Katja Schenk

Prospective Study of a Cementless, Mobile-Bearing, Third Generation Total Ankle Prosthesis

Background: The SALTO total ankle prosthesis is a nonce-mented mobile bearing anatomic design characterized by dual Ti-HA coating. This study reviews our results with this prosthesis. Materials and Methods: Between 2001 and 2007, 413 consecutive SALTO prostheses were implanted in our institution in 215 women and 198 men, aged 57.1 ± 11.9 years. At the last visit, 401 implants (47% in the left ankle) were available with a mean followup of 29 (range, 1 to 84) months. Results: Based on the results of the 218 patients with at least 2 years of postoperative followup, the 5-year estimated survivorship, with the primary end-point being implant removal, was 86.6% and ranged from 85.1% in patients with post-traumatic osteoarthritis to 95.6% in those with rheumatoid arthritis. The AOFAS score increased from 50.9 ± 16.8 points preoperatively to 82.2 ± 14 points at followup (mean difference, 31. 1 ± 1.4, 95% confidence interval (C.I.) for the difference, 28. 3 to 33.8, p < 0.001). Visual analog scale for pain decreased from 7.4 ± 1.1 preoperatively to 2.0 ± 2.0 postoperatively (mean difference, −5.4 ± 0.7, 95% C.I. for the difference, −5.6 to −5.2, p < 0.001). Flexion/extension ROM increased from 25.2 ± 14.1 degrees to 33.1 ± 13.6 degrees at the last followup visit (mean difference, 7. 9 ± 0.5 degrees, 95% C.I. for the difference, 4. 3 to 7.2, p < 0.001), while pronation/supination ROM increased from 23.8 ± 13.7 degrees to 25.4 ± 14.5 degrees (mean difference, 1. 6 ± 0.7 degrees, 95% C.I. for the difference, 0. 9 to 2.2, p = 0.005). Conclusion: The SALTO prosthesis provided good clinical and functional results and we believe helps validate the concept of anatomic replacement. Level of Evidence: IV, Retrospective Case Series

[Supramalleolar, subtractive valgus osteotomy of the tibia in the management of ankle joint degeneration with varus deformity].

ZusammenfassungOperationszielZiel der supramalleolären Tibiaosteotomie bei varischer Fehlstellung im oberen Sprunggelenk ist die Verlagerung der Belastung von dem schwer arthrotisch veränderten medialen Gelenkanteil auf den lateralen Abschnitt und somit die Wiederherstellung einer physiologischen Rückfußposition und eines plantigraden Fußauftritts. Damit sollen eine Schmerzreduktion erreicht sowie der Zeitpunkt einer totalendoprothetischen Versorgung bzw. Arthrodese hinausgezögert werden.IndikationenSchmerzhafte, konservativ erfolglos behandelte Varusarthrosen im oberen Sprunggelenk mit > 15° Achsfehlstellung in der tibiotalaren Gelenkachse.KontraindikationenHochgradige, bewegungseinschränkende Arthrosen des oberen Sprunggelenks.Floride Infektionen.Ausgedehnte Knochen- und Weichteildefekte.Osteonekrosen des Talus mit Nekrosebezirken > 50%.OperationstechnikVentraler Zugang über dem oberen Sprunggelenk und supramalleoläre keilförmige Resektion eines zuvor definierten Knochenkeils mit lateraler Basis. In der präoperativen Planung ist die gewünschte Korrektur genau zu berechnen. Nachfolgend lateraler Zugang über der distalen Fibula. Hier Entnahme eines weiter proximal gelegenen Segments aus der Fibula. Nun Schließen der Tibiaosteotomie („closed wedge“) und Osteosynthese der Fibula.ErgebnisseBei 27 Patienten wurde zwischen 2002 und 2006 eine supramalleoläre, valgisierende Osteotomie („closed wedge“) durchgeführt. Präoperativ zeigte sich eine durchschnittliche Varusfehlstellung von 27°, welche postoperativ auf durchschnittlich 6° korrigiert werden konnte.21 Patienten waren bei den Nachuntersuchungen sehr zufrieden, drei Patienten wurden im weiteren Verlauf endoprothetisch und weitere drei Patienten mit einer Arthrodese versorgt.AbstractObjectiveThe aim of supramalleolar osteotomy of the tibia in the management of varus deformity of the upper ankle joint is to shift load bearing away from the severely degenerated medial part of the joint to the lateral part and thus restore physiological alignment of the hindfoot and a plantigrade foot. The intention is to reduce pain and to postpone the need for total endoprosthesis or arthrodesis.IndicationsPainful degeneration of the ankle joint with varus deformity that has proven resistant to conservative treatment, i.e., > 15° axial malalignment of the tibiotalar joint axis.ContraindicationsSevere ankle joint degeneration that restricts movement.Florid infections.Extensive bone and soft-tissue defects.Osteonecrosis of the talus with necrotic regions > 50%.Surgical TechniqueAnterior approach to the upper ankle joint and supramalleolar wedge-shaped resection of a predetermined bone wedge with lateral base. The desired correction is precisely calculated during preoperative planning. Subsequently, lateral approach over the distal fibula. Resection of a more proximal segment from the fibula. Closure of the tibial osteotomy (closed wedge) and osteosynthesis of the fibula.ResultsA supramalleolar valgus osteotomy (closed wedge) was performed in 27 patients from 2002 to 2006. Preoperatively, there was an average varus deformity of 27°, which was corrected to 6° on average postoperatively.21 patients were very satisfied at follow-up, three patients required joint replacement during the later course, and another three patients needed arthrodesis.

