made by specific palpation over the nerve that is very uncomfortable
and sensitive. Frequently, a Nerve Conduction Test, which measures the electrical conduction of the
nerve over the ankle, is performed to confirm the diagnosis.

Treatment of Tarsal Tunnel Syndrome includes rest, physical therapy treatments and medication. Rest
entails immobilization of the ankle in a brace, boot or a cast. In certain conditions aggravated by an
excessive flat foot or pronation of the foot, an orthotic arch support is helpful. Sedative medications that
decrease the electrical activity of the nerve are frequently prescribed.

If these treatments do not relieve symptoms, surgery (Tarsal Tunnel Release) may be performed. An
incision is made behind the ankle and a ligament that compresses the nerve is released. This decreases
the pressure on the nerve by the overlying ligament. Following surgery a removable boot is worn for
approximately four weeks. Physical therapy will decrease the swelling and scarring over the nerve.

HAMMER TOES

Corns, Calluses and Pain May Indicate Joint Problems

Many disorders can affect the joints of the toes, causing pain and preventing the foot
from functioning as it should. People of all ages can have toe problems, from infants born
with deformities, to older adults with acquired deformities.
 The major culprit of toe deformities in adults is tendon imbalance. When the natural
function of the foot is disrupted (through a variety of causes), the tendons may
stretch or tighten to compensate. Thus, people with abnormally long toes, flat feet
or high arches have a greater tendency to develop toe deformities.

Arthritis that slowly destroys the joint surface is another major cause of discomfort and
deformity. Toe deformities also can be aggravated by restrictive or ill-fitting footwear
worn for a prolonged amount of time. Or, problems with toe position may occur if a
fractured toe heals in a poor position.

Common Deformities

The most common digital deformities are hammertoes, claw toes, mallet toes, bone
spurs, overlapping and underlapping toes, and curled toes.

These deformities may or may not be painful. Corns and calluses - a buildup of skin on
the affected joint, often associated with bursitis (inflammation of small pouches, called
bursas, which lie above the joint between the tendon and skin) - are perhaps the most
noticeable and bothersome symptoms. If deformities are left untreated, the toe's mobility
may become limited, and more serious problems, such as skin ulceration and infection,
may develop.

Hammertoes

A hammertoe may be flexible or rigid, and may occur on any of the lesser toes.
Ligaments and tendons that have tightened cause the toe's joints to buckle, cocking the
toe upward. Shoes then rub on the prominent portion of the toe, leading to inflammation
or bursitis. Corns and calluses soon form.

During the early stages, a hammertoe remains flexible, meaning it will straighten when
pressure is applied to the buckled area. As time passes, the toe can become permanently
buckled or rigid, requiring surgery for correction. Painful calluses on the bottom of the
foot may accompany rigid hammertoes because of pressure generated on the joint.

Mallet Toes and Claw Toes

Mallet Toe Claw Toe

Mallet toes and claw toes are similar in appearance to hammertoes, but joints at different
locations on the toe are affected. The joint at the end of the toe buckles in a mallet toe,
while a claw toe involves abnormal positions of all three joints of the toe.

Bone Spur

A bone spur is an overgrowth of bone that may occur alone or along with a hammertoe.
Pain, corns and calluses are the major symptoms. Left untreated, a bone spur may
eventually be accompanied by bursitis or small skin ulceration.

Overlapping and Underlapping Toes

 Any one of the toes can overlap or underlap, pushing on adjacent toes
and causing irritation.

Overlapping or underlapping of the fifth toe is a common congenital problem that is

easily corrected in children. Bunions can cause the second toe to overlap in adults.

Pain, inflammation and small corns or areas of built up tissue may result. This deformity
also can interfere with the normal function of the foot, and if left untreated, may lead to
enlargement of bone or bone spur formation.

Treatments for Toe Deformities

Any toe problems that cause pain or discomfort while walking should be given prompt
attention by a podiatric surgeon. Ignoring the symptoms can aggravate the condition,
and over time may lead to an infection, a breakdown of tissue or ulceration. For people
with poor circulation or an underlying medical problem, loss of the toe is possible.

Recommended treatments will vary depending upon the severity of the condition.

Conservative Treatments

For people who have minor discomfort, less advanced conditions or are unable to
undergo surgery, the symptoms may be treated conservatively (without surgery). This
usually involves:

 Trimming or padding corns and calluses.

 Wearing supportive orthotics (individually fitted plastic or leather inserts) in
shoes. This helps relieve pressure on toe deformities and allows the toes and
major joints of the foot to function more appropriately.
 Splints or small straps to realign the toe.
 Wearing shoes with a wider toe box.

