Future prospect of Total Ankle Arthroplasty

Unlike the hip, shoulder and knee, the articulation of the ankle has proven to be
more challenging in attempt to artificially replicate. Despite the numerous
revisions of its designs, the total ankle Arthroplasty is still considered to be the
least effective treatment and received the least satisfactory responses in clinical
long-term follow-ups compare to arthroplasty procedures of other joints.

The Gold Standard

(Bowers, Catanzariti & Mendicino 2009)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799972/pdf/ymj-51-100.pdf
Prior to total ankle arthroplasty, another surgical procedure known as total ankle
arthrodesis was commonly performed in patients with painful joints caused by
osteroarthritis - the procedure includes removing head of the tibia and part of the
talus and then fusing the two parts with bone graft and steel pins to prevent then
movement of the two components and therefore eliminate the source of pain.
The promising result earned this procedure the name "Golden Standard" as a
token that it is indeed an effective and permanent solution to the painful join
problem. Though at the same time, the procedure will severely restricted the
movement of the ankle and thus reduce the mobility of the patient.
As the result of 20 years of experience, the design of the ankle prosthesis has
evolved gradually over time. The focus on the physiology and the anatomic
structure of the ankle; engineering considerations to reduce the interface stress
between the bone and the prosthesis, the attempt to mimic range of movement
of a natural ankle; and finally the advent of the hydroxiapitite coating.
Nevertheless, a number of important issues need to be addressed in order to
ensure the success of total ankle Arthroplasty.

Designs Specifications
(Leardini 2001)
(Alvine 2002)
(Dettwyler et al. 2004)
(Ranawat et al. 2005)
(Myerson, Won 2008)
http://www.ejbjs.org/cgi/content/abstract/91/7/1587
The effectiveness of total join arthroplasty is inversely proportional to the
architectural complicity of the said joint. Comparing to other arthroplasty

procedure - the total hip arthroplasty for example , is possible to achieve 100%
satisfactory rate in 5 years clinical studies where as oppose to 70% for total
ankle arthroplasty. (Dettwyler et al. 2004)
The complex anatomy of the ankle is one of the first problems we are facing,
such as the lack or incomplete understanding of the interaction and movement
between the components of the ankle. A solution for this problem is by research
deeper into the anatomy and the working of the ankle - and hopefully able to
produce a more accurate and complex model of the part. (Leardini 2001)(Alvine
2002)(Dettwyler et al. 2004)

The implantation of the prosthesis can potentially cause infection

Not compatible with younger patients/active patients

Restrict activity level of the patient the bonding interface between the
bone and the prosthesis can be very fragile.

One of the most recent attempts in adapting the procedure in younger patients is
by producing the prosthesis from High Density Polyethylene. The device is
currently used in total knee replacement but the concept can possibly extend to
arthroplasty devices as well. The lack of a metal component is both the biggest
advantage as well as the biggest disadvantage: the all-polyethylene design is
more susceptible to wearing, more precisely, backside wearing of meal backing
design and finally less resilience to trauma. In exchange, the mobility of the
patient is mostly restored, and has minimal influence on the patient's activity
that are metal sensitive (i.e. MRI scans, Airport metal detectors etc.)
The polyethylene-based prosthesis is designed specifically with the growth of the
patient's bone being the most prioritised concern. In the five years of clinic
follow-up studies, the polyethylene has demonstrated a promising result: it
achieved a 95% satisfactory rate with a general failure rate of approximately
1.8%, which is very close to the statistics of the metal prosthesis.(Ranawat et al.
2005)
(http://www.ejbjs.org/cgi/content/abstract/91/7/1587 )

One of the difficulty to apply the concept to ankle prosthesis is due to the
complex movement of the ankle and thus cause stability issues as oppose to
the knee joint, the ankle is capable of plantarflexion/dorsiflexion as well as
eversion/inversion. There is a significant lacking in the study of the allpolyethylene prosthesis, due to the fact that the result of the design is highly
design sensitive. (Myerson, Won 2008)

Artificial Cartilage

One of the major applications of total ankle arthroplasty is patients with

osteroarthritis - the degeneration of the cartilage around the head of the bone.
Our current prospective is to artificially replace and recreate the site of
connection - by replace the head of the tibia and part of the talus. As effective
as it may be by current standard, the procedure still has its problem and
limitations.
The procedure can be extremely traumatic, especially for order patients - who
also happens to be the most common patients who undergo this procedure, as
the normal risk of infection apply, and the possibility of the newly implanted
device triggering the body's defence mechanism and cause inflammatory
response; the decreased regeneration ability of the elderly means they also need
a very long period of recovery from the procedure, the slower regeneration of
bone tissue means the newly invented hydroxiapitite will decrease in
effectiveness in such patient and finally, a possibility of the device not being
properly implanted.
Thus the alternate solution to treat arthritis - artificial cartilage.
The field of cellular research and engineering as well as the technology was
extremely lacking around the time arthrodesis was developed. due to the
insufficient knowledge and the dire for an effective treatment for arthritis comes
arthrodesis. Today, with the advanced technology, as well as our research into
stem cells and cellular engineering, there appears to be a possibility of artificially
creating human tissue specifically, the cartilage tissue.
The principle behind the artifical cartilage is by differentiating the progenitor cell
Mesenchymal Stem Cells into Chondrocytes which forms the cartilage tissue and
injecting into joint of the patient to regrow and repair the damaged cartilage
tissue.(Nesic et al. 2006) The advantage of of the artificial cartilage is bluntly
obvious the lacking of a implanted prosthesis device that is alien to the body
tissue to a avoid inflammatory response and infections due to accidental
contamination of the device prior to the implantation procedure; avoiding a
extremely traumatic surgical procedure which consists of removing a large
amount of health bone tissue for the implantation as well as associated problems
such as weakening of bone structure due to the removal of the bone tissue or
prosthesis becomes detached from the bone over time. Furthermore, the
procedure can be applied to wide array of arthritis conditions due to different
causes from post-trauma to acute cartilage defects, as well as patients of all age
groups.(Aoki et al. 2003)