Die supramalleoläre, subtraktive, valgisierende Tibiaosteotomie bei Varusarthrose des Sprunggelenks

ZusammenfassungOperationszielZiel der supramalleolären Tibiaosteotomie bei varischer Fehlstellung im oberen Sprunggelenk ist die Verlagerung der Belastung von dem schwer arthrotisch veränderten medialen Gelenkanteil auf den lateralen Abschnitt und somit die Wiederherstellung einer physiologischen Rückfußposition und eines plantigraden Fußauftritts. Damit sollen eine Schmerzreduktion erreicht sowie der Zeitpunkt einer totalendoprothetischen Versorgung bzw. Arthrodese hinausgezögert werden.IndikationenSchmerzhafte, konservativ erfolglos behandelte Varusarthrosen im oberen Sprunggelenk mit > 15° Achsfehlstellung in der tibiotalaren Gelenkachse.KontraindikationenHochgradige, bewegungseinschränkende Arthrosen des oberen Sprunggelenks.Floride Infektionen.Ausgedehnte Knochen- und Weichteildefekte.Osteonekrosen des Talus mit Nekrosebezirken > 50%.OperationstechnikVentraler Zugang über dem oberen Sprunggelenk und supramalleoläre keilförmige Resektion eines zuvor definierten Knochenkeils mit lateraler Basis. In der präoperativen Planung ist die gewünschte Korrektur genau zu berechnen. Nachfolgend lateraler Zugang über der distalen Fibula. Hier Entnahme eines weiter proximal gelegenen Segments aus der Fibula. Nun Schließen der Tibiaosteotomie („closed wedge“) und Osteosynthese der Fibula.ErgebnisseBei 27 Patienten wurde zwischen 2002 und 2006 eine supramalleoläre, valgisierende Osteotomie („closed wedge“) durchgeführt. Präoperativ zeigte sich eine durchschnittliche Varusfehlstellung von 27°, welche postoperativ auf durchschnittlich 6° korrigiert werden konnte.21 Patienten waren bei den Nachuntersuchungen sehr zufrieden, drei Patienten wurden im weiteren Verlauf endoprothetisch und weitere drei Patienten mit einer Arthrodese versorgt.AbstractObjectiveThe aim of supramalleolar osteotomy of the tibia in the management of varus deformity of the upper ankle joint is to shift load bearing away from the severely degenerated medial part of the joint to the lateral part and thus restore physiological alignment of the hindfoot and a plantigrade foot. The intention is to reduce pain and to postpone the need for total endoprosthesis or arthrodesis.IndicationsPainful degeneration of the ankle joint with varus deformity that has proven resistant to conservative treatment, i.e., > 15° axial malalignment of the tibiotalar joint axis.ContraindicationsSevere ankle joint degeneration that restricts movement.Florid infections.Extensive bone and soft-tissue defects.Osteonecrosis of the talus with necrotic regions > 50%.Surgical TechniqueAnterior approach to the upper ankle joint and supramalleolar wedge-shaped resection of a predetermined bone wedge with lateral base. The desired correction is precisely calculated during preoperative planning. Subsequently, lateral approach over the distal fibula. Resection of a more proximal segment from the fibula. Closure of the tibial osteotomy (closed wedge) and osteosynthesis of the fibula.ResultsA supramalleolar valgus osteotomy (closed wedge) was performed in 27 patients from 2002 to 2006. Preoperatively, there was an average varus deformity of 27°, which was corrected to 6° on average postoperatively.21 patients were very satisfied at follow-up, three patients required joint replacement during the later course, and another three patients needed arthrodesis.

