Ankle Arthritis On Demand Seminar


(upbeat music) – I want to thank everybody
for coming tonight. My name is Scott Sauer. I’m an orthopedic surgeon, and I’ve done a fellowship in foot and ankle surgery, so that’s really my primary focus, is foot and ankle. I cover all treatment options
of the foot and ankle, conservative, surgical,
and really focus on individual treatments tailored
to your specific needs. Tonight I though it was an important topic to talk about ankle arthritis. I think it’s something that we have that’s pretty prevalent in society that people don’t really know a lot about. They don’t know what to do. I hope with this discussion
to give you some ideas about what arthritis is in general. I’ll show you some drawings and pictures that kind of demonstrate
what arthritis is, and then some of the treatment options for ankle arthritis particularly, since that’s an area of my focus, that we can discuss and
show you some pictures and I can tell you about that. With me tonight is Mark Llewellyn. He’s a physical therapist
that I work closely with. He has a particular
interest in foot and ankle, and we work together on a lot of patients. He’s going to provide
the therapy perspective, which is going to be a
conservative treatment option, which I think is important, prior to any kind of
surgical intervention. Then postoperatively, physical therapy is definitely an important aspect if there’s any kind of surgery done. We’ll start off with our first slide here. Exactly what is arthritis? Arthritis is inflammation of the joint. It’s derived from the Latin
arthros, which means joint, and then -itis, which is
any type of inflammation. It’s one of the leading causes of disability in the United States. There are several different
types, which we will cover just a few of those things, just so you can be educated on that. Then basically, any type of arthritis can lead to destruction of the cartilage, and that’s the underlying problem with arthritis in any joint. These are some pictures
of what arthritis is. On the left side is a
normal-appearing joint where the nice, white articular cartilage, which is that slippery substance that you might see on the end of bones. If you look at the end of a chicken bone you’ll see this white
and glistening cartilage. That is what cartilage is. It helps the joint move more fluidly. Then underneath that cartilage is the lining of the bone,
which is called periosteum, and then the bone underneath, which appears normal on the left. Then when you look to the right, that picture is significantly different, where there’s no cartilage. There’s a lot of cystic changes, as well as the bone has
sort of eroded down, which is common with severe arthritis. In this picture, this is
a little bit different, where there’s more … It’s a similar image,
where the normal side has normal cartilage. There’s normal joint
surrounding it, and normal bone. But on the right side
there’s significant change. That’s because the
cartilage has worn down. The joint fluid, which
is inside the joint, can get pushed into the bone, and it forms these little cysts. Sometimes on x-rays,
and we’re going to see some of the x-rays, sometimes that appears like a little hole in the bone. It just provides this
raggedy, roughened surface that really doesn’t move very fluidly. So what happens in arthritis? Again, the same side, normal
side there on your left has a normal cartilage cap where the white cartilage is, and then the bones. In the ankle joint, there are three bones. There’s the tibia, the
fibula, and the talus bone. That’s really the part that makes your ankle go up and down. The ends of the bones are
covered in white cartilage, and that’s what provides
the surface to glide and makes the joint move nice and smooth. Well now if you look at the right side, the cartilage has been cracked and broken. It’s wearing down, and there really not a good cartilage surface that allows the joint to move nicely, and this is really what an
arthritic ankle joint looks like. In terms of pain, the typical symptoms for arthritis of the ankle
are pain, stiffness, swelling. So what causes the pain? Usually it’s because of
this damaged and flaking cartilage that can cause
the ankle to become painful. The cartilage and the
pieces that break off can float around and damage the joint. The ankle can feel unstable. Because of that, the pieces
that are floating around, they can actually get stuck in the joint. It’s kind of like a pebble in a gear. It gets stuck. Your ankle may lock and
cause pain that way. There’s bone-on-bone contact. What does that mean? When the cartilage wears away, there’s bone left underneath, and that bone-on-bone is very sensitive, and it rubs and grinds. It’s almost like sandpaper
rubbing together. You can have swelling and stiffness. There’s also the ligaments
that can be looser. Sometimes they’re tighter or looser, and you can have an unstable feeling. Bone spurs and extra
bones around the joint is basically the body’s response to that arthritis and inflammation. It’s forming more bone to
