New ankle surgery allows better mobility

LOS ANGELES Beverly McFarland has had ten surgeries because of painful rheumatoid arthritis. Now she's going in for number eleven.

Click in the Eyewitness News story window above to watch Denise Dador's report.

"They told me the incision is going to go from here to here," explains McFarland.

Beverly is the first person in the world to get a new type of ankle replacement.

Surgeons at the Cleveland Clinic are trading in traditional ankle fusion, that gives very limited mobility, with a new ankle replacement.

"Instead of locking up those two bones, you replace the end of each bone, and allow the patient to maintain normal mobility of that ankle joint," explains Dr. Brian Donley the director of Foot and Ankle Center at the Cleveland Clinic.

Surgeons remove the bumpy arthritic portion in the ankle joint and attach a metal plate to the end of the leg bone. Then, they place a metal cap on top of the ankle bone. A piece of plastic is put in between to keep the metal from rubbing.

"The patients seem to be doing exceptionally well. They seem to really enjoy the relief of pain and almost all patients have had complete relief of pain," said Dr. Donley.

Donna Maiken's dog, Cleo, licks the spot where she had her ankle replaced.

" I was walking bone-on-bone. I had no cartilage," said Maiken.

She broke her ankle more than two decades ago. Since then, Donna's lived in pain.

"It got really, really uncomfortable, where I could be up like three or four hours a day and then I had to sit down," said Maiken.

Now, just weeks after surgery she says she is already feeling better.

"Everyday it gets a little bit better," said Maiken.

"I get to stand up on it today to see if it works," said McFarland.

Both women are on their feet and pain-free.

Since this is a new implant, there are no final results on how long it will last. The best candidates for an ankle replacement are older and less active people. Web extra:

How is total ankle replacement different from traditional ankle replacement procedure?

Dr. Donley: The traditional way to treat ankle arthritis through the years has been an ankle fusion. It has been the mainstay of treatment for people who suffer from ankle arthritis. An ankle fusion is when you would fuse the two bones of the ankle together so they would not grind or cross each other and create the pain an arthritic joint creates. An ankle replacement is different than ankle fusion because, instead of locking up those two bones, you replace the end of each bone and, therefore, allow the patient to maintain normal mobility of that ankle joint and at the same time give them pain-free function as an ankle fusion has traditionally done.

What are the treatment options available now for patients with ankle arthritis?

Dr. Donley: There are many options available for people with ankle arthritis. Often times, people can be treated without an operation at all and you can do things such as exercise, weight loss and braces. When it comes time for surgery, there are many options available. The two main options are an ankle fusion and then, in selected patients, ankle replacement has become a more viable option in this patient population.

What are the downsides of traditional ankle fusion surgery?

Dr. Donley: The downsides of ankle fusion surgery are the patient loses motion of the ankle and actually has to trade in that motion in order to get pain-free function, or to get less pain when they function. Now, the other downside of the ankle fusion is by losing that motion, it has been shown, years down the road, you have an increased chance of getting arthritis in the surrounding joints of the ankle. So an ankle replacement has an advantage over an ankle fusion in that it allows the patient to have pain-free function, but also maintain mobility. Another advantage to an ankle replacement is that years down the road, they will likely have less of a chance of developing arthritis in the surrounding joints because they've maintained the motion of the ankle joint.

If there's such a difference between the two procedures, why doesn't everyone get an ankle replacement?

Dr. Donley: Although the ankle replacement has many great advantages, it is a very difficult surgery and really has a small population of patients that are good candidates for it. The younger a patient is, the more likely they'll wear out that ankle replacement in time and need further surgeries in the future, which become more difficult each time. It's for that reason an older patient -- a general rule would be over 60, when you're a good candidate for an ankle replacement.

How does total ankle replacement work?

Dr. Donley: The way an ankle replacement works is very similar to how a hip replacement works or a knee replacement works in that you remove the end of each bone that creates a joint. In the ankle case, that would be the end of the tibia bone and the top of the talus bone. You would shave those off and then put a new surface on the end of the tibia and a new surface on the end of the talus. The critical part of an ankle replacement is that they have to be perfectly aligned in order to allow normal motion of the ankle and to decrease the chance of the artificial joint wearing out.

Are there different sizes for men and women?

Dr. Donley: The market for ankle replacement actually is a very small market. When you look at the number of hip and knee replacements done in a year in the United States, it's approximately 900,000. When you look at the number of ankle replacements done in a year, it's roughly around 1,500 ankle replacements. We have not been able to devise an implant that is more for a woman or more for a man, when you're dealing with such a small market size.

Who would need this kind of surgery -- you mentioned people in their 60s?

Dr. Donley: The person who would benefit most from ankle replacement or the ideal candidate for an ankle replacement is someone that is older with lower demands. It's because they'll have a less chance of wearing out the prosthesis and needing further surgery or revision surgery for the ankle replacement. So when I think of an ideal candidate for an ankle replacement, I think of someone that's 60 years or older, someone that does not have comorbidities such as diabetes -- smoking is also difficult for healing from the operation -- and certainly a really important factor is a person's size. The heavier someone is, the more they'll put stress on the ankle replacement. So you really would like to have someone of a more normal body weight and someone of a lower demand.

How long does it take someone to recover from the procedure?

Dr. Donley: A normal recovery for an ankle replacement is, a person is kept in a splint for a week and they are kept non-weight bearing. At a week, we'll check the patient, check the wound for healing and then put them in a cast for two weeks. Then we'll see them back at three weeks. We'll remove their stitches and put them in a boot and have them start working on range of motion, but keep them on crutches non-weight bearing. Six weeks from the time of the operation, we allow them to start walking in the boot and at 12 weeks from the operation, they can start getting out of the boot and start increasing their activity. It's about six months until we expect them to have full clinical benefit from an ankle replacement.

Are there any risks to total ankle replacement surgery?

Dr. Donley: The risks involved in ankle replacement are many. The risks that are inherent to all operations certainly exist for an ankle operation; but then there are risks specifically with the ankle replacement. It's a very difficult and tedious operation and in time, sometimes the replacement can wear out, which will make the person more likely need another operation, which would be even more difficult than the first operation. There is risk of infection, which would require removal of the prosthesis and there are other risks involved with the operation, such as a blood clot or other risks.

What have your patients that have had the procedure done say about it?

Dr. Donley: It's still early for the patients that I've done this operation on. I did the first one in December of 2006, so our longest recovery at this point, from this operation, is approximately 14 to15 months. So far though, in this short time period, the patients seem to be doing exceptionally well. They seem to really enjoy the relief of pain and almost all patients at this point have had complete relief of pain and they still appreciate having the mobility of the ankle. We have many patients that have enjoyed the fact they can go back out for walks and be more active than they've ever been over the last five or ten years, as they have been suffering with this ankle arthritis.


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