CHICAGO (Ivanhoe Newswire) — More than 50 million Americans suffer from some form of arthritis. Between 6 percent and 13 percent of them have ankle arthritis.
These patients feel pain with every single step they take, but now ankle replacements are giving patients a new lease on life.
Diane Shaughnessy knows the pain of ankle arthritis.
“It’s as if a vice was constantly being turned and squeezed.” Shaughnessy told Ivanhoe, “Go to bed with pain, sleep with pain and wake up with pain.”
Joey Meyer has had similar experiences. “It was grinding. Sometimes, it would catch, and I’d just drop to my knees.” Meyer explained, “Life was not a whole lot of fun.”
Doctors used to fuse ankles to relieve the pain, but that meant very limited mobility. Now there’s ankle replacement surgery.
With an ankle replacement, surgeons remove abnormal bone and cartilage and insert a metal and plastic implant. Newer implants mimic the human ankle and allow for better rotation and movement. Doctors can also treat more patients with a variety of injuries. In fact, between 2011 and 2012, the number of ankle replacements doubled.
After a replacement, patients can enjoy almost any low impact activity, but running is not recommended.
“For me, it’s very gratifying to restore function instead of just improving upon abnormal function.” Johnny Lin, MD, Orthopedic Surgeon at Midwest Orthopedics at Rush, told Ivanhoe.
Now, Shaughnessy and Meyer can enjoy life without pain.
“I walk. I do the elliptical. I ride the bike, I mean I do a lot of things now, and the ankle’s fine.” Meyer said.
Doctors believe ankle replacement will last about 15 to 20 years which is what any joint implant is expected to last.
Candidates are those over 50 years of age with severe arthritis that doesn’t respond to medications. Patients cannot be severely overweight to qualify for the procedure.
ANKLE ARTHRITIS: Arthritis is a chronic condition that causes pain, swelling and stiffness in the joints of many over the age of 50. Arthritis can form in the ankle when the ankle has damaged or worn cartilage. Ankle arthritis can be a serious condition that causes pain in every step you take and can cause the ankle to lock up, severely limiting one’s mobility. The ankle is composed of three bones, the tibia, fibula and talus. These three bones come together to create the connecting joint between the leg and foot. Arthritis can form in any of these ankle bones and can occur as a part of rheumatoid arthritis or stem from a physical injury. (Source: www.orthop.washington.edu)
TREATMENTS: The current, most common treatment option for dealing with ankle arthritis is medication. Arthritis medications work to slow pain and stiffness, prevent joint damage and relieve inflammation. Many anti-inflammatory medications can be purchased over-the-counter and are used for all types of arthritis, not just in the foot and ankle. Analgesics are commonly prescribed medications that focus only on relieving pain and are used to treat many forms of arthritis and injuries. For patients with more serious conditions, medications may not be enough and surgery may be necessary. An ankle fusion is a procedure done to ease pain by removing the surface of the joint affected by arthritis and using screws and bolts to join bones until they fuse together. While this procedure is effective in reducing pain in the ankle, it also reduces mobility by keeping the ankle from moving side-to-side and up-and-down. (Source: www.arthritistoday.org)
NEW TECHNOLOGY: A new procedure can now ease pain from ankle arthritis without limiting the ankle’s mobility. Total ankle replacement is done by removing the damaged bone and cartilage through a surgical cut in the ankle and replacing it with prosthetic parts. These replacement ankle parts are expected to last around 20 years. Since 2012, the number of total ankle replacement surgeries has doubled as doctors have become more accustomed with the procedure and patients spread positive word of mouth. (Source: www.nlm.nih.gov/medlineplus)
Simon Lee, M.D., Orthopedic Surgeon, Midwest Orthopaedics at Rush University talks about ankle replacements are giving patients a new lease on life.
In the last year ankle replacements across the United States have doubled. Why is there suddenly this new interest in it?
Dr. Lee: I finished my fellowship 10 years ago and that was probably the beginning of when total ankle replacement started finally making a comeback. So if you review the history of total ankle replacements, they’ve gone through several generations. It’s trial and error unfortunately in some cases for patients and the last generation of ankle replacements was basically completely abandoned. We don’t use the old prostheses anymore at all and this new generation of implants is incorporating a lot of new modern technologies and techniques. The new generation is also, to some degree, borrowing and taking the trial and error and advances in traditional ankle or traditional replacements like total knees and total hips, and finally incorporating them into total ankles. That’s why we’ve been much more successful. I think people have found that while they were doing them preliminarily in some patients, with the successes we’ve seen suddenly they’re kind of catching on and everyone is jumping on the bandwagon.
What about outcomes, how long ago did you do the first one?
Dr. Lee: My first total ankle replacement was probably 10 years ago and it was the older version of this new generation of implants. That implant is not even on the market anymore.
Do you follow that patient still?
