HINTEGRA revision arthroplasty for failed total ankle prostheses

[Aseptic loosening of total ankle replacement and conversion to ankle arthrodesis]

OBJECTIVE

To remove loosened prosthesis components, to perform augmentation, to address osseous defects, to perform neutrally aligned ankle arthrodesis, and to achieve postoperative pain relief.

INDICATIONS

Symptomatic, aseptic loosening of total ankle replacement (TAR) with/without substantial bone defect of the tibial and/or talar bone stock.

CONTRAINDICATIONS

General surgical or anesthesiological risks, periprosthetic infection, local or systemic infection, nonmanageable soft tissue problems.

SURGICAL TECHNIQUE

Removal of both prosthesis components using the previous incision (mostly using anterior ankle approach). Careful debridement of bone stock at the tibial and talar side. Osseous augmentation of defects using autologous or homologous cancellous bone, if needed, using structural allografts.

POSTOPERATIVE MANAGEMENT

A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6-8 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated gradually after progressive osseous healing has been confirmed.

RESULTS

Between January 2007 and December 2012, ankle arthrodesis was performed in 9 patients with failed TAR (6 men and 3 women, mean age 56.4 ± 7.0 years, range 47.8-66.0 years). The mean time between the initial TAR and revision surgery was 4.5 ± 2.4 years (range 1.2-7.9 years). In one patient irrigation and debridement was performed due to superficial wound infection. Another patient had a delayed osseous healing 11 months after the revision surgery.

Custom-made total ankle arthroplasty for the salvage of major talar bone loss

Aims

A failed total ankle arthroplasty (TAA) is often associated with much bone loss. As an alternative to arthrodesis, the surgeon may consider a custom-made talar component to compensate for the bone loss. Our aim in this study was to assess the functional and radiological outcome after the use of such a component at mid- to long-term follow-up.

Patients and Methods

A total of 12 patients (five women and seven men, mean age 53 years; 36 to77) with a failed TAA and a large talar defect underwent a revision procedure using a custom-made talar component. The design of the custom-made components was based on CT scans and standard radiographs, when compared with the contralateral ankle. After the anterior talocalcaneal joint was fused, the talar component was introduced and fixed to the body of the calcaneum.

Results

At a mean follow-up of 6.9 years (1 to 13), 11 ankles were stable with no radiological evidence of loosening. Only one was lost to follow-up. The mean arc of movement was 21° (10° to 35°). A total of nine patients (75%) were satisfied or very satisfied with the outcome, two (17%) were satisfied but with reservations and one (8%) was not satisfied. All but one patient had an improvement in the American Orthopaedic Foot and Ankle Society hindfoot score (p = 0.01). Just one patient developed deep infection, leading to arthrodesis.

Conclusion

A custom-made talar component yielded satisfactory results with regard to function, stability and satisfaction. This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA. Cite this article: Bone Joint J 2017;99-B:231–6.

Variable Volumes of Resected Bone Resulting From Different Total Ankle Arthroplasty Systems

BACKGROUND

The increased popularity and success of total ankle arthroplasty (TAA) has resulted in the development of varying TAA hardware designs, many of which include specific bone-sparing or bone-sacrificing features. The goal of this work was to determine differences in the volume of bone removed for implantation of different total ankle arthroplasty hardware systems.

METHODS

Sixteen cadaveric specimens were computed tomography-scanned preoperatively and after total ankle arthroplasty using either an INBONE II, Salto Talaris, STAR, or Zimmer TMTA implant. Geometries of the talus and the distal tibia were manually segmented and converted to 3D bony surface models. The volume of bone removed for each implant was calculated as the difference in volume between the preoperative and postoperative bone models. To account for differences in specimen size, volume was expressed as a percentage of the intact bone.

RESULTS

There was a significant difference (P = .049) in the average percent of talar bone removed, with the STAR and INBONE II systems requiring removal of greater volumes of bone. The INBONE II system required significantly (P < .004) more tibial bone resection than the other 3 implants when evaluating a long span of the distal tibia. However, most of this increased bone resection was medullary bone. Close to the articular surface, bone volumes removed for the various tibial components were not significantly different (P = .056).

CONCLUSION

Volume and location of bone removed for different implant systems varied with implant design.

CLINICAL RELEVANCE

Primary bone resection associated with different implant hardware systems varied more on the talar side of the articulation, and the stemmed prosthesis did not result in dramatic increases in periarticular bone resection. Clinicians should weigh the effects of greater or lesser bone resection associated with various implant designs against other factors used for hardware selection.