In certain cases, anti-inflammatory medications may be injected to relieve pain and

inflammation. Medications have proven to be successful in relieving the discomfort
associated with bursitis.

Unfortunately, conservative treatments provide only temporary relief of symptoms - they

do not correct the deformity.

Surgical Treatments

When the deformity is painful or permanent, surgical correction is recommended to

relieve pain, correct the problem and provide a stable, functional toe. Some of the most
common surgical procedures are described below.

Depending on health status, surgery may be conducted on an outpatient basis at the

surgeon's office. The procedures are usually comfortably performed under local
anesthesia or with intravenous sedatives administered by trained anesthesia personnel.

Tenoplasty and/or capsulotomy refer, respectively, to the release or lengthening of

tightened tendons and ligaments that have caused the joints to contract. In some flexible
hammertoe cases, the toe straightens out after these soft tissue structures are
lengthened or cut and relaxed. Surgery relieves pain and improves the toe's mobility.
 Tendon transfer, another treatment for a flexible hammertoe deformity, involves
the repositioning of a tendon to straighten the toe.

During bone arthroplasty procedures, some bone and cartilage is removed to correct
the deformity. A small portion of bone is removed at the joint, eliminating pressure on
the toe, relieving pain and straightening the digit. The tendons and ligaments
surrounding the joint also may be reconstructed. Multiple digits can be operated on
simultaneously in certain cases.

Derotation arthroplasty is a variation of arthroplasty used to realign the toe. A small

wedge of skin is removed and the toe is properly positioned. The surgeon also may remove a
small amount of bone, and will repair the toe's tendons and ligaments.

Implant arthroplasty is similar to arthroplasty in that a small portion of bone is

removed. A silicone rubber or metal implant specially designed for the toe is inserted to
replace the gliding surfaces of the joint and to act as a joint spacer. Implant arthroplasty
helps maintain toe length while relieving pain, and realigning and stabilizing the joint.
Implants may be recommended when previous surgery has left the toe improperly
positioned or without skeletal support.

Fusion of the toe is most often used to correct toe fractures or, like implant arthroplasty,
to increase the stability of the toe after arthroplasty. After the bone ends are removed,
they are positioned together and compressed so that the bones unite.

Fusions may be stabilized with a stainless steel pin as the bone heals. Care must be
taken to avoid any impact that would damage or break the pin after surgery. Pins
typically remain in place for approximately five to eight weeks.

Care After Surgery

Some swelling, stiffness and limited mobility can be expected following surgery,
sometimes for as long as eight to twelve weeks.

Keeping the foot elevated above heart level and applying ice packs will help reduce
swelling during the first few days after surgery. Many people can walk immediately
afterward, although the podiatric surgeon may restrict any such activity for at least 24
hours.
Wearing a splint or surgical shoe for the first two or three weeks after surgery is
recommended. The shoe protects the foot and helps properly disperse body weight.
Stitches, if present, must be kept dry until removal - generally seven to ten days
following surgery.

Total Ankle Arthroplasty

By Steven L. Haddad, MD

Improved prosthesis designs have sparked renewed interest in ankle

joint replacement procedures for the treatment of trauma,
osteoarthritis, and rheumatoid arthritis.
Ankle arthritis is generally seen as a sequela of one of the following conditions: trauma, osteoarthritis,
and rheumatoid arthritis. Since the turn of the 20th century, ankle arthrodesis has been considered the
definitive treatment for this disorder when all other treatment modalities failed. Explorations into joint
replacement surgery for end-stage disease began in the 1970s, with most early prostheses meeting
failure from subsidence, wear, and loosening within a few years following implantation. Rates of
loosening with these cemented designs ranged from 25% to 75% within 3 years. 1-4 Poor results lead
most surgeons to abandon implant arthroplasty and return to ankle arthrodesis as their treatment of
choice for the severely arthritic ankle.

Recently, there has been renewed interest in ankle arthroplasty, fueled by two separate design
rationales as second-generation prostheses. One such design incorporates a fusion of the
syndesmosis to share the load between the distal tibia and fibula. The second design principle is a
three-component, mobile-bearing implant. Both have shown survivorship rates of 93%, rejuvenating
interest in this treatment modality.

