Current Status Of Total Ankle Replacement - Central Indiana ...

A publication from the physicians and staff at Central Indiana Orthopedicswww.ciocenter.comVolume 2 • Issue 4Current Status ofTotal AnkleReplacementACL ReconstructionKnee Injury TreatmentImproving

In This Issue May 20084. Current Status of TotalAnkle Replacement6. ACL Reconstruction8. Knee Injury TreatmentImprovingOrthopedic Review is an educationalresource for physicians,health care professionals, and thegeneral public. This publicationprovides a forum for communicatingnews and trends involvingorthopedic-related diseases,injuries, and treatments, as wellas other health-related topics ofinterest.The information contained in thispublication is not intended toreplace a physician’s professionalassessment. Please consult yourphysician on matters related toyour personal health.Central Indiana Orthopedics LocationsCentral Indiana Orthopedics physicians offer patient services at six locationsthroughout Central Indiana. Both of the main locations - Andersonand Muncie - include walk-in clinics and outpatient surgery centers. Call forour office hours and scheduling information.Central Indiana Orthopedic Center2610 Enterprise DriveAnderson, IN 46013(765) 683-4400(888) 622-7255A publication fromCentral Indiana OrthopedicsDavid W. Graybill, MDPresidentKarla K. HostetlerCEOVictor MoranCFOJohn HargraveDirector of Marketing & Worker’s CompensationJulie LozierDirector of OperationsBarb FrostDirector of Reimbursement & Quality ManagementTodd HoladayDirector of Information SystemsKeri BrobstonOffice Manager, AndersonLesa PinkertonDirector of Surgery, MuncieTiffany AndersonDirector of Surgery, AndersonCommunity HealthPavilion Saxony13121 Olio RoadFishers, IN 46037(317) 773-4301Welcome to the fourth issue ofour Orthopedic Review. We at Central IndianaOrthopedics think you will find it both interestingand informative.Central Indiana Orthopedics is the premierorthopedic group along the I-69 corridor. Weare a twenty physician group with offices fromFishers to Upland. We have a wide variety oftypes of physicians covering almost all aspects of musculoskeletalcare. Our group includes specialists in SurgicalSports Medicine, Non-surgical Sports Medicine,Arthroscopy, Hand Surgery, Foot and Ankle Surgery,Pediatric Orthopaedics, Hip and Knee Reconstruction(joint replacement), Spine Surgery, Physical Medicineand Rehabilitation, Interventional pain managementand Neurodiagnostics, Spine Surgery, Shoulder Surgery,and fracture Care. Our two main Orthopedic Centers inMuncie and Anderson have onsite Digital X-Ray, MRI,Surgical suites, Physical Therapy, and a Walk-In-Clinicoperating Monday thru Friday.We cover Ball Memorial Hospital, Saint Johns Hospital,Community Hospital of Anderson, Community HospitalNorth of Indianapolis, and Riverview. We provide24hour a day ER coverage to both Anderson hospitalsand Ball Memorial hospital.There are three new articles in this issue, if you are interestedthere are different topics in our previous three editions,which are available online at www.ciocenter.com.I hope you enjoy this issue.Sincerely,Central Indiana Orthopedic Center3600 W. Bethel Ave.Muncie, IN 47304(765) 284-7738(800) 622-6575American HealthNetwork3631 N. Morrison RoadMuncie, IN 47304(765) 284-7738David Graybill MDPresidentCentral Indiana OrthopedicsSt. Vincent Mercy HospitalMedical Specialty Center1331 South A St.Elwood, IN 46036(765) 552-4584Upland Healthand Diagnostic Center1809 S. Main St.Upland, IN 46989(765) 284-7738 • (800) 622-6575Hattiesburg Clinic Digest is published by Custom Publishing Design Group, Inc. To advertise in an upcoming issue pleasecontact us at 800.246.1637 or visit us online at www.MyCompanyMagazine.com This publication may not be reproducedin part or whole without the express written consent of Custom Publishing Design Group, Inc. March 20093

