For 15 years the worsening arthritis in John C. Rahmann’s ankles caused him agony.
“If I walked on a hard marble floor for a few minutes, I was in great pain,” said the 74-year-old Glencoe resident.
But after having two artificial ankles implanted, Rahmann walks pain-free with greater mobility than he has had in years.
That makes him part of an emerging medical science that is still taking baby steps compared with other joint replacements. But doctors are making advances with artificial ankles that could, like the more established procedures for hips and knees, liberate patients from unrelenting pain.
“I was also born with two club feet, which were corrected when I was a child. I had to wear casts and braces for many years. But that didn’t keep me out of the military. I served 21 years in the infantry carrying heavy packs up and down mountains,” said Rahmann, observing that his ankles have taken quite a beating.
Rahmann is a former paratrooper who made 40 jumps, a former Army Special Forces and Rangers officer and a retired lieutenant colonel. He also was executive vice president of WTTW-Ch. 11 when he retired from his second career in 1992.
“Both of my ankles were implanted by Dr. Steven Haddad of Glencoe. I heard about him by accident on the radio in 1999, when he had done the first ankle implant in Chicago. Before that the only solution was ankle fusion, which fuses bones and you end up with a stiff ankle and no range of motion.”
Describing his recovery period, Rahmann said, “I was in a cast for six weeks and was told not to put any weight on my foot. Then I was in a big boot with braces, like a space boot worn by a moon walker. It immobilizes the foot, but you can put weight on it and walk. I can walk up and down stairs normally now. Before I had to go up and down one step at a time.”
Rahmann said his surgery and some incidental costs were covered by Medicare and some of it by Blue Cross-Blue Shield supplemental.
“As I remember,” he said, “total cost, including hospital stay, was about $30,000 or $35,000.”
Rahmann’s artificial ankles, implanted by Haddad, whose practice is limited to foot and ankle surgery, were invented by another orthopedic surgeon, Dr. Frank Alvine of Sioux Falls, S.D.
Alvine’s ankle, known officially as the Agility Total Ankle System, is manufactured by DePuy Orthopaedics Inc. of Warsaw, Ind. The Agility ankle is the only artificial ankle approved so far by the FDA.
“My interest in the artificial ankle stems from the failure of so many different artificial ankle joints starting about 1978,” Alvine said. “I looked at all the old designs and tried to figure out why they failed.”
Among other problems, he said, was that there was “no instrumentation at the time to implant accurately. About 1980 orthopedics started changing with the advent of new technologies, particularly the CAT scan.”
The CAT scan, or computerized axial tomography, provides a detailed picture of the ankle’s bony structure, according to Alvine.
“I took CAT scans of about a hundred different ankles, studied them carefully, measured dimensions and then decided that certain things had to change if you wanted a successful artificial joint,” Alvine said.
His research determined that there was not enough surface area on most ankles to support an artificial joint. To overcome this problem, Alvine designed a wider ankle implant that also would require the fusion of the fibula and tibia bones. The fused bones would result in a transfer of weight to the fibula, an engineering solution that works well in conjunction with the artificial ankle. Alvine created a prototype ankle and began the long process of refining it.
“I had no engineering background,” Alvine said. “I’ve worked with engineers from DePuy for the past 20 years and a lot of the gain came through their assistance.”
Since 1984 about 3,800 Agility ankles have been implanted, according to DePuy’s Jose F. Guzman, product director for the device.
That is a figure dwarfed by total knee and hip replacements, which numbered 267,000 and 168,000 respectively in 1999, the last year for which figures are available from the National Center for Health Statistics.
Beginning in 1994, the pace of Agility ankle implants increased after FDA approval, and the number continues to grow as more surgeons learn the surgical procedure.
Today’s Agility ankle comes in six sizes and is obliquely rectangular so it conforms to the anatomy of the ankle, Alvine said.
“Previously, artificial ankle joints were `one size fits all’ and had a square shape. The Agility ankle also is the only implant that tries to achieve proper tension on ligaments.”
Mobility also has been improved, with a 60-degree range up and down. Normal range, according to Alvine is 65 to 70 degrees. “You can walk without a limp with only 30 degrees mobility.”
Since 1984, Alvine has implanted more than 600 of his ankles with excellent results, he said.
Pain from arthritis
Jack Holland, 71, a mechanical-engineering consultant from Dallas, had both ankles replaced with the Agility implant after about eight years of arthritic pain so bad he could hardly walk, he said.
“I used to jog,” he said, “and I guess I beat my ankles to death jogging on concrete. First, I had my knees replaced in 1996. Then I realized that my ankles hurt.”
