Tibio-astragalus arthrosis

[Kinetix]

Hi, everyone!

I am a Kinetotherapist from Romania (it's surely not on the Moon ) and I have descoverred this forum by chance. I like it, but I don't know much english and can't understand some of your abreviations, so I stayed in the shadow till now.
Anyway, I'll try to tell you something about one of my pacients that had a fracture of the ankle in march, last year. Was treated by surgery (they used three big nails) and imobilized for a few months but the incision (rupture made by the bones) was infected for a long period. In july he came to me for rehabilitation and we began it slowly.

After a few weeks he got an increase mobility by aprox. 10 degrees but then he discontinued to come to treatment because of some family and career problems. Those problems caused him to hardly use his leg (by staying, walking long periods of time).

In autum he came back but with a "bigger" and less moving leg. I suspected algoneurodisthrofia (is it correct?) and sent him to doctors for medication. We continued to exercise carefully for a few weeks but the pain didn't go and the mobility didn't increase. Sent him again to the doctor that took an X ray... Disaster!... The image was worse than a few months ago...

Surgeons say arthrodesis (is it correct ?), I mean to imobilise (to glue) the bones in a functional position. It doesn't sounds very good to me cause the man is only 46 years old.

I need help to guide him somehow.

What do you suggest?

Thanks!

Here is a series of xray images, pre and post injury

http://i163.photobucket.com/albums/t...DIOGRAF_01.jpg
http://i163.photobucket.com/albums/t...DIOGRAF_02.jpg
http://i163.photobucket.com/albums/t...DIOGRAF_03.jpg
http://i163.photobucket.com/albums/t...DIOGRAF_04.jpg
http://i163.photobucket.com/albums/t...DIOGRAF_05.jpg

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[physiobob]

Well this person has had a nasty injury. Thanks for the great images, well done. I think that if available to this client a resurfacing operation of the ankle might be just the thing if pain at the talocrural joint is the issue. Of course this is if the underlying bone is in a position to take the prosthetic device.

This is a similar approach to hip resurfacing made popular in the UK by Derek McMinn ( http://www.mcminncentre.co.uk/ ). This operation would preserve this flexion and extension at the ankle joint which the arthrodesis would not. This is a much preferred option and should be carefully considered, even if it means a flight to the UK for the surgery.

Some examples can be seen at:

http://www.uihealthcare.com/depts/an...ntreplace.html

http://www.orthopedictechreview.com/...apr03/case.htm

Best of luck

[Kinetix]

Thanks, physiobob!
Yes, a total ankle prosthesis is the best option, I think.
Since you know London, could you tell me where could he adress to get it mounted and what costs are involved? I think he could get some courage to fly there for his leg.
Thanks again!

[junior_physiotherapist]

hi physioBob:

woud u plz clear the meaning of resurfacing operations! i'm not familiar with this term..

regards

[Latrobe2000]

Hi Guys,

If there is an orthopaedic surgeon around somewhere in this forum. Would like to know his opinion regarding the type of ORIF they used for this patient. I havent seen 3 long pins like this before, and such a poor post ORIF result ie. joint surface appears completely gone, if anyone can shed some light on it would be good. I would assume somehow the infection got into the ankle joints and also contributed to this persons non-union of fracture. Not sure if anyone else thinks hes got non-union or reduction in his bone mass in that area. Couldnt see any callus really. Anyway guess it depends on the exact time of his xrays, infection cleared up or not and xray quality...
Any further discussion from orthos especially would be helpful

[physiobob]

hi physioBob:

woud u plz clear the meaning of resurfacing operations! i'm not familiar with this term..

regards

Have a look at the links in my post. They will explain. It is like a joint replacement except the prosthesis is smaller.

[physiobob]

Thanks, physiobob!
Yes, a total ankle prosthesis is the best option, I think.
Since you know London, could you tell me where could he adress to get it mounted and what costs are involved? I think he could get some courage to fly there for his leg.
Thanks again!

Here is an email response I have received from one of the top London guys (Nick Cullen who is a specialist foot and ankle surgeon at Royal National Orthopaedic Hospital). I presented this issue to him over the weekend.

Nick's response:

I'm an Orthopaedic surgeon with a pure interest in disorders of the foot and ankle,working out of the rnoh stanmore and the wellington.

Ankle replacements are coming along well, the mobility ankle specifically seems to have moved us forward, but the long term results are still not there. For a young active man, I think that universally a fusion is the gold standard at present. the problems really lie in implant longeivity and in revision of a failed ankle replacement which often necessarily requires an additional subtalar arthrodesis due to bone loss in the talus which is functionally alot more limiting than an isolated ankle fusion (and obviously requires a second operation i.e total ankle + fusion)

On the whole ankle arthrodesis provides a decent functional result allowing in many cases return to even heavy manual labour, but running jumping etc is unusual, this might be possible with a replacement but has been shown to lead to earlier failure.

I'm sorry If this is a little non specific for you, if you have any more information re: patient age, activity level comorbidity I'd be delighted to be more specific!

Kind regards
Nick Cullen
Nick can be contacted on [email protected]

[Aisha_kb]

Wow, ankle joint prosthesis... Unheard of here.
Another factor that could be considered is patient compliance.
As the patient didnot follow up with physio, did he really take good care of his foot? He probably stressed it out un-necessarily, with poor diet and mybe infection control leading to this.
Also, could you tell us, does he have any other medical complications like diabetes? hypertension? is he obese / over weight? that might shed more light.

[Kinetix]

My pacient is a little over weight, an old smoker, but has not diabetes or hypertension.
Infection was one of the problems that kept him from beginning kinetotherapy earlier. Also, the surgical wound failed to heal very quickly. And remember one of the pins that fixed (sticked) the joint for a while...
Yes, unfortunately, his ankle was a little bit stressed cause he had to be present at his stepdaughter wedding (also shoppings, etc.), and after that had to travel and to assist at some meetings regarding the job. After that period he came back to me and the mobility measured was worse, the pain too.
Maybe the arthrodesis is a good option for a surgeon, but I can't keep myself thinking of the spine and leg repercussions...

[Aisha_kb]

Well, manipulating the natural way of things always leads to reprecussions.

Provide to him the other option, It sounds really interesting, and he can decide according to his convenience which he prefers.

Even as therapists there is only so much we can do. There are times we end up at a point where we have to admit that there is nothing more we can do! Right!