THE CASE: A PATIENT WITH ANKLE OSTEOARTHRITIS

A 57-year-old male presented with a 15-year history of primary

ankle osteoarthritis, having undergone ankle arthroscopy with
debridement 10 years prior to presentation. He is an extremely
active individual, enjoying hiking, fishing, bicycling, and golf,
and wished to maintain this lifestyle following corrective surgery.
His ankle pain was significant enough to wake him up at night,
and limited his activities during the day. His pain scale was
routinely 8/10, with 10 being pain significant enough to request Figures 1a,b. Preoperative radiographs,
an amputation of the extremity. He had refused an ankle fusion weight-bearing, of the involved ankle.

in the past for fear of limiting the activities he enjoys.

He presented with severe pain and crepitation across the dorsum of the ankle joint. He had specific
tenderness over his medial malleolus where a stress fracture had been diagnosed. His motion was
limited to 5 degrees of dorsiflexion and 15 degrees of plantar flexion. His opposite extremity range of
motion measured 15 degrees of dorsiflexion and 45 degrees of plantar flexion. His mechanical
alignment revealed a very mild valgus deformity.
Radiographs are noted in Figure 1.

He underwent total ankle arthroplasty and syndesmotic

fusion, in combination with a Hoke Achilles tendon
lengthening and open repair of the medial malleolar
stress fracture (to prevent a complete fracture from
developing) on September 11, 2001. He began physical
therapy for passive and active range-of-motion Figures 1c,d. Preoperative CT scan, involved
ankle.
exercises at 3 weeks postoperatively, and began full weight-bearing in a controlled ankle motion boot
locked at neutral at 6 weeks postoperatively following radiographic confirmation of syndesmotic fusion.
The boot was discontinued at 3 months following surgery, and aggressive walking and cycling were
encouraged. By 4 months postoperative, he had achieved 15
degrees of dorsiflexion and 40 degrees of plantar flexion in
physical therapy, and returned to golf and cycling. In the clinic,
he was noted to walk barefoot without a limp. Radiographs and
a clinical photo are presented in Figure 2.

He suffered one setback with acute cellulitis developing 9

months post-operative, which was related to a tinea infection in
his foot. This resolved with a short course of intravenous
antibiotics, and has not recurred. Currently, at one and a half Figure 2a,b. Weight-bearing radiographs
years following surgery, the patient enjoys a very active of the prosthetic that resurfaces the
lifestyle. He recently returned from an aggressive hiking and ankle joint medially, laterally, and
superiorly, obtained 4 months
fishing trip in Patagonia where he was able to perform unlimited postoperatively.
hiking at steep elevations and fish in rocky creek beds (Figure
3). He participates in all activities without pain.

DISCUSSION

There is no defined age where total ankle arthroplasty is considered

appropriate for an individual, though most surgeons use the age of 50
years as a benchmark for implantation. However, there are many
circumstances (ie, severe rheumatoid disease) where ankle arthroplasty
may be appropriate in a younger patient, though it is incumbent upon the
surgeon to educate the individual about potential future surgeries.
Accepted contraindications for this procedure are active infection,
avascular necrosis of the talus or tibia (affecting bone ingrowth), and a
Charcot neuropathic ankle joint. Figure 3. Patient on a recent
hiking and fishing trip in
Patagonia.
Though there are a variety of ankle implants available in the United
States, there are currently two prostheses used in volume. The first
resurfaces the ankle joint medially, laterally, and superiorly. This prosthesis requires the conversion of
a three bone ankle into a two bone ankle through fusion of the syndesmosis (Figure 4). It is FDA-
approved for cement implantation only, though most surgeons
implant this prosthesis as an ingrowth device. The second
prosthesis resurfaces the superior ankle, and requires a mobile-
bearing polyethylene component to enhance mobility of the ankle
while limiting bone resection (Figure 5). It is currently undergoing
an extensive FDA trial.

As noted, both prostheses rely on bone ingrowth for fixation,

attempting to resolve one of the major factors leading to early
implant failure in previous ankle designs, that being cement
implantation. There are a number of theoretical advantages to
bone ingrowth prostheses over those that require cement: bone
resection is minimized by direct contact between the prosthesis
and nascent bone; cement contact with the surrounding soft Figure 2c. Dorsiflexion ankle
tissues (creating thermal necrosis) or bone (creating impingement) following arthroplasty.
is avoided; and accelerated third body wear from cement
fragmentation is avoided.

