This surgical procedure became available to Americans in October of 1998.

Prospective patients who are implantable may talk with other patients in their age group who have had this procedure.

The Implant

Pictures of the Buechel-Pappas ankle joint implant.

Surgical Technique

Here you will find the abbreviated surgical technique to implant the Buechel-Pappas ankle joint implant. Be advised that this contains actual surgical images taken in the operating room and if you have an aversion to such, you should not view these pictures.

Before & After X-rays

A sample of X-rays before and after implantation of the Buechel-Pappas ankle joint.

While I know journalists dread the multi page letter, I write nonetheless because of the educational importance encompassed in presenting Total Ankle Joint Replacement as a surgical procedure which replaces a deformed or diseased ankle joint with a titanium prosthesis, heretofore unknown. As I am privileged to have been selected as one of ten surgeons in the United States permitted to implant the Buechel-Pappas Total Ankle Replacement, I feel it is important to provide you with sufficient information relevant to your profession.

Explained in layman's terms:
Individuals who need this operation have exceedingly severe ankle pain. It is not an overstatement to say that the pain is so disabling that many of them want their lower legs removed rather than continue to suffer with every step they take. Try to imagine a nail within your ankle joint with the point moving against the ankle bones with each step, and you will have some idea of the suffering these patients endure. Many become narcotic dependent because of their inability to function throughout their daily lives.

Their ankles are so painful because of either rheumatoid arthritis or bone/joint arthritis from a previously broken ankle. Until Oct. of 1998 the only possible relief was an operation that removed the ankle joint entirely and fused the foot to the leg. This means the foot and leg become one piece. The patient then walks with a limp with the remaining foot joints taking the force and movement their prior ankle did. In most cases, the abnormal walking causes the remaining foot joints to become diseased and destroyed from the stress placed on them. Usually within 5 years the foot joints must be surgically fused from the stress placed on them. After 12-20 weeks in a cast the patient’s ankle pain is gone but it for tells additional limb pain for the remainder of the patients life as the stress is transferred to the hip and knee.

The titanium ankle joint took 20+ years to develop because of the small size of the ankle compared to the hip and knee. In addition the hip and knee absorb 2x body weight stress per step while the smaller ankle absorbs 5x body weight per step. In Oct. of 1998, a prosthetic ankle joint became available in the same way the now common hip and knee replacements are available. The diseased ankle is removed and a new one implanted. The patient is in a cast from the toes to the knee for 6 weeks after which he begins normal walking activity. Equally important is that many of the patients who under went ankle fusion may have the fused ankle removed and replaced with a new functioning ankle joint.

Statistically, according to U.S. government records about 9,000 individuals over the age of 65 break their ankles or are afflicted with rheumatoid or osteoarthritis each year. In younger Americans it is greater through accidents from athletics, automobiles, home injuries and job related fractures. As such, severe ankle injuries leading to disabling arthritic ankles, affect thousands of persons every year.

In Medical terms:
Enclosed is a letter sent to physicians and surgeons about the Buechel-Pappas Total Ankle Replacement. It is indicated for patients with severe pain from rheumatoid arthritis or osteoarthritis from previously intra articular fractured ankles. Prior to now these patients faced ankle fusion as the only procedure that had a chance to relieve their unrelenting pain. Ankle fusion has a failure-pseudoarthrosis rate of 20-30%, depending upon the reported literature published. Total ankle implant replacement arthroplasty failure rates are 3-5% and result in fusion. Today ankle fusion is no longer the procedure of choice for patients with these debilitating diseases except in non-candidates, with insufficient osseous integrity e.g. Charcot joints. Previous fusions may, in many cases, be replaced with a functioning ankle joint.

During the past two years I scrubbed more than 30 implantations throughout Europe. In an effort to become proficient I was taught by some of the finest joint replacement orthopedic surgeons in several cities including, but not limited to, Prague, Copenhagen, Amsterdam, Zurich, Oxford, Yorkshire, Manchester, Edinburgh, Hamburg, and Reims. Historically, there were about 8 total ankle prosthetic designs in use in the United States and Europe 23-25 years ago The collective Worldwide literature reported +/- 900 implants over 5 years with a failure rate of 50+%. Failures were attributed to the designs, cementing in place and several other factors eventually causing the procedure to be abandoned in America.

Undaunted, Fred Buechel, M.D. and Michael Pappas, Ph.D., in New Jersey, set about over a 15+ year quest to solve this most perplexing of joint replacement problems. A truism because the hip and knee support joint stress forces of 2x body weight per joint per step while the ankle endures 5x body weight stress per joint per step. Drs. Buechel and Pappas have exemplary credentials to undertake the solution, as they are the designers and manufacturers of the most successful total knee replacement, The LCS Total Knee, in use around the world.

Since 1970, Hakron Kofoed, M.D., of Copenhagen and Frank Alvin, M.D. in Iowa, developed two other ankle replacement designs, much more complex. The 3 designs have been in use throughout Europe for more than 12 years. Surgeons in The Netherlands, The United Kingdom, The Czech Republic, Italy, France, Ireland, Japan, Switzerland, Denmark, and Sweden implanted the prostheses. During this time almost 1700 cases, some bilateral, were placed in patients ranging in age from the early 20’s to 81. After 10 years of implantation 80+% of patients report pain free ankles.

The reasons for the new design success are multiple, but three aspects are primary. They incorporate an ultra high molecular weight polyethylene meniscus bearing spacer between the talar and tibial components; are made of titanium nitride or Cobolt chromium; and most important, are non- cemented. The now 3 piece, rather than two, implants are coated with titanium nitride beads or a hydroxy apitite coating, which permits cancellous bony ingrowth to the extent that full weight bearing is permitted after 6 weeks in a short leg cast. Of course other engineering aspects of the new designs made the prosthesis possible, such as making the implants more anatomical by realizing they needed to fulfil the 9-11 sq. cm. of ankle joint surface, previously design deficient. The designs permit 10+ years of implant life expectancy of the prosthesis as has been seen in more than 80% of European patients.

Of the three designs, and I have significant experience with all of them, I use the Buechel-Pappas because of success percentages, less bone removal is needed to implant it and the design makes it possible to implant after excising a previously fused ankle. A functioning ankle joint is the result.

The development of the common and reliable total hip and total knee prostheses took almost 35 years to reach the now commonplace 20+ years of pain free use. It cannot be surprising that an anatomical ankle would take time to be reliable. Happily it is a reality in far less time than the hip or knee and can return patients with the severe debilitating disease that osteo and rheumatoid arthritis is, to full functioning individuals. Patients walk, climb ladders and stairs, swim and play golf. Provided, of course, they could play before their operation. If not, their new ankle joint permits learning.

If there was a Nobel Prize for Medical Devices, Drs. Buechel and Pappas certainly deserve it. Against the extraordinary failure rates of 8 prostheses they endeavored to solve a problem when nearly all the orthopedic world espoused that the ankle joint cannot be replaced with a prosthesis. I am certainly privileged to implant this most extraordinary device. Should questions ensue, please contact me at the above address or by E-Mail at ankleimplant@gmail.com.