Easley reports he has a royalties and research support relationship with and is a consultant for Exactech; receives royalties, financial or material support from a publishers relationship with Wolters Kluwer Health – Lippincott Williams & Wilkins and with Elsevier; and has board member or committee appointments for a society relationship with International Federation of Foot and Ankle Surgeons.
In discussing total ankle arthroplasty performed to treat stage 4 flat foot deformity, a presenter said results depend on creating a stable platform for the ankle and the occasional need for soft tissue balancing.
At the virtual American Orthopaedic Foot & Ankle Society Annual Meeting, Mark E. Easley, MD, an associate professor of orthopedic surgery at Duke University Medical Center, likened gap balancing during total ankle arthroplasty (TAA) for post-traumatic or adult acquired flatfoot to the steps used during gap balancing for total knee arthroplasty, both of which call for minimized bone resection, performing a lateral release, or a lateral gutter release in the case of TAA, and no tightening of the medial side of the joint.
At Duke “we rarely do any medial reconstruction, but we are really careful in soft tissue reconstruction. We are very careful to get the ankle in proper position and a good solid platform,” Easley said.
However, any medial column instability that is present must be addressed, he said.
That can be done either by creating a better platform or doing a medial reconstruction in conjunction with establishing a stable platform for the patient’s ankle, according to Easley.
Patients undergoing TAA whose ankle joints are tilted may lead a foot and ankle surgeon to want to consider a ligament reconstruction or a medial reconstruction or a combination of the two to correct the deformity, Easley said. However, surgeons should be cautious in how they proceed.
“We have to be very careful in not damaging the blood supply from the approaches and also [in] just thinking about potentially anchoring into the talus, as well. So, there’s a risk of avascular necrosis and also, with more exposure, of wound complications. So, we may be foot and ankle surgeons, but we still wear orthopedic and arthroplasty hats,” he said.
For ankles that are in severe varus, gap balancing may need to be augmented with tightening of the lateral ligaments, as well as a medial release, to fully balance the ankle, according to Easley.
He recommended using a lamina spreader in cases like these to minimize bone resection.
“I definitely want to minimize my bone resection,” Easley said.