SURGICAL MANAGEMENT OF FOOT AND ANKLE ARTHRITIS Verity

SURGICAL MANAGEMENT OF FOOT AND ANKLE ARTHRITIS Verity Currall, Consultant Orthopaedic Surgeon, LDH 19 th July 2018

OVERVIEW • Introduction • Surgical Options • Hindfoot/Midfoot • Ankle Replacement • Ankle Fusion/Arthrodesis • Triple Fusion • Forefoot • Hallux • Lesser toes • Joint sparing procedures • Surgical Concerns in Inflammatory Arthropathy

SURGICAL OPTIONS • Joint replacement • Ankle • 1 st MTPJ • Joint fusion (arthrodesis) – most foot & ankle joints • Joint excision – lesser MTPJs • Joint sparing procedures

ANKLE REPLACEMENT 2016 Total Inflammatory % (RA) Arthropathy (RA) TAR 728 60 (50) 8. 2 (6. 9) THR 93, 234 1231 1. 3 TKR 102, 519 1808 (1112) 1. 8 (1. 1) Source - http: //www. njrreports. org. uk/

ANKLE REPLACEMENT • Suitable for patients without significant deformity

ANKLE REPLACEMENT COMPLICATIONS • Infection • wound or deep • early or late • local or haematogenous • Loosening • Septic • Aseptic • Ongoing symptoms

ANKLE FUSION • Remove articular cartilage • Fixation • Allow to heal • NWB 6 -8 weeks • WB in cast/boot 4 -6 weeks • Gait good, problems with wellies!

ANKLE FUSION Arthroscopic • Fewer wound healing problems • Improved union rates Open • Deformity correction • Plate fixation - ? better in poor quality bone

ANKLE FUSION

HINDFOOT FUSION • Ankle & subtalar fusion • Severe deformity and/or arthritis in both joints • Usually held with nail

TRIPLE FUSION • Subtalar, talonavicular and calcaneocuboid joints (often done without CCJ) • Planovalgus deformity with arthritis

TRIPLE FUSION Before After

TRIPLE FUSION Before After

1 ST MTPJ Fusion • All forms of arthritis • Poor quality bone • Deformity correction • Permanent Replacement • OA only • Good bone quality • No deformity • Loosening/failure

1 ST MTPJ FUSION

1 ST MTPJ REPLACEMENT

LESSER MTPJs • Don’t do well with fusion • Excise part of proximal phalanges (Stainsby procedure) • Excise MT heads • Low demand inflammatory arthropathy only • Kates-Kessel-Kaye procedure (all lesser MTs)

LESSER MTPJs • Don’t do well with fusion • Excise part of proximal phalanges (Stainsby procedure) • Excise MT heads • Low demand inflammatory arthropathy only • Kates-Kessel-Kaye procedure (all lesser MTs)

LESSER METATARSALS

JOINT SPARING PROCEDURES • Synovectomy • Single joint – preserved articular cartilage • Ongoing synovitis despite optimal medical management • Remove synovium (arthroscopic/open)

ARTHROSCOPIC SYNOVECTOMY

JOINT SPARING PROCEDURES • Synovectomy • Single joint – preserved articular cartilage • Ongoing synovitis despite optimal medical management • Remove synovium (arthroscopic/open) • Tophus excision • Not routinely recommended • Persistent mechanical symptoms with no inflammation

GOUT

JOINT SPARING PROCEDURES • Cheilectomy • Excision of osteophytes • 1 st MTPJ, ankle • Improves range of movement, but may increase pain

JOINT SPARING PROCEDURES • Cheilectomy • Excision of osteophytes • 1 st MTPJ, ankle • Microfracture • OCD ankle • Bleeding encourages fibrocartilage formation

JOINT SPARING PROCEDURES • Cheilectomy • Excision of osteophytes • 1 st MTPJ, ankle • Microfracture • OCD ankle • Chondrocyte Implantation • Still experimental • Costly & variable results

JOINT SPARING PROCEDURES • Osteotomy • Often post traumatic arthritis • Realign joint • Allow better articular cartilage to bear weight

SURGICAL CONCERNS IN INFLAMMATORY ARTHROPATHY • Infection • • Steroids - continue DMARDs – continue Biologics – stop for 1 cycle preop, restart on wound healing Antibiotic prophylaxis – controversial • Bone Quality • Steroids, disuse osteopenia, cysts • Preop DEXA • Care, stronger meatalwork, longer NWB

QUESTIONS?