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    Expert Advice from Methodist Professionals

    Ankle Fusion: What’s Old Is New Again

    By Michael O’Brien, M.D.

    When severe ankle pain affects your ability to walk and prevents you from doing the activities you want to do, a surgical procedure called ankle fusion may return you to a more active lifestyle.

            Before the advent of joint replacement, fusion was the primary surgical treatment for extremely painful ankles and other joints. For some patients, it is still the best option.

     
    Goals of Ankle Fusion

    Your orthopedic surgeon may suggest fusion when medications and other conservative treatments do not provide adequate relief. The goals of this surgery are to relieve pain, stabilize the joint, and restore function. Although joint fusion results in loss of mobility of the ankle, many patients have debilitating pain that has already caused some loss in their range of motion.

            Candidates for ankle fusion surgery typically include people who have severe ankle misalignment, which is commonly caused by a fracture or osteoarthritis. The procedure also may benefit people who want to participate in high impact sports, such as skiing, and it may be a good option for young patients. When fusion is successfully performed, it should last a lifetime – which may not be the case with an artificial joint.


    Inside the Ankle

                Three bones make up the ankle joint -- the lower end of the tibia, or shinbone; the fibula, a small bone in the lower leg; and the talus, the bone that fits into the socket formed by the tibia and the fibula. Ligaments on both sides of the ankle help hold these bones in place, and numerous tendons that cross the ankle help the joint and the toes move. (Ligaments connect bone to bone, and tendons connect muscle to bone.)

                A slick material called articular cartilage covers the ankle bones and allows them to move smoothly against one another. When the cartilage wears away, patients are left with a painful condition in which one bone rubs against another bone.


    Open & Arthroscopic Surgery

    The two basic procedures for fusing an ankle are traditional open surgery and the newer arthroscopic technique. The orthopedic surgeon will determine which procedure is most appropriate for you based on your medical history, current health, the condition of your ankle, and other factors.

            The most common way to perform open surgery is to make an incision, open the joint, and clean away articular cartilage surfaces from the ankle, which will allow the tibia and the talus bones to fuse or grow together. The surgeon then inserts pins, rods or plates to immobilize the bones and prevent additional damage to the joint. In some cases, surgical pins are inserted inside the leg and ankle, and a metal rod and pins are placed on the outside. More commonly, only internal plates and screws are used.

            During arthroscopic surgery, the orthopedic surgeon makes several small incisions and inserts an instrument called an arthroscope, which contains a tiny camera.  With the arthroscope and other surgical instruments, the surgeon can visually monitor progress as he or she treats the joint. As with the open method, screws or pins are used to hold the bones together.


    Recovery & Rehab

                Following surgery, you can expect to wear a padded plaster cast, which will be removed in approximately two weeks and replaced with a short-leg cast. After eight to 12 weeks, the shorter cast will be replaced by an ankle brace.

            You should avoid putting weight on the affected ankle during this time. As the ankle heals, you may work with a physical therapist to regain your ability to walk smoothly, without a limp. Once the bones have fused and completely healed, you may be fitted for a shoe insert to make walking easier, or you may simply wear flat shoes.

     

    About the Author: Michael O’Brien, M.D., is a board certified orthopedic surgeon on the staff of Methodist Medical Center of Oak Ridge. He is in practice with Orthopaedic Surgeons of Oak Ridge. Dr. O’Brien earned his medical degree from St. Louis University of Medicine in St. Louis, Mo., and completed an orthopedic surgery residency at William Beaumont Hospital. He is a member of the American Academy of Orthopaedic Surgeons.

    Tuesday, December 15, 2009 - Living an Independent Life: Avoiding Amputation

        
     
    Dr. David Stanley
    With each passing year, millions of Baby Boomers join the ranks of senior citizens. Many of them live fulfilling lives, enjoying the greater freedom they have to spend time seeing the people and taking part in the activities that they love. For others, the so-called “golden years” are less than golden because they are dominated by difficult health problems.

    The following article features advice on preventing chronic wounds and amputation from David Stanley, M.D. He is a board-certified surgeon and wound treatment specialist on the staff of Methodist Medical Center of Oak Ridge.

    How does amputation generally affect patients?
    Dr. Stanley: Amputations are categorized as minor and major. When the lower extremities are involved, minor amputations involve removal of a toe or part of a foot, while major amputations involve removal of the entire foot or part of a leg.

    This type of surgery – especially major amputation -- significantly affects a person’s quality of life, decreasing life expectancy, limiting mobility, and impacting self-image. For diabetic and older patients, amputation often results in loss of ability to be independent, leading to admission to an assisted living facility. Consequently, preventing the need for amputation is in patients’ best interest. Once surgery has been performed, people need a team of health professionals that may include physicians, a physical therapist, occupational therapist, social worker, psychologist and others, to assist with post-surgery recovery and rehabilitation.