provide more surface area for the joint to move, so you get spurs. That’s a result of inflammation. That can also cause pain as well. What are the types of ankle arthritis? These are just a few, but the main ones. Osteoarthritis, that’s your typical wear and tear arthritis, just from it being active your entire life. It’s a slow progression. The cartilage loss is very slow over time. It really doesn’t have
to do with an injury. Sometimes it can occur just primarily from that active lifestyle wear and tear. Other arthritises include rheumatoid and post-traumatic. So rheumatoid arthritis
is a little different. That’s when you have your body, and it’s immune system is
actually attacking the joint. It looks at the lining of the joint as a foreign thing inside your body, and it reacts to it. You get inflammation inside the joint. It causes pain,
inflammation, and swelling. That can affect any joint in the body. That’s often something
that’s treated with medicines to try to suppress the immune system in an effort to keep it
from attacking your joints, keep it from getting painful. Then the post-traumatic arthritis can lead to osteoarthritis. It’s more of a secondary phenomenon. But what happens is, you have an injury. Could be a sprain. Could be a fracture
that’s severe from trauma, or even just stepping off the curb wrong. That alters the mechanics in the joint, and over time, because
of that altered angle or a deformity that occurs, you can have the development of an arthritis from that, where the joint wears away over time. These are some x-rays that you can see. Again, on your left is a normal x-ray. That’s the tibia above. If you remember the picture
from a few slides ago, they are all the same bones. Tibia above, fibula all
the way to the outside, and then the talus bone underneath. If you look, there’s a nice space here between all the bones, and that’s where the cartilage is. You can’t see cartilage on x-ray. It’s basically just bone. That’s what you seen on an x-ray. It’s a 2D picture. In mild arthritis, which is here, you start to see a little narrowing here. There’s narrowing, there’s
a little spur formation. But in general, the cartilage is intact. Okay. Go ahead. On these other moderate and
severe arthritis pictures, you’re going to see a totally
different picture now. On the left, more moderate. There’s pretty severe narrowing here, some little spurs that are formed. Then this is severe arthritis, where you have bone-on-bone, so there’s no space anymore. There’s even these little circles here that are black dots and they look like, those are cysts, okay? That’s what they look like on x-ray. Just there’s a space
there that the x-ray beam gets through a lot easier. It’s a cystic formation that occurs because the fluid gets
pushed into the bone. It’s forced in there, because there’s no space left anymore. It’s pretty unusual to get
MRIs on late arthritis, because it’s severe bone-on-bone and you can often see it on x-ray, but sometimes in the earlier stages an MRI is helpful, because you can see localized areas of arthritis. In this case you can see little areas in the bone that are not flat. There’s a little valley there, almost like a pothole in the road. That’s how I describe it. There’s a hole there that’s formed from either trauma, or
over time it’s worn away. It really is helpful to get
an MRI in the early stages if you’re not sure it’s a
purely arthritic phenomenon. But in most cases, you
can see it on x-ray. What are our treatment goals
with arthritis in the ankle? We want to relieve pain and inflammation. We also want to slow
the disease progression. Unfortunately, we
haven’t figured out a way to cure arthritis yet, but we want to prevent it from getting worse if possible, and we want to control
the symptoms from it. That really comes down to after doing that you’re improving a quality of life, as well as improving or maintaining some kind of functional independence. Treatment options really vary. We’re going to talk about
conservative treatment options, those are non-surgical treatment options, and we’re going to exhaust all those before we talk about surgical options. The conservative treatment options include medications, lifestyle changes, physical therapy, bracing. Those are things that don’t involve any type of surgical intervention. When those things don’t work, we consider doing surgery. Medications that you’ve all
heard of and talked about, pain relievers like tramadol, opioids, those are like the narcotic medications, like Percocet, Vicodin, those are pretty strong pain pills that we reserve for the
most severe cases of pain, maybe a flareup that really
you’re having trouble sleeping, things like that. We try to use those judiciously, though. Non-steroidal
anti-inflammatory medications like ibuprofen, naproxen, Aleve. All these things are
the nonselective type. Those are the types that can affect your stomach a little bit more. They inhibit all the enzymes that affect inflammation in your
body, and that includes the protective enzymes for your stomach. We use those as a first line of defense, but if it’s something
