Ankle Transplantation

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Introduction

The ankle joint is a complex structure, that, in normal conditions allows for the full body weight to be transfer through a relatively small joint surface from one limb to another, permitting a degree of movement and at the same time maintaining its stability.

An ankle joint injury or chronic degeneration leads to instability, deformity, pain, limited movement, and an overall poor quality of life. After conservative treatments have been exhausted, a surgical treatment is considered. Available options are: ankle fusion, total ankle replacement or ankle transplant, each having its specific advantages and disadvantages and being offered based on individual patient’s needs.

Ankle transplantation offers a unique solution – a transplantation of a healthy ankle (an “allograft”) from a deceased donor to a recipient, in place of their degenerated and painful joint. The aim is to eliminate pain, restore mobility and provide recipients with a chance to regain their independence and quality of life. The allograft’s size and age is matched with the recipient, similar to other organ transplantation. The major difference is that transplanted bone and cartilage do not induce significant immunologic response, moreover donor bone, with time, will be replaced with patient’s own bone. Therefore, no immunosuppression medication is needed after ankle joint transplantation.

Indications and Contraindications

Ankle transplantation is considered for individuals who have lost ankle function and:

have severe ankle arthritis, in which the joint’s cartilage has degenerated, causing deformity, subluxation (loss of normal joint alignment), pain and stiffness,
who have failed courses of non-surgical therapy,
who failed previous reconstructive surgeries,
who are young patients with good bone stock and good healing potential,
who are not good candidates for ankle fusion (their job requires good ankle range of motion)
who are too young and too active for artificial ankle replacement (there is a high risk of artificial ankle replacement in young and active patients)

Common indications include:

Post-Traumatic Arthritis: Arthritis resulting from a previous ankle injury such as fracture of the joint surface or form of chronic joint instability after repetitive sprains or severe ligamentous injury, in young and active patients.

Contraindications to an Ankle transplant

Patients who can be considered for a safe total ankle replacement: total ankle replacement is a well-established and more predictable procedure than an ankle transplant.
Severe Osteoporosis and Poor bone stock: Fragile or deficient bones may not support an ankle transplant.
Avascular Necrosis: Loss of blood supply leading to necrosis of an ankle bone – most often talus.
Active Infections (locally or generally): Infections complicate the surgical site and recovery, a chronic infection that developed around an ankle transplant can even lead to ankle amputation.
Poor Vascular Supply: Inadequate blood flow to the foot compromises wound healing and can even lead to ankle amputation.
Neuropathy: Nerve damage affects sensation and healing potential.
Significant Ankle Deformity: Anatomical abnormalities of the ankle should be addressed prior to the transplant surgery to ensure transplant’s longevity through normal joint alignment and normal forces distribution.
Patients with general medical conditions being a contraindication to any surgical intervention

Benefits and Risks

Ankle transplantation offers recipients the potential to regain significant mobility and quality of life with satisfaction rate higher than in patients with ankle fusion. However, it is a complex procedure with multiple potential risks, including graft collapse and failure, infection, and the need for revision surgery. Recovery from ankle transplant can take several months to a year, and commitment to rehabilitation as well as follow-up appointments is essential for optimal outcomes.

Always consult with your healthcare provider for personalised guidance and recommendations.

Surgical approach

Ankle transplantation is a complex procedure that requires careful planning and precise execution. Their surgical approach will be based on the patient’s condition, the need for accessory reconstructions, the quality of available grafts and the surgeon’s expertise.

Pre-Surgery Information

The following is what can be expected before an ankle transplantation procedure

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

Anesthesia: General anaesthesia or regional anaesthesia (spinal or epidural) is used to ensure a pain-free procedure.
Incision: A carefully placed incision is made to access the ankle joint.
Joint Preparation: Damaged cartilage and bone are removed using the 3D-printed patient-specific cutting jigs, to create space for the transplant.
Transplant Preparation: A matching fragment of the ankle joint is cut using the 3D-printed transplant-specific cutting jigs, to match the patient’s joint perfectly.
Transplant Placement: The donor transplant components are inserted into the joint to mimic its natural movement. The donor’s bone is transfixed to the patient’s bone using screws. The position of the transplant and screws is confirmed with x-rays.
Additional reconstructive procedures: If indicated, joint realignment or stabilisation is performed at the same time as ankle replacement.
Closure: The incision is closed using sutures. A dressing and cast are applied.

Post-surgery Information

Hospital Stay: You’ll typically stay in the hospital for a few days for monitoring and initial rehabilitation.
Pain Management: Pain medications will be administered to keep you comfortable.
Immobilization: After surgery, you will be put in a cast for a week, this will be changed to a moon boot at a 1-week wound check. You will wear the boot for at least 3 months, this will be determined by the potential of the donor bone healing together with your bone.
Weight-Bearing: You’ll be non-weight bearing for the first 6 weeks to 3 months, then you will commence weight-bearing gradually, with a protection of a boot, following the surgeon’s instructions.
Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:
– 1 week postop: for wound check,
– 2 weeks postop: for sutures removal,
– 6 weeks postop: for xray assessment of healing progressing,
– 3 months postop: a CT scan and X-ray for assessment of healing and determining if the full weight-bearing can be allowed.
– Later a 6-month postop, 1 year postop and further annual follow-up with xray will be mandatory.
Physical Therapy: A tailored rehabilitation program will help regain strength, flexibility, and mobility.

Special Considerations

Immunosuppression: Recipients DO NOT NEED to take immunosuppressive medications.
Rehabilitation: Meticulous adherence to weight-bearing and exercise recommendations is mandatory.

Long-Term Monitoring: Regular follow-up appointments are necessary as the bone recovery and remodelling takes over a year and failure can be noted at any point in time.

High failure rate: Current specialized literature indicates a 50% success rate in total ankle transplantation.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000