Specialty Update   |    
What’s New in Foot and Ankle Surgery
Brett Fink, MD; Mark S. Mizel, MD
J Bone Joint Surg Am, 2001 May 01;83(5):791-799
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case


The amount of new information in all subspecialties of orthopaedic surgery continues to increase at an exponential rate. It is no longer possible for one textbook to contain all of the information necessary to practice state-of-the-art orthopaedic surgery. To keep abreast of this tide of information, most major textbooks are being revised more frequently. Similarly, a single specialty journal can no longer be expected to cover all of the important advances in all of the subspecialties.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mark S. Mizel
    Posted on July 08, 2001
    Response to: Further Clarification is needed
    U of Miami

    Dear Sirs, We appreciate Dr. Guzman's comments regarding total ankle replacements, in "What's New in Foot and Ankle Surgery". Dr. Saltzman's study of first ten cases of three surgeons was provocative, but would be significantly strengthened if it were to be repeated with all of the first ten surgeons trained by Dr. Alvine, the designing surgeon. Dr. Saltzman's symposium at the 2001 AAOS meeting was quite interesting and educational, but could not provide the long-term results of implantation of these devices by numerous surgeons with various backgrounds and abilities. Until the actual clinical results of other (non-inventor) surgeons are presented and published we will not know whether these newer designs hold real promise for changing recommended treatment for most patients with ankle arthritis.

    With the disappointing record of past total ankle replacements, and anecdotal stories of trans tibial amputations resulting from complications of newer ankle implants, we would welcome the creation and funding by DePuy of a registry, for all the Agility ankles that have been, and will be, implanted. In this field - as much as any - we need good post- marketing surveillance. This should clearly be managed and run by an independent, non-profit organization, and could accurately describe the experience with the implant. The senior author of this note (MSM) has ankle arthritis, and harbors sincere hope that success will be achieved with the development of long lasting ankle replacements, but at the present time would select an arthrodesis.

    Mark S. Mizel MD Brett Fink MD

    Jose F. Guzman
    Posted on June 20, 2001
    Further Clarification is needed
    DePuy Orthopaedics

    Dear Sirs, As my occupation describes, I may have an implied bias towards the Agility Ankle and the positive representation of its capabilities. However, the following comments are sustained by facts that can be corroborated by the authors mentioned and the record of their public presentations. Drs. Mizel and Fink’s statements about total ankle arthroplasty and the articles cited left important information that should be considered before making a true assessment of the current status of this procedure. Drs. Mizel and Fink cited a study by Saltzman et.al. presented at the 2000 AAOS annual meeting. In this study, Dr. Saltzman describes his and two other surgeons first 10 cases experience with the Agility Total Ankle. In his review, Dr. Saltzman doesn’t clarify that he and the other surgeons visited the designing surgeon and trained on the system during the early stages of the implant design and procedural identification. For instance, Dr. Gall trained over 10 years before the 1998 market release of the implant. If fact, in the cases presented in the study the Agility Ankle design version utilized didn’t include the posterior augmentation to cover the entire distal tibia and the availability of 6 sizes which are part of the current system and introduced to increase the efficacy of the system. Their one-on-one initial exposure to the surgical technique may also lack the “pearls” and complication avoidance information which are an integral part of the surgical technique training required since 1998 for surgeons to have access to the system. Subsequently, a year later, Dr. Saltzman clarified and put into context his study findings during the 2001 AAOS annual meeting “State of the Art in Total Ankle Arthroplasty: Unanswered Questions and Unquestioned Answers” Symposium. Dr. Rippstein’s presentation at the 2000 AOFAS summer meeting described the experience of his first 27 cases with the Agility Ankle. To no surprise his report is in line with the findings stated by Saltzman et.al. because his initial exposure and system status was similar to that of the other three surgeons. However, some facts orally presented by Dr. Rippstein and not included in his abstract cited include the randomization of the most complicated cases to the Agility Ankle. Dr. Rippstein’s practice is located in Switzerland, which allows him access to two other mobile bearing total ankle replacement systems (STAR and Beuchel/Pappas). Dr. Rippstein presented an algorithm in which he described utilizing the Agility Ankle in the most demanding cases not suitable for the other two systems. Therefore it may be expected that complications in these cases may have a greater likelihood of occurring. Good clinical outcomes are a combination of many factors which that include implant design, patient selection and surgical training.

    Lastly, it is troublesome that the authors make no mention of other recently published studies and presentations like the 2001 AAOS Total Ankle Symposium which may accurately reflect the current state of the art of this procedure. Based on the successful clinical experience that has and is being reported, it is my opinion that is not correct to call this procedure experimental. Opinions like this may be used by insurance payers to deny care and deprive patients of an alternative to an ankle fusion.

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