COMPARING PROSTHESES’ FEATURES

Both prostheses are semiconstrained, again building on the failures of the earlier constrained and
unconstrained prostheses of the 1970s and 1980s. The prosthesis that resurfaces the ankle joint
medially, laterally, and superiorly becomes semiconstrained through the smaller width of the talar
component compared to the tibial polyethylene. The prosthesis that resurfaces the superior ankle
becomes semiconstrained through the separate articulations between the tibial tray and polyethylene
and the talar component and polyethylene. Theoretically, such
semiconstrained designs dissipate the shear forces across the ankle
that naturally occur with dorsiflexion and plantar flexion.

The major disadvantages of the prosthesis that resurfaces the ankle

joint medially, laterally, and superiorly over the prosthesis that
resurfaces the superior ankle are the larger amount of bone
resections necessary to implant the prosthesis, as well as the
required solid fusion of the syndesmosis for longevity. Resecting
more bone may make revision surgery more difficult due to less
bone stock, and conversion to an ankle arthrodesis (if the prosthesis
fails) would require a supplementary bone block to maintain leg
length. Conversely, the prosthesis that resurfaces the ankle joint
medially, laterally, and superiorly is more favorable than the Figure 4. FDA-approved prosthesis
prosthesis that resurfaces the superior ankle for the following for cement implantation. It is used
as an ingrowth device.
reasons: the increased surface area allowed by the syndesmotic
fusion may lessen subsidence of the tibial tray; the power of the
larger and more stable prosthesis allows better correction of deformity.

The major disadvantages of the prosthesis that resurfaces the superior ankle over the prosthesis that
resurfaces the ankle joint medially, laterally, and superiorly are the potential instability created by the
mobile polyethylene surface and the lack of resurfacing of the medial and lateral gutters. Instability
may create subluxation or even dislocation of the polyethylene. While the talar component does cover
both the medial ankle lateral portions of the talus in the prosthesis that resurfaces the superior ankle,
the tibial component does not do the same, leading to the potential for pain at the bone-metal interface
(similar to a hemi-arthroplasty in the hip). The primary advantage of the prosthesis that resurfaces the
superior ankle over the prosthesis that resurfaces the ankle joint medially, laterally, and superiorly is
the smaller amount of bone removed during implantation, making revision or conversion to arthrodesis
easier. In addition, stresses at the polyethylene-metal interface are
lessened by the mobile-bearing plastic, theoretically leading to less
wear and subsequent increased longevity.

Both prostheses have shown more-than-satisfactory results in

medium-term studies. The prosthesis that resurfaces the ankle joint
medially, laterally, and superiorly ankle underwent an independent
review by Pyevich and Saltzman6 in 1998. With an average 5-year
follow-up, 83% of patients reported no pain or mild pain with the
prosthesis, and 92% were either extremely satisfied or satisfied with
the procedure. Radiographic follow-up was at least 2 years,
revealing a 9% nonunion rate of the syndesmosis, and a 29%
delayed union rate (greater than 6 months following implantation).
Figure 5. The Scandinavian total
Though talar component migration and subsidence were
ankle replacement ankle
independent of syndesmotic union (or delayed union), 67% of those prosthesis.
tibial components demonstrating subsidence were directly affected
by the solidity of the syndesmosis. One patient out of the 100 studied required conversion to an ankle
fusion within the study period, and three talar and one tibial components required revision.

The prosthesis that resurfaces the superior ankle has been studied as both a cemented and
uncemented device. Kofoed and Sorensen7 reviewed 52 cemented ankle arthroplasties demonstrating
a 72.7% survival for an osteoarthritic group and 75.5% for a rheumatoid group at 14 years.
Hintermann8 studied 50 consecutive uncemented prostheses that resurface the superior ankle
between 1996 and 1999. Three patients required revision for painful lateral impingement at the
prosthesis-bone interface (seven in total required secondary surgery); 91% were very satisfied or
satisfied with the prosthesis. The total range of motion averaged 30 degrees with the prosthesis. No
migration or subsidence was noted in this short- and medium-term follow-up study.
A TIME FOR REHABILITATION

Rehabilitation following total ankle arthroplasty is tempered by wound healing. One of the more
frequent complications with either prosthesis is marginal or full-thickness necrosis of the surgical
incisions. The tenuous nature of the blood supply to the anterior ankle coupled with the lack of adipose
and subcutaneous tissue surrounding the deep structures creates a potential for wound complication.
We study every patient preoperatively with a noninvasive arterial Doppler test to ensure the blood flow
is adequate to the ankle. In addition, the incision is approximated with a running monofilament suture
to evenly distribute suture tension and avoid concentration of tension at the knots of an interrupted
suture.

