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Patients and surgeons have enjoyed great success with hip and knee replacements, but ankles have proven far more vexing.
Now some surgeons believe they have the hardware and know-how to effectively replace an arthritic ankle joint, while other surgeons await results over the long term.
Even those who like the latest generation of artificial ankle joints say they aren't for runners, basketball players or farmers who jump off tractors. They are generally appropriate for middle-aged and older people, and those who aren't severely overweight.
The younger the patient and the more stress he puts on the ankle, the more likely an ankle replacement will break down and have to be reworked. And fixing an ankle replacement is tougher than redoing hip and knee replacements because there is less bone and tissue to work with.
"The ankle is just a unique joint," said Dr. Annunziato Amendola, a professor of orthopedic surgery at the University of Iowa. "The ankle is just the skin and the bones."
It doesn't have a big envelope of muscle bolstering it the way the knees and hips do, he said.
Only 1,596 ankle replacements were done in the United States in 2009, compared with 621,029 knee replacements and 285,471 hip replacements, according to the American Academy of Orthopaedic Surgeons.
Dr. Shane Schutt, a Methodist Hospital orthopedic surgeon, believes that the number of ankle replacements will double in the next 10 years. Only 33 years of age, the Omaha native completed training last year under Dr. Michael Coughlin, an internationally known foot and ankle surgeon in Boise, Idaho.
Including his training, Schutt estimates that he has placed ankle implants in about 80 patients. One of several metro-area surgeons who performs ankle replacements, Schutt has done three since joining Methodist last year.
Doctors in the U.S. have been using the device Schutt uses, a Scandinavian implant called STAR, for only about 10 years including clinical trials, but the data appear promising. A report published last year said 91 percent of 84 artificial ankle joints remained in patients after an average of more than nine years.
"The bottom line is that it's still early. And so we don't know what happens after that," Schutt said, referring to an implant that was placed in a patient's ankle a decade ago. "In my opinion, it's cutting edge technology that I believe is going to make a big difference in patients' lives."
Lee Hohenstein, who recently sat in Schutt's exam room, said he was in sales for decades. "And I literally pounded the pavement, and the pavement pounded back."
Hohenstein had severe arthritis in his left ankle. It hurt badly and hindered his ability to enjoy retirement.
At 80 years of age, Hohenstein was a good candidate for ankle replacement, which he underwent last November. Now in for a follow-up, he sat with his left shoe and sock off and smiled about his progress.
"Excellent, excellent," Hohenstein said. "I've been pleased. The doctor's been pleased."
His ankle remained somewhat swollen, which Schutt said was to be expected.
"The old gold standard was the fusion," Schutt said. "And that would have been a fine option for you."
But Hohenstein hadn't wanted his ankle fused, a fairly common procedure to end arthritis pain. In ankle fusion, a surgeon removes the damaged cartilage and connects the end of the leg bone to the ankle with screws, locking the joint in place.
Hohenstein wanted more ankle flexibility so he could fish with ease with his grandchildren.
The STAR differs from its predecessors in part because it allows not only up-and-down flexibility but also some side-to-side motion. A hard plastic piece moves between two metal components, allowing flexibility.
Schutt said precision cutting equipment now enables surgeons to fit the implant more securely into bone. And they understand better the importance of lining the ligaments up precisely on both sides of the ankle, and of the heel lining up squarely with the leg bones. That way, the force is distributed equally on the gliding plastic device.
"In my opinion, I think we're breaking through," Schutt said.
While ankle replacements began about the same time as knee and hip replacements some 40 years ago, ankle replacements have performed with much less success. Designs have been tweaked and welcomed as having great potential, then have fallen away after failing at too high a rate.
Surgeons reported in 1996 that 57 of 160 devices called "the Mayo total ankle replacement" had to be removed because of complications. The surgeons said they no longer recommended using the device.
Dr. Clifford Boese, an orthopedic surgeon who practices in Council Bluffs and Omaha, was enthusiastic 11 years ago about a new implant called the Agility.
But Boese is no longer excited. "I've got to tell you, I quit doing them about four years ago," he said this week. "They just weren't durable enough."
He said he put in about 25 Agility devices and roughly one-third failed within 10 years.
Dr. Lori Reed, assistant professor of orthopedic surgery at the University of Nebraska Medical Center, said she put in some ankle implants while in training. She hasn't chosen to do any in her seven years at UNMC.
When ankle implants go bad, "it's not an easy thing to fix," Reed said. "My message is not that ankle replacements are bad. You just have to be very cautious in your patient selection."
Dr. Scott McMullen, an orthopedic surgeon with GIKK Ortho Specialists in Omaha, said he and a partner put in about 15 Agility implants, and they have placed two STAR implants over the past year.
"I like them," he said of the STAR. Nevertheless, his view of ankle implants is neutral. An implant is prone to collapsing into the talus bone between the heel and lower leg, he said. And the soft tissue around the ankle isn't robust, so infection and wound-healing challenges may crop up, he said.
"Those anatomic problems are things that still exist," he said. The STAR implant "is another variation of a concept that's been around for years. But from my perspective, in no way is it a complete game-changer that will come in and take over the treatment of ankle arthritis."
Schutt and Dr. John Galligan believe that the number of ankle replacements in the United States will go up significantly because of the STAR, which won Food and Drug Administration approval three years ago.
Galligan, 40, performs ankle replacements at Nebraska Orthopaedic Hospital with Dr. Michael Thompson. Galligan said that they have put in 39 STAR implants and that 95 percent of the patients are doing well.
Nationwide, the big names in foot and ankle surgery are using STAR implants, Galligan said. "It's definitely the wave of the future," he said.
Coughlin, Schutt's mentor, helped oversee the STAR's trial last decade. In Europe, he said, where the device has been used for years, it has held up well in about 80 percent of patients after 15 years.
Coughlin said patients who undergo the ankle replacement surgery shouldn't weigh more than 250 pounds, shouldn't be battling diabetes and should be about 55 or older.
The implant can stand up to hiking, fishing and golfing, he said, but he would never place one in a triathlete.
He acknowledged that there is no consensus among orthopedic surgeons on the value of ankle replacements. He said: "I think that discussions will continue on."
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