that we might want to consider using more long term, then we’re going to go to maybe
a more selective medication. Those are the Celebrexes or the Mobics, that sometimes they only inhibit the certain enzymes that
affect inflammation, as opposed to the stomach one. So a little bit better on the stomach, but they do have their
risks, there’s no question, and we talk about all those things. The other medications, like
nutritional supplements and joint injections, the
nutritional supplements that are used are like the
glucosamine chondroitin sulfate. Those are the ones that are most studied. Those basically are nutritional for the cartilage in the joint, so they really go to every joint. They basically supersaturate the body with the nutrient for the cartilage, and they get into the joint
through the bloodstream. It provides the cartilage
with better nutrients. Something that you probably
get enough of in your diet, but in some studies it’s
shown to be beneficial over longer periods of
time to preserve cartilage. The other supplements like
fish oil and vitamin E really haven’t been studied in depth, although there are some that believe they have an anti-inflammatory effect, and they’re often taken
for other reasons anyway, so they’ve found that on that level. The joint injections, pretty common to do cortisone in any arthritic joint. Now you’re putting the
anti-inflammatory drug right into the joint. Instead of having it pass through your body or GI system into the blood, you’re putting it directly in there, and it bathes the inflamed surfaces, and reduces inflammation over time. It’s much more beneficial
in earlier arthritis, because you already have
a lot of cartilage there. When it’s bone-on-bone,
sometimes that can … It’s not as effective, okay? Then we discuss hyaluronic acid. I like to call them the
joint jelly injections. Basically the things
like Simvisc, Supartz, Hyalgan, there are many other ones. Euflexxa, Orthovisc, all that. They’re basically, now you’re replenishing the joint fluid, the synnovial fluid. This is the main
component, hyaluronic acid. It’s only FDA approved for
the knee at this point. But it’s, I’ve found,
beneficial using it off label in the ankle because it’s basically the same type of joint. You’re injecting the same medication. In my hands, I get about a 60% relief with some of the arthritis, depending on how severe it is. People seem to do pretty well. There are some studies that support it. We work with you on that and decide if that’s the best option for you. Platelet-rich plasma sort of has … It’s in its early stages of being used. It’s not often covered by insurance. They basically draw the
blood out of your body and they spin it down to a
good, concentrated solution that then you would inject
into the affected joint. It’s used for other
things like tennis elbow, tendonitis in the foot and the ankle. It has a limited role,
only because insurance doesn’t really cover it, and sometimes you’re paying out of
pocket to get it done. There are some facilities
that don’t even offer it, which really, at this
point, it’s not unusual just because of the cost involved. The data’s still be developed
for that particular therapy. It’s something to look to in the future. This is just an example and a picture of what an ankle joint
inject would look like. This is basically putting
the needle around the area. It’s really, I think, if
you’re really inflamed and sore it’s probably one of the better options, just because you’re going
to get, not instant relief, but it’s pretty quick over time. Another conservative
choice is lifestyle change. That’s something that most people do before they come into the office. They’ve stopped walking
for longer periods of time or they’ve altered the way they do their normal athletic activities. Basically, avoiding any
kind of impact activity, which can mean a walk. It could mean going up and down stairs if that’s what they need to do, which sometimes, in terms
of normal daily activities, isn’t acceptable. But most of the time running, aerobics, treadmills, those are things
that they avoid as well. Non-impact exercise is often used, something like swimming or biking, yoga, pilates, those are
things that don’t involve a lot of impact on the joint, but can be just as effective
in terms of exercise. Using an assistive device
like a cane or a walker is not unheard of. Typically, now you’re taking the pressure off of that particular joint. Because in the ankle specifically, it’s about five times your body weight. Weight loss, assistive device, those are all things that we discuss. I’m certainly not a weight loss counselor, but we do talk about that briefly. It just makes sense from
a physics standpoint. You’re going to lose
the mass on that area, it’s going to feel better. That’s something that we always consider. Physical therapy, I think, is important in the conservative treatment options, because if you have
weakness around the ankle, but also in the other areas of the leg, knee, hip area, that
is all going to affect your ankle biomechanics
and range of motion. We always consider that. It’s important to improve