Most often, a compromised surgical incision can be treated by moist dressing changes and local
wound care. Occasionally, however, free muscle transfer is required. Thus, this author delays
aggressive controlled range of motion of the prosthetic ankle for two to two-and-a-half weeks following
the procedure (motion is begun only when the wound is considered free of necrosis). The ankle is
rigidly splinted until that time, and the extremity is kept elevated to decrease swelling and lessen the
tension on the suture line.

Assuming a satisfactory wound, physical therapy is begun to aggressively reestablish the motion
achieved at surgery. The therapist must attempt to eliminate micromotion at the prosthesis-bone
interface through both axial compression and avoidance of varus/valgus stress. Bone ingrowth
generally takes 6 to 12 weeks, though there is some suggestion that hydroxyapatite-coated implants
create satisfactory ingrowth by 3 weeks following surgery.4 The physical therapist must also utilize
manual massage to lessen the scar contracture around the anterior tendons of the ankle. These
tendons are subcutaneous and are thus subject to this motion-restricting complication.

Weight-bearing is begun 6 weeks following surgery with either prosthesis, though it may be delayed in
the prosthesis that first resurfaces the ankle joint medially, laterally, and superiorly if syndesmotic
nonunion is present. Technically, this author has learned that syndesmotic union may be enhanced by
the addition of a noncontoured lateral (spring) plate to the fibula. This plate both increases
compression applied to the syndesmosis and creates increased medial force against the lateral wall of
the tibial tray, enhancing bone ingrowth. Following successful arthroplasty, patients are allowed to
resume normal physical activity at 3 months postoperatively.

Finally, supplementary procedures are frequently necessary in this often-complicated patient

population. A calcaneal osteotomy, gastrocnemius recession (or Hoke Achilles tendon lengthening),
plantar flexion arthrodesis of the first metatarsocuneiform joint, or lateral ligament reconstruction of the
ankle may all be done simultaneously with the arthroplasty procedure. If a triple arthrodesis is required
for severe foot deformity, that procedure is generally performed 3 to 6 months prior to the arthroplasty
to enable adequate time for successful fusion. This permits removal of potentially obstructing screws
around the talar component.
Steven L. Haddad, MD, is an assistant professor of clinical orthopedic surgery at Northwestern
University, and practices foot and ankle surgery with Illinois Bone and Joint Institute, Chicago.

References

1. Bolton-Maggs BG, Sudlow RA, Freeman MAR. Total ankle arthroplasty: a long-term review of
the London Hospital experience. J Bone Joint Surg Br. 1985;67:785.
2. Carlson AS, Henricson A, Linder L, et al. A survival analysis of 52 Bath-Wessex ankle
replacements. Foot. 1994;4:34.
3. Helm R, Stevens J. Long-term results of total ankle replacement. J Arthroplasty. 1986;1:271.
4. Kitaoka HB, Patzer GL. Clinical results of the Mayo total ankle arthroplasty. J Bone Joint Surg
Am. 1996;78:1658.
5. Saltzman CL. Perspective on total ankle replacement. Foot and Ankle Clinics. 2000;5:761.
6. Pyevich MT, Saltzman CL, Callaghan JJ, et al. Total ankle arthroplasty: two to 12 year follow-
up of a unique design. J Bone Joint Surg Am. 1998;80:1410.
7. Kofoed H, Sorensen TS. Ankle arthroplasty for rheumatoid arthritis and osteoarthritis:
prospective long-term study of cemented replacements. J Bone Joint Surg Br. 1998;80:328.
 8. Hintermann B. Short- and mid-term results with the STAR total ankle prosthesis. Orthopade.
1999;28:792-803.

DEFINITIONS & PROCEDURES

Ankle Arthroplasty

An arthroplasty is a surgical procedure in

which an artificial joint replaces a
damaged joint (See Figure 1.). An ankle
arthroplasty is an alternative to an ankle
joint fusion (arthrodesis). Your doctor will
determine if you are a candidate for a joint
replacement surgery or a fusion
(Performed by Orthopedic Surgeons).

Components or hardware
   in an Ankle Joint
replacement.
This is an x-ray of an ankle joint
replacement (ARTHROPLASTY).

DEFINITIONS & PROCEDURES

Joint Fusion or Arthrodesis

Injury to a joint or arthritis can cause pain when the foot moves. If you suffer from a
lot of pain and have severe joint destruction, your doctor may recommend a surgical
procedure called a fusion. This procedure is also known as an arthrodesis. Surgery
involved: (1) removal of the painful joint; (2) fusion of the two bones. The surgeon will
use screws and/or special brackets to help hold the bones together and in the correct
position while the joined bones heal.

