The purpose of a total ankle is to relieve pain in the ankle while still allowing the ankle move. Usually this type of pain is caused by arthritis, a condition that can take many forms and may go by many names, including osteoarthritis, post-traumatic arthritis, and rheumatoid arthritis.
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Ankle Fusion vs. Total ankle replacement
When an ankle is fused, the joint is removed and the tibia and talus heal together to make one bone. This results in good pain relief, but no motion at the ankle joint. When an ankle is replaced, the joint is removed and replaced with metal and plastic components. These components maintain joint motion. One of the major benefits of having motion at the ankle joint is that it relieves pressure on adjacent joints of the foot and ankle and we believe lessens the propensity for degenerative arthritis of these joints. Likewise, the ability to move the ankle 25 to 35 degrees is critically important to having a normal gait pattern. Activities such as walking up or down a slope, walking on uneven ground, golfing, and hiking are more difficult with a fused ankle than with a mobile ankle.
The Scandinavian Total Ankle Replacement (S.T.A.R.)
Dr. Coughlin and Dr. Hirose are currently utilizing the S.T.A.R. total ankle system, which was developed by Dr. Hakon Kofoed of Denmark.
The S.T.A.R. Total Ankle is unique because of its design. It is the only ankle replacement of it’s kind being used in the United States. What makes it unique is its 3-part design, instead of just two parts like most ankle replacements currently available. It is an unconstrained mobile bearing device, which basically means that the ankle replacement mimics your natural motion compared to other types of ankle replacements.
The S.T.A.R. ankle is the only 3-part ankle replacement system that is approved by the FDA. The FDA approved it for use in June of 2009. In addition, the American Academy of Foot and Ankle Surgeons (AOFAS) have deemed total ankle replacement as an acceptable alternative to ankle arthrodesis in the proper patient population. Dr. Coughlin was the principal investigator in the clinical trial that proved the effectiveness of the S.T.A.R total ankle.
Dr. Coughlin, Dr. Hirose, and Dr. Kemp lead the Coughlin Clinic at Saint Alphonsus Regional Medical Center, which is the foot and ankle center of excellence in Boise, Idaho, and the surrounding region. They have both been trained in ankle replacement surgery utilizing the S.T.A.R total ankle replacement technique.
The Selection Process for Total Ankle Arthroplasty
In the STAR study, the patients were chosen very carefully using strict selection criteria. A very specific list of indication and contraindications is listed below. While these are not set in stone, they certainly are the guidelines that have resulted in excellent outcomes for our patients. If you do not meet the criteria, for example, if you are overweight or have other issues, an arthrodesis is still a good alternative to ankle replacement. We offer that procedure at the Coughlin Clinic as well.
- Ankle arthritis (osteoarthritis, rheumatoid arthritis or post-traumatic arthritis)
- Failed no less than six (6) months of conservative therapy including bracing and NSAID medication.
- Marked limitation in activities of daily living due to your ankle
- Good ankle range of motion
- Prior infection of the ankle
- Weight over 250 lbs
- Insulin dependant diabetes
- Peripheral neuropathy
- Peripheral Vascular disease leading to poor wound healing
- Malalignment of the ankle or hindfoot
- Relatively young age
- Desire to perform high impact activities such as running or jumping
During your preoperative evaluation you and your surgeon will review all of your records and existing x-rays, MRIs, and CT scans. Even if you have existing x-rays, your visit will include new standing x-rays of your ankle joint.
Once you and your surgeon have decided that you are a good candidate for total ankle replacement, we will arrange a surgery date. While you are in the clinic, we will ask you to sign a consent form for your surgery and answer any questions that you may have regarding the surgery and your recovery.
We may ask you to participate in a study about total ankle replacement, which involves answering questions and having additional testing completed. There is no additional cost to you. Your participation is optional and does not change your care in any way. We only wish to continue to improve on an already successful procedure, and you can help us with this goal.
The Surgical Procedure
Total ankle replacement is performed in an in-patient setting at St. Alphonsus Hospital in Boise. Depending upon the your age, medical conditions, whether you live locally or at a distance, as well as several other factors, determine how long you stay in the hospital. Typically a 36 – 48 hour stay is routine.
The procedure is performed in the operating room. You typically receive a general anesthetic. A nerve block is used for postoperative pain control as well. The procedure lasts usually less than 2 hours. After surgery you will go to the recovery room for a few hours and then to your regular patient room. You will have a nasal cannula (tube) delivering oxygen to you until you are discharged from the hospital to help with wound healing. Transfusions are not used as the procedure is done under a tourniquet. Sometimes added procedures accompany the total ankle replacement such as lengthening of a tight Achilles' tendon, hardware removal, or fixation of weak bone.
You will receive 24 hours nursing care from the highly skilled nurses at St. Alphonsus. Dr. Coughlin, Dr. Hirose, Dr. Kemp, and/or their Fellow will see you every morning.
The first day after surgery is spent resting and elevating your leg. On the second day after surgery the splint placed during surgery is changed to a more permanent cast.
During your hospital stay we will control your pain and to teach you to walk with crutches or a walker while not bearing weight on the ankle.
Physical therapy is performed once or twice daily to make sure you can safely ambulate non-weight bearing at the time of discharge. At the time of discharge, appropriate analgesics will provided for use at home.
Follow up care after hospitalization
Your ankle is usually immobilized for six weeks in a cast. You will not be able to bear weight during the first three weeks and will need to use crutches, a walker, or a roll-a-bout. The cast immobilization is utilized to promote wound healing and to protect your wounds. At the first visit to the office at three-weeks, sutures are removed and a new cast is placed. You are then allowed to bear full weight in this cast. At six weeks following surgery the cast is removed and you are placed in a Cam-boot walker and allowed to start ankle motion exercises. At this time, physical therapy is begun.
Further follow-up after the six-week visit depends upon individual patients. Usually a six-month visit and yearly visit are recommended to check on motion and to ensure no other problems are developing. Necessary visits after surgery are at 3 weeks, 6 weeks, six months and yearly after that.
Results and Complications
The pivotal study performed under the direction of Drs. Coughlin and Mann demonstrated that results of the Scandinavian Total Ankle Replacement are very gratifying. The functional results regarding walking, standing, pain control, etc. were superior to ankle fusion. There were more complications with the total ankle than with the ankle arthrodesis but part of this is explained by the unfamiliarity of the surgeons in the study at the initial time when this total ankle was started. With time their familiarity with the procedure led to a marked reduction in complications and other operative problems.
Scheduling an Appointment
Should you wish to proceed with an evaluation at our Boise office, feel free to cal l208-367-3330 to schedule an appointment. Or you can email the Lead Nurse, Margaret Collins at firstname.lastname@example.org for more information. Any radiographs, scans, or pertinent medical information will be helpful. Usually at least two visits are required prior to scheduling surgery. The complexities of planning the surgery, and determining whether you qualify for a total ankle takes some time and we want to make sure that you have all of the information and time to think about your decision.
Likewise insurance authorization can be a time consuming process. Follow up appointments are necessary and required. You will not be able to come to Boise for surgery and then expect to have your follow-up care done elsewhere. We will need to see you for follow-up in Boise. Minimum follow up is at 3 weeks, 6 weeks, 6 months, and 1 year after surgery.
Below are links to more information including a patient brochure, the FDA approval, a story featured in Horizon Airlines Magazine titled “Special Treatment,” the history of the S.T.A.R. Ankle, the AOFAS position statement, evidence supporting the S.T.A.R. Ankle, and technical documents. We hope that these help to educate you on this ground breaking and successful option for treating your ankle pain.