Holland did some research, talked to orthopedic surgeons and to people who had had ankle replacements and learned about Alvine and the Agility ankle. In late 1997 Holland had his right ankle replaced and the left ankle the following year, both surgeries performed by Alvine.
“I told those orthopedic surgeons who wanted to fuse my ankle that they were practicing 18th Century medicine,” Holland said.
The Agility ankle surgery takes 2 1/2 to 3 hours, depending on complexity, according to Haddad, who also is an assistant professor of orthopedic surgery at Northwestern University Medical School. “The patient stays in the hospital two days. Then the patient is on crutches for six weeks with no weight placed on the ankle to allow the bones to heal and the prosthesis to become well-seated. Physical therapy is begun about two to three weeks after surgery to develop flexibility in the ankle joint.”
No jogging
Full weight bearing usually takes about a month after the patient is off crutches. “The patient can eventually participate in low-demand sports like swimming, tennis, golf. Jogging is out, but fast walking is OK,” Haddad said.
There are other artificial ankles available, though none as yet has been approved by the FDA.
These include the Buechel-Pappas ankle and the Froehling ankle, invented by Dr. Alan Froehling, an orthopedic surgeon of Mt. Vernon, Ill.
Froehling emphasized that his artificial ankle is still in its experimental and research stage. It is not available commercially.
“I’ve implanted 23 [Froehling ankles] starting with patients about six years ago,” Froehling said.
Explaining how he invented the ankle, Froehling said, “I had a patient in 1994 who declined an ankle fusion and asked me to look for a replacement ankle. I called all the major orthopedic equipment companies, and they told me there was no such device available. If there was, I wasn’t aware of its existence.”
Undaunted, Froehling said he started working to invent an artificial ankle. “I went to the drawing board, came up with some ideas, and went to Warsaw, Ind., where I talked with one of the companies that made orthopedic implants, Biomet Inc.
“They had some experience with other [prosthetic] designs,” he said. “I showed them my design; we did some cadaver work, and in 1996 we had come up with a design we were comfortable with. A woman volunteered to be a guinea pig, and we did the implant. She is now active, pain-free and wears high heels.”
Some differences
The Froehling ankle differs from the Agility ankle in two major ways, according to Froehling. “My ankle is implanted from the side. The Agility ankle is inserted from the front. Our ankle is also designed to order and custom-sized for each patient.”
Unlike the Agility ankle, which requires a fusion of fibula to tibia, the Froehling ankle does not use a bone-fusion technique. Instead, a cut is made on the fibula and after the bone heals, the Froehling ankle is inserted.
Surgery for the Froehling ankle takes less than an hour and a half.
The recovery period is about 12 weeks, six weeks on crutches and another six weeks in a walking cast.
“All my patients are doing fine post-surgically,” Froehling said.
Despite these reported successes, if and until the Froehling and other artificial ankles are approved by the FDA, the Agility ankle probably will be the prosthesis of choice.
“Only a handful of surgeons do the [Agility] procedure,” Haddad said. “But it’s catching on, and more surgeons are learning how to do it. The procedure is technically challenging because of the alignment required. It also carries risks like any major procedure.”
Ankle implants are not recommended for patients younger than about 45, Haddad said. Artificial joints tend to wear out or come loose in younger recipients.
Good health required
The surgery also is not for patients in poor health, with diabetes, with vascular impairment or poor blood flow into the extremities. Healthy older recipients of the Agility ankle implant–most with a history of osteoarthritis, or with traumatic injury that caused arthritis–usually do well.
Jean Runia, 74, of Tyler, Minn., may be typical.
“I broke my left ankle a couple of times,” she said. “It was painful, but I could stand it. But Dr. Alvine recommended ankle replacement and he did the surgery in 1991. That was almost 11 years ago, and I’m real happy with the results. I’d be more physically active if I didn’t have back surgery. But my ankle is fine.”
“Patients of mine who have had this procedure are probably some of the most satisfied patients I have,” Haddad said. “Before the operation they were miserable for years. Afterward, they’re walking around pain-free.”
Exactly what `Decade’ is it?
For those who might have thought this is the Abdomen Decade or the Neck Decade, stand corrected. This is the Bone and Joint Decade, as declared by 50 governments and 750 organizations worldwide.
The purpose actually is quite serious. Though great emphasis is placed on such problems as cancer or heart disease, joint diseases account for half of all chronic conditions in the elderly.
With an aging population, especially in this country, the consequences will become unwieldy as that population grows, demanding more care.
The www.boneandjointdecade.org/us/ Web site provides the particulars.