It is important to understand that only the bones

involved in the fusion are solidly fixed. All of the
other joints in the foot will still move. For example, if
you have an ankle fusion your range of motion in
your ankle will decrease a lot. However, there are
many other joints (e.g. toes and arch) in your foot
and they will still be able to move.

Ankle Fusion: The damaged The ends of the bones are

cartilage is surgically removed joined together and held in
from the ends the talus, tibia place by scres. In time, new
and fibula (the blue-shaded bone forms and "glues" the joint
area). together.

Foot Fusion Types

Orthopaedic surgeons perform fusions in any region of the foot or ankle: forefoot
(green), midfoot (blue), hindfoot (orange) and ankle (yellow).

Operative podiatrists mostly perform forefoot fusions (green coloured bones)

More examples of specific types of foot fusions are listed below.

Simply click on a thumbnail image (below and on subsequent fusion pages) and
a larger picture will load separately in a new window.

*You must have the more recent versions of Microsoft Explorer or Netscape to
be able to view the pictures. Also, if you are running software such as "Pop-up
stopper", be sure to disable it because after all, these are pop-up windows.

Ankle: (ortho) fusion of the talus to the tibia; fibula to tibia. This fusion is shown on
the previous page with the "arrow in the middle" of the two diagrams.

Subtalar: (ortho) fusion of talus to calcaneus. (*Click on any of the three photos below
to enlarge)

Foot Fusion Types

Triple Arthrodesis: (ortho) fusion of talus to navicular; calcaneus to cuboid; and, talus
to calcaneus. (*Click on any of the photos below to enlarge)
Isolated calcaneus to cuboid: (ortho) fusion of calcaneus to cuboid. (*Click on any of
the photos below to enlarge)

Isolated talus to navicular: (ortho) fusion of the talus to the navicular. (*Click on any
of the photos below to enlarge)

Navicular/Cuneform: (ortho) fusion of the navicular to the cuneform. (*Click on any

of the photos below to enlarge)
Navicular/Cuneform: (ortho) fusion of the navicular to the cuneform. (X-rays taken of
above fusion) (*Click on any of the photos below to enlarge)

Foot Fusion Types

Tarsal Metatarsal Joint (TMT) Fusions: (Tarsal bones = cuboid + cuneforms (medial,
middle, lateral)).

1st TMT (pod and ortho): Medial cuneform to 1st metatarsal. (*Click on any of the
photos below to enlarge)

1,2 TMT (ortho): medial cuneform to 1st metatarsal; and, middle cuneform to 2nd
metatarsal. (*Click on any of the photos below to enlarge)
1,2,3 TMT Also known as a Lizfranc Fusion (ortho): medial cuneform to 1st
metatarsal; middle cuneform to 2nd metatarsal; and lateral cuneform to 3rd
metatarsal. (*Click on any of the photos below to enlarge)

1,2,3,4 TMT (ortho): medial cuneform to 1st metatarsal; middle cuneform to 2nd
metatarsal; lateral cuneform to 3rd metatarsal; and, cuboid to 4th metatarsal.

1,2,3,4,5 TMT (ortho): medial cuneform to 1st metatarsal; middle cuneform to 2nd
metatarsal; lateral cuneform to 3rd metatarsal; and, cuboid to 4th & 5th metatarsals.
(*Click on any of the photos below to enlarge)

Foot Fusion Types

Metatarsal to Phalanx: 1st MTP (pod and ortho): 1st metatarsal to 1st proximal
phalanx.

Interphalangeal ("IP" Fusions): Proximal Interphalangeal (PIP):

1st PIP (pod & ortho): 1st proximal phalanx to 1st distal phalanx.
2nd PIP (pod & ortho): 2nd proximal phalanx to 2nd middle phalanx. (*See 2nd PIP
example below for x-ray).
3rd PIP (pod & ortho): 3rd proximal phalanx to 3rd middle phalanx.
4th PIP (pod & ortho): 4th proximal phalanx to 4th middle phalanx.
5th PIP (pod & ortho): 5th proximal phalanx to 5th middle phalanx.

(*Click on any of the photos below to enlarge)

 1st PIP 2nd PIP 3rd PIP 4th PIP 5th PIP

2nd PIP (pod & ortho) example: 2nd proximal phalanx to 2nd middle phalanx.(*Click
on any of the photos below to enlarge)

DEFINITIONS & PROCEDURES

Tendon Transfers

A tendon transfer involves release of one end of a tendon from bone or soft tissue
and its reattachment to another bone or tendon.

