Raising Questions About Ankle Arthrodiastasis

I read the recent article “A New Solution For The Arthritic Ankle?” (see page 36, December 2005) with interest. I applaud the authors for their work and agree that this is an option for patients with degenerative joint disease of the ankle. George R. Vito, DPM, et. al., accurately point out that there are few surgeons who have total ankle implant training and regularly perform this procedure. I have had years of training with the inventor of the only FDA approved ankle implant, and have performed a tremendous number of these procedures successfuly. Unfortunately, the authors’ review of total ankle arthroplasty articles is incomplete. I understand that it would be impossible to cite every reference. However, Knecht, in a 2004 article in The Journal of Bone and Joint Surgery, showed an 11 percent revision rate and 92 percent overall satisfaction rate with the Agility (DePuy) total ankle. This was at a mean follow-up of nine years. Dr. Vito and his co-authors summarize implant arthroplasty by citing Salzman’s 2000 article and stating “the literature regarding ankle implants suggests that improvements in implant design are needed.” However, there are many more recent papers, such as the aforementioned Knecht paper, that show favorable outcomes. Implant design improvement is an appropriate and even necessary goal of any system, and there have been multiple and ongoing design improvements with the Agility implant. Additionally, the authors claim the combination of arthrodiastasis and joint fluid replacement is a minimally invasive operation. While the incisions may be minimally invasive, is this procedure really minimally invasive to the patient (see the photo on page 38 of the article)? Other than the benefit of joint sparing, how much less invasive is this treatment compared to an implant or fusion? These are big, clumsy, very invasive devices to a patient’s life. Also, the cited statistic of only 17 percent pin tract infections is very low. In my experience, almost all pins and wires of external fixators become at least superficially infected in a five-week course and a headache at best. On that same note, five weeks of treatment is significant. Six weeks after a total ankle arthroplasty, the patient is beginning to bear weight. In looking at the pre- and postoperative X-rays provided, this patient has severe end-stage ankle arthritis with a significant varus deformity. Even if there is some reparative process to the articular cartilage that goes on as the authors eloquently discuss in the article, I cannot imagine that this patient will not need an implant or arthrodesis in the very near future. Furthermore, for this patient, delaying an ankle implant can be detrimental to the patient as the longer this deformity is allowed to progress, the more damage to surrounding soft tissue and bone occurs, making an implant much more difficult if not impossible. It seems that a less advanced scenario with no deformity would lend itself more favorably to your study treatment. In the conclusion, the authors claim that, “One can use these minimally invasive procedures to treat ankle arthritis and delay, if not avoid altogether, the need for ankle fusion.” I can accept that this may delay joint destructive procedures but the follow-up is only one year. At another point in the article, the authors claim they “are unable to determine how long the positive trend in pain relief will continue.” I congratulate Dr. Vito, et. al., on their innovative work. I believe that arthrodiastasis and joint fluid replacement is a tool to delay joint destructive procedures in the appropriate patient. However, in my hands, joint replacement is a very reliable option when “conservative” measures such as arthrodiastasis fail. In fact, survivorship at 10 years is approaching that of hips and knees in the experienced surgeon’s hands. —Jerome K. Steck, DPM, FACFAS Assistant Clinical Professor of Surgery, University of Arizona Ankle & Foot Institute of Arizona Institute for Peripheral Nerve Surgery jksteck@hotmail.com Why I Prefer Ankle Arthrodiastasis Over Ankle Implant Arthroplasty Dr. Vito responds: I would like to thank Dr. Steck for his response to the recently published article in which I was the senior author. I would like to congratulate Dr. Steck on his advanced training in ankle implant arthroplasty and his extensive experience with the ankle implant. Dr. Steck and a few others in the country have extensive experience with this type of surgery and may have excellent results. However, there is a vast number of surgeons who are performing this type of surgery in this country who have limited experience and training to perform this type of surgery adequately. The implant in question is not the cure-all for arthrosis of the ankle joint and, in fact, is not a superior design when compared to other implants that are not available in this county. The implant in question is the only implant available in the United States. Therefore, the surgeon has no choice but to use this implant. I have also performed the procedure with this implant with less than desired results. The use of total joint arthroplasty has a significant way to go if one is to compare it to other implants that are used by podiatric and orthopedic surgeons in this country and around the world. In reference to the statement of the procedure being minimally invasive, if one performs an arthroscopy with the placement of external fixation and weekly injections of Supartz and compares it to total joint arthroplasty, there is no comparison. With the amount of bone resection and length of multiple incisions, along with the less than favorable results and the high learning curve involved with total joint arthroplasty, one cannot compare the two procedures. Our pin tract infection rate is very small. I am sure Dr. Steck is referring to pin tract irritation and not infections. Irritation rates of the pins are very common and pin tract infections are very low as stated in the article. Having a considerable amount of experience with this procedure, I have been able to reduce the postoperative complication rate. Patients achieve full weightbearing on post-op day one and this does not contribute to any type of skin irritation of the pins if they are properly placed. Any types of headaches experienced by the surgeon may perhaps be due to a lack of experience with the procedure as opposed to the ability of the procedure to be successful. I do not treat X-rays. I treat the condition that is represented by the X-rays. Radiographic appearance has no correlation to the postoperative pain or function. It is unfair and unjust to keyhole this diagnosis with only one type of surgical procedure. Being trained in both procedures and having had extensive training in all aspects of foot, ankle and leg surgery, I can say without hesitation that one should perform ankle distraction prior to any type of ankle joint replacement. Currently, we have a five-year follow-up of 45 procedures with excellent results. In total, we have performed this procedure on 178 patients with a success rate exceeding 90 percent. This number compares to any study or surgeon experience anywhere in the world. In fact, many of the European surgeons have changed their method and protocols of this type of procedure to parallel our surgical protocols in order to achieve similar results. I find it very hard to believe that the results that Dr. Steck is achieving compare to results for total hips and knees. It may be good for the profession and other similar professions if Dr. Steck could share with us his pearls in achieving such results. I can only look forward to his published results documenting his outstanding surgical outcomes. In conclusion, I would like to thank Dr. Steck for his questions and comments. Ankle diastasis is fast becoming the procedure of choice for ankle arthrosis. With the high complication and failure rate of the total ankle implant, it would be hard for me at the present time to justify placing an implant for ankle arthrosis no matter how severe the deformity or progression of the disease. — George Vito, DPM, FACFAS Director, Atlanta Leg Deformity Correction Center Macon, Ga.