Dr Lee: Yes I still see that patient. I think that relatively they’re doing okay, better than they were, but alternatively you almost wish it was a take back. You wish you could do it again in terms of seeing that patient with the newer implants and newer technology. Ultimately I think that’s an important thing about total ankle replacements. You don’t want any part timer or someone who dabbles in total ankle replacement. You want someone who is truly focused and concentrating on the technique, concentrating on outcome, really focusing on what can make this technology and this procedure better. If you have a failure or an unfortunate outcome, you can learn from that and incorporating that into the next patient and the next treatment regimen. So being at a major academic referral center where we’re constantly on the cusp and following these things, I think is important for patients.
If I came to you, how would you encourage me to have an ankle replacement?
Dr. Lee: The traditional gold standard as we say for end-stage ankle arthritis is typically with fusion. 10 or 20 years ago, any orthopedic surgeon you ran into or any foot and ankle specialist you ran into would tell you it’s time to fuse your ankle. The total ankle replacements are making that comeback and ideally and theoretically as well as from a functional standpoint. Total ankle replacements should be the gold standard. Ultimately, what I tell people at this point is total ankle replacements are a little bit like the electric car. I think the electric car is a great technology that’s environmentally friendly and makes a lot of sense. But I think 10 years ago nobody would have bought an electric car because they would’ve thought that technology hasn’t caught up yet. So similarly I tell people the total ankle is kind of like an electric car now. Nowadays people would think about an electric car or a hybrid and say, oh that’s a great idea those cars are fantastic and doing well. In the same way, total ankle replacements for the right candidate in the right hands are doing fantastic and outperforming ankle fusions at this point.
I find few doctors liken this to a whole car; that’s a great analogy.
Dr. Lee: Five years ago somebody would have come in and I’d say, would you by the Nissan Leaf today? They would say no and nowadays I think more people would actually buy it.
And you would compare that to ankle replacement?
Dr. Lee: Correct. I think the longer something’s been around and has a proven track record, the more confident you are and as you alluded to I think that’s why you’re seeing doubling in the number of total ankle replacements. The track record is finally coming through and we’re seeing good results that are sustained.
Before, you were telling me a little bit about fusion versus ankle replacement and you were using an analogy about old cars.
Dr. Lee: Sometimes I tell people that we’ll look at ankle fusions or somebody who has an ankle fusion. Ideally everything around that ankle and making that ankle function has essentially become worn out and stiffened. To some degree, trying to reverse an ankle fusion is sometimes like finding a 20 year old car in the garage and then you’re thinking to yourself, oh if I put a new engine in this thing it’s ready to go and that’s just the beginning. In the same way, we don’t necessarily advocate or tell people to get a fusion with the idea of replacing that ankle at a later date.
Is it exciting to be in the forefront of this new development in the foot and ankle? It seemed like right now foot and ankle is the fastest-growing specialty in orthopedics and here you are in the forefront of ankle replacement.
Dr. Lee: I would say foot and ankle as an orthopedic specialty has really kind of been the stepchild of orthopedics. But I think people are finally kind of recognizing the importance, as well as the deficiency, cutting-edge technology and incorporation of current orthopedic techniques and technology into the foot and ankle. So certainly being at a referral center that truly advocates and pushes cutting-edge advancement in technology in patient care is certainly something that’s satisfying from a professional standpoint.
Let’s talk about your two patients Karen Moss and Joey. Tell me what happened when Karen came in; that was a very unusual situation.
Dr. Lee: Karen’s case is unique. Most forms of arthritis typically develop from wear and tear and a previous energy over time and you can actually remember a period in your life where you were pain free and had no joint pain. Unfortunately, Karen has had juvenile rheumatoid arthritis so as long as she can remember she’s had constant pain and joint problems. She’s had multiple orthopedic surgeries and joint replacements in other areas of her body and issues mainly in the ankle and the foot. At one point in her life she actually had arthritis that was so bad that part of her foot is actually fused already. Her foot is already much stiffer than a normal person would be. Then secondarily she still has pain in that ankle joint. For as long as she can remember she’s dealt with ankle pain. She’s relevantly young for a joint replacement so whether we talk about knees or hips even specifically for the ankle, she’s young. I think the question becomes how long can she live with just constant chronic pain that really affects her with every waking moment and every step she takes.
Was it just the ankle replacement that you did? Or was there another thing, something about the problem with the fusion, but you fixed that?
Dr. Lee: Her previous fusion resulted in arthritis that developed in what we consider an alignment issue. The joint wasn’t completely lined up, so part of the replacement was kind of realigning and correcting the position of her ankle joint.
So you did that and the ankle replacement?
Dr. Lee: Correct, more than just a bread-and-butter ankle replacement. We actually had to do a little bit more fine-tuning to get things settled down.
And she says that you changed her life.
Dr. Lee: Yes, she’s always had pain in that ankle. The morning-after, she said her ankle pain was gone. She’s never looked back since then.
She can go to the mall.
Dr. Lee: Yes
She can hold her grandchildren. She can hold her husband’s hand and walk down the street. I mean all these things she couldn’t do for you. She can go to the gym and work out. She said she can do everything now.
Dr. Lee: Yes. As most joint replacement patients will tell you in terms of any joint that’s truly and stays arthritic, joint replacement surgery is truly a game changer and a life changer for most people.