the motion of the ankle. Somehow stretching the ankle if the Achilles tendon is tight. Improving ankle strength
is very important, because that provides more stability, not only in the ankle, but
for the upper part of the leg, the knee, the hip, things like that. Decreasing pain and swelling is important. There are a number of modalities that they can utilize in therapy, that if it’s appropriate
for you they can use, things like ultrasound, electrical stim. There’s iontophoresis, which is actually putting steroids transdermally
through the skin, which is done through a patch that’s applied to the area. So there are many ways to try to reduce pain and inflammation using these particular modalities in
the physical therapy office. Mark is going to touch on that, obviously, and many other things, I assume. We’ll talk a little bit about bracing. I think bracing is an
important option for arthritis, because it really can limit or support the affected joint. We do it in knees. Mostly ankles though,
because that can definitely give a lot of support
around a smaller joint that takes a lot of pressure. We talk about shoe wear modifications, things like inserts, rocker
soles, cushioned heels. Those are all things that
can decrease the impact on the joint with walking. Non-fixed supportive
braces basically just mean a soft brace around the ankle. That can give some
support, some compression, maybe decrease the
inflammation and swelling. Supportive braces that are fixed now have a little more rigidity to them. That’s something that you can do, like a standard ankle brace that you maybe get for an ankle sprain. That gives you a lot of support. I know they have them at
sporting goods stores. We have them in our office. We give them out commonly. Sprains are one of the most
common orthopedic injuries. Then the more rigid braces, or the circumferential braces, maybe like a custom brace. They actually wold have your foot molded, and then a brace made for the ankle that would give it more support. These are just an example of a couple non-fixed supportive braces. The cloth lace up brace, ASO type brace, something that you could probably buy at a sporting goods store. I know we have them in our offices. And then the plastic hinge brace is a very common brace
used for ankle sprains. But it also serves a secondary role in arthritis, because it
gives that lateral support, the support in the ankle to keep it from moving back and forth. The next types of braces, now these are a little bit more custom. They provide a lot more support than the other braces. These are the fixed braces. It’s rare that I use this
brace on the left here. It’s a molded ankle foot orthosis. Basically a MFAO. It limites, or eliminates
any ankle joint motion. You can imagine if you have bone-on-bone and you’re ankle’s
grinding away and moving, well, you want to eliminate
that movement there. This can help with that. I tend to use the brace on the right more, which is called an Arizona brace, basically development for
this particular problem as well as others, other
arthritis in the foot. there are tendinopathies,
or tendon inflammations that can be treated with this. It basically is custom made. It’s mainly leather around these areas with the lace up, and then
inside is a plastic mold around the ankle that really eliminates movement at the ankle joint. These are two, well mainly
the Arizona, I think, is in my hands a better alternative, because patients are
more compliant with it. It’s a little bit easier to wear than the other brace in this case. Shoe wear modifications like this. This is a cushioned heel above. It’s also called a S.A.C.H. heel. Then like a rocker bottom
or a little wedge heel in a sneaker can help
just to take the force off the joint when you land on your heel. That can take away some of the pain, just a simple modification
on a shoe like that. We’ve talked a little bit about the conservative treatments. We try to exhaust as
much of that as we can. I’ll be honest with you, if your ankle is really pretty severe bone-on-bone, we’re going to eliminate the ones that I don’t think are going to work. But there may be some
surgical considerations then if we get to a point where
you’re not comfortable, we’ve tried some things, and we’re just not getting anywhere. The surgical treatment options, I think, there are three, really. Arthroscopic debridement. There’s arthrodesis,
which is ankle fusion, and arthroplasty, which
is joint replacement. Ankle arthroscopy, I think has its role in early stages of arthritis. This is where you have
a lot cartilage left. It’s just maybe certain areas of it that have been damaged, and you have small little pockets
that maybe are flaking. It’s kind of like that
pebble in a gear scenario. If a piece of cartilage
is floating around, you can go in there
arthroscopically and get it, clean out the inflamed tissue, and generally have a pretty
good result from that. It takes small incisions and there’s a little camera you use. It’s really no bigger than a pencil. You can do your work minimally invasive. Arthrodesis or fusion is really reserved for advanced arthritis. Now you’re talking about