Total Ankle Arthroplasty: An Overview of the Canadian Experience

Total ankle arthroplasty use has increased across Canada over the last two decades. Multiple implant designs are readily available and implanted across Canada. Although arthrodesis is a reliable procedure for treating end-stage ankle arthritis, ankle replacement is often the preferred surgical treatment by patients. A recent prospective study evaluated intermediate-term outcomes of ankle replacement and arthrodesis at multiple centers across Canada, with variability in prosthesis type, surgeon, and surgical technique. Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation; however, rates of reoperation and major complications were higher after ankle replacement.

Outcome After Salvage Arthrodesis for Failed Total Ankle Replacement

BACKGROUND

In cases with total ankle replacement (TAR) failure, a decision between revision TAR and salvage arthrodesis (SA) must be made. In a previous study, we analyzed revision TAR and found low functional outcome and satisfaction. The aims of the current study were to analyze SA concerning failure rate and patient-related outcome measures (PROMs).

METHODS

Until September 2014, a total of 1110 primary TARs were recorded in the Swedish Ankle Registry. Of the 188 failures, 118 were revised with SA (and 70 with revision TAR). Patient- and implant-specific data for SA cases were analyzed as well as arthrodesis techniques. Failure of SA was defined as repeat arthrodesis or amputation. Generic and region-specific PROMs of 68 patients alive with a solid unilateral SA performed more than 1 year before were analyzed.

RESULTS

The first-attempt solid arthrodesis rate of SA was 90%. Overall, 25 of 53 (47%) patients were very satisfied or satisfied. Mean Self-reported Foot and Ankle Score (SEFAS) was 22 (95% confidence interval 20-24), Euro Qol-5 Dimensions 0.57 (0.49-0.65), Euro Qol-Visual Analogue Scale 59 (53-64), Short Form-36 physical 34 (31-37) and mental 50 (46-54). The scores and satisfaction were similar to those after revision TAR but the reoperation rate was significantly lower in SA (P < .05).

CONCLUSION

Salvage arthrodesis after failed TAR had a solid arthrodesis rate of 90% at first attempt, but similar to revision TAR, less than 50% of the patients were satisfied and the functional scores were low. Until studies show true benefit of revision TAR over SA, we favor SA for failed TAR.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Total ankle replacement

BACKGROUND

About 1% of adults suffer from painful osteoarthritis of the ankle. The current literature contains no information on the percentage of such patients who derive long-term relief of symptoms from conservative treatment. Advanced ankle osteoarthritis can be treated with non-joint-preserving measures, such as total ankle replacement and ankle fusion.

METHODS

This review is based on selected relevant publications, guidelines from Germany and abroad, and the authors' personal experience.

RESULTS

Before surgery is considered, conservative measures such as physiotherapy and orthopedic aids should be used to the fullest possible extent. No randomized trials have yet been published comparing total ankle replacement with ankle fusion. Total ankle replacement with newer types of prosthesis yields good to very good intermediate-term and long-term results, with mean success rates of up to 90% at 10 years (range, 68-100%). Independent risk factors for the failure of ankle replacement are age over 70 years (odds ratio [OR] 3.84), primary osteoarthritis (OR 7.19), post-traumatic osteoarthritis (OR 6.2), and type of prosthesis (e.g., single hydroxyapatite coating: OR 15.04). The average range of motion of the replaced ankle joint is 25° to 30°, with values as high as 60°.

CONCLUSION

Total ankle replacement is a good treatment option for complete, end-stage ankle arthritis. It can restore joint function and make the patient mobile with little or no pain. There are, however, many contraindications to be taken into account. There is a need for further studies of the biomechanics of arthritic and replaced ankle joints and for long-term follow-up studies of total ankle replacement.

Radiographic Outcomes of Preoperative CT Scan-Derived Patient-Specific Total Ankle Arthroplasty

BACKGROUND

Preoperative computer navigation and patient-specific instrumentation have had promising results in total knee arthroplasty and in a previous cadaveric total ankle arthroplasty (TAA) study. Potential benefits of patient-specific guides include improved implant alignment and decreased surgical time. The purpose of this retrospective case series was to evaluate the accuracy, reproducibility, and limitations of TAA tibia and talar implant placement and radiographic alignment using preoperative computed tomography (CT) scan-derived instrumentation in a clinical setting.

METHODS

Between 2012 and 2014, 42 consecutive TAA cases in 42 patients using preoperative CT scan-derived patient-specific plans and guides (PROPHECY, Wright Medical Technology, Memphis TN) were reviewed from a single center of foot and ankle fellowship-trained orthopaedic surgeons. TAA implants used included 29 intramedullary referencing implants (INBONE II, Wright Medical Technology) and 13 low-profile tibia and talar resurfacing implants (Infinity, Wright Medical Technology). All patients had standardized preoperative CT scans before surgery that were used to create custom surgical plans and 3-dimensional solid cutting guides and models. All patients had a minimum 3-month follow-up with weightbearing postoperative radiographs. Patient demographics were recorded, and coronal and sagittal alignments were compared among weightbearing preoperative radiographs, CT scan-derived surgical plans, and weightbearing postoperative radiographs using a digital picture archiving and communication system.

