Artificial ankle brings help for those with long-term suffering

As a health care worker, Victor Neufer knew about knee and hip replacements, but not so much about artificial ankles until he needed one. A few years ago, he was riding a bicycle on Scenic Drive in Modesto, Calif., when a car forced him off the road, causing him to hit a sign and land hard on the ground, he said. The driver didn't stop.

It felt like his right ankle was sprained and a year later surgery was performed to repair tendons in that ankle.

Arthritis set in, and to make matters worse, his job as an emergency room technician at Memorial Medical Center required him to stand for hours on the chronically swollen ankle.

"When I came home, it was all I could do to get in the house, get my foot up and do something for the pain," he said. "It became a choice of not doing a lot of things, such as walking my dog, because it hurt."

Doctors found the 49-year-old Modesto resident had bone degeneration, spurs and other problems, and he wasn't a good candidate for a fusion procedure commonly given to patients after years of suffering.

Another surgical option was amputation below the knee and a prosthetic leg, his doctor said, but Neufer couldn't wrap his mind around that.

In August, he was given an artificial ankle, a surgery performed on about 2,500 patients per year in the United States.

"I'm limping around really well now," he said this week. "Long-term, I should be walking fine. I will be going dancing again."

Artificial ankles have never become as popular as other joint replacements. The implants that emerged in the 1970s couldn't take the pounding of daily life and later versions often came loose, requiring another surgery to have them anchored again or removed.

But the newest artificial ankles are designed more like the natural joint and are supposed to be more durable.

Dr. Paul Braaton, orthopedic surgeon at the OrthoMed Center of Modesto said he was never impressed with the older implants, but has done several ankle replacements with the newer versions in the last 18 months. The devices are easier for surgeons to implant and provide more range of motion for the patient, he said.

In addition, the implants should be able to take more punishment, although time will tell how long the newer versions last.

"The short-term results are good," said Braaton, who replaced Neufer's ankle at Memorial. "Ten to 15 years down the road nobody knows. ... I think it's a good option for people who really haven't had good options."

Ankle replacements are one of the few surgical options for people with severely damaged ankles. Most candidates are age 30 to 70 and have suffered for years from osteoarthritis or rheumatoid arthritis or long-term inflammation from a broken ankle, and have exhausted other treatments such as physical therapy, weight loss, foot braces and medication.

Braaton said it's a good option for people age 50 and older who are fairly sedentary or other adults with moderate activity levels.

It's for people who would like to walk, swim or ride a bicycle again without pain, but is not likely to support activities like aerobic dancing or running.

For younger adults who do manual labor or heavy lifting at work, a fusion surgery is the better option, he said. That surgery removes damaged cartilage and fuses the ankle joint, making the foot as stiff as a board, he said.

The Food and Drug Administration has approved new versions of the artificial ankle in the last three years. Neufer was given an Inbone Total Ankle, marketed by Tennessee-based Wright Medical Technology, consisting of two attached parts. A stem at the top has a smooth plastic surface that rotates on the polished metal surface of the lower piece, facilitating the heal and toe motion of the ankle.

Ankle replacement surgery takes about three hours. After the patient is put to sleep, surgeons make incisions on the bottom of the foot and the lower part of the front leg. A tunnel is bored into the lower part of the shinbone, then the stem is inserted and secured. The lower piece of the artificial joint is inserted in the ankle bone.

Following the surgery, the patient is in the hospital two or three days and wears a cast for four to six weeks. Recovery may take up to six months.

Neufer has physical therapy three days a week. He spends time in a pool walking and doing other exercises designed to work flexibility into the foot. As of last week, he had 30 to 40 degrees of motion in the ankle and should have 45 to 60 degrees in time.

He wears a special boot that provides support while the foot heals. He is taking short walks and hopes to recover well enough to return to work in February, he said.

Neufer looks forward to pain-free walking and tromping around Knights Ferry with his dog. He'll soon start looking for a dog to replace his black Labrador that died in June.

Ankle replacements are covered by Medicare and a growing number of insurance plans. Still, Braaton said, he's spent almost a year asking one patient's insurer to approve the surgery.

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© 2008, The Modesto Bee (Modesto, Calif.).
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