There’s Such a Thing as a Total Ankle Replacement?

Within the last several years, although around for decades, Total Ankle Replacements have been gaining popularity in both the Podiatric and Orthopedic medical fields as a means of treating chronic ankle arthritis and pain. On the tails of success of the total knee and total hip replacements, used for treating painful hip and knee joints that have become chronically arthritic, technology for total ankle replacements has taken flight.

To many, understanding the science and theory behind total hip and total knee replacements makes sense and it seems as though these procedures have been around for long periods of time. Total ankle replacements have been around since the 1970’s and although they originally gained popularity in Europe, there are currently four Total Ankle Replacement systems that are FDA approved and available for use in the Unites States of America.

Indications for a total ankle replacement include ankle joints that have reached end-stage arthritis with chronic pain and have not responded to other conservative treatment options. Those ankles most likely to suffer end-stage ankle arthritis are ankles in patients who have a history of ankle trauma (fracture, joint infection etc) that has led to chronic pain. Conservative treatment options that may be explored prior to consideration of total ankle replacement include: joint injections, immobilization, physical therapy, and ankle scope.

In the past and currently, although times are changing, the ‘gold-standard’ treatment for end-stage ankle arthritis has been ankle fusion. An ankle fusion basically employs a cleaning up of the inside of the ankle joint followed by permanent consolidation of the bones that make up the ankle. The procedures end result is a permanent loss of motion at the ankle joint. If you prohibit motion at the ankle joint, or any joint with chronic pain and end-stage arthritis, you eliminate pain. A loss of motion = a loss of pain. However, with ankle fusion procedures, the motion lost (beneficial in the normal gait cycle), requires your body to make adjustments in gait. This inconvenience, for patients suffering from chronic pain and arthritis is nothing in comparison to the elimination of joint pain, and patients tend to do extremely well post-operatively. However, total ankle replacements aim to preserve ankle joint motion while still eliminating pain.

Preservation of motion while eliminating a patient’s pain would be far superior to ankle fusion, where motion is eliminated. Total ankle replacements are intended to allow the patient to ambulate with “normal” use of their ankle joint. If ankle replacements become the ‘gold standard’ of treatment in treating end-stage ankle conditions, they provide a viable option for patients before consideration of fusion.

Not all patients are candidates for total ankle replacement, so a discussion of all options should be explored with your Podiatrist. In addition, the technology is still expanding, but in the coming years it looks to be a promising alternative to treating patients with chronic ankle arthritis and pain.

Over the Counter “Custom Fit” Orthotic Inserts

Last week we talked about custom molded orthotic devices and the differences between those that are functional and those that are accommodative. Just as a reminder, functional orthotic devices are made to align the foot in a neutral position and work to support the surrounding structures, allowing the foot to function as normally as possible. Accommodative orthotic devices are indicate for patients with rigid deformities and accommodate the foot rather than attempt to realign it. A great example of the use of accommodative orthotics is in diabetic patients, as they will allow off-loading of high-pressure areas prone to ulceration.

We also briefly touched on the idea of “custom orthotics” being sold over the counter. If I didn’t make myself clear last week, let’s be clear this week: If you are purchasing something over the counter and off-the shelf in a drug store, they are not custom orthotics. Custom orthotics can only be manufactured in an orthotic lab using casts and/or scanned images of your feet, sent to the lab with specific manufacturing instructions from your Podiatrist.

What I want to discuss this week is the claim that such companies are making, like the newly advertised “Dr. Scholl’s Custom Fit Orthotic Insert Kiosk,” and what they actually mean when they say “custom fit.”

If you have yet to see the commercial, check out the Dr. Scholl’s website: http://www.footmapping.com/footmapping/about-the-kiosk/index.jspa

There, you can watch a video on how the Kiosk works and how it recommends which ‘custom orthotics’ to select off-the shelf. Let it be known that Dr. Scholl’s is not the only company who sells “custom orthotic inserts over the counter,” but it happens to be their commercial that sparked my writing about this topic.

Now, many of you might be confused, because this particular Kiosk “maps” your foot, similar to scanned images that might be taken by your Podiatrist if you’re set to purchase custom orthotics. This mapping allows the computer to understand the basic make-up of your foot and uses that information to generalize your overall foot-type. The kiosk will then suggest to you, based on the mapping of your foot, which Dr. Scholl’s “custom fit orthotic insert” best suits your generalized foot-type. You will be directed to either the left or right side of the Kiosk, where your ‘custom fit orthotic’ awaits you!

In reality, what this Kiosk is suggesting to you is what we as Podiatrist’s call, a Pre-fabricated Orthotic Device.” What that means is that those orthotic devices are manufactured to fit a generic foot-type. There might be one device that is pre-fabricated for a generic flat-foot and another pre-fabricated for a generic high-arched foot, but in no way is your foot, or anyone else’s foot generic. You have a specific foot that differs from each and every other individual, therefore, although these Pre-fabricated orthotic devices may help, they cannot be called “Custom Fit Orthotic Devices” because they were not made to specifically fit your foot.

Now with that said, if you remember back to last week, there are instances where as Podiatrist’s we will recommend an over the counter orthotic device to you. The recommendation depends on the deformity for which you present with in addition to whether the Podiatrist believes an over the counter, non-custom device will be beneficial. If they deem that an over the counter device would be suitable, or suggest such a device as a starting point, what you will be purchasing is a pre-fabricated orthotic device such as mentioned above at the Dr. Scholl’s Kiosk. It is not custom to your foot, but it may be sufficient enough to provide you significant relief.

Dr. Scholl’s is not the only company who manufactures such pre-fabricated devices; in fact there are hundreds of companies that offer these. You’re Podiatrist will most likely have a manufacturer who they particularly like and will recommend to you, should pre-fabricated orthotic devices be a viable option. It never hurts to mention or ask your Podiatrist about trying such orthotics prior to ordering a custom molded pair. As was mentioned last week, custom molded orthotics although necessary in some instances can be expensive, and we are not in the business of bankrupting our patients.