A tendon transfer is used when a muscle or group of muscles are weak, torn or
paralyzed. The transfer can correct: a flat foot, high arch, clawed toes, a drop foot or
a weak heel cord ( Achilles Tendon).

An example of a common tendon transfer is the "Tibialis Posterior Tendon to the

Tibialis Anterior Tendon. This transfer is used to correct a "drop foot" resulting from
nerve injury.
DEFINITIONS & PROCEDURES

Osteotomy

An osteotomy is a surgical procedure whereby a cut is made through a

bone. The pieces of bone are then removed, or repositioned. Sometimes
when the pieces are repositioned, they will no longer appear aligned. Notice
the overlapping pieces of bone in the illustration. In time, new bone growth
will fill in the areas that do not overlap. Lower limb and foot osteotomies will
change the shape of the foot and reduce the pain originally created by the
deformity. Here is a general list of the osteotomies performed by BC Foot
and Ankle Specialists:

This picture illustrates the steps involved in an osteotomy: (1) original

foot (2) bone cut (3) fragment repositioned (4) bone fragment fixed in
place with screws.
Tibial osteotomy (ortho)

Fibular osteotomy (ortho)

Calcaneal osteotomy (ortho)

Metatarsal osteotomies: 1st, 2nd, 3rd, 4th & 5th metatarsals (ortho & pod):

Here are preoperative and postoperative pictures of a patient who has

undergone osteotomies in both feet.

This is an x-ray of a calcaneus osteotomy and also a joint replacement.

  

The Journal of Bone and Joint Surgery (American). 2006;88:303-308.

doi:10.2106/JBJS.E.00033
© 2006 The Journal of Bone and Joint Surgery, Inc.

Autologous Chondrocyte Transplantation for Treating

Cartilage Defects of the Talus
M.H. Baums, MD1, G. Heidrich, MD1, W. Schultz, MD1, H. Steckel, MD1, E. Kahl, MD1
and H.-M. Klinger, MD1
1
Departments of Orthopaedic Surgery (M.H.B., W.S., H.S., E.K., and H.-M.K.) and Radiology (G.H.), Georg-
August University Göttingen, Robert-Koch-Strasse 40, D-37075 Göttingen, Germany. E-mail address for M.H.
Baums: mike.baums@freenet.de

Investigation performed at the Departments of Orthopaedic Surgery and Radiology, Georg-August University
Göttingen, Göttingen, Germany

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and
on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
The authors did not receive grants or outside funding in support of their research for or preparation of this
manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits
to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which
the authors are affiliated or associated.

Background: Despite its highly specialized nature, articular cartilage has a poor reparative
capability. Treatment of symptomatic osteochondral defects of the talus has been especially
difficult until now.

Methods: We performed autologous chondrocyte transplantation in twelve patients with a

focal deep cartilage lesion of the talus. There were seven female and five male patients with a
mean age of 29.7 years. The mean size of the lesion was 2.3 cm2. All patients were studied
prospectively. Evaluation was performed with use of the Hannover ankle rating score, the
American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a visual
analogue scale for pain, and magnetic resonance imaging.

Results: All patients were available for follow-up at a mean of sixty-three months. There was
a significant improvement in the Hannover score, from 40.4 points preoperatively to 85.5
points at the follow-up examination, with seven excellent results, four good results, and one
satisfactory result. The AOFAS mean score was 88.4 points compared with 43.5 points
preoperatively. Magnetic resonance imaging showed a nearly congruent joint surface in seven
patients, discrete irregularities in four, and an incongruent surface in one. The patients who
had been involved in competitive sports were able to return to their full activity level.

Conclusions: The promising clinical results of this study suggest that autologous chondrocyte
transplantation is an effective and safe way to treat symptomatic osteochondral defects of the
talus in appropriately selected patients.

Foot and Ankle Surgery

Volume 8 Page 285  - December 2002
doi:10.1046/j.1460-9584.2002.00337.x
Volume 8 Issue 4

 
 
Case report
Initial presentation of gout at the site of silicone interpositional
arthroplasty
S. Mulay* and R.A. Power†
 Summary

Gout is known to occur occasionally at the site of trauma and has been reported in association
with hip and knee arthroplasty. The initial presentation is similar to that of an infected joint and
may be associated with loosening. Here we present a case of gout as an initial presentation, in
association with silicone interpositional arthroplasty of the first metatarsophalangeal joints,
which to the best of our knowledge is the first reported case. Why gout should initially present at
the site of arthroplasty is not known; however, it is possible that the abnormal tissue
 surrounding the joint replacement allows the build-up of urate crystals at a time when the gout
is still in its subclinical phase.

