STANFORD, Calif.— Sam Schillace was stoked on that gorgeous Sunday afternoon in November.  He wheeled his vintage '68 BSA motorcycle out of the garage and was jumping on the kick-starter when something went horribly wrong. 

The motorcycle back-fired with explosive force, dumping Schillace on the ground with a pilon fracture of his left tibia and ankle, broken in four places, and a dislocated ankle joint.

In the emergency department of Stanford Hospital & Clinics, Schillace met Kenneth Hunt, MD, an orthopaedic surgeon in the foot and ankle clinic of the Stanford Medicine Outpatient Center in Redwood City. The following day, Hunt performed an external fixation surgery, and a couple of weeks later, followed that with an open reduction internal fixation procedure, inserting metal plates to stabilize Schillace's ankle joint. 

Six months later, Schillace said his recovery has been "phenomenal," even considering the six weeks he spent fighting a staph infection. "The joint is totally recovered from what was a really horrible injury, and has full motion back." 

Loretta Chou, MD, the other orthopaedic surgeon in the foot and ankle clinic, only has to glance at the colorful quilt that's draped across an office chair to be reminded of the grateful patient who made it for her. "She was an 82-year-old woman who had a bad injury, and then developed an infection," said Chou, a professor of orthopaedics. "She was in a wheelchair for a year, then had surgery and is walking today—which is very gratifying."

Another of Chou's patients was burned in an electrical accident. Because he spent long weeks recovering in the ICU, the muscles in his feet contracted and they became deformed. "We treated one foot, and then the other," Chou said. "And now he walks and drives his truck and recently went on vacation to Italy." She paused. "Those kinds of cases are very memorable for me."

The range of surgeries Chou and Hunt perform is extensive, including those to correct fractures of the foot and ankle, congenital and neurological deformities, bunions, hammer toes and tendonitis. And there are non-surgical treatments, as well: injections with anti-inflammatory medications, bracing, modifying shoe wear, physical therapy.

Determining how to treat an ankle injury like Schillace's depends largely on the patient's expectations. "We have an armamentarium of operations to offer, depending on how bad an injury is, where it is, how old the patient is, the quality of his health, what he does for work and what he does for sports," Chou said.

"Our bodies are very effective at healing, and our job as surgeons is to identify conditions that are not going to heal appropriately without some surgical intervention," Hunt, an assistant professor of orthpaedics, added. "It's very satisfying to have a patient undergo surgery, go through rehabilitation and get back to doing what they love to do." 

Hunt, a former running back for Brigham Young University, is an assistant team physician for the Stanford football program and sees student athletes once a week at a clinic in the Arrillaga sports complex. Those who play collision sports—football, lacrosse, soccer, basketball—tend to have more acute injuries, including torn ligaments, cartilage and joints, while track and running athletes are more apt to have chronic injuries and stress fractures.

As Baby Boomers age, Chou and Hunt are seeing a new cohort of patients in their clinic: those who are candidates for total ankle replacement. Nationwide, some 50,000 new cases are reported each year, according to a study published in the Journal of Orthhopaedic Trauma. Although replacement procedures date from the 1960s and have been widely available in Europe, the early devices did not perform well or hold up well. But thanks to approval of new implants by the U.S. Food and Drug Administration over the past eight years, today's third-generation total ankle replacements have become a viable option—"for a limited, select group of patients," Chou added.

Because it's a smaller joint than either the hip or knee joint—both of which are more commonly replaced—an ankle supports more weight, proportionally, sustains more wear and tear, tends to wear out and can easily develop arthritis. For decades, surgeons have performed ankle "fusion" procedures, which are durable, reliable, reduce pain and allow some return to function. But fusions also make the ankle completely stiff. 

The primary advantage of a total ankle replacement is that it enables patients to retain motion in their ankles and in other joints of the foot, so those don't become arthritic. "In the right patients, ankle replacements can be very effective," Hunt said.

Schillace, whose broken ankle is "almost 100 percent" after his motorcycle accident, said that being a patient at the outpatient center was a satisfying experience on several levels. "I didn't feel like the stereotypical piece of meat," he said. "Dr. Hunt was incredibly responsive and answered all of my questions so that I completely understood what was going on, and I felt like a full partner in the treatment."

By Diane Rogers