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Nov 24, 2023

A CT woman needed a new ankle. So they printed one.

Lori Cannon really smashed up her ankle in a fall from a ladder, with multiple

Lori Cannon really smashed up her ankle in a fall from a ladder, with multiple fractures and one bone sticking out through the skin.

But her surgeon brought Cannon's case to a conference of female orthopedic surgeons, where a high-tech solution was found.

It was so successful that Cannon, 65, of Durham, recently took a hike on her new 3D-printed ankle.

The accident occurred June 16, 2021, when she was helping paint a neighbor's house.

"We wound up about 3½, 4 feet at the most off the ground, and I came down into a sitting position," Cannon said. "I moved my right leg. When I looked down at my left. I was like, wow, I got a piece of wood sticking into my leg. And then I was like, Oh, that's not wood, that's your bone. It was pretty gruesome."

A nurse for 40 years, Cannon said she had never seen an ankle bone break the skin like that. It didn't help that she had red paint splattered on her. "I looked like something out of a horror movie when the poor, young EMTs came to pick me up," she said.

She was brought first to Yale New Haven Hospital because it was closest to Durham. "I went to the OR the next morning and they debrided it quite a bit," Cannon said. "And they put a couple of stabilization bars in there to hold the bones in place because I had broken it in three different places." It's known as an external fixator.

"They were trying to be as careful as they could to make sure I didn't have any ongoing infection in there, because I did get a lot of dirt and moss into the wound," she said. She had a plate and 14 screws, in addition to a non-weight-bearing cast.

Cannon began physical therapy but by late fall "it started going downhill and getting worse," she said. "I was having a lot of swelling, a lot of pain. The whole lower leg blew up at one point and I had to go back to two weeks of antibiotics in December."

It turned out there was a serious infection. But her ankle not only hurt, it was stiff because of arthritis she had developed. She was given two choices: fuse the ankle, which would have left her with no flexibility, or try for an ankle replacement, which would be difficult because of the seriousness of the break.

Cannon called friends at UConn Health, where she teaches the EPIC system to doctors, nurses and others. They referred her to Dr. Lauren Geaney, an orthopedic foot and ankle surgeon. The first thing Geaney did was remove all the hardware.

"She said the challenge for me was going to be that I have an area on the fibula, the outer bone on your lower leg (where) I had fractured the bones so badly there was actually bone missing, and it was too large of an area that you couldn't just take a simple graft from elsewhere and do an ankle replacement," Cannon said.

Cadaver bone wouldn't work either because it wouldn't support her weight.

"The challenge is that she had a lot of bone loss related to the fracture," Geaney said. "Essentially, she had areas where she had no support in the ankle joint, which is what made this a challenging situation."

The problem was that there were so many pieces of bone, she said.

"When you have a couple big pieces, you can put them back together," Geaney said. "If there are areas where the bone is what we call comminuted, so it's in a lot of small pieces, you can't fix every little piece together. But your body can absorb all those little pieces with time, and so in that area there actually ended up being essentially a hole in the bone."

Cannon still had pain. She had X-rays done and the radiologists thought she still might have infection in her ankle. But another radiologist said, "No, I think what you’re seeing, it developed what they call post-traumatic severe osteoarthritis," she said. "And that's why I was having so much pain and extremely limited movement in that foot altogether."

Biopsies were done to be sure there was no more infection. "It was a whole year process of getting this going," Cannon said.

Geaney wasn't confident an ankle replacement would work because of the hole in Cannon's ankle bone, but Cannon didn't want it fused.

"I said, Well, listen, I’m going to a conference. We’re presenting cases," Geaney said. "Let me present your case and see if we can come up with maybe a less traditional option as far as what we can do to try to help you without fusing it."

At the conference, there was a representative from Paragon 28 (there are 28 bones in the foot), which creates mechanical solutions for foot and ankle surgeons. One of its subsidiaries, Additive Orthopaedics, did the 3D printing.

"I said, wait a second, let's work on this together," Geaney said. "See if this is something you guys think you could do or have done in the past, and we worked together on a plan at that point."

Together, they came up with a 3D-printed titanium plate that would cover the hole in Cannon's ankle. The polyethylene ankle then would be attached to it. The other end was made of cobalt chromium.

"When you do a normal joint replacement, what you do is you take out the area where the cartilage is or isn't, you take out the ends of the bone and you replace it with metal and plastic and the metal has to grow into the bone," Geaney said.

"The problem in her case is that when we were cutting it, there was a hole. So I couldn't just put the metal plate on a hole because it would just collapse into the defect," she said.

"So what we did is we got our CAT scan and we created an implant. Then in addition to just the plate, we added an area of metal that fit into that hole, so the bone could grow into it. And so it kind of created its own support system within the implant itself," she said.

Geaney had had two different models printed, Cannon said, "because she wasn't sure … which one she was going to use until the day of surgery, which one was going to be the better fit." Geaney performed the surgery Jan. 10.

Geaney said the procedure was a bit scary. "You don't really have many options. If this doesn't work, then we’re left with nothing because I had to take more bone out to put the ankle replacement in," she said.

"It is a little bit of a gamble but, at the same time, what other options does she have?" Geaney said. "Live with horrible pain, not be able to play with her grandkids and go for hikes and do the things she wants to do or take risks and hope that it does the trick."

She said fusing the ankle would have been the only option if the 3D-printed piece didn't work.

"I’m very grateful that it ended up as well as it did because there's no tenure data on this," Geaney said. "So we were taking a risk on it without knowing exactly what to expect."

After more physical therapy, putting more weight on her ankle, Cannon felt healed, so much so that she took a walk in the woods.

"Mother's Day weekend, I had gone up to Maine with my boyfriend and my grandson and his two daughters, and we went hiking in the woods and there was no set trail or anything. This was a heavily wooded area. We’re looking at some undeveloped property up there," Cannon said.

"You can't really call it a road because you could barely get a four-wheel-drive vehicle down in one lane. It's insane. That's how rough the terrain was," she said. "And we hiked for about an hour on that property and I was able to keep up with them. A year ago I wouldn't even have considered it."

Cannon is pretty much back to normal, she said. "My ankle is never going to be the same as my right foot. It's never going to be 100% like that," she said. "But I’m able to go up and down stairs now where I couldn't do that. … I don't have pain in the ankle. I have some stiffness still from the muscles and the tendons because you’re not using them the same way."

More PT will help, she said. "My gait has smoothed out quite a bit. I don't feel like I’m walking like a stroke patient anymore. I don't have that pronounced limp you would have," she said.

"I’m glad it worked out," Geaney said. "It's a little bit of a long shot, but it's working."

Ed Stannard can be reached at [email protected].

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