1	Ankle and Foot Surgery general aspects Jan Willem Louwerens Foot and Ankle Reconstruction Unit Nijmegen The Netherlands
2	Outline presentation ankle to forefoot standard surgical procedures indications and results selected new developments
3	Ankle joint End stage secondary arthrosis Not about conservative measures WHAT is the standard surgical procedure ? Total ankle replacement, TAR Ankle arthrodesis open technique arthroscopically percutaneous/ nearly closed
4	Advantage TAR patients with RA benefit most mean 30 degrees motion even with ankylosis of distal joints relatively normal walking beneficial for adjacent joints in literature: no statistical significant difference of scores between RA and OA
5	TAR, Results Revision for any reason as end point, estimated survival rate: between 70% after 5 years and at best 90% after 10 yrs. Rates of failures, including revisions and radiographic evidence of loosening: 16% - 42%
6	Survivorship analysis, remark: Endpoint determined as being the time of revision or conversion to an arthrodesis
7	TAR, results, considerations technically demanding procedure long learning curve high rate of early and late complications
8	TAR, results, considerations
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10	TAR, results, considerations functional scores not 100% roughly 70 – 85 on scale up to 100 up to 80% no or mild pain the other 20% pain! up to 10% not satisfied motion pre-op. relates with post-op. less motion in case of fused tarsus
11	Don’t forget the ankle fusion longer follow-up (7, 10 & 20 yrs. ) near all, return activities daily living good clinical outcome 80 of 100 no significant difference regarding the quality of life
12	Don’t forget the ankle fusion 77% supportive walking shoes without modification 12% able to run one block at the least 26% of motion in sagittal plane non-union < 10% in literature: ca. 20% (0% - 40%) deep infection: 1% malalignment: 5%
13	Ankle fusion, no other options: deformity/instability ‘salvage’ infection necrosis failed TAR bonestock soft tissue
14	CT scanning: severe malalignment & poor bone
15	Ankle fusion, however: 11% NOT satisfied pain non-union infection loss mobility arthrosis subtalar & tarsal joints !!
16	Individualize the choice Find out if the patient is suitable for TAR, individualize the choice. Is the patient compliant enough?
17	What about the other joints? < 5 yrs 8% > 5 yrs 25 % talonavicular: 39% subtalar: 29% calcaneocuboid: 25%
18	Different patterns Secondary arthrosis Ankylosis Deformity
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20	Typical deformity
21	goals surgery: plantigrade, neutral, foot foot must fit in a (custom made) shoe stand & walk without pain or with only mild pain optimize the situation for the adjacent joints
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23	Isolated subtalar fusion
24	triple arthrodesis, results Bennet GL et al. Foot Ankle 1991 Figgie MP et al. Clin Orthop 1993 Graves SC, Mann RA. JBJS 1993 Sangeorzan BJ et al. Clin Orthop 1993 Sangeorzan BJ et al. Foot Ankle 1993 Horton GA and Olney BW. Foot Ankle 1995 Bednarz PA et al. Foot Ankle 1999 Pell RF, Myerson MS, Schon LC. JBJS 2000
25	triple arthrodesis, results ‘satisfaction rate’ round 80% categories > good : 75%-85% walking with mild acceptable pain increase walking distance 80% less problems with shoe
26	Own results, n=90, 2002-2003 18 RA, 38 NM Satisfaction 75/17/8 Subjective improvement 95% Procedure again 93% Custom made shoe no longer neccesary 37 pat. Ankle function, mean 6⁰ – 0 ⁰- 26⁰ AOFAS hind foot score 74
27	AOFAS score in literature Pell RF JBJS 2000 vol 82-A;1:47-57 AOFAS hindfoot score 60,7 FU 5,7 years Bednarz PA Foot & Ankle int. 1999 vol 20;6:356-63 AOFAS hindfoot score 81 FU 2,5 years
28	Foot Function Index
29	Own results: complications 17% Non-union 1 pt Malalignement of hindfoot 5 pt Deep infection 1 pt Superficial infection 5 pt Neuropathy of sural nerve 6 pt Stress fracture MT 1 1 pt Malposition of screw 2 pt
30	This does not help
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32	realignment is important
33	Advise earlier intervention?
34	Advise earlier intervention?
35	Advise earlier intervention?
36	MP joints, first and most common location RA
37	reumatoid forefoot deformity
38	Hoffman 1912, Keller 1904
39	M.L. Clayton, Arthritis Rheum 1959 saw good functional results after forefoot amputation resection caput MT1 excision MT heads + base proximal phalangeal bones, ARCH- vormig all rays, ‘all or none’ approach both feet 85% - 90% good results, 10% reop.
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41	Literature Clayton. Arthritis Rheum 1959, Clin Orth 1960 Vahvanen et al. Scand J Rheumatol 1980 Mann & Thompson JBJS 66A 1984 Cracchiolo et al. JBJS 74A 1992 Moeckel et al. JBJS 74A 1992 Tillmann. Clin Orthop 1997 Coughlin. JBJS 82A 2000
42	Discussion concerning 1st ray Resection arthroplasty (Keller, Brandes) Residual deformity, floppy hallux Less stable, less weightbearing capacity Fusion MP1 Joint replacement (more reinterventions)
43	Fusion MP1 generally advised
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45	Should we continue like this? actually an internal amputation lesser rays shortened, loss of function, plantar plate and aponeurosis patients are satisfied, no more pain but what do we no about the function could we perhaps do better?
46	Briggs & Stainsby, Foot Ankle Surg. 2001
47	Why not reposition ?
48	Why not reposition ?
49	Why not reposition ?
50	More research warranted
51	prospective randomized study
52	Thank You