Carl Maronich (Host): This is Expert Insights, life changing with the Carle Foundation Hospital. I'm your host, Carl Maronich. And today, we're going to be talking about innovative ankle arthroplasty. And to walk us through that discussion, we're going to be joined by distinguished Podiatrist, Dr. Stephanie Mignano. Doctor, welcome.

Stephanie Mignano, DPM: Hi. Thank you so much for having me. It's a pleasure.

Host: Great. Well, ankle arthroplasty. Let's talk a little bit, and start with what exactly is that?

Stephanie Mignano, DPM: So. arthroplasty is creating a new joint.

Host: So, it is replacement of the existing joint.

Stephanie Mignano, DPM: Correct.

Host: And from a functional standpoint, what's the goal of that procedure?

Stephanie Mignano, DPM: The goal is to restore some motion in an arthritic joint and also to alleviate the pain that's associated with ankle arthritis.

Host: So, let's talk a little bit about candidates for this procedure, and how they might come to you. Who is an ideal, if you will, candidate? And what has happened in their past perhaps that's led to this?

Stephanie Mignano, DPM: So, an ideal candidate would be, well first of all, somebody that has kind of an end-stage arthritic ankle. The ideal candidate is somebody that if you had to pick the perfect patient, this is what they would look like. It'd be somebody over the age of 55, mild-to-moderate activity level, severe ankle arthritis associated with pain; a low BMI, so not anybody that's too overweight; no neuromuscular diseases such as cerebral palsy or anything that would compromise your muscles and walking. Yeah, I mean that would really be the ideal patient.

Host: So, that's the ideal. On either scope of that or on either direction of that ideal, you may have somebody a little younger, maybe a little older with some comorbidities a bit. But by and large, if there's ankle arthritis or even trauma, is that another issue that could lead somebody to need this procedure?

Stephanie Mignano, DPM: Yeah. So, what we often see is patients that have bad ankle fractures, they run the risk of developing what's called post-traumatic arthritis. And that's usually anywhere between the 10 to 20-year post ankle fracture timeframe. And so, it's inevitable they'll develop some form of arthritis after that injury. And it just kind of depends on their age and activity level and how much they're moving around after the injury. But those patients would be good candidates because ultimately it's leading to ankle arthritis. And if it's severe enough, they would be a good candidate as long as they fall in those other parameters.

Host: The title of the episode here is Innovations in Ankle Arthroplasty. So, have there been innovations in this technology and the procedure?

Stephanie Mignano, DPM: Yeah. So, there are numerous companies that make total ankle replacement hardware. Now, it's leaning more away from this, but it's called fixed-bearing ankle replacements, All that means is that there's two components. One that goes into the tibia, one that goes into the talus. And in the tibial component, the polyethylene, which is essentially the false cartilage, the fake cartilage is attached to the tibial component. But now, they're moving towards more mobile bearing devices. And what that means is you still have your tibial and your talar component, but the poly insert, which is the cartilage, is not attached to either component. It's just placed in between the two, if that makes any sense.

Host: And are there non-surgical procedures or alternatives to surgery for these kinds of things?

Stephanie Mignano, DPM: Yep. So, conservative measures that can at least alleviate the pain would be if the patient came in for steroid injections into the ankle joint. There's also custom braces, they're custom molded to the patient's ankle. They limit that ankle motion. And by limiting that motion of the arthritic joint, you reduce the pain in that joint.

Host: How might somebody, if they were having some issues, kind of get led to your door? Starting with their primary care provider many times? Or how does that journey tend to work?

Stephanie Mignano, DPM: Yeah, it's typically a referral from a primary care provider and a patient that they've been seeing for a while, maybe trying some over-the-counter arthritis medications or some oral steroids, and they're just not responding.

Host: The time may come when the procedure is needed. Now, let's talk a little postoperative. When someone has had this procedure, what is their post-op journey like?

Stephanie Mignano, DPM: So, this is very physician dependent. So, every doctor has their own post-op course. But I would say in general, because the ankle bears so much of the body's load, I mean, when you're Standing or walking, it's five times your body weight. If you're running, it's like 13 times your body weight on the ankle, so it bears a lot of weight.

 So typically, you want to keep the patients non-weight-bearing for at least six to eight weeks postoperative. And then, at about six to eight weeks, you can graduate them into a protected walking boot and maybe start some non-weight-bearing range of motion and physical therapy. And then, I would say at about 12 weeks, you're looking at getting them into like a sturdy tennis shoe or sneaker. But patients really aren't going to reap the full benefit of the surgery until at least six to 12 months post-op, in my opinion.

Host: And after that, say, 12-month period, what is life going to be like generally for that patient? And what is their activity level likely going to be?

Stephanie Mignano, DPM: Well, they definitely have an improved quality of life, and that's for sure because their pain is gone a hundred percent, if not close to a hundred percent. Now, in regards to restoring full range of motion as if they had never had arthritis, they're not going to get that. They'll get some improvement in range of motion, but it's never going to be like if you never had the replacement or an arthritic joint to begin with. But most patients are very satisfied because their pain's alleviated.

Host: Is running activities like that possible after this kind of procedure?

Stephanie Mignano, DPM: It's not ideal because, again, the ideal candidate is somebody with a mild-to-moderate activity level, not somebody that's an active runner. Because the more activity you do, you have the higher chance of wearing out the polyethylene and either requiring a revision replacement or going on to have a surgical fusion of the ankle.

Host: And a fusion would be a more permanent, less mobile option.

Stephanie Mignano, DPM: Correct. The other alternative to end-stage ankle arthritis is to do a fusion of the ankle, but there's factors that you have to take in consideration with that sort of procedure. But not everybody likes that procedure because you are locking your ankle joint up so you lose the ability to propel yourself forward. And it does require that you have a custom rocker bottom shoe made in order to allow yourself to walk properly.

Host: So, Doctor, what advice would you give to someone who's considering ankle replacement surgery?

Stephanie Mignano, DPM: My advice would be to go to somebody that specializes in foot and ankle, somebody that has experience in doing this sort of procedure, somebody that would be able to lay out all of the options for you, conservative to fusion, to replacement, so that way you can make an informed decision.

Host: And replacement is not to be feared, though, it sounds like.

Stephanie Mignano, DPM: No.

Host: The relief of pain and the other things you said certainly are positives that patients can look forward to.

Stephanie Mignano, DPM: Yeah, I mean there's complications with any surgery that you have done. But no, I mean, overall, patients have really good satisfaction after the procedure.

Host: Well, we appreciate it. We've been joined by the esteemed podiatrist, Dr. Stephanie Mignano, from the Carle Foundation Hospital's Podiatry Department. Thank you so much, Doctor.

Stephanie Mignano, DPM: Yeah, it was a pleasure. Thank you so much.

Host: For more information on how to get connected with a Carle provider, please visit carle.org or head over to carleconnect.com for a listing of Carle providers and to view Carle-sponsored educational activities. If you've enjoyed the podcast, please share it on your social channels and check out the entire podcast library. If you haven't enjoyed it, don't tell anyone. I'm your host, Carl Maronich. And this is Expert Insights, life changing from the Carle Foundation Hospital. Thanks for listening.