RESULTS

Average age for all patients was 63 ± 9 years, with a body mass index of 29.8 ± 5.9. Average total surgical time for all TAAs was 100 ± 11 minutes, with Infinity TAAs taking less time than INBONE II TAAs (92 vs 104 minutes; P < .05). Average preoperative coronal alignment was 1.9 degrees varus ± 6.4 (range, 14 degrees valgus to 10 degrees varus). Postoperative weightbearing alignments for all TAA cases were within ±3° of the predicted coronal and sagittal alignments from the CT scan-derived surgical plans. There were no significant differences in pre- or postoperative weightbearing alignments between INBONE II and Infinity TAA cases. Neutral coronal and sagittal alignments were obtained for all TAA cases regardless of preoperative deformity. Patient-specific surgical plans were accurate to within 1 size for tibia and talar implants used. Surgical plans predicted the actual tibia implant size used in 100% of INBONE II cases and 92% of Infinity cases. Plans were less accurate for talar implants and predicted the actual talar implant size used in 76% of INBONE II cases and 46% of Infinity cases. In all cases of predicted tibia or talar size mismatch, surgical plans predicted 1 implant size larger than actually used.

CONCLUSIONS

Results from this study provide early clinical evidence that preoperative CT scan-derived patient-specific surgical plans and guides can help provide accurate and reproducible TAA radiographic alignments. Talar implant sizing was not as accurate due to individual surgeon preference regarding the extent of gutter debridement. Similar to other modern computer navigation and patient-specific instrumentation systems, final coronal and sagittal alignments were within 3 degrees of the predicted surgical plans, and sizing was accurate within 1 implant size. Future studies are warranted to investigate the clinical and functional implications of patient-specific TAA and the overall cost-effectiveness of this technique.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Salto Talaris XT Revision Ankle Prosthesis

The Salto Talaris XT Revision Ankle Prosthesis is an anatomically designed fixed-bearing prosthesis available in the United States based on the design of previous Salto systems. The Salto Talaris XT Revision Ankle Prosthesis design optimizes surface area, cortical contact, and ultrahigh-molecular-weight polyethylene conformity. Two tibial component designs, both with the same base plate dimensions, are available, the standard conical fixation plug affixed to a short keel and a long-stemmed version. The author presents an overview of the Salto Talaris XT Revision Ankle Prosthesis surgical technique and pearls for successful application.

Poor prosthesis survival and function after component exchange of total ankle prostheses

BACKGROUND AND PURPOSE

In failed total ankle replacements (TARs), fusion is often the procedure of preference; the outcome after exchanging prosthetic components is debated. We analyzed prosthetic survival, self-reported function, and patient satisfaction after component exchange. Patients and methods We identified patients in the Swedish Ankle Registry who underwent exchange of a tibial and/or talar component between January 1, 1993 and July 1, 2013 and estimated prosthetic survival by Kaplan-Meier analysis. We evaluated the patient-reported outcome measures (PROMs) SEFAS, EQ-5D, EQ-VAS, SF-36, and patient satisfaction by direct questions.

RESULTS

69 patients underwent revision TAR median 22 (0-110) months after the primary procedure. 24 of these failed again after median 26 (1-110) months. Survival analysis of revision TAR showed a 5-year survival rate of 76% and a 10-year survival of 55%. 29 patients with first revision TAR in situ answered the PROMs at mean 8 (1-17) years after revision and had the following mean scores: SEFAS 22, SF-36 physical 37 and mental 49, EQ-5D index 0.6, and EQ-VAS 64. 15 of the patients were satisfied, 5 were neither satisfied nor dissatisfied, and 9 were dissatisfied.

INTERPRETATION

Revision TAR had a 10-year survival of 55%, which is lower than the 10-year survival of 74% for primary TAR reported from the same registry. Only half of the patients were satisfied. Future studies should show which, if any, patients benefit from revision TAR and which patients should rather be fused directly.

Evaluation and management of the painful total ankle arthroplasty

Total ankle arthroplasty (TAA) is an increasingly popular treatment option for patients with end-stage ankle arthritis. Although improved short- and long-term clinical and radiographic outcomes have been achieved with TAA, revision surgery may be necessary in the setting of aseptic loosening, subsidence, impingement, arthrofibrosis, or infection. Factors such as patient selection, implant design, and surgical technique can all contribute to TAA failure. Treatment of patients with a painful TAA is complex and requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options. Surgical management of failed TAA includes arthrodesis, revision surgery, or below-knee amputation.

