How Might Revision Surgeries Benefit From Patient-Specific Implants?

At the APMA National, Patrick Burns, DPM, FACFAS, takes on the topic of patient-specific implants and their role in revision foot and ankle surgery. Podiatry Today spoke with him about his lecture, and what he most wants the audience to know.

Q: What do you feel the benefits are of patient-specific implants specific to revision cases?

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Dr. Burns begins by sharing the obvious benefits include specific, matched implants tailored to a single patient’s anatomy.

“I think in the foot and ankle, this has great benefit,” he explains. “We have difficult anatomy to start, with small bones, irregular shapes and in cases of revision, cases of limited real estate for fixation. Patient specific implants can help fill these voids literally, but also allow the physician to tailor amounts, types, and orientation of fixation to come up with the best configuration to give the best chance for improved outcomes.”

Q: Are there any challenges or learning curves you feel surgeons may face in employing these types of implants? 

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The biggest challenges Dr. Burns says he encounters deal with hospital approval and cost. Specifically, early on, for the first few implants, he notes potential for significant delays in having the implant fabricated.

“My hospital required approval and even discussion with a committee to discuss the rationale and alternatives,” he says. “I think this is important as we do need to be responsible fiscally but also medically. These implants are expensive and there should be a clear indication with good plans and a reasonable possibility of improving the patient’s function.”

As far as learning curves, in his experience, Dr. Burns cites the need to learn the process of design, the rationale of materials, and the timing of imaging and surgery.

“If you are going to use these implants, you should be familiar with the types of materials and when they are utilized,” he adds. “You should also be introduced to the process, from initial design to the actual fabrication. This gives you a sense of appreciation for the process. You should expect meetings with a design team to discuss and then approve the implant before it is fabricated.”

He shares that there are special considerations regarding imaging, as well.

“Imaging should be done as close to the final operation as possible to make sure the implant design is as close to actual as it can be,” he expands. “The surgeon should try to limit hardware in the images to give the best pictures and if possible, imaging such as CT of the other limb can be very helpful in cases of abnormal anatomy.”  

Q: Can you share an example or two of instances where this particular option may have a significant impact?

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Dr. Burns feels some of the best and most common uses are for talar voids and revision of the first ray. As common issues for foot and ankle surgeons, he says these implants can help solve some issues such as bone loss and provide help with fixation options.

“Talar fractures, AVN, failed ankle implants, and other revisions of the ankle and tibiotalocalcaneal segment are difficult many times due to the void to fill,” he says. “The option of a large allograft bone such as femoral head has been a standard, but patient-specific implants can help manage this in a more predictable way. Likewise, the first MTPJ can have issues with loss of length and with the small bones in the area, fixation can be difficult to achieve. 3D custom implants can help manage these issues as well.”

Q: Are there any tips or pearls that you’d like to share in general?

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Familiarity with alternatives to custom implants is imperative, he says, as the surgeon must be able to an educated argument for their use to the hospital, the patient, and fellow surgeons.

“Custom implants, like many new technologies, are exciting but are often misused,” says Dr. Burns. “I would caution that there be a good reason/rationale before utilizing this technology. You should also be familiar with similar surgeries so you case go smooth. It would not be a good idea to have an expensive custom implant be the first time you try a tibiotalocalcaneal fusion with and intramedullary rod.”