Hindfoot balancing in total ankle replacement: the role of supramalleolar osteotomies

Challenges in Total Ankle Replacement in Post-Traumatic Ankle Osteoarthritis

A previous trauma is the most common origin of ankle osteoarthritis. Patients with post-traumatic osteoarthritis are generally younger. Due to the previous trauma and surgical treatment, the surrounding soft tissues are often scarred and inelastic. Structural changes of the osteoarthritic ankle are often significant, including deformity and instability, thus making the replacement surgery highly complex. Careful clinical examination and thorough radiographic assessment