Ballooning osteolysis in 71 failed total ankle arthroplasties

Background and purpose — Aseptic loosening is a major cause of failure in total ankle arthroplasty (TAA). In contrast to other total joint replacements, large periarticular cysts (ballooning osteolysis) have frequently been observed in this context. We investigated periprosthetic tissue responses in failed TAA, and performed an element analysis of retrieved tissues in failed TAA. Patients and methods — The study cohort consisted of 71 patients undergoing revision surgery for failed TAA, all with hydroxyapatite-coated implants. In addition, 5 patients undergoing primary TAA served as a control group. Radiologically, patients were classified into those with ballooning osteolysis and those without, according to defined criteria. Histomorphometric, immunohistochemical, and elemental analysis of tissues was performed. Von Kossa staining and digital microscopy was performed on all tissue samples. Results — Patients without ballooning osteolysis showed a generally higher expression of lymphocytes, and CD3+, CD11c+, CD20+, and CD68+ cells in a perivascular distribution, compared to diffuse expression. The odds of having ballooning osteolysis was 300 times higher in patients with calcium content >0.5 mg/g in periprosthetic tissue than in patients with calcium content ≤0.5 mg/g (p < 0.001). Interpretation — There have been very few studies investigating the pathomechanisms of failed TAA and the cause-effect nature of ballooning osteolysis in this context. Our data suggest that the hydroxyapatite coating of the implant may be a contributory factor.

Implantation einer Sprunggelenktotalendoprothese vom Typ Salto 2

AIM OF SURGERY Operative treatment of advanced primary and secondary arthritis of the ankle was carried out with the aim of achieving pain-free movement and retention of mobility. INDICATIONS Surgery is indicated when conservative therapy is no longer sufficient for treatment of arthritis of the ankle with painful limited movement, sufficient bony joint conditions and correctable instability or axis malpositioning. CONTRAINDICATIONS Surgery is not recommended with general surgical or anesthesiological contraindications, rampant infections, severe disturbances of peripheral perfusion, bony defects in areas relevant for anchoring, unstable soft tissue conditions, talus necrosis >30 %, manifest osteoporosis and severe non-correctable instability or malpositioning. OPERATION TECHNIQUE Tibial and talar bone resection was carried out via ventral access to the ankle through an incision and if present, soft tissue correction of instability after insertion of test components. Cement-free implantation of the original implants followed by subtle reconstruction of the extensor retinaculum and layer for layer closure of the wound. ADDITIONAL INTERVENTIONS Additional measures were necessary on the periarticular soft tissues, the hindfoot and lower leg due to movement restrictions, instability and axis malpositioning which could be carried out in a one or two stage procedure depending on the extent and morphology. RESULTS Between February 2009 and February 2010 a total of 115 patients (52 % with posttraumatic arthritis) received a cement-free implantation with a Salto 2 prosthesis. Additional corrective interventions were carried out in the presence of varus and valgus deformities. The degree of movement for dorsal extension and plantar flexion could be increased by an average of 8.3°. The interventions resulted in a significant reduction in pain from an average preoperative visual analogue pain scale (VAS) score of 7.8 (range 5-10) to an average postoperative score of 1.9 (range 0-6.1).

Implantation of a Salto 2 total ankle prosthesis

AIM OF SURGERY Operative treatment of advanced primary and secondary arthritis of the ankle was carried out with the aim of achieving pain-free movement and retention of mobility. INDICATIONS Surgery is indicated when conservative therapy is no longer sufficient for treatment of arthritis of the ankle with painful limited movement, sufficient bony joint conditions and correctable instability or axis malpositioning. CONTRAINDICATIONS Surgery is not recommended with general surgical or anesthesiological contraindications, rampant infections, severe disturbances of peripheral perfusion, bony defects in areas relevant for anchoring, unstable soft tissue conditions, talus necrosis >30 %, manifest osteoporosis and severe non-correctable instability or malpositioning. OPERATION TECHNIQUE Tibial and talar bone resection was carried out via ventral access to the ankle through an incision and if present, soft tissue correction of instability after insertion of test components. Cement-free implantation of the original implants followed by subtle reconstruction of the extensor retinaculum and layer for layer closure of the wound. ADDITIONAL INTERVENTIONS Additional measures were necessary on the periarticular soft tissues, the hindfoot and lower leg due to movement restrictions, instability and axis malpositioning which could be carried out in a one or two stage procedure depending on the extent and morphology. RESULTS Between February 2009 and February 2010 a total of 115 patients (52 % with posttraumatic arthritis) received a cement-free implantation with a Salto 2 prosthesis. Additional corrective interventions were carried out in the presence of varus and valgus deformities. The degree of movement for dorsal extension and plantar flexion could be increased by an average of 8.3°. The interventions resulted in a significant reduction in pain from an average preoperative visual analogue pain scale (VAS) score of 7.8 (range 5-10) to an average postoperative score of 1.9 (range 0-6.1).