Current Statusof Total Ankle ReplacementBy Steven A. Herbst, MDIt is hard to believe that 35 yearsago the standard treatment for hip andknee arthritis was fusion (locking together)of the arthritic bones. Throughadvancements in research and medicine,the treatment options are very differentand much improved today. Predictablyexcellent results have been obtained usingtechniques such as hip and kneereplacement.In contrast, total ankle replacementsurgeries have been performed for nearly40 years. Over the course of those years,multiple different ankle replacementshave been designed and implanted. Unfortunately,results have not always beenpredictable and failure rates with certainimplants have been unacceptably high.With further research and understandingof the mechanics of the ankle joint,designers have improved the total anklereplacement.During the past three years, two newtotal ankle replacements have been approvedby the U.S. Food and Drug Administration.The early results of thesetwo newer ankle replacements seemto surpass the results of previously implantedankles. The short term complicationssuch as loosening of the implantand malpositioning seem to be improved.Also the older generation ankle requiredthe lower leg bones to be fused together.The newer models have eliminated thatrequirement and subsequently recoveryseems to be quicker.The pendulum seems to be swingingfrom fusion of the ankle joint to total anklereplacement in a significant numberof situations. Ankle fusion is still a veryviable and appropriate option in a younghigh demand patient with healthy jointsthroughout the remainder of the foot. Atany age isolated arthritis of the ankle canbe well taken care of with fusion and painrelief is predictably good.The only downside of the fusion seemsto be the rather predictable developmentof arthritis in some other joints of the footmany years or decades down the road.Treatment of that adjacent joint arthritiscan be challenging.In older patients, those who alreadyhave fusions within the foot, or those whohave significant arthritis in other parts ofthe foot, total ankle replacement oftengives superior results and is becomingthe procedure of choice in a much largerpercentage of patients.» During the pastthree years, twonew total anklereplacements havebeen approved bythe U.S. Food andDrug Administration.4 Central Indiana Orthopedics

The total ankle replacement surgerylasts about 1 to 1½ hours. Typicallypatients go home the day aftersurgery. As most patients are candidatesfor a nerve block in the leg,there is little to no pain after surgery.After 10-14 days in a splint, patientsare allowed to start moving the ankle.There is a weight-bearing restrictionfor four weeks in most situations,after which advancement of weightbearingactivities is allowed as tolerated.Physical therapy is requiredbetween weeks four and eight to aidrange of motion and strengthening ofthe new joint.Pain relief is often very quick, andthe results are usually predictable.About 15 patients have received totalankle replacement in the Muncieand Anderson area over the past 18months. Recovery has been uneventfulfor the vast majority of patients.However, there are complicationswhich can occur with any jointreplacement. Fractures around thejoint replacement, wear of the jointreplacement parts over time, looseningof the joint replacement partsover time, and erosion or loss of bonefrom certain conditions that can occurwith a joint replacement, are allpossible. These problems howeverappear to be few and far between.When reaching a decision betweenankle fusion and ankle replacement, asports car versus truck analogy seemsto help explain the differences:• The ankle fusion appears to bemore like a pickup truck in that it isa fairly predictable surgery with goodlong-term results. Usually it is easy tofix, it can haul heavy loads, and it typicallydoes not break down.• The total ankle replacement hasbeen likened in the past to being morelike a sports car. When they workwell, they work exceptionally well;however, there can be complicationsand those complications can be troublesometo fix and may sometimesrequire new parts and another trip tothe shop (operating room).The decision ultimately comesdown to an individual decision on thepart of the patient with input from thesurgeon on which procedure wouldlikely perform best over time.There have been two new implantsapproved in the United States overthe past two to three years. There aremore implants and designs to come.Central Indiana Orthopedics has asurgeon who is deeply involved withthe development of total ankle replacementand is a co-patent holderof a replacement that is expectedto be available in the second quarterof 2009. We have high hopes forthe performance and function ofthat ankle replacement and expectit to exceed currently available anklereplacements.The world of ankle replacement,at this point in time, is dynamic andexciting. There are newer and betteroptions available now for anklearthritis than have ever been in thepast. If you have ankle arthritis orthink you have ankle arthritis it maybe time to see what options you havefor pain relief.Dr. Herbst is an orthopedicsurgeon specializing in Footand Ankle Surgery. Dr. Herbstearned his undergraduate degreefrom Indiana University.He attended medical school at the IndianaUniversity School of Medicine and completedan internship from the University ofIowa School of Medicine. His orthopaedictraining was at University of Iowa Hospitaland Clinics. After graduating in 2001,he completed a Foot and Ankle SurgeryFellowship at Union Memorial Hospitalin Baltimore, Maryland. After completinghis fellowship, he began practice withCentral Indiana Orthopedics in 2002.Dr. Herbst is Board Certified by the AmericanBoard of Orthopedic Surgery and amember of the American Academy of OrthopedicSurgeons.Ankle fusion is like apickup truck — it is a fairlypredictable surgery withgood long-term results.Usually it is easy to fix, haulsheavy loads, and typicallydoes not break down.Total ankle replacementis like a sports car. Whenthey work well, they workexceptionally well; however,there can be complicationsthat are troublesome to fixand may sometimes requirenew parts and another trip tothe shop (operating room).5