close to bone-on-bone, or just intractable pain,
that you’re going to remove the ankle joint entirely by taking out the arthritic portion of it, put the bones directly
adjacent to each other and hold them there with
some type of fixation, screws, plate, something
to push it together, kind of like you’re putting
two pieces of wood together. Then over time the body takes over and it heals like it
would heal a fracture. The bone grows together. Now you have a fused joint. So that eliminates the
movement in the joint and basically there’s no
joint to be inflamed anymore, and the pain subsides substantially. This is really the mainstay of treatment for severe arthritis in
the ankle is a fusion. It’s been done for years and years, and it seems to be a
more popular procedure, just in terms of the
outcomes are a little bit more predictable for
that particular surgery. The recovery can be a little bit longer, and we’re going to talk about arthroplasty in the same sense, but there’s definitely a little bit more length to
a fusion surgery recovery. Arthroplasty or joint replacement is also reserved for advanced arthritis. Now you’re cutting out
the arthritic joint, but you’re not fusing it. You’re actually putting now, you’re resurfacing it basically, and you’re putting in
a new tibial surface, a new talar surface, and
then some plastic in between. So you’re really able to maintain a somewhat normal joint motion. It’s pretty important. You’re preserving the joint motion. One of the downsides in the past with these arthroplasties
is the implant can loosen or even fail over time. So there’s going to be some complications that can occur with
arthroplasty, with fusion, and we’ll touch on all of that. Arthroscopic debridement, I mean basically I just have the picture. The camera’s going into the ankle joint. But you can see just how
small those cameras are. They’re pretty small. The ankle joint, the toes
are going towards that side. There are two small incisions to do that kind of surgery. This is what you would
see inside the joint. If you look at the talus,
that’s the bottom bone, the joint is really smooth. It’s nice and white and glistening, kind of looks like a cue ball type effect. That’s what normal
cartilage should look like. Then the tibia above looks the same way. There may be some synovitis. That’s basically inflamed
tissue inside the joint. That’s common with any inflamed joint. This is what you’d see in early arthritis. Now I have a little grasper in there and I’m grabbing a piece of cartilage that’s floating around. Then where that cartilage came from is a little divot in that area. Now I’m scooping out the bad
scar tissue that’s in there because I want that to fill in on its own. The body will fill that in. It’ll bleed. It’ll form like a scar
cartilage in that area that’s not quite normal
articular cartilage, which is the white, glistening cartilage, but it’s good enough for that area, such a small region. Even though it looks big on the picture, it’s really only millimeters big. That scar cartilage does
the job it needs to do. Before we get to this slide, that arthroscopic surgery,
it’s really reserved for the early stages, because you really can’t do a lot in advanced arthritis. There’s not any cartilage left. You really are just debriding and maybe cleaning out some of the
loose bodies that are there. But it’s not really been
shown to improve outcome, much like knee arthritis with arthroscopy, it’s kind of the same thing. Ankle arthrodesis. This is just a diagram or a picture of what an arthrodesis is. If you remember the
picture a few slides ago with a normal bony anatomy,
with the tibia on top, the fibula outside on your left here, and then the talus below. This is what happens. You cut out this area, and then you fix it with either screws or a plate. There are many different types of products that you can put in to
get it to stay together. Every surgeon that does a fusion has his or her own way of doing it, either a screw or a plate. There’s a lot of things you can do. This is just an x-ray now. Remember the x-rays from before. Well, now we don’t have a joint anymore. We have a lot of screws that go across it to fuse it together. You can’t see that nice line where the joint is anymore. It’s grown together into one bone. I think some important
things to think about with a fusion, and a misconceptions, that you’re going to have a limp. You’re not going to be
able to walk normally. I think that’s sort of a misconception. The gate in an ankle
fusion is generally normal. As long as you have normality
around the ankle itself with other joints that
are normal appearing in the foot, in the bone, in
the knee, in the heel bone, I think there’s no reason
to not expect a normal gait. That really involves postoperative rehab and things like that. You may have a limp. I’m not a hundred percent. I can’t promise you that
you wouldn’t have one. But in general, some people
you wouldn’t even know have an ankle fusion that walk around. They look fairly normal walking. The joints, like I said, above and below have to be normal. Otherwise we have to
