Replacement of the upper ankle with an endoprosthesis? This operation is used for idiopathic arthrosis, post-traumatic arthrosis or rheumatoid arthrosis. In the case of osteoarthritis of the upper ankle in the final stage, the surface replacement must be discussed after all non-surgical measures have been exhausted.
The replacement of the upper ankle with an endoprosthesis is carried out approximately 1,500 times a year in Germany.
Nowadays, only modern 3-component prostheses of ankle joint are used. The main development of these prostheses with the star prosthesis has been taking place for more than 15 years by H. Kofoed from Copenhagen. Since then, various other models have also been developed. The most common ankle joint prostheses are - apart from the star prosthesis - the Hintegra prosthesis, the salt prosthesis, the mobility prosthesis and the box prosthesis of ankle joint.
3-component prostheses have been used since the early 1980s. The design of the prostheses was gradually changed. The surgical technique is similar for the different prostheses. There are differences in the preparation of the prosthesis bearing in the lower leg bone. In part, a large central pin is anchored (as in the somersault and mobility prosthesis), in part by tongue and groove principle (as in the Star, Box and Hintegra prostheses).
There are differences in the amount of preparation for the ankle joint. In the Star, Hintegra and Salto talus components, the side cheeks that are in contact with the inner ankle and fibula are replaced. The side panels of the Buechels-Papas, Mobility and Box Talus components are not replaced. The anchor pins in the talus (ankle bone) are also different.
There are testimonials about 15 years about the results of the star prosthesis. The prosthesis survival rate after 10 years is 93%, the prosthesis survival rate after 15 years is 64% (Kofoed). Changes in the design of ankle joint prosthesis, with regard to the surface in the contact zone with the bone, must be taken into account. The patient-dependent factors such as the history of rheumatism, condition after accidents and axis deviations must also be taken into account.
The operation is compulsory inpatient. A stationary stay of 1-2 weeks is to be expected.
What Is An Artificial Ankle?
An artificial ankle is tailored to suit the human anatomy and the movement of a normal upper ankle. It mimics its natural form, function and movement. With the aim of preserving as much bone material as possible, the joint surfaces of the worn and destroyed upper ankle, i.e. the surfaces of the anklebone (talus) and the shinbone (tibia), are coated with a surface replacement. If such an artificial ankle joint fails, it is always possible to perform a fusion operation (arthrodesis).
There are many different types of artificial ankle joints. These include:
- STAR® ankle prosthesis,
- Hintegra® ankle prosthesis,
- Salto® ankle prosthesis,
- Mobility® ankle prosthesis
- BOX® ankle prosthesis.
All these types of ankle prostheses consist of three components:
- a rounded cap for the talus head
- a plate for the shin component surface
- a freely movable polyethylene sliding core
Therefore, if a replacement operation is necessary, not the entire artificial ankle must be removed and replaced, but only the defective component.
Each of these ankle prostheses is available in different sizes and shapes. In this way, an artificial ankle joint is adapted to the anatomy of each individual patient. What particular artificial ankle will be implanted (its model and size) is decided by the treating surgeon based on various preliminary examinations. Among other things, the age, bone quality, weight and health of the patient play a decisive role, too.
What Materials Is an Artificial Ankle Joint Made Of?
The aim of an artificial ankle is to restore trouble-free and painless ankle movement and thus provide a long-term increase in the quality of life and mobility of the patient in everyday life, work and leisure. In order for an artificial ankle joint to satisfy these requirements, the materials used must meet different criteria. Since an artificial ankle joint stays in the body permanently, these include the greatest possible durability and a good body compatibility of the materials.
The exogenous material used for the components of a ankle prosthesis
- must not trigger rejection or intolerance reactions,
- must not wear out prematurely,
- must be corrosion-resistant and
- should be able to withstand the load of the body.
In addition, no wear may occur when the various components of an ankle prosthesis are rubbing on each other. Therefore, special metals and plastics are generally used for an artificial ankle joint. For example, the artificial joint surfaces of the anklebone and the shinbone are usually made of body-compatible metal alloys containing chromium and cobalt. On the other hand, the freely movable sliding core between the two joint surfaces is made of a high-quality special plastic called polyethylene.
Components of an Ankle Joint Prosthesis: The Construction of an Artificial Ankle Joint
Ankle prostheses have been used since 1969 and since have been continuously refined and improved in order to further optimize their mobility in all directions and their stability. The modern ankle prostheses implanted since the mid-1980s consist of three components that are modeled after the anatomical structure of a natural ankle:
- a rounded metal cap for the talus head,
- a metal plate for the shin component surface and
- a movable polyethylene sliding core.
The two metallic joint surfaces for the shin and the talus are implanted into the bone as a surface replacement, while a free-moving sliding core in between is made of high-quality polyethylene.
Metal cap for the talus head: The lower part of the ankle, i.e. the anklebone or talus head, is coated with a rounded cap made of a cobalt-chromium alloy. Using small pins and a special coating that sticks firmly to the bone and grows together with it over time, this metal cap is attached to the ankle bone. Its surface is designed in such a way that the individual components of the artificial ankle joint optimally interact during the joint movement.
Metal plate for the shin joint surface: The upper part of the artificial ankle consists of a straight plate made of a cobalt-chromium alloy, which is placed on the joint surface of the tibia and connected to the bone using a center-mounted dowel. The metal plate for the joint surface of the shinbone, just like the metal cap for the talus head, is also coated with a special material that with time fuses with the bones. In order to prevent the mobile bearing from slipping and hitting the inner bones, the metal plate also has a fin on the edge.
