Dr. Peña Forges New Ground in Ankle Surgery

Orthopedic surgeon Fernando Peña, M.D., an assistant professor in the Department of Orthopedic Surgery at the University of Minnesota and a practicing ankle surgeon, could not sleep one night and instead lay in bed debating what to do about one of his young patients. The young woman had arthritis in her ankle and was in a great deal of pain.

If Peña fused the bones in the patient’s ankle all motion in the joint would be gone. If he installed an artificial joint, as is done with hips and knees, the joint would last a maximum of ten years. (Peña compares artificial joints in the ankle to tires on a car. With use they wear out.) A second replacement joint would last only five years—due to scaring and changes in the bone. A third joint, if one were to be installed, he said, would have a life of only two and a half years.

Peña and his patient, decided on a totally different approach. Peña cut off the arthritic end of the bone in the bottom half of the ankle joint (called the talus), removing the dome of the bone. Then he made an identical cut on the bone of a teen-aged cadaver and fixed that piece of bone, with screws, to the talus of his patient. Within six weeks the transplant had fused into the patient’s ankle and Peña reported that healthy bone and healthy cartilage extended across the joint.

That was four years ago and the first time that Peña performed this surgery. The patient was a 17-year-old girl who, to treat her leukemia, had been treated with steroids. The steroids had effectively killed the bones in her ankles. When she first appeared in Peña’s clinic she was a wheel chair bound 16 year old. It’s a much different story today. After performing his unique operation of attaching cadaver bone from a youthful donor to the ends of her talus, she was able to leave her wheelchair behind. Today the young woman is finishing college, walking and has had a healthy baby. “She is doing perfectly fine, ” said Peña.

To date, Peña has performed this surgery on approximately 20 patients and is following up on all of them. “I am not the only guy doing it, ” he says. He believes that there may be three other surgeons in the U.S. who are performing similar but not exactly the same ankle procedure as he is. He compares the situation to occasions where three individuals, contestants for major prizes, will be found to have simultaneously come up with the same idea.

Peña has found the talus to be a common site of arthritis. He says that 80% to 90% of arthritis is found to be there with only 10% to 15% located on the upper surface of the joint, which is the lower end of the tibia. While he believes his approach has a great deal of potential, he also notes that “a problem is that, to be successful in the surgery, patients cannot have arthritis on the upper surface of the ankle. Only on the bottom. If they have it on both sides it is bi-polar disease and for this we need to truly fuse the ankle.”

Peña is skeptical about ankle replacements saying that “it is extremely difficult to make them work.” He claims that “the data on ankle replacements is debatable because the results that the ankle designers have accomplished have not been reproduced by other surgeons.” He says ankle replacements “are a solution but not a good solution. We are still in diapers compared to where the science is on the replacement of ankle is concerned compared to hips and knees.” Hips and knees, he says, have been done for 50 years. “We have been doing ankles for ten years, ” he said.

Peña says that he went into ankle surgery because “it is a humongous black box—people do not understand ankles well. There is so much potential for learning and innovation. The difference between ankles and knees is that ankles are very forgiving. They can look horribly bad and still work quite well. While a knee can look so-so and still hurt like the dickens. Foot and ankle has not been researched as much as shoulders and knees.”

Peña was born in Brazil and moved with his family to Spain where he grew up and attended medical school. Since his teen years he wanted to be an orthopedic surgeon. Disillusioned by the attitudes of physicians in the socialized medicine system of Spain Peña, at the age of 24 and speaking little English, came to Minneapolis where he had one contact, a friend of his father’s who was the head of radiology at the University of Minnesota medical school.

Peña learned English, went back to Madrid to finish his sixth year of medical school and returned to Minnesota where he passed his board examinations, was admitted to the residency program of the University of Minnesota and became the first foreign student to graduate from the orthopedics department. Study in Canada, Norway and London completed his preparation for joining his alma mater, the orthopedics department of the University of Minnesota in 2003.

Ankles are the only joint surgery that Peña does and, in his mind, there is beauty in the fact that foot and ankle have not been well researched and explored. He says that knees were the joints of the 1990s; shoulders were the joints of the 2000s. He believes that ankles and elbows may be next. He notes that he has very satisfied patients. “They were once miserable and we made them happy by enabling them to do just plain walking, ” he said. Patients have said to Peña, “I would like to walk again, free of pain.” He finds that to be “in this country a pretty basic, very humble request.”