Image Previews

[Full Size]

Figure 1 X-ray of the right first metatarsophalangeal joint with the silicone interpositional
arthrop...

[Full Size]

Figure 2 Low power (100x) histology of the synovium showing the amorphous material in the
synovium ar...

[Full Size]

Figure 3 High power (400x) histology of the synovium showing the amorphous material in the
synovium a...

 Introduction Go to:
 Gout is a disease characterized by the deposition of monosodium urate crystals in synovial fluid as a result of
either overproduction or undersecretion of uric acid. Clinical manifestations include acute and chronic arthritis,
tophi, interstitial renal disease and uric acid urolithiasis [1,]. Hyperuricaemia and identification of urate crystals
in synovial fluid are diagnostic [2].

We present a case report of initial presentation of gout at the site of silicone arthroplasties
of both first metatarsophalangeal joints.

 Case report Go to:

A 60-year-old woman presented with pain and swelling of both metatarsophalangeal joints. Fourteen years
previously she had undergone bilateral silicone replacement arthroplasty for hallux rigidus. There was no
other history of joint pain or swelling. On examination, both metatarsophalangeal joints had synovitic swelling
extending proximally along the line of extensor hallucis longus tendon. Radiographic examination revealed
extensive osteolysis around the pegs of both prostheses (Figure 1).

The patient underwent surgical removal of both implants to leave a pseudarthrosis. At surgery there was
extensive tophaceous-looking material surrounding both implants and extending along the tendon of extensor
hallucis longus.

Histological examination of the tissue removed showed amorphous material within the synovium which was
arranged in small clumps [Figures 2 and 3]. Microscopic examination of the fluid aspirate showed no organisms.
Examination under polarized light revealed needle shaped bi-refringent crystals characteristic of gouty
arthropathy.

The patient made an uneventful recovery with resolution of pain and swelling. However,
6 months later she presented with multiple joint pains affecting predominantly both feet,
ankles and knees. There was a mild effusion in both ankles and knees. The erythrocyte
sedimentation rate was raised at 50 mm/h, the C-reactive protein was raised at 77 mg/L
and the serum uric acid was raised at 726 micromol/L. A diagnosis of acute gout was made
and she was commenced on non-steroidal anti-inflammatory medication, colchicine and
prednisolone. This was associated with rapid improvement of symptoms.

 Discussion Go to:

Gout is known to occasionally present at the site of trauma [2]. Acute gouty arthropathy has also been
reported in association with both hip and knee arthroplasty [3,4]. The usual presentation is of acute pain and
swelling, similar to that of an infected joint, from which it should be differentiated [4]. There may also be
loosening of the joint, although it is not possible to decide whether gout is the primary cause of the loosening
or is a secondary event [5]. To the best of our knowledge this is the first reported case of gout in association
with silicone arthroplasty.

Why gout should present initially in this way is not clearly understood. It is possible that, in the presence of
otherwise sub-clinical gout, the abnormal synovial tissue surrounding a joint replacement allows the build-up
of urate crystals in the joint which then in itself gives rise to further inflammation and the clinical symptoms
described.

When acute pain and swelling occurs in association with a joint replacement, and infection has been
excluded, a diagnosis of gout should be considered.

 
 References Go to:
  1    Kelly W, Wortmann R. Gout and Hyperuricaemia. In: Kelly W, Ruddy S, Harris E et al. Eds, Textbook
of Rheumatology 5th edn, Vol. 2. Philadelphia: W.B. Saunders Company, 1997: 1313–1351.
   2    Scott J. Gout. In: Scott, J, Ed. Copeman's Textbook of the Rheumatic Diseases, 5th edn. New York:
Churchill Livingstone, 1978: pp. 647–691.

  3    Healey J, Dines D, Hershon S. Painful synovitis secondary to gout in the area of a prosthetic hip joint:
A case report. J Bone Joint Surg (Am) 1984; 66A: 610–611.
   
  4    Williamson S, Roger D, Petrera P et al. Acute gouty arthropathy after total knee arthroplasty. A case
report. J Bone Joint Surg (Am) 1994; 76: 126–128.
 
  5    Ortman B, Pack L. Aseptic loosening of a total hip prosthesis secondary to tophaceous gout: A case
report. J Bone Joint Surg. (Am) 1987; 69A: 1096–99.
   

 
 
Foot and Ankle Surgery
Volume 8 Page 285  - December 2002