Intermediate-term Results of Mobile-bearing Total Ankle Replacement

BACKGROUND

The literature analyzing total ankle replacement (TAR) results should be critically interpreted because studies made by the design surgeons are potentially subject to bias. European nondesigner surgeon studies reviewing the HINTEGRA TAR system are scarce in the literature. The present study is a European nondesigner surgeon study reviewing a consecutive series of 50 HINTEGRA TAR systems with a minimum follow-up of 2 years, focusing on clinical and radiographic outcomes.

METHODS

Fifty primary TAR procedures were performed between February 2008 and January 2012 by a single surgeon. Every patient underwent a standardized clinical and radiographic follow-up at 6 weeks, 3 and 6 months, and 1 year postoperatively and annually thereafter. The mean time to final follow-up was 45 months.

RESULTS

The mean American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score significantly increased from 43.5 preoperatively to 83.8 postoperatively. Clinical range of motion of the ankle also improved from 23.3 degrees preoperatively to 28.3 degrees postoperatively. In 70% of the TAR procedures, the talar component was positioned anteriorly with respect to the tibial axis. Radiological evidence of osteolysis was identified in 24 ankles. The failure rate in the present series was 10%, which was defined as having major revision surgery within 4 years.

CONCLUSION

The survival of the first 50 HINTEGRA TAR systems in this series was satisfactory from clinical and radiological points of view. However, the incidence of asymptomatic periprosthetic osteolytic lesions was quite high (24 ankles).

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Total ankle replacement in patients with von Willebrand disease: mid-term results of 18 procedures

von Willebrand disease (VWD) is a recognized cause of secondary ankle osteoarthritis (OA). Few studies have examined orthopaedic complications and outcomes in VWD patients treated for end-stage ankle OA with total ankle replacement (TAR). To determine the clinical presentation, intraoperative and postoperative complications and evaluate the mid-term outcome in VWD patients treated with TAR. Eighteen patients with VWD with mean age 47.3 years (range = 34.0-68.7) were treated for end-stage ankle OA with TAR. The mean duration of follow-up was 7.5 years (range = 2.9-13.2). Intraoperative and perioperative complications were recorded. Component stability was assessed with weight-bearing radiographs. Clinical evaluation included range of motion (ROM) tests using a goniometer and under fluoroscopy using a lateral view. Clinical outcomes were analysed by a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score and Short Form (36) Health Survey (SF-36) health survey. One patient sustained an intraoperative medial malleolar fracture. In two patients delayed wound healing was observed. Two secondary major surgeries were performed. Pain level decreased from 8.2 ± 0.9 (range = 7-10) preoperatively to 1.1 ± 1.2 (range = 0-4) postoperatively. Significant functional improvement including ROM was observed. All categories of SF-36 score showed significant improvement in quality of life. Mid-term results of TAR in patients with VWD are encouraging. The total rate of intraoperative and postoperative complications was 33.3%. However, longer term outcomes are necessary to fully understand the clinical benefit of TAR in patients with VWD.

HINTEGRA Revision Arthroplasty for Failed Total Ankle Prostheses: Surgical Technique

Introduction

In our experience, revision ankle arthroplasty with a three-component total ankle prosthesis following a failed total ankle replacement has provided encouraging midterm results with substantial pain relief while preserving the range of motion of the replaced ankle.

Step 1 Preoperative Assessment and Planning

Determine the treatment using a decision algorithm.

Step 2 Patient Positioning

Use spinal or general anesthesia, administer intravenous antibiotics, position the patient supine, and apply a tourniquet.

Step 3 Surgical Approach to the Failed Prosthesis

Use an anterior approach to expose the failed ankle prosthesis.

Step 4 Removal of the Prosthesis

Remove the polyethylene insert, the talar component, and the tibial component, making sure to not compromise any remaining bone stock.

Step 5 Revision Ankle Arthroplasty

Prepare the tibial and talar bone stock to obtain solid osseous surfaces, and use the appropriate prosthetic components.

Step 6 Additional SurgicalProcedures If Necessary

If necessary, perform arthrodesis of adjacent joints, correcting osteotomies of the distal parts of the tibia and fibula, calcaneal osteotomy, and/or ligamentoplasty.

Step 7 Closure of All Incisions

Close all incisions.

Step 8 Postoperative Care

A short leg splint is worn for two days, followed by partial weight-bearing; the ankle is protected in a splint at night and with a walking boot during the day for six to eight weeks.

Results

Between 2000 and 2010, 117 ankles in 116 patients (fifty-six female and sixty male; mean age, 55.0 ± 12.0 years) who presented with a failed total ankle arthroplasty after a mean of 4.3 ± 3.9 years were treated by revision arthroplasty with use of the HINTEGRA three-component total ankle prosthesis¹².

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.