ACL ReconstructionBy P. Jamieson Kay, MD and Stacey Ross, RNThe anterior cruciate ligament(ACL) is one of four ligaments that helpto stabilize the knee. The other stabilizingligaments found in the knee are the medialcollateral ligament (MCL), the lateral collateralligament (LCL), and the posteriorcruciate ligament (PCL). The ACL providesapproximately 90% of the stability to theknee joint by preventing forward movementof the tibia on the femur (See Kneeanatomy.). The ACL is one of the most importantligaments within the knee and themost common of the ligament injuries, occurringat a rate of 100,000 people per year(Bueche & Peterson, 2007).The causes of an ACL tear are typicallysports related and usually a result of hyperextensionof the knee or pivoting injuries,many times without direct contact to theknee itself (noncontact injuries). Sportsthat are more likely to cause hyperextensioninclude volleyball, soccer, skiing, basketball,and football. Pivoting injuries aremore common in football, basketball, tennis,and soccer. An accidental fall or slipcan also result in an ACL tear.Diagnosing an ACL tear can involveseveral steps. First of all an orthopedic surgeonshould be consulted if an ACL injuryis suspected. Symptoms of an ACL tearmight include pain, swelling, inability tobear weight, and feelings of instability or“giving way. Some patients will complainthat their knee “feels like it is coming apart.”After physical exam to assess the stabilityof the knee, x-rays will be ordered to viewthe bony structure of the knee to help ruleout a fracture. Then a magnetic resonanceimage (MRI) will typically be ordered toprovide a 3-D image of the structures of theknee and help confirm an ACL tear and assessfor other injuries to the knee, such asmeniscus (cartilage) tears. Diagnosis willThe anterior cruciateligament (ACL)connects the femur tothe tibia in the centerof your knee. It limitsrotation and the forwardmotion of the tibia.The lateralcollateral ligament(LCL) runs on theoutside of your knee.It limits sidewaysmotion.be based on the history,MRI and thephysical exam.Treatments foran ACL tear dependon the age of theindividual, activitylevel, and commitmentto rehabilitation after the surgery(Bueche & Peterson, 2007). Older patientswith sedentary lifestyles may not need tohave surgery, while older patients that areactive and cannot tolerate an unstable kneemay choose a surgical approach. Patientswho choose a more conservative approachwill likely be referred to physical therapy tostrengthen the muscles around the knee.The goal is to increase stability and reducepain. A knee brace may be considered forincreased activity. Young patients usuallychoose to have surgery.Surgery is done on an outpatient basisand involves using a graft to reconstruct theACL. The graft can be taken from the patient(autograft) or from a cadaver (allograft).Different autografts can be used dependingon patient and physician preference. Onegraft is taken from the patella and includesFemur(thighbone)Tibia(shinbone)The posteriorcruciate ligament(PCL) also connectsthe femur and tibia. Itlimits backward motionof the tibia.The meniscus iscartilage that absorbsshock in your joint.The medial collateralligament (MCL) runsdown the inside of yourknee joint. It connectsthe femur to the thighand limits the sidewaysmotion of your knee.a piece of the patella, patella tendon, anda piece of the tibia. This is also referred toas a bone-tendon-bone graft. Advantagesinclude elimination for the chance of diseasetransmission or rejection, by using thepatient’s own graft, and the strength of thegraft is as strong as or stronger than theoriginal ACL. The disadvantages are pain atthe site where the graft is removed and aslightly larger incision to remove the graft.A hamstring graft is also an autograft thatcan be used for reconstruction. The advantagesare the same as the patella tendonwith the added advantage of a smaller incisionin comparison. The disadvantage isthat because the hamstring has no bone, ittakes the soft tissue longer to adhere to thebone of the femur and tibia, which may extendrehabilitation.>> Continued on page 96 Central Indiana Orthopedics

