Alison Whittaker, who has suffered from rheumatoid arthritis since childhood, likes to spend Labor Day weekend at the coast. But in 2007, Whittaker was able to do something she hadn’t been able to do in years without severe pain -- walk barefoot in the sand. Thanks to a total ankle replacement, known as total ankle arthroplasty (TAA), Whittaker now has no pain in her left ankle. Simple daily activities, such as a trip to the grocery store, are no longer filled with discomfort and exhaustion.

Whittaker is one of hundreds of people with debilitating ankle arthritis who are experiencing significant pain relief and improved quality of life after TAA at Duke. Duke orthopaedists, including Whittaker’s surgeon, Mark Easley, MD, and division chief James Nunley, MD, have long been at the forefront of advancements in ankle replacement.

With the recent addition of James DeOrio, MD, ankle replacement specialist and former chair of Mayo Clinic Orthopaedics in Florida, Duke has expanded its TAA orthopaedic services to Durham Regional Hospital as well as Duke University Hospital -- and, Nunley says, Duke may now be performing more ankle replacements than any other institution in the country.

James DeOrio, MDWhen first performed 30 years ago, TAA proved less successful than anticipated. Advancements in ankle replacement lagged behind hip and knee replacement because replacing an ankle is far more difficult, DeOrio says. Hips and knees have large amounts of bone and can be partially or fully dislocated, giving the surgeon more visualization of the surgical area. The ankle, however, must be replaced where it lies.

“It’s like building a ship in a bottle,” says DeOrio. Adding to the delicacy of the procedure is the critical need for proper alignment. He notes, “Unlike hip or knee replacement, the ankle is much less forgiving because of the smaller surfaces and more compact environment.“

However, the past decade has seen a surge in new prosthetic designs that more accurately mimic the human ankle and improved surgical techniques that allow for more precise alignment. The Duke team has experience with all three ankle prostheses currently approved for use in the United States (Agility, INBONE, and SaltoTalaris) and all three surgeons recently completed clinical trials of the Scandinavian Total Ankle Replacement (STAR), expected to be approved by the FDA in early 2008.

The orthopaedists describe the ideal candidate for TAA as a patient with severe, debilitating ankle pain from arthritis or cartilage injury. Patients tend to be over age 50, weigh less than 250 pounds, and have a good blood supply to the leg. Patients with skin problems, severe misalignment, ankle deformities that cannot be corrected, large areas of dead bone, or current infection are generally not good candidates for the procedure. However, DeOrio notes that newer prostheses allow for greater flexibility in choosing candidates.

Davyne Dial was a typical candidate for TAA. Dial broke her ankle in 1973 and subsequently developed severe arthritis. By 2000, Dial was almost completely wheelchair-bound. But after her ankle replacement, Dial says, her life has been transformed. “I can walk my dog, pain-free. I even slip on a pair of pretty heels every now and then, as long as I have an escort to help keep me steady.”Severe ankle arthritis with deformity before ankle replacement (left) and after surgery (right)

While mid-term data for TAA are promising, Easley cautions that the newest prostheses have not been in use long enough to determine whether they can successfully carry the strain of higher activity levels over the long term (10 years or more). Consequently, ankle fusion is still generally the most common choice for younger, more active patients. Unfortunately, ankle fusion restricts ankle movement and leads to arthritis of the surrounding joints. TAA, on the other hand, allows patients to maintain the range of motion they start out with before surgery. Time and clinical data will tell whether TAA supersedes ankle fusion for all patients with severe ankle pain.

To refer a patient or make an appointment to discuss total ankle replacement with DeOrio, Easley, or Nunley, call 800-MED-DUKE (physicians) or 888-ASK-DUKE (patients).