focus on whether or not you have arthritis in the
other joints around the ankle. That can be common as well. Because of this fusion, depending on when it’s done in your life, you can develop further arthritis in these other joints long term. When you immobilize a joint, the pressure and the
forces go through that and into another joint. So when you fuse the ankle, the forces are going to go into the other joints, and over time that may wear them down. So that’s why the arthroplasty
or joint replacement has come about to try to preserve normal joint motion if possible. Fusion rates are very high, so it’s a very successful surgery. Usually it takes about six to eight weeks for the fusion to occur. So you do have to wait
and be off your foot for that long, which can be a long time. Residual discomfort can
occur in some cases. But again, it really
depends on the patient, how bad the arthritis is, and what the results are from the surgery. Other complications that can occur are what’s called malunion. That means that when you fuse the ankle it’s fused in a poor position. That’s pretty unusual, but it can happen. Sometimes the ankle settles
with time as it’s fusing. So you can imagine if your foot is pointed downward more, it’s
a little bit harder to walk. Nonunion is also a risk that can occur, which means that even
though you’ve done your best to fuse it together, it doesn’t fuse. For some reason the body doesn’t heal. That can happen in people that smoke, that have bad blood flow
to their lower extremity, other medical problems. Those are things that you
have to consider with that. Sometimes they can
require another surgery. That’s why they’ve developed
the ankle replacement. The ankle replacement that I use is called the STAR
total ankle replacement. It’s the Scandinavian
total ankle replacement. It’s basically a resurfacing. We have the metal tibial
component on the tibial side. We have the talar component
on the talus side. Then in between we have a plastic insert, which is very common in
any joint replacement. I have a model here that
I’m going to pass around, and you can move it around and see how the ankle joint moves. This is really the only ankle replacement that is FDA approved for this particular replacement type that has three components that allows these kind of movements. I’ll pass that around. Then afterwards if you have questions about it in particular. It’s S-T-A-R. STAR. It
should be in there, too. This is just the picture of
the components themselves, not inserted in the body. These are x-rays of what
it looks like in your body. Basically, you’ve removed
the arthritic part. You’re putting in the metal parts, which show up on x-ray really good, and then the plastic part
that doesn’t show up, but they put this little metal implant, it looks almost like a
little wire in there. That’s just so you know
where the plastic insert is. That insert really is like
your replacement cartilage, and it slides and glides
on the metal parts of it to keep you moving. What are some concerns
with ankle arthroplasty? The same with any surgery. You worry about incisions healing. That can vary depending on the patients and if there are
complicated medical issues, diabetes and things like that. Infections can occur with
all joint replacements, just like any surgery. But we always worry
with joint replacements because we’re putting in
metal and plastic in somebody. That’s always a concern. So we give antibiotics before, give it after surgery. Depending on how things go, you might need a little
bit more antibiotic if you did get an infection, but it’s pretty unusual. Parts can wear out over time, and I think that’s always a concern with any joint replacement. Fortunately with the new designs on any of the total ankle systems, it’s a pretty low wear rate. Now depending on how they’re inserted, there’s a lot of reasons
that the parts can wear down. I think the data for
the ankle replacements is much better than it
has been in the past. It’s certainly not anywhere near what a total knee or a total hip is, but there are so many of
those that have been implanted over 10 and 20 years,
even longer than that, 50 years, that the ankle replacement, in terms of these particular models, the STAR being one of them, I think has a good track record so far. This is going to be a
little bit hard to read because of the screen size, but this just compares the two, ankle replacement versus the ankle fusion. I wanted to just point out that both are good surgeries. Both are indicated for ankle arthritis. It really just depends on the patient and how we decide. The advantage of the joint replacement is that it allows motion to occur. The fusion locks the ankle
joint at a fixed position. They both provide pretty
predictable relief of pain, because you’re eliminating
the arthritic ankle joint. You can correct significant
deformities in the ankle. Not everybody has a perfectly
aligned ankle joint. You have to work around what’s there. In cases of both the replacement