    The goal of rehab is to help patients adjust to life after amputation. Patients may be fitted for an artificial limb and learn to use other assistive devices in order to resume many daily activities. They also may need psychological counseling. Some people who experience pain in the amputated limb – called “phantom pain” – may require pain medication and therapy to deal with the discomfort.



    Why are most amputations necessary?
    Dr. Stanley: Most amputations in this country are performed on people age 65 and older, and they involve removal of part of the leg. They are usually necessary because of tissue damage or gangrene associated with diabetes, loss of sensation in the feet and peripheral artery disease (PAD).

    PAD is a condition in which arteries harden and block the flow of blood and oxygen. It can occur anywhere in the body, but most often affects the feet and legs. It is common and more difficult to treat in people who have diabetes.
    Less common reasons for amputations are traumatic injuries, or accidents, cancer, and congenital conditions.

    How can people minimize their risk for PAD?
    Dr. Stanley: Certain risk factors such as aging or having a personal or family history of PAD cannot be changed. People can, however, work with their doctor to manage their diabetes if they are diabetic, avoid tobacco products, maintain a healthy weight, live a physically active life, and control cholesterol and blood pressure levels.

    What are the symptoms of PAD?
    Dr. Stanley: Common signs are discomfort, cramping or heaviness in the toes, feet or legs, non-healing wounds in those areas, difficulty walking, and localized pain in the lower leg or foot.

    How is PAD treated?
    Dr. Stanley: The two major treatment goals are recognizing symptoms such as leg pain and early signs of foot injury such as blisters, ulcers or trauma from pressure points on a deformed or numb foot. Some patients achieve these goals with lifestyle changes such as smoking cessation, proper exercise, weight control and dietary changes. Others require medication to control blood pressure, blood sugar and cholesterol, prevent clots, or manage pain.

    In some cases, vascular surgery may be necessary. Angioplasty is a procedure to open the narrowed arteries. A surgeon inserts a catheter through a blood vessel to the affected artery, and inflates a small balloon to reopen the artery and flatten the blockage against the artery wall. The surgeon also may insert a mesh device called a stent to keep the artery open. Bypass surgery is another option. During this procedure, the surgeon uses a synthetic blood vessel or a vessel from another part of the patient’s body to bypass the blocked area. If a blood clot is causing the blockage, the doctor may inject a clot-dissolving drug.

    Post-surgery treatment may include medication, supervised exercise and lifestyle changes to prevent the spread of PAD throughout the body. Foot care is extremely important in preventing chronic wounds from developing in the feet and legs. Patients should wash and moisturize their feet every day, wear well-fitted shoes, trim their toenails regularly, and receive prompt medical treatment for foot or leg infections.

    What happens when chronic wounds develop?
    Chronic leg wounds from varicose veins may require antibiotics and compression therapy to eliminate infection and direct blood flow through superficial veins into the deep veins. Debridement also may be necessary. This treatment is a surgical procedure to remove dead and infected tissue and stimulate healing.

    Another option for some patients is a unique new treatment called Apligraf®, which is a living, skin-like substance. It is grown from human skin cells in a laboratory and grafted over certain types of wounds. Applying it to a wound is simple and painless. Unlike conventional skin grafts, surgery is not required, and no skin has to be removed from another part of the body for the graft. Like human skin, it has an outer protective layer of cells and an inner layer containing cells that are important in the healing process.

    When these treatments are unsuccessful, hyperbaric oxygen therapy is an option for certain people. During hyperbaric treatment, a patient lying in a comfortable hyperbaric chamber breathes pure oxygen that is gradually pressurized.

    This process allows them to dissolve more oxygen in their red blood cells and plasma. Oxygen circulates throughout the body and reaches tissues that are not receiving enough oxygen under normal circumstances. The action stimulates new blood vessel growth and promotes healing during and after the treatment. Patients should show signs of new artery growth and healing by 14 to 20 treatments, but may need 40-50 treatments for maximum benefit. Hyperbaric treatment is rapidly gaining greater acceptance in this country and is helping a growing number of patients with chronic wounds heal without the need for amputation.

    David Stanley, M.D., is a board-certified surgeon on the staff of Methodist Medical Center of Oak Ridge and medical director of the MMC Wound Center and the Vascular Diagnostic Center in Oak Ridge. A graduate of the University of Tennessee College of Medicine in Memphis, he completed a general surgery residency at Emory University in Atlanta and at St. Francis and Veterans Hospital in Wichita, Kan. Dr. Stanley is board certified in general surgery, vascular surgery and vascular medicine. He also trained in the evaluation and treatment of chronic, non-healing wounds at The Hyperbaric and Wound Healing Center at Palmetto Health Richland in Columbia, S.C. Dr. Stanley is a fellow of the American College of Surgeons, past president of the International College of Surgeons-U.S. section, a member of the editorial board of the International Journal of Angiology and a member of the Undersea and Hyperbaric Medical Association.