Implantation einer Sprunggelenktotalendoprothese vom Typ Salto 2@@@Implantation of a Salto 2 total ankle prosthesis

AIM OF SURGERY Operative treatment of advanced primary and secondary arthritis of the ankle was carried out with the aim of achieving pain-free movement and retention of mobility. INDICATIONS Surgery is indicated when conservative therapy is no longer sufficient for treatment of arthritis of the ankle with painful limited movement, sufficient bony joint conditions and correctable instability or axis malpositioning. CONTRAINDICATIONS Surgery is not recommended with general surgical or anesthesiological contraindications, rampant infections, severe disturbances of peripheral perfusion, bony defects in areas relevant for anchoring, unstable soft tissue conditions, talus necrosis >30 %, manifest osteoporosis and severe non-correctable instability or malpositioning. OPERATION TECHNIQUE Tibial and talar bone resection was carried out via ventral access to the ankle through an incision and if present, soft tissue correction of instability after insertion of test components. Cement-free implantation of the original implants followed by subtle reconstruction of the extensor retinaculum and layer for layer closure of the wound. ADDITIONAL INTERVENTIONS Additional measures were necessary on the periarticular soft tissues, the hindfoot and lower leg due to movement restrictions, instability and axis malpositioning which could be carried out in a one or two stage procedure depending on the extent and morphology. RESULTS Between February 2009 and February 2010 a total of 115 patients (52 % with posttraumatic arthritis) received a cement-free implantation with a Salto 2 prosthesis. Additional corrective interventions were carried out in the presence of varus and valgus deformities. The degree of movement for dorsal extension and plantar flexion could be increased by an average of 8.3°. The interventions resulted in a significant reduction in pain from an average preoperative visual analogue pain scale (VAS) score of 7.8 (range 5-10) to an average postoperative score of 1.9 (range 0-6.1).

Protheseninfektionen des oberen Sprunggelenks

Infektionen stellen in der Gelenkendoprothetik eine schwere und sehr ernstzunehmende Komplikation dar. Die Endoprothesenchirurgie des Huft- und Kniegelenks fand in den spaten 60er und beginnenden 70er Jahren flachendeckende Verbreitung und war in diesem Stadium mit Infektionsraten von 5–10 % behaftet (Ahlberg et al. 1978; Bengtsson et al. 1987). Seither wurde das Risiko infektioser und septischer Prothesenkomplikationen schrittweise gesenkt. Strikte pra- und perioperative Routinemasnahmen sichern heutzutage bewahrte Standards und sind fester Bestandteil der Qualitatssicherung. Dazu zahlen z. B. kurze praoperative Hospitalisierungszeitraume, die Vermeidung operativer Eingriffe bei Patienten mit floriden Infektions- und Erkaltungskrankheiten, die Pausierung immunsuppressiver Medikamente z. B. bei Rheumapatienten, die perioperative Antibiotikatherapie und die Einhaltung und Kontrolle geltender Hygienebestimmungen. Verbesserungen der OP-Verfahren und Instrumentation sorgen ebenso, wie die technische Ausstattung der OP-Sale (z. B. Luftfuhrungssysteme mit turbulenzarmer Verdrangungsstromung extrem keimarmer Luft, Raumluftpartikelfilterung, autarke und abgeschlossene OP-Raumlichkeiten etc.) fur die notige Asepsis bei der Operationsdurchfuhrung. Das Infektionsrisiko fur Knie- und/oder Huftendoprothesen wird fur einen Zeitraum von 10 Jahren derzeit mit unter 1 % angegeben (Lidgren 2001).

Allgemeine Operationstechnik der Sprunggelenksendoprothetik

Die vorliegende OP-Anleitung soll einige praktische Tipps fur die Implantation einer Sprunggelenksendoprothese aufzeigen. Aufgrund der Vielfalt der zurzeit auf dem Markt erhaltlichen Prothesentypen ist es nicht moglich, fur jeden einzelnen Prothesentyp eine detaillierte OP-Beschreibung vorzunehmen. Deshalb werden wir uns auf einige aus unserer Sicht wesentliche Operationsschritte beschranken, die uns aus unserer Erfahrung (nach uber 1,000 Prothesenimplantationen am Sprunggelenk) mit vier verschiedenen Prothesentypen relevant erscheinen.

Indikation/Differentialindikation der Sprunggelenksendoprothetik

Bis heute besteht kein Konsens uber die Indikation zum endoprothetischen Ersatz des oberen Sprunggelenks. Die Erfahrung zeigt, dass je nach Fachrichtung des Operateurs und seiner individuellen Erfahrung die Indikationsstellung zu den einzelnen Verfahren gestellt wird. Vielerorts ist die Arthrodese des oberen Sprunggelenks ein etabliertes Verfahren. Sie stellt eine uber viele Jahre praktizierte Prozedur dar und ist in der Literatur mit uber 30 verschiedenen Verfahren beschrieben (Jerosch et al. 2006). Mitunter wird die Sprunggelenksendoprothetik noch immer als ein experimentelles Verfahren betrachtet, das nur in wenigen, spezialisierten Zentren zur Anwendung kommen sollte.