And she’s here because you made a difference in her life and that’s pretty cool. How do you feel knowing that you had that kind of impact?
Dr. Lee: I think most people went into medicine because they’re people pleasers. This is the profession that truly allows an individual to make a difference in people’s lives and in a way that isn’t just about making money or doing a job every day. In orthopedics especially, we’re blessed with the fact that we are making a difference and making a change in people’s lives.
That’s really cool. Say that again.
Dr. Lee: Those of us who became doctors truly and essentially want to please people. We kind of went into this profession because we want to help people and make people better.
Typically you wouldn’t do a patient that young.
Dr. Lee: Correct, that’s the goal as well in medicine. It is a case-by-case basis. I think you rarely want to say “always” or “never” in medicine and she’s a very unique case and at the same time she wasn’t looking for the typical procedure. She was looking for a different answer for her problem. So yes she is generally younger than we would like a patient to be with an ankle replacement. We have the expectation that she will live long enough that she won’t require any revision. I think that ultimately we’re hoping that the technology catches up in that respect as well, so in the future you look at somebody like Karen think any of us would make that same choice. Do you want to live the next five to ten years of your life with constant pain in every step you take or would you rather live the next five to ten years of your life pain-free and able to do many of the things that most of us take for granted. Know that yes, potentially I’m going to need a revision or another procedure down the line but at least I know I’ve got five to ten years of pain-free function and activity. I think with her life and the way it’s kind of evolved, that’s the gamble she wants to take and I think it’s certainly reasonable and I would do it in her shoes as well.
What measures are being done for revision or is it the implant itself you can replace?
Dr Lee: Yes, as opposed to the human body which God gave us a 70, 80 year lifespan, joint replacements usually have a 20 year life span. So in terms of ankle replacements I think we’re looking at 12 to 15 years and typically the parts wear out. It’s a bit like changing a tire on a car. You eventually have to change some of the tires and ankle replacements or any joint replacement is like that.
So what can happen? Are there various parts that you could just go in and replace?
Dr. Lee: Right. It depends on what the ultimate worn out parts are. But yes, essentially the same way you replace parts in any machinery depend on what’s worn. We have a certain expectation knowing that. One certain part, for example, the liner is probably the thing that’s going to wear out soonest and then it’s a matter of what the other components look like when we’re in there.
So Joey, let’s talk about Joey Myers. He came to you and he had a lot of replacements because he played basketball and then was on his feet doing coaching right?
Dr. Lee: Right. Joey Myers is a typical joint replacement patient. We’ve all seen Joey Meyer and can look at footage of him when he was a player as well as when he was a coach. He was giving a 110 percent effort all the time. He basically has wear and tear. His joints kind of wore out on him. He’s really a traditional type of joint replacement patient but specifically in the same respect Joey had ankle pain on a daily, regular and constant basis. It really started affecting his normal function and even his ability to work and do some of the normal things that we take for granted.
So when he came to you, did he come and say I want an ankle replacement or did you suggest it?
Dr. Lee: Joey and I have actually known each other and we’d seen each other on several occasions before he made that decision for the ankle replacement. He is what I call an educated consumer. He didn’t come in saying this is what I want, he asked what his options were and we had that general discussion about ankle replacement versus an ankle fusion as well as just waiting it out longer. He made the decision to proceed ahead with an ankle replacement.
And how is he doing?
Dr. Lee: Joey is doing fantastic. He would similarly say that this is a life changer with his ankle as well as with his general function. He was seeing a slow decline for the most part until he had the ankle replacement. Now he is functioning and performing at a different level than he was prior to the replacement.
Dr. Lee: Foot and ankle or any orthopedic injury is really the same. I tell patients you have to listen to your body. For a lot of high-level, high endurance type training I think you have to fight through it a little bit. But at the same time you know your body is giving you signals and to some degree people need to realize that a period of rest is definitely required, sometimes more than a day, that’s what your body is telling you. People need to work on cross training because marathon trainers just run and run and you’re really working a specific set of muscles and joints that can break down over time if you’re not paying attention and not giving yourself appropriate rest and cross training.
Lastly dancers, there’s been a 37 percent increase in the past 10 years in injuries and 50 percent of all injuries among dancers are foot and ankle related. What’s going on?
Dr. Lee: The trend that we’ve seen lately as opposed to when I was growing up and I was a child is there’s just a lot more activities. There’s a lot more access to certain types of activities. The number of dance troupes, dance companies and dance instructors there are in the community now has really exploded in the last 20 years. Generally there are a lot more people participating in dance. As a result, you’re seeing a lot more dance related issues. But obviously the foot and ankle is always significantly impacted so sometimes I liken dancing to basketball. There a lot of foot and ankle injuries in basketball because we’re talking about a lot of jumping, high-impact type activities and a lot of 360 degree movements. Runners are just going straight ahead, maybe taking a turn. But when you see people on the basketball court they’re moving in all directions at all times and that’s the same way with a dancer. They are on their toes a lot and they’re making very quick and sudden movements in multiple directions that mainly put a lot of stress on the lower extremity.
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