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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.

    Monday, November 30, 2009 - Living an Independent Life: Preventing Stroke, Vascular Dementia

    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.

    Methodist Medical Center is providing a series of articles to help people live more independent lives as they age. This article features information from David Stanley, M.D., a board-certified surgeon and wound treatment specialist on the Methodist staff.

    What is vascular disease?
    Dr. Stanley: Vascular disease is a condition in which plaque -- a combination of cholesterol, calcium and other substances -- builds up in blood vessels and interferes with blood flow. It is a common cause of disability, affecting five to eight million Americans.
        
    Blockage can occur in blood vessels anywhere in the body, but it is especially serious when it occurs in arteries of the limbs, heart, and neck. Obstruction of arteries in the limbs, primarily the legs and feet, can lead to amputation, while blocked arteries around the heart can cause a heart attack and plaque in the neck can lead to stroke or vascular dementia.

    What happens during a stroke?
    Dr. Stanley:    A stroke is sometimes referred to as a “brain attack,” and it is a medical emergency. It occurs when a blood vessel in the brain bursts or there is a sudden interruption of blood flow to the brain by plaque embolus or a blood clot. Two million brain cells die every minute during an attack, increasing the risk for permanent brain damage, disability or death.

    A common symptom is sudden numbness or weakness in the face, arm or leg, especially when only one side of the body is involved. Other symptoms include sudden confusion, vision problems, dizziness, loss of balance, trouble walking or a severe headache. If these symptoms occur for a short time period, a person may be having a “transient ischemic attack,” or TIA. TIAs are emergencies because they indicate that a stroke may soon occur if the patient does not receive appropriate treatment.

    If you suspect that someone is having a stroke or a TIA, ask the person to smile and see whether their face droops. Ask them to raise both arms and see whether one arm drifts down. Ask them to repeat a simple sentence and listen for any slurring or other speech problems. If you note any of these symptoms, call 911 or immediately take the person to the nearest hospital.

    What can people do to reduce their risk of stroke?
    Dr. Stanley: Certain factors, such as high blood pressure, heart disease, diabetes, high cholesterol, smoking and heavy alcohol use, may be controlled. Other factors such as an age of 55 or older, ethnicity, and family history of stroke cannot be changed.
        
    My advice is to know your blood pressure level and talk to your doctor if it stays higher than 135 over 85. If you smoke, quit, and if you drink alcohol, do so in moderation. If you have diabetes, follow your doctor’s advice about diet, exercise and medications to manage it. If your cholesterol is high, work with your doctor to get it under control because high cholesterol can indirectly increase the risk of stroke by increasing the risk of heart disease.
        
    What are the treatments for a stroke?
    Dr. Stanley: Initially, treatment depends on whether the stroke was caused by a blood clot or bleeding in the brain. The physician will order a CT scan, vascular ultrasound exam, and other tests to determine which type of stroke a person has had.
        
    Clot-dissolving medication may be prescribed for stroke patients who have a blood clot and are diagnosed within three hours of developing symptoms. Treating a stroke caused by bleeding in the brain is more difficult. Patients are monitored for signs of increased pressure in the brain and may receive medications to control brain swelling, blood pressure, blood sugar, or seizures, as appropriate. Surgery is not usually recommended unless the bleeding is severe or a blood vessel has ruptured.  If a TIA is related to carotid artery plaque, emergency vascular surgery may be indicated.
        
    After a patient’s condition stabilizes, treatment focuses on prevention of another stroke and on rehabilitation. It generally includes use of medications and management of controllable risk factors. Depression is common after a stroke, and the patient may need treatment for this problem, as well.
        
    About half of all stroke survivors have difficulties with coordination, communication and other skills needed for independent living. The greatest progress in physical recovery generally occurs within the first three months, while speech and balance improve more slowly.  

    What is vascular dementia?
    Dr. Stanley: Vascular dementia is one of the most common forms of dementia. It is closely related to diseases of the blood vessels and develops when blood flow to the brain is restricted.

    Symptoms may appear suddenly after a major stroke involving a significant part of the brain, or they may develop over time as the cumulative effect of several small strokes. The symptoms vary depending on which area of the brain has been affected. Patients may or may not have memory problems. They may become confused, especially at night, and have difficulty speaking, concentrating, communicating, and following instructions.

    What are the treatments for vascular dementia?
    Dr. Stanley: Aggressive management of risk factors such as blood pressure, weight, blood sugar and cholesterol may prevent symptoms from becoming worse. The U.S. Food and Drug Administration has not approved any drugs for the treatment of vascular dementia once it develops. However, most of the drugs used for cognitive symptoms in Alzheimer’s patients seem to help.


    Dr. StanleyDavid 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, and a member of the editorial board of the International Journal of Angiology.