Walk thisway By DAVID SHOOK Staff Writer

Before William Marshall's ankle replacement surgery last year, the Maplewood resident could hardly manage going up stairs. Step ladders and uneven sidewalks were out of the question. Marshall's spill on an icy driveway in 1983 caused a compound ankle fracture. Years later, painful arthritis set in. The cartilage in his right ankle eroded to the point where bone was wearing on bone. "I couldn't sleep and could barely walk. I tried drugs, braces, everything," said the 56-year-old antique furniture restorer.

Then Marshall had ankle replacement surgery. The procedure, pioneered by Drs. Frederick F. Buechel and Michael Pappas, vastly improved Marshall's ability to walk. Few people receive ankle replacements, but the procedure is becoming more accepted in the United States as a way to treat debilitating ankle arthritis often associated with a past injury, say the two partners, whose offices are in South Orange. "It's been a 20-year process," Buechel said. Less mobile and weaker designs were used as long as 25 years ago. Most wore out or became unstable. "That left a bad taste in the mouths of surgeons who used them," he said. "Many of the surgeons bailed out and stuck with ankle fusion, rather than attempt to solve the problem."

Buechel and Pappas are famous for their New Jersey Knee, a prosthetic device implanted in the knees of thousands of arthritis sufferers each year. Now, they're trying to get their ankle replacement approved for widespread use in the United States.  Ankle replacement is much less common than knee and hip prostheses. More than 200,000 people get new hips and knees each year, but doctors have never developed a widely accepted ankle replacement. The standard approach to repairing a worn-out ankle joint is fusing the bones together. This relieves pain but takes away mobility, leaving patients with an unsparing limp.

Constructing a titanium and ceramic joint that withstands the pressure of a normal ankle -- mimicking its ball-and-socket mobility -- proved elusive until the Buechel-Pappas ankle was refined about 10 years ago. The ankle has been available in Europe since then, and more doctors have been learning to use it here.  Buechel and Pappas established a company in South Orange, Endotec Inc., to market the ankle as well as other devices. The Food and Drug Administration is allowing at least 10 doctors nationwide to implant the ankle in patients, testing its effectiveness and durability over a number of years.

While a few other companies make ankle replacements, the beauty of the Buechel-Pappas device is its mobility, design, and durability, said Dr. Mark Figgie, an orthopedic surgeon for the Hospital for Special Surgery in Manhattan.

Figgie does three to four ankle replacements a year using the Buechel-Pappas ankle, which he describes as a better device than similar ones designed by other companies.

Buechel estimates the ankle will be suitable for 3,000 to 5,000 people in America each year if it receives full marketing approval from the FDA in the next few years.

The best candidates for ankle replacement are those who suffer from rheumatoid arthritis or arthritis linked to a severely broken ankle. Primary degenerative arthritis, or osteoarthritis, is rarely found in ankles, although it is a primary cause for knee and hip replacement, doctors say.

A successful ankle replacement leaves people who once limped painfully walking comfortably and climbing stairs, even playing golf or riding a bicycle. More strenuous exercise like running and tennis is not advised.  Making a replacement ankle that allows full rotation was no easy feat. The ankle, after all, is a small and narrow joint that can support five times the body's weight.

Pappas and Buechel began their ankle joint designs in the Seventies. Within two years half of their early models had loosened up and failed in patients. The doctors continued undaunted. "This technology has been tried so many times in the past. The fundamental problem is that the ankle is small and yet it carries so much weight," Pappas said.

Eventually, the two researchers developed a sliding cylindrical ankle supported by mobile bearings that worked relatively well. Buechel and Pappas continued to improve their device over 20 years, honing its three basic components.

The device works by replacing the damaged or worn-out parts of the ankle with a ceramic-coated titanium joint. One piece, shaped like a short finger, connects to a leg bone. The lower piece, shaped like an upside-down bowl with a groove through it, connects to a foot bone.  Between those pieces a square-shaped polyethylene bearing fits into the grooved bowl and moves forward and backward, replacing the function of cartilage that has deteriorated. The bones are cut to make the surfaces exactly the right shape for the replacement parts, and the ceramic coating has tiny pores on the surface that mesh with the bone.

"The goal is to get the bones to grow into these pores. We proved that this works with our knee joint," Buechel said. The surgery takes about two hours for those with rheumatoid arthritis because the bone is soft. For old fractures, where more bone must be cut away, surgery can take as long as four hours. After a hospital stay, patients wear a cast for several weeks, then have physical therapy for one or two months.

Because the surgery is relatively new, no one knows how long the ankle can last or what long-term complications lie ahead. Buechel says the bearings can be replaced relatively easily and wouldn't be expected to wear out for 10 to 15 years, depending on lifestyle.

His patients include a schoolteacher who quietly suffered from ankle arthritis for several years and a swimming pool contractor who had both ankles replaced. Buechel has fitted prosthetic ankles in retirees in their 70s and working people in their 20s.

But even patients who've had successful surgery say it is a difficult ordeal and not suitable for everyone. "I'm not totally pain-free, but I'm almost there," Marshall said of his surgery. His commute back and forth from Maplewood to New York City is now relatively painless, he said. "The one caution I would give people is that, although this is technologically amazing, the procedure is painful," Marshall said. "The surgery is difficult, and the recovery is a long, slow process. It really takes more than a year. In my case it was worth the effort."

Ankle replacement was also successful for Carmen Giordano, who used to walk backward on tilted sidewalks and wear high-top shoes because the pain was so great in his arthritic left ankle. The 77-year-old Morris Plains retiree sprained the ankle in Army boot camp at age 21. His life was never the same. "It feels natural," Giordano said of his ankle, which was replaced seven years ago. "I can't explain how much this helped me. I suffered [for nearly] 50 years. I couldn't go up ladders or participate in any fast walking. Then, after one surgery, the pain was gone. I went to 43 doctors before I found Dr. Buechel." 

Most insurance plans cover the charges of ankle replacement surgery, Buechel said. Giordano and Marshall said they had no problems getting full coverage. Medicare, which approves the procedure, pays between $12,000 to $15,000 for hospital costs. The cost of the surgery depends on the condition of the ankle, but in most cases is $4,000 or more.

Reproduced with permission of The Record of Hackensack, NJ. Back to Recent News