8 Central Indiana Orthopedics

Continued from page 6The advantages of the cadaver graft (allograft)are the pain from harvesting the graftis not a factor and rehabilitation time is reduced.A disadvantage is the risk for diseasetransmission, even though it is extremelylow and each graft is tested extensively. Thecadaver grafts are also put through a sterilizationprocess which causes them to potentiallynot be as strong as autografts (Bueche& Peterson).Regardless of which graft is used, surgerytakes approximately one to two hours and patientsare sent home that day with an immobilizerto prevent the knee from buckling andtearing the new graft. Crutches or a walkerare used for one to two weeks after surgery,or until the patient is comfortable and stableto walk without them. Physical therapystarts within a few days of surgery and lastsapproximately ten weeks. Rehabilitation isvery important and can greatly influencethe outcome of the surgery. The postoperativegoal is to restore the knee’s stability andthe patient’s confidence to use the knee topresurgical activity (Bueche & Peterson). Dependingon graft choice and rehabilitation,full return to sporting activity is generally allowedwithin 4-6 months after surgery, but itmay take up to a year to reach pre-injury levelof performance.Dr. Kay is a general orthopedicsurgeon with specialinterest in Joint Replacement, Arthroscopyand Sports Medicine.Dr. Kay earned his undergraduatedegree from Purdue University. He attendedmedical school at the Indiana UniversitySchool of Medicine and completed and internshipat the Indiana University Medical Center.His orthopaedic training was at the IndianaUniversity Medical Center. After graduating in2001, he began his practice at Central IndianaOrthopedics. Dr. Kay is Board Certified by theAmerican Board of Orthopedic Surgery and amember of the American Academy of OrthopedicSurgeons.ReferenceBueche, K. L. & Peterson, E. M. (2007). ACLreconstruction from a to z. OrthopaedicNursing, 24 (6), 450-453.»The causes of an ACL tear are typicallysports related and usually a result ofhyperextension of the knee or pivotinginjuries, many times without direct contactto the knee itself9

