From Prosthesis to Prosthesis
From Arthrodesis to Prosthesis
You don’t need to rip off pages of life, just know how to turn the page and restart.
– Jim Morrison –
Arthrodesis is an orthopedic term that means the fusion of a joint. Ankle arthrodesis has the goal of fusing the ankle.
This surgery has historically represented the only possible surgical solution for the treatment of ankle arthritis.
Today there are different solutions that allow movement preservation, which are contained in two broad categories:
- joint-preserving-surgery: a surgery aimed at saving the joint, realigning the deformity, and favoring cartilage regeneration;
- ankle arthroplasty.
Therefore, it is correct to state that arthrodesis today is used only when movement preservation is not possible by joint-preserving-surgery or by arthroplasty.
However, arthrodesis was a very popular solution in the past and today many patients live with ankle arthrodesis.
If the arthrodesis is positioned correctly (with the physiologically supported foot and the ankle at 90 °), the patient is likely to be satisfied with the arthrodesis and lead a normal life, without a limp or severe limitations.
Over time, however, the sacrifice of an important joint, such as ankle, can lead to nearby joints having to work harder.
There are studies that show how a patient undergoing ankle arthrodesis has a significantly increased risk of developing osteoarthritis in the nearest joints and, therefore, would need another surgery to treat this condition.
Why can Arthrodesis Become Painful?
Arthrodesis can become painful and induce severe disability in a patient in the following 3 cases:
- the onset of osteoarthritis in nearby joints (a problem that normally occurs in the long term);
- the arthrodesis did not stabilize in the correct alignment;
- most often there is a misalignment in equinism (i.e. “on tiptoe”).
In these cases, walking is painful and disability and lameness are important, often involving the knee to compensate for this deformity; the arthrodesis has not healed, or in other words, it has not consolidated.
Disarthrodesis: Revising Painful Arthrodesis
The surgical solution of disarthrodesis is undoubtedly made easier by a lateral approach, even if objectively possible even with an anterior approach.
The advantage of a lateral approach is that it allows you to have a full view of the arthrodesis plane and to accurately plan not only the plan of the future joint, but also its center of rotation.
In addition to this, the lateral approach offers another advantage: the possibility of performing an effective lysis of the posterior soft tissues (muscles and tendons), which with arthrodesis will be adhered to the bone plane following the many years of fusion.
In my experience, the choice of approach for disarthrodesis turns out to be the lateral one, respecting the different surgery lengths of time in a very similar way to a traditional ankle replacement.
However, it is a more difficult surgery – technically speaking – for the whole team: surgeons, nurses, and patients. Therefore, careful planning and a thorough assessment of the risks and benefits is necessary.
Who is an “Ideal” Candidate for Disarthrodesis?
It is not enough to have ankle arthrodesis to be a candidate for ankle arthroplasty.
There are patients with completely asymptomatic arthrodesis or who complain of small disabilities: these are not candidates to undertake such a surgical procedure.
In fact, it is good to remember that it is a path designed for patients with a severe disability.
Disarthrodesis has the objective to return the patient to a plantigrade foot. This means a foot that physiologically supports the ankle at 90 ° and that has further possibility of extending and flexing.
We should not think of disarthrodesis as a healthy ankle that will move widely on all levels.
It is good to remember that a successful disarthrodesis is better than painful arthrodesis, but it will never achieve the performance of a healthy ankle.
Therefore, a balanced reflection must always be at the base of this choice. Disarthrodesis is not chosen in regret of having had ankle arthrodesis instead of arthroplasty, but is chosen only when the arthrodesis is painful and disabling.
Expert Visit for Arthrodesis Revision
The advice for disarthrodesis is planned during the specialist visit, in which it is advisable to have in-depth imaging investigations and blood tests available.
Blood tests (blood count, ESR, PCR and fibrinogen) are useful to help rule out a septic process in place (infection) before surgery. In this case, it would not be possible to proceed with the disarthrodesis surgery, but a transitory surgical procedure will be planned to help with the recovery from the infection.
The imaging investigations are then fundamental, particularly the feet and ankle radiographs taken when bilateral weight is occurring (performed standing up).
The radiography is essential for the correct study of the deformity.
It is very useful to have the image also available on the contralateral side in order to study the patient’s original, healthy anatomy.
Finally, the Weight Bearing X-Rays and the Ct-Scan are the exams that allow the bone quality to be studied and to verify the real reliability of the surgery. In order for an arthroplasty to be successful it must rest on bone of sufficient quality to guarantee the stability of the implant.
Each of our prosthetic surgeries follows a precise path that begins, in reality, before surgery, with the choice of anesthesia.
We follow a protocol in line with the principles of Rapid Recovery of prosthetic surgery of other anatomical areas, for which the patient normally undergoes peripheral anesthesia, associated, if needed, with sedation or general anesthesia.
The patient will have the sensation of having his leg asleep for as long as possible, sometimes until the next day. This will serve as good pain control.
In addition, the patient will exit the operating room with a fiberglass cast, which he will keep for for 4 weeks.
Discharge is foreseeable in a period that varies between 2 to 3 days post-operation.
At home, the patient will be asked to keep the limb elevated and to move the toes actively and passively.
The first check-up will be scheduled after 15 days for suture removal and resumption of gradual weight.
The cast will be kept for 4 weeks, at the end of which it will pass to the use of a brace, in which full weight will be allowed.
The brace will be kept for 15 days and then the patient will be free to apply full weight, possibly without using crutches.
Therefore, the course is similar to that of a normal arthroplasty.
However, it is foreseeable that patient satisfaction will occur over longer periods, which may be around 10-12 months after the surgery.