As a result of a serious motor vehicle accident, a woman in her early 20s lost the talus and the majority of the medial malleolus of her left ankle. Her right ankle sustained a closed injury that surgeons were able to stabilize. Orthopaedic surgeons in her community placed an external fixator device on her left side and discussed her options: below-the-knee amputation or a shin-to-ankle fusion, which would shorten her leg and cause a limp.
Knowing these options would significantly affect her daughter’s quality of life, the woman’s mother sought alternate solutions for limb salvage. Through social media, she learned about the 3D printing expertise of foot and ankle orthopaedic surgeon Selene G. Parekh, MD, MBA, and transferred her daughter’s left ankle care to Duke.
A Limb-Saving Second Opinion
Upon examination of the patient six weeks after her initial injury, Parekh realized that the left ankle reconstruction would require a novel approach to using 3D printing. What further complicated the case, he notes, is that the patient first had to be treated for an infection in her joint that was discovered when she presented at Duke. “She was in that external fixator four or five months while we tried to clear the infection, which can be depressing for a young woman with a vibrant life,” he says.
QUESTION: Given the complex nature of the patient’s ankle injury, how did Parekh use 3D printing technology to customize a solution and preserve her quality of life?
ANSWER: Parekh performed a 3D printed total talus replacement with a custom medial malleolar component and reconstructed the ankle joint with 3-D printed replacements of the two bones at once.
“At Duke, we’re one of the leading centers in the world for 3D talus replacement, so the novelty for us in this case was to replace two bones at the same time,” Parekh says.
A Leader in 3-D Printing for Limb Salvage
Despite the fact that the patient’s right ankle had sustained injury in the accident, Parekh was able to use CT scans to create a mirror image and print the bones that had been lost on the left side. Then, he stabilized the newly printed talus in her existing shin bone and allowed the ligaments to scar into the 3D-printed metal.
“Basically, we sent a rod into the bone that was remaining to help stabilize the 3D-printed piece, and then we 3D printed an extension from the plate on top of the bone to that 3D-printed piece, so it was all one piece,” he said.
As an early adopter of 3D-printed limb salvage technology, Parekh—Director of Digital Strategy and Innovation for the Department of Orthopaedic Surgery—and his colleagues have offered these types of innovative solutions for limb salvage to patients around the world.
Excellent Patient Outcomes After Surgery
After surgery with Parekh, the patient returned home after one day and was non-weightbearing in a cast for ten weeks. She then transitioned into a boot for another month. Three months later, she could walk in her shoes but has since done a lot of physical therapy to recover motion, strength, and walking mechanics, Parekh says.
According to her referring provider, the patient is ambulating with no assistive devices currently, has minimal to no limp, and has a good functional arc of motion. Though she can no longer run or jump, she can do all kinds of non-impact activities, Parekh adds.
“One of the biggest things that helped her is that the orthopaedic surgeons she saw first put her in an external fixator device,” Parekh explains. “If she hadn’t had that external fixator on, it would have become more and more difficult to bring her leg back out to length because the muscles would have been too tight at that point.”