Knee Injury Treatment ImprovingBy Marshall L. Trusler, MDWeekend warriors. Student athletes.Senior citizens. At most any ageand due to many activities, knee pain mayresult in a visit to an orthopedic surgeon.Injury to the cartilage in your knee is acommon condition. This type of injury affectspeople of all ages and can vary greatlywith regards to severity. Injury patternsdiffer among age groups, but the conceptsand methods of treatment remain thesame. Many of these injuries require surgeryto either repair or remove the damagedtissue. In fact, knee arthroscopy isone of the most common orthopaedic proceduresperformed and is frequently usedto treat torn and damaged cartilage withinthe knee.What is cartilage?The term “cartilage” is a general onethat describes more than one type of tissue.Within the knee, there are basicallytwo types of cartilage that can becomeinjured: fibrocartilage and hyaline cartilage.Fibrocartilage is the type of cartilagefound in the meniscus of the knee. Themeniscus is a wedge and crescent-shapedstructure that acts to “deepen” the jointsurface allowing for more uniform stressdistribution and shock absorption. Thereare two meniscal cartilages in each knee,and a large percent of cartilage injuries areto the meniscus. Hyaline cartilage, on theother hand, is the smooth and shiny cartilagethat covers the surfaces of the boneswithin a joint. Hyaline (or articular) cartilageallows for joint movement with minimalfriction. Hyaline cartilage injury anddamage forms the basis for arthritis.Common symptoms of knee cartilageinjury include pain, swelling, sensations ofcatching or locking, as well as loss of motion.Most cartilage damage is the resultof a traumatic injury, but also may occurwithout an obvious inciting event. Diagnosisis made most frequently by obtaining aMagnetic Resonance Imaging (MRI) study,which is an excellent method to imageboth the meniscal and hyaline cartilages.Treatment of cartilage injuryOnce the diagnosis of a cartilage injuryhas been made, treatment alternatives canvary considerably. In general, treatmentis either conservative (nonsurgical) orsurgical.Conservative therapy includes anti-inflammatorymedication, physical therapy,rest, activity modifications, and local jointinjections of corticosteroids. Additionally,newer biologic joint lubricating agents (i.e.Supartz and Synvisc) can be injected intothe knee to improve symptoms in thosepatients with mild to moderate damagefrom osteoarthritis.As previously mentioned, arthroscopyalso is commonly utilized to treat kneecartilage injuries. Through the use of asmall quarter-inch incision, a pencil-sizedcamera (arthroscope) can be placed withinthe knee to visualize damaged tissue.Then, through an additional quarter-inchincision, the damaged tissue can either berepaired or removed. Knee arthroscopy isgenerally performed on an outpatient basis(the patient returns home the same dayas surgery), and recovery time is relativelyshort.Future treatmentA great deal of research is being doneto develop better ways to treat injuredcartilage. The problem lies in the fact thatdamaged cartilage has poor healingpotential. Although certaintypes of cartilage injuriescan be» Through current techniques, orthopaedicsurgeons are able to effectively treat patientswith painful and frequently debilitatinginjuries. Although a great deal of progresshas been made to date, futuretechnologies likely will result in evenbetter outcomes for the patient.10 Central Indiana Orthopedics

»Symptoms of knee cartilage injury includepain, swelling, sensations of catching orlocking, as well as loss of motion.repaired (most notably a meniscus tear in ayoung patient), most current surgical techniquesinvolve careful removal of only thedamaged tissue. However, newer techniquesare being refined and developed, which mayhave a significant impact on people withthese types of injuries.For example, a technique known as microfractureis now often used to treat focalareas of damage to the articular or hyalinecartilage. In this technique, small holes arecreated in the bone at the base of the cartilagelesion that allow bone-marrow elementsto escape and form new cartilagewithin the area.Also, cadaver transplants of meniscal aswell as articular cartilages have been performedon select patients with good overallsuccess. In addition, chondrocytes (articularcartilage cells) can now be taken froma patient’s knee and grown in a lab for implantationinto the damaged area at a laterdate. Lastly, biological growth factors maybe available in the future to enhance or acceleratethe body’s own healing response totorn and damaged cartilage.As orthopaedic surgeons, we have comea long way in the last two or three decadeswith respect to our knowledge of knee cartilageinjury and treatment. Through currenttechniques, we are able to effectivelytreat our patients with these painful andfrequently debilitating injuries. Althougha great deal of progress has been made todate, future technologies likely will result ineven better outcomes for the patient.Dr. Trusler is an orthopedic surgeonspecializing in injuries anddisorders associated with theShoulder and Knee. Dr. Truslerearned his undergraduate degreefrom Purdue University. He attended medicalschool at the Indiana University Schoolof Medicine and completed an internship atthe Indiana University Medical Center. Hisorthopaedic training was at Indiana UniversityMedical Center. Dr. Trusler received hisfellowship training in Sports Medicine fromBaylor College of Medicine in Houston, Texas.After completing his fellowship in 2000, hebegan his practice in Noblesville, Indianaand joined Central Indiana Orthopedics in2007. Dr. Trusler is Board Certified by theAmerican Board of Orthopedic Surgery and amember of the American Academy of OrthopedicSurgeons.11

