Abstract
Arthritis of the ankle continues to be a significant problem for patients and its prevalence, at least posttraumatic arthritis, appears to be increasing. Currently there is a great deal of interest within the orthopaedic foot and ankle community concerned with treating patients with arthritis of the ankle. Traditional teaching has indicated that ankle arthrodesis is a satisfactory procedure to solve the pain of ankle arthritis and yields reliable results. Yet, as our orthopaedic knowledge has expanded and the length of our follow-up of ankle arthrodesis patients has lengthened, we see that there are many secondary problems associated with ankle arthrodesis. Thus, this timely text addresses a significant problem for patients and their physicians.
In the 1970s as surgeons began routine replacement of the hip and knee joints, many believed that replacement of the ankle would be easy and would yield results similar to the excellent results seen with total hips and total knees. Unfortunately, as we have learned, these early promising ankle results deteriorated quite rapidly and the first generation total ankle replacements were largely unsuccessful.
Over the last decade there has been significant progress made in the understanding of biomaterials, biomechanics, and much progress has been made in extending the excellent results of total joint replacement throughout the body. Moreover, recently there has been a resurgence of interest among foot and ankle surgeons in finding a way to replace the ankle joint. Thus, this book by Hintermann on Total Ankle Replacement is a timely addition to the foot and ankle surgeon's armamentarium and to the orthopaedic surgeon who must treat these difficult problems, for it is only through study of our past history of ankle replacement surgery that one can avoid the mistakes of the past into the future. Hintermann has clearly indicated through his historical review of previous ankle replacements the mistakes of the past. With this as a knowledge base, he then proceeds to outline for us the current state of affairs into the future.
Chapter 2 is particularly useful as it illustrates the characteristics of post-traumatic ankle arthritis. Many orthopaedic surgeons having performed anatomic open reduction internal fixation of ankle fractures truly believe that the patient will be sparred the development of post-traumatic arthritis in the future. Nevertheless, as Hintermann illustrates, even well done open reduction internal fixation will frequently lead to a post-traumatic arthritis and a significant problem for the patient. Thus, we should anticipate that in the future we will continue to see an increase prevalence of this problem as more and more trauma victims are surviving with these devastating ankle fractures.
Chapter 4, which deals with the anatomy and biomechanics of the ankle joint, is a “must read” for any serious student of foot and ankle surgery. It is only through an understanding of the complex anatomy and biomechanics that we can address many disorders of the ankle. Hintermann is recognized as a world authority on biomechanics and ligamentous stability of the ankle. This beautifully illustrated chapter takes us through the importance of the bony restraints, ligamentous anatomy, fixation of the prosthesis, contact area, and biomechanics of this complex joint. Once one has an understanding of these basics, designing a total ankle replacement becomes an easier task.
To give us an overview of what is currently available, Chapter 6 is an excellent addition as it shows all of the current total ankle designs that are used worldwide and allows the reader to become familiar both with the design and characteristics of the individual prostheses. This chapter also addresses the surgical technique and the published results for each of the ankle replacements. This is an outstanding accumulation of all of the current literature and the bibliography is a wonderful resource.
With his thoughtful approach to ankle and ankle arthritis, Hintermann takes us through the current indications and contraindications for ankle replacement. He particularly draws attention to malalignment of the extremity as this has caused a problem for surgeons both at the hip and at the knee and certainly has plagued ankle surgeons in the past. With this understanding of alignment, adjacent joint arthritis, and the previous chapter on anatomy and biomechanics, one can easily understand the indications and contraindications for total ankle arthroplasty.
One of the true strengths of this text is the beauty of its illustrations. This is a massive collection of cases and case material which Hintermann accumulated through his lifelong study of ankle instability and ankle arthritis. The chapter on techniques is beautifully designed to allow the surgeon to understand the intricacies of this procedure.
Certainly the most thought provoking and impressive chapter is the one on the possibilities. Through creative thought and sound reasoning, Hintermann has illustrated how to perform osteotomies of the tibia above the ankle while simultaneously performing total ankle arthroplasty or conversely performing osteotomies and fusions below the ankle joint and simultaneously correcting foot and limb malalignments. The depth of this chapter is breathtaking and some of the surgical results could probably not be reproduced many places in the world.
To add overall balance, the chapter on complications brings us back to the many nuances that must be considered when one undertakes such a difficult procedure.
I find this book to be extremely timely. I believe it is an accumulation of a lifelong effort in collecting cases and thinking about and improving on techniques related to the treatment of ankle arthritis. This will become a “must textbook” for all serious foot and ankle surgeons and will certainly help our understanding of this complex joint.
Taken from: Hinterman, B: Ankle Arthroplasty. Preface by Nunley, JA, Wien-New York: Springer, 2005.