as well as the fusion, you can work around a deformity. The advantage with the joint replacement is that you can bear weight a lot faster. Whereas you might wait two weeks after the joint replacement to put any weight on the ankle, the fusion you would have to wait at least four to six weeks, probably more like the six-week range, because it takes longer for the body to heal the bone together than the ankle replacement to set in. Revision rate at five years is pretty low. That just means that some people, and a small percentage of them, would need another surgery
on the ankle replacement, because for whatever reason it’s either, it can loosen just like
any joint replacement. It can wear a little bit faster. So you’d have to revise it. But that’s a pretty low percentage rate, compared to a little
bit higher nonunion rate in the ankle fusion surgery. You have complications that can occur. They’re pretty low percentage, but again that’s something to consider. The STAR, the ankle replacement, can require a device replacement
if that does wear out. It’s pretty unusual. The fusion can result in
arthritis in other joints. Again, that’s over many years. I don’t look at those
as really bad issues, but it’s just something that can happen. A lot of the orthopedic societies have supported the ankle replacements now, whereas before they were looked at more as experimental. I think now that they’re a little bit, they’re not quite mainstream, but they’re reserved for most people that
do foot and ankle surgery. The Academy of Orthopedic Surgeons, the American Orthopedic
Foot and Ankle Society, I think it’s becoming more accepted. It’s a good option. Basically these societies
have accepted it. It’s utilized in most of
the orthopedic hospitals that are ranked the best in the U.S. News and World Report. I think, in terms of the STAR itself, it’s becoming the total
ankle replacement of choice. You can see in that last
little graph there in 2011, there are significantly more
trained surgeons doing it. Insurance coverage had
been a problem in the past, but now it’s not. Basically that’s what this slide says. Before, because of its status, it hadn’t really been
covered by insurance, and it hadn’t been done a lot. But now, since it’s become
FDA approved in 2009, in particular the STAR implant, now we’re dealing with
pretty good coverage, so it’s not really a concern anymore. In summary, there are several
types of ankle arthritis. We’ve touched on a few types, but I think the important ones, probably the more common ones. It’s painful, but treatable. We’ve talked a lot about conservative and surgical treatments. There’s a variety of treatment options. I think really it comes down
to an individual approach. Not everybody here has the same type of ankle arthritis, if they even have it. It’s basically, you have
to see what you have, you have to see how severe it is, and then you go from there. It’s important to talk to your doctor, your family doctor, or
your orthopedic surgeon. If that’s a condition that you have, that can be easily diagnosed. I think you have to be careful about some of the things you read. You go online, look on the internet, you just have to be
careful with some of that. Use some better websites. Certainly talking with
your doctor about it I think is important. I think that’s it. I’m happy to answer any questions. We can talk about it now. I know Mark has some
thoughts that he’s prepared to talk about therapy considerations. Then we can talk more on an
individual basis if you’d like, and just go from there. Sir. – [Audience Member] Doctor,
are you talking about, whatever we’re seeing we’re talking about various kinds of arthritis,
including rheumatoid arthritis. – Yes. Yes. – [Audience Member] I’m told
that rheumatoid arthritis is a little worse, as far as pain, and possibly some crippling, I don’t know. The other word that jumps
out at me all the time is the fusion. It appears to me, when you fuse something that’s placed, that’s fused in place. You have to lose some motion. – Absolutely. Your first question, arthritis types. Rheumatoid arthritis, I
think, it’s definitely a problem in terms of
any type of arthritis. It’s hard to rank what
is better and worse, if rheumatoid is worse
than osteoarthritis, because I think it’s rare to have both conditions at the same time, but oftentimes rheumatoid arthritis, because it can affect the entire joint, it’s the body attacking the joint, and it could affect
any joint in your body, it can definitely look a lot worse than just a normal osteoarthritis. You could be catching
the osteoarthritis early. Maybe there’s just a little
area that’s worn away. But if you have osteoarthritis, that’s basically bone-on-bone, it could be equal in intensity, compared to the rheumatoid. That’s just from basically
looking at a lot of that you can see both rheumatoid and osteo can be just as bad. It just they’re two
different things to treat. That’s why it’s hard to
treat either one of them. The fusion, absolutely,
you’re fusing the joint. There’s no joint left. You’re fusing it in one position, a functional position,
