Does your ankle hurt, you can't walk and your doctor told you, that given to the range of damage, it would be ideal to replace the joint? In the following lines we will try to explain the problematics concerning endoprosthesis of the ankle and all the complications joined with it, as well as current success of implantation of post-operational phase.
Ankle is a burdened joint which is complexive not only by its structure but mainly by the biomechanics. It is composed from three bones: shinbone (tibia), calf bone (fibula) and ankle. Its function is static, but also dynamic and therefore it has to be sufficiently flexible, and at the same time firm enough. The static function is secured be its bone system and large amount of ligaments, which are present in the individual bones. The dynamic function is composed of the two arches - transversal and longitudinal.
WHAT DOES THE TEP OF ANKLE MEAN?
The abbreviation TEP stands for total endoprosthesis, meaning complete artificial replacement of the joint. In case of ankle TEP, the end of the shinbone and the upper part of the ankle bone is replaced. In between both of these implants is an insert made from polyethylene, which enables movement of the endoprostheses against each other. Materials from which the endoprosthesis are usually made is alloy of cobalt and chromium, which are at the same time covered in a layer of Hydroxyapatite. Thanks to these new methods and materials the TEP of ankle is being done more and more frequently in the last decade. Before the doctors would choose as an option arthrodesis (artificial ankylosis), the big disadvantage of this solution is a gradual development of degenerative arthrotic changes of the forefoot joints, when the joints start to collapse and the ankle is immovable. On the other hand the TEP of ankle can preserve the needed mobility in the ankle joint.
MOST COMMON INDICATIONS FOR SURGERY
- Post-injury condition
- Degenerative diseases - usually arthrosis (painful diseases of the joints)
- Avascular necrosis (cellular death of bone tissue, forming without the presence of infectious inflammation, no clear cause)
- Congenital defects
- Significant instability in the ankle
Before the surgery, it is necessary for your doctor to internally examin you, evaluate the degree of risks, estimate whether you are able to undergo this operation, and assist on the optional choice of anesthesia. Usually general anesthesia is used, in some cases you can ask for spinal anesthesia, which will „deaden” the you only from your waist down, so you will stay conscious. In the day of operation you will be treated by a doctor - orthopedist (usually the surgeon), who will explain you the process of operation, as well as the process of post-operational phase. Before operation, the doctors take patient's blood, which is then used as autotransfusion, if there is a need to replace the lost blood.
Certain circumstances or conditions of the patient exclude the possibility of operation. Contraindication can be split into two groups:
- Infection in the ankle
- Skin infection, pressure ulcers, boils
- Folliculitis - staphylococcus skin infection
- Patient is not cooperating
- The condition of the patient, disabling walking after the operation
- Inflammatory source
- Allergy to artificial material
- Bad quality of the bones
- Neurogenic arthropathy - degenerative diseases manifesting by lost sensitivity
DAY OF THE OPERATION
In the day of the operation, doctor will apply a dosage of anti-inflammatory drugs and antibiotics into your muscles as a part of premedication. In most cases the patient is lying on the back. Usually the surgeon chooses the approach, during which he cuts the skin, subcutaneous tissues, fasciitis (ligamentous sheath of the muscles), ligaments and he will uncover the joint itself. In the first stage the damaged parts of the bone are removed, and then it's replaced by the prosthesis. The surgeon then inserts an insert in between the prostheses, on which will the replacements slide, and the ankle will be able to move. It is important to correctly sew all the skin layers, subcutaneous tissues and ligaments especially, so that they would not ingrow together. Such adhesion can have a negative effect on the mobility of the ankle and function of the muscles and at the same time on the recovery of the wound.
Immediately after the operation you will be transferred to the intensive care unit, where you will receive anti-inflammatory drugs, drugs against pain and your life functions will be monitored. If there won't be any complications, you will be transferred the second day to a standard room. The ankle will be fixed in a cast, which you will wear for 3 - 4 weeks. That is followed by intensive rehabilitation. Walking is enabled only with crutches in length of 6 - 12 weeks after operation. You can put your whole weight on the ankle as soon as two and half months after operation.
In the first phase it will be very important to take care for the scar, which alone can cause some complications, especially if it's closed for 3 - 4 weeks in a cast. In order for the single skin layers to not grow together, along with ligaments and fascitis, it is important to apply soft tissue techniques to relieve this area. Ideal is also gentle pressure massage, stimulating massage, or taping (supporting the joints and muscles in the problematic areas, thanks to special cotton band sticked to the skin), which can not only relieve the area but it can also help to absorb the hematoma which are often accompanying the post-operational period. For keeping the maximum range of mobility, the ankle needs to be (after removing the cast) exercised into all directions - stretching the toes, flexing, circling with the heel into all directions. The movement will be certainly significantly restricted, it is caused by a long term fixation, but also be the weakened muscle groups, which functionally relate to the ankle. That is especially calf muscles, which has to get quickly back into „condition”, so that the walking would be as natural as possible and it wouldn't hurt.
Given the complexive structure of the joint and the soft tissues around it, it is important to recover the stability of the ankle ideally as soon as possible. For that there are number of tool you can use: unstable surfaces, BOSU, Posturomed, which can not only train the ankle in stability, but to prepare it also for situations which may occur during daily activities. The more prepared the foot will be, the bigger certainty you will feel during walking, running or any other movement.
It is also necessary to take care of the muscles of the feet, which are composing the two arches significant for correct walking and standing. Their proprioceptive (deep sensitivity) function is very important. Proprioception is a function of the receptors in the feet, which secures the correct and fast communication with brain. Simply said, what proprioceptors receive as an information from the terrain on which we walk, that will they send to brain center, which has to adequately respond to the correct tension in the muscles, tendons and other soft tissues, so that you could have a support and stability. Therefore it is ideal to stimulate the foot, support the blood supply, in order for this function to recover and function correctly. Stimulation pads are optional, as well as various massage devices, but also walking on smaller stones or beans.
After the operation the muscle groups in the area of the surgery are rather weaker, however the muscles which had to “carry” the leg, will welcome this treatment. That is especially muscles in the area of the lumbar spine, thigh muscles and muscles of the shoulder girdle, which are very burdened when walking with crutches. It is ideal to apply radial shock wave therapy, which can quickly and effectively relieve the muscles, support the blood supply in the whole area, application should be done in intervals of 3 - 7 days with number of 8 - 10 applications into one area.
- TEP of ankle - post-operational treatment
- TEP of ankle - consecutive care
Author: Mgr. Iva Bílková, FYZIOklinika fyzioterapie Ltd, Prague, Czech Republic
Source: Clinical experience from a private practice in the physiotherapeutic field, FYZIOklinika