C E N T R A L I N D I A N A O R T H O P E D I C S P H y S I C I A N SComprehensive specialty care…Muncie 765.284.7738Anderson 765.683.4400Fishers 317.773.4301Upland 765.284.7738Elwood 765.552.4584orthopedicssports medicinephysical medicine & rehabilitationneurosurgerykerry D. Bennett, DOGeneral Orthopedics, Sports Medicine& Joint replacementMuncie OfficeLi Chen, MDhand & Upper extremity SurgeryMuncie & Anderson OfficesJOSeph C. DUnCan, MDneck & Spine SurgeryMuncie OfficeDaviD w. GrayBiLL, MDhip/knee replacement,knee arthroscopy& kyphoplastyAnderson & Fishers Officeskenneth h. haLLer, DOFamily practice& primary Care Sports MedicineMuncie OfficeJeFFrey a. heaviLOn, MDpediatric Orthopedics, Spine Surgery,Foot & ankle SurgeryMuncie OfficeSteven a. herBSt, MDFoot & ankle Surgery,General OrthopedicsMuncie & Anderson OfficesJereMy J. hUnt, MDFamily practice& primary Care Sports MedicineMuncie Office (both locations)JOSeph G. JerMan, MDGeneral Orthopedics& Joint replacementAnderson & Elwood OfficesJareD w. JOneS, MDinternal Medicine& primary Care Sports MedicineAnderson Officep. JaMieSOn kay, MDGeneral Orthopedics, Sports Medicine& Joint replacementAnderson & Fishers OfficesrOBert a. LiLLO, MDphysical Medicine & rehabilitation,electrodiagnosisMuncie & Anderson OfficesL. Jay MatChett, MDSports Medicine & Joint replacementMuncie Officekeith w. MiLLer, MDFoot & ankle Surgery,Joint replacementMuncie & Upland OfficesStephen w. ShiCk, MDGeneral Orthopedics& Joint replacementAnderson OfficeniMU k. SUrtani, MDGeneral Orthopedics & Sports MedicineAnderson OfficeFranCeSCa D. tekULa, MDneurosurgery, neck & SpineAnderson OfficeMarCUS a. thOrne, MDGeneral Orthopedics & Joint replacementAnderson OfficeMarShaLL L. trUSLer, MDShoulder & knee SurgeryMuncie OfficeSCOtt w. waLker, MDJoint replacement & knee arthroscopyMuncie Office

Advertiser DirectoryCentral Indiana Orthopedics thanks the followingcompanies for helping make this publication possible.Arthrocare Spinesee page 7Bethany Pointe1707 Bethany RoadAnderson, IN 46012(765)622-1211(765)622-1214 Faxwww.trilogyhs.comBioMetsee page 7CISCRPsee page 7Community Hospital Andersonsee page 14Fred Toenges Shoessee page 14Hely & Weber, Inc.457 Watercress WayBrownsburg, IN 46112(317)985-0631(317)858-2811 Faxwww.hely-weber.comMidwest HealthStrategiessee back coverOld National Banksee inside front coverPA Labs1200 West White River Blvd.Muncie, IN 47303(765)284-7795(765)741-5609 Faxwww.palab.comPrevail Orthoticssee page 13Royale Pharmacysee page 13Saint John’s Health Systemsee inside back coverSomerset CPAssee page 8Strykersee page 13Unified Group Services, Inc.see page 8Wabash Medical Companysee page 8Zimmer Midwestsee page 1414 Central Indiana Orthopedics

Central Indiana Orthopedics2610 Enterprise Dr.Anderson, IN 46013