Freely movable polyethylene sliding core: The third component is a freely movable, mobile polyethylene sliding core that takes over the function of the natural joint cartilage. Accordingly, it is located between the ankle and the shin components of the artificial ankle. It is bent towards the anklebone, i.e. on the bottom, and sticks to the metal cap and it is flat on the top towards the shin and fits exactly to the metal plate. This sliding core enables a friction-free movement between the shinbone and ankle bone and minimizes the lifting and gravity forces between the two metallic components of the ankle prosthesis.
How Is an Artificial Ankle Joint Attached to the Bone?
Nowadays, an artificial ankle is only anchored in a bone-sparing and cement-free way. Modern artificial ankle joints are thus implanted as ingrown prostheses without bone cement. This so-called cementless osseointegration significantly improves the durability and stability of an ankle prostheses and reduces the risk of its later loosening.
Cementless osseointegration of an artificial ankle using press fit method If an artificial ankle joint is attached to the bone without cement, the two prosthetic components on the anklebone (talus) and shinbone (tibia) are first mechanically connected to the bone using press fit method. A rough surfaces on the sides of the two prosthetic components facing the bone have a special coating, for example from titanium/potassium phosphate, that subsequently enables the gradual firm and stable fusion of the individual prosthetic components with the natural bone of the ankle.
Prerequisite for the cementless osseointegration of an artificial ankle joint To perform a cementless osseointegration of the prosthesis the precise preparation of the prosthesis stem is necessary. This is usually done in a bone-sparing manner. This means that only a couple o millimeters of the patient's anklebone (talus) and shinbone (tibia) sacrificed. On the other hand, in order to have a cementless osseointegration of an artificial ankle performed you need to have a good bone quality and bone substance, which enables the fusion of the body's own bone with the special coating of the prosthetic components.
Surgical Implantation of an Ankle Prosthesis
The surgery is often performed under regional anaesthesia, since it has less impact on the patient’s vascular system than total anaesthesia. The doctor uses spinal anaesthesia to anesthetize either only the injured leg or both legs. A long skin incision is made on the rear foot, the tendons and muscles are moved aside until the surgeon sees the joint space. He opens the joint capsule and begins to prepare for the installation of the prosthesis.
Straight before the operation, using the obtained images of the joint, it is estimated how much bone tissue is needed to be removed. The surgeon acts very sparingly to preserve the bone and leave as much surface as possible for future replacements or enhancement of the prosthesis. During the operation, the optimal position of the prosthesis is determined with the help of various angle measuring instruments, which is then checked and defined more exactly by using X-ray. For successful surgery, it is important to preserve the ligaments around the joint as dense as possible.
An artificial ankle is attached to the bone with screws. Over time, thin trabeculae are formed, which go from the supracalcaneum bone, lower leg and fibula, and fuse with the rough surface of the prosthesis. On average, the surgery takes about 90-120 minutes.
In about 14 days the foot can be placed in a special shoe which must be worn for 6-8 weeks. Depending on the state of the patient’s health, full rehabilitation takes about 12 weeks.
Replacement of the Ankle Prosthesis
When the artificial ankle joint needs to be replaced (the procedure is called revision or replacement operation) either one or two of the three prosthetic components, or the entire previously implanted ankle prosthesis, are exchanged surgically.
Post-Inpatient Treatment for Ankle Prosthesis
During or after the surgery, infection may occur in the area of the prosthetic joint. To prevent the progression of the infection around the prosthesis, it is extremely important that during the operation the operating surgeon should precisely record all indications. Acute inflammation should be ruled out under any circumstances. The use of modern equipment and complete sterility in the operating room are also of great importance for the prevention of inflammation in the prosthetic joint.
Immediately after installing the ankle prosthesis, a stay in the hospital for 5-7 days is required to monitor, treat the wound and maintain a fixed position of the foot. At this time the joint is carefully exercised. If the postoperative period takes its normal course, the patient will have to wear a plaster cast for two weeks, which is necessary to protect the soft tissues. After that it is estimated whether the patient is ready to wear the so-called Aircast Walker boot. This design helps the patient load the ankle partially. In complete 4 weeks, the full load on the joint is allowed.
Rehabilitation to Restore Full Range of Motion
As a rule, the period of hospitalization and the healing of the open wound are followed by a rehabilitation phase that takes about 12 weeks. It includes physiotherapy, massage and light sport exercises, done under the supervision of a physician. Eight weeks after the operation on the ankle joint, the patient can again become a full-fledged traffic participant, as well as drive a car, provided that the foot has restored its ability to withstand the load even in the most dangerous situations.
Postoperative Care is Mandatory
One of the main postoperative risks is loosening of the ankle joint prosthesis as a result of improper handling or force action. Incorrect rotation of the joint should also be avoided. Thus, the patient should regularly visit the treating orthopaedic doctor for postoperative observation. With the help of X-ray images, the doctor will be able to detect the loosening of the prosthetic ankle joint in the early stage and prevent the situation from worsening. Without proper treatment, loosening of the prosthesis can damage the bone tissue. It is not only painful, but also complicates the further fixation of the prosthesis on the bone which continues to collapse. The further course of rehabilitation also includes long-term mobilization of the joint through sports.
The recommended sports are:
- Running (in the right shoes on a flat surface)
All kinds of sports with quick changes in the load are absolutely unacceptable and harmful:
- Martial arts
During the first two years after the operation, the vast majority of patients who have gone through the ankle replacement surgery restore their athletic activity by 56%. This estimate is based on control test data.