2. Anatomy of the Ankle
• Hinge Joint
• Made up of 3 bones
• Lower end of the
tibia (shinbone),
• Fibula (the small
bone of the lower
leg)
• Talus, the bone that
fits into the socket
formed by the tibia
and the fibula
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6. Ankle-FOOT COMPLEX
• Stability demands-
1.Providing a stable base of support for the
body in a variety of weight bearing postures
without undue muscular activity and
energy expenditure.
2.Acting as a lever for effective push-off
during gait.
7. Mobility demands-
1.Dampening of rotations imposed by more
proximal joints of LL.
2.Being flexible enough as a shock absorber
3.Permitting the foot to conform to the
changing and varied terrain on which foot is
placed.
11. Capsule
• Is attached just beyond the
articular margin
• Except anterior-inferiorly and
postero-superiorly
• Attached to the neck of the
talus and the inferior part of
tibiofibular ligament.
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12. Ankle Biomechanics• Tri-plane motion
• The load bearing force in stance phase of gait is 4 times
the body weight
• Normal ROM:
• At least 10 degrees of dorsiflexion (extension) is needed
for normal gait
13. CAUSES OF ANKLE ARTHRITIS
• Primary Osteoarthritis of the Ankle
• Post traumatic Osteoarthritis
• Secondary Osteoarthritis
• Rheumatoid
• Hemochromatosis
• Hemophilia
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14. SYMPTOMS
• Pain
• During activity
• At rest or sleeping
• Swelling and Tightness
• Squeaking or grinding sound when ankle is moved.
• Stiffness and decreased movement
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16. Physical Exam
• Note obvious deformities
• Neurovascular exam
• Pain to palpation of malleoli and ligaments
• Pain at the ankle with compression
• syndesmotic injury
• Examine the hindfoot and forefoot for associated injuries
17. Stability Tests
• Anterior Drawer Test:- Used to evaluate tibiofibular
ligament. Perform in both plantar flexion(test ATFL) &
dorsiflexion(test CFL)
18. Continued…
• Talar Tilt Test :- With the
patient relaxed & knee flexed,
stabilize the leg with one hand &
grasp the heel with other.Then
foot 1st dorsiflexed & plantar
flexed, invert the hindfoot.
Excessive motion may indicate
instability of tibio talar joint,
subtalar joint or both.
19. Continued…
• External rotation test:-
Foot should be in neutral
position with the lower leg
stabilized. Examiner should
then externally rotate the foot.
If this causes pain then must
consider a tear of the anterior
tibiofibular ligament. Depending
on severity the interosseous
membrane may be involved.
Pain will be at site of the
anterior tibiofibular ligament.
21. NONSURGICAL
• Pain relievers and anti – inflammatory meds
• Orthotics such as Soft pads or arch supports
• Custom made shoes – Stiff soled shoe with a rocker
bottom
• An Ankle – Foot – Orthosis
• Physical therapy and exercises
• Steroid medications injected into the joint
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23. ARTHROPLASTY
• Recommended in patients with Advanced arthritis
• Destroyed ankle joint surfaces
• An ankle condition that interferes with daily activities
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24. Classification of Total
Ankle Replacement
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• Surgical approach
• Bearing type
• External surface
• Bearing surface
• Sulcus type
• Surface morphology
25. ABSOLUTE
CONTRAINDICATION
• Neuropathy ( Charcot foot)
• Non – manageable hind foot malalignment
• Massive joint laxity (Eg: Marfan disease)
• Highly compromised periarticular soft tissue
• Severe senomotoric dysfunction of foot and ankle
• Advanced soft tissue or bony infection
• AVN of talus ( needs custom made implants )
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26. HISTORY
• First ankle replacement was performed in 1970s
• Two types of designs were developed
Constrained
Unconstrained
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27. • Constrained
• Greater stability but with reduced motion
• Increased stresses at the bone – cement – implant interfaces
leading to early loosening and failure
Ex – St. George/Buchholz, Imperial College London Hospital,
Conaxial and Mayo designs
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28. • Unconstrained
• Improved ROM in multiple planes but with reduced
stability.
• Less stress at the bone – cement – implant interface
Ex – Waugh / Irvine, Smith and Newton Prostheses
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29. ‘Old generation’ ankle replacements consisted of a polyethylene tibial component and a
metallic talar component.
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30. Modern ankle replacement consists of metallic tibial and talar components, stabilized with or
without cement.
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31. • In 1970, study was done by Lord and Marotte and was
concluded with the current implants, Arthrodesis is a
better option than Arthroplasty.
• Inverted hip stem was used for tibia, talus was completely
removed and then a cemented acetabular cup was inserted
in the calcaneum
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33. NEW GEN IMPLANTS
• The new generation implants presently in use can be
classified
• (a) as two- or three-component designs and
• (b) as fixed or mobile-bearing designs.
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34. The INBONE™ ankle
(Boulder, USA)
• This is the only TAA with an
intramedullary alignment
system design.
• Over 200 INBONE™ ankle
replacements have been
performed in the USA.
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39. The BP total ankle
replacement
• Its upper surface is flat, whereas its lower surface
conforms to the trochlear surface, thereby providing
unconstrained, sliding cylindrical motion with LCS on the
bearing surfaces, allowing inversion, eversion motion.
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40. The tibial stem and the deep sulcus of the talar component
accommodating a matching polyethylene surface, allowing
inversion/eversion motion, are characteristic features of the Buechel–
Pappas ankle replacement.
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46. The SALTO ankle prosthesis ‘fixed-bearing’ version is used in the USA,
whereas the original ‘mobile-bearing’ design is used in Europe.
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50. The Agility prosthesis, a two-component design, requires tibio-fibular fixation.
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51. • Benefits of Agility implant
• Greater ankle support and longer-term stability than earlier
implants
• Multiple sizes for a more precise fit
• More natural joint movement than is possible with ankle fusion
surgery
• A unique feature of the Agility is the addition of a
syndesmotic fusion to allow load transfer from the tibial
component to both bones of the leg.
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54. OTHER NEW IMPLANTS
• BOX Total Ankle Replacement
• The German Ankle System
• The ZENITH total ankle replacement system (Corin,
UK)
• The Alphanorm total ankle replacement
• The TARIC prosthesis
• The CCI evolution total ankle prosthesis
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61. Structures at risk
• Cutaneous branches of the superficial peroneal nerve
• Neurovascular bundle consisting of
• Deep peroneal nerve and
• Anterior tibial artery
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63. POST-OP Protocol
• ROM within first week. Non weight bearing walking.
• 6 weeks (with Doctors Instruction)
• Gradually put weight on the leg
• Use of a cane or walker.
• Begin Driving
• 6 to 8 weeks - automatic shift
• 12 weeks – manual shift
• 12 weeks - low-impact activities, such as walking.
• Up to 1 year - may require the use of an ankle support
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