so that it’s not moving and it doesn’t hurt anymore. That’s I think where the disadvantage is, compared to the arthroplasty, because the replacement
now is sort of allowing a relatively normal movement, although it’s not going to
be the same motion you had before you got ankle arthritis. That disperses your forces differently in the joints around it, so it may not be as bad to those joints. – Thanks, everybody. My name is Mark. I’m one of the PTs of Coordinated Health. As Dr. Sauer mentioned earlier, I work very closely with him. I guess I can start as a dovetail off one of your questions, sir. You had mentioned the
question to Dr. Sauer about the fusion. I think if you talk to somebody who had really severe
ankle pain and arthritis that affected the quality of their life and their daily living and the way that they moved and couldn’t move, and when they opted to get a fusion, and I’ve seen these
patients postoperatively, and they don’t have that pain anymore. We’re working on moving
the joints that can move, restoring the strength in the limb, in the foot and ankle,
and improving their gait, and sometimes making shoe modifications to help smooth out their
gait, they’re quite happy. Again, if you know anyone
who has been down that road, they sometimes will take the fusion. Sometimes it can be a very positive thing. From a rehab standpoint,
the way I look at things, again, as Dr. Sauer mentioned, I try to tailor things. It’s individualized. Knowing the type, how the joint, is the arthritis mild,
moderate, or severe. What is the person’s lifestyle? What’s the impact on their life right now. Then looking at how the
joints move or don’t move, what muscles are weak,
from the foot and ankle all the way across the
knee and through the hip, because those can affect
how the foot works. When we address these
things, we want to look at how can we make some
of these things better to improve the overall
function of the foot and ankle. First to address things like
the pain and inflammation, we can use things like
ultrasound, heat, ice, TENS units for home to address pain. We can get those for patients who have pretty constant pain. There’s all kinds of
things we can do there. One thing I think is very important is to talk about setting limits. If you have more of a
moderate or severe arthritis, or you have a lot of pain and inflammation that affects the quality
of your daily movement, and you’re somebody that
likes to do a lot of things. Well, sometimes I have a
little sit-down with patients and help them plan and
set limits for their days, and maybe not to exhaust
all their movements. Because once the pain and swelling starts, then the rest of the day is shot. You’re not feeling well. You’re miserable. You have to deal with it
for the next few days. So kind of sitting down and having a little planning session. What needs to be done in a day? What activities do you have to do? What can you get help to do? How many times do you have
to climb the stairs in a day? Some of this sounds very common sensical, but some people don’t really evaluate that when they’re looking at
how an arthritic condition can affect their life. Another important thing
I always talk about is footwear. I see through the treatment of lots of foot and ankle conditions, a lot of poor footwear. That has a really large impact on how your foot and ankle moves, and again on other joints in your body. When Dr. Sauer was talking
about bracing and orthotics, a lot of those work very well, but they also need to be
put into very good shoes. We have wonderful places
here in the Lehi Valley like Aardvark, like Sidells,
like Foot Solutions, where there’s people there
who can help you with whether you want a walking shoe, or more of an orthopedic
shoe, or running shoe. These are things that
really I talk a lot about with patients, because I think people try to wear their shoes
a little bit too long. Sometimes they have good shoes, but they’re just maybe a
poor selection for them, without even knowing it. When we talk about
strategies for exercises, instructing patients on
basic things they can do to stretch, to maintain range of motion, little things you can do in the morning to get your ankles moving so those first few steps aren’t so cranky. Or if you’ve been sitting watching a movie or in a long car ride, these are all the things
I hear from patients. Little things you can teach them to try to help them move better, making those first few steps not so bad. We address looking at the strength. There’s a lot of muscles
around the foot and ankle, muscles around the knee,
muscles around the hip. I assess all those. Those have an impact on
the leg, on your gait, on how you stabilize your
pelvis and your trunk, which when those aren’t stabilized well can actually impact how
your foot strikes the ground during your walking cycle. Sometimes working on things
away from the foot and ankle can have positive effects on offloading an arthritic joint, because
when the joint is arthritic, we want to spare the
joint as much as possible. That’s really what we do in therapy. (upbeat music)

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