In this seven part series, Thomas San Giovanni, M.D. performs a total ankle replacement at Doctors Hospital in Miami, Florida. This video is the only available unedited video of a live total ankle replacement. Total ankle replacements are helping patients who suffer with painful ankle arthritis. Improvements to implant designs have allowed for improved longevity and better movement, and is an excellent treatment option for patients who need surgery . Doctors Hospital is home to the Center for Orthopedics & Sports Medicine, and is recognized as a leader in total joint replacement.
Interviewer:

[Transcript]

[Doctors Performing Ankle Surgery]
Is that correct?
Dr. Sangiovanni:
Yes, it's a drill. Yep, exactly. Maybe come down a little further on this side, [inaudible 00:00:05]. Let's loosen this up.
Interviewer:
No, I had a friend once tell me that orthopedic surgeons are just like carpenters. They have a lot of the same tools in their toolbox. Is that correct, Dr. Hodgkins?
Dr. Hodgkins:
It absolutely is.
Dr. Sangiovanni:
I took wood shop in high school and I don't know if Dr. [Togno's 00:00:21] out there listening, but I think he'd be very proud of me.
Interviewer:
That's what led to this. Again, so now you're ... Dr. Hodgkins, Could you explain to us what he's doing?
Dr. Hodgkins:
So he's actually placing the tibial cutting guide on the end of the jig, and he's just making sure that's secure. He's fixing it in the distal tibia with pins so that it holds steady and allows him to make an accurate cut.
Interviewer:
Now, do these pins stay in the patient or they're extracted at the end of the day?
Dr. Hodgkins:
You're exactly right. There'll be extracted as he moves through the surgery. Once he's finished making this tibial cut, take those pins out and remove the guard so he can then remove the bone and move on to the next stage.
Interviewer:
It really is a construction project, isn't it?
Dr. Hodgkins:
It really is. It really is.
Interviewer:
It's fascinating to watch. How was this condition treated in the past before this kind of prosthetic was available?
Dr. Hodgkins:
Well, it was treated by a number of means. The traditional surgical treatment for it was ankle fusion, and that's still a valid treatment option for many people in many cases.
Interviewer:
Before you go further, can you explain to us what is involved in an ankle fusion?
Dr. Hodgkins:
Ankle fusion is also called ankle arthrodesis. It's essentially, rather than replacing the joint, you are removing the joints and joining those two bones together. So essentially the tibia and the talus are joined together and they heal as one bone. So you lose the motion in the ankle, but it relieves the pain just as well. But you do lose the motion. So it was treated with fusion for a long time, and as I say, it still is, but this is now an option for patients who want to preserve the motion.
Interviewer:
Do you also perform ankle fusions here at Doctor's Hospital?
Dr. Hodgkins:
Yes, we do. We also perform ankle fusions.
Interviewer:
Besides losing the range of motion, are there other drawbacks to that procedure?
Dr. Hodgkins:
Well, there are theoretical drawbacks with an ankle fusion.
Interviewer:
I'm going to interrupt you just for a second. Can you tell us what Dr. Sangiovanni is doing right now?
Dr. Hodgkins:
Now he is actually using a saw and you can see that the saw is going through the jig there so he can make an exact cut in the distal tibia. This is the cut to resect the distal tibia.
Interviewer:
So once again, the jig is there to make sure the cut is exactly where it needs to be on the body so that the prosthetic will fit where the ankle did back in the day when it was healthy.
Dr. Hodgkins:
That's right. So he attached that to the jig that he had already made sure was parallel, for he feeds off that to make sure the next cut is also correct.
Interviewer:
All right. I'm sorry. I interrupted you. You were talking about why there are some other drawbacks to ankle fusion.
Dr. Hodgkins:
Right. There's a theoretical risk that once you lose the motion in the ankle, the adjacent joints have to pick up a little bit of motion. The results of that may have accelerated arthritis themselves. That's a theoretical risk, and so it's something to consider when you're making the decision.
Interviewer:
Does ankle fusion actually affect your walking gait? Your normal walk will be altered by this kind of surgery?
Dr. Hodgkins:
It certainly does alter it somewhat, but however, if you looked at someone with an ankle fusion walking down the street, the lay person wouldn't necessarily be able to notice that they'd had an ankle fusion.
Interviewer:
Dr. Sangiovanni, can you tell us what you're doing now?
Dr. Sangiovanni:
Yes. We're making our initial cut in the tibia. So we're going to be resecting out this portion of the tibia. Then once we make that cut, then we're going to start working on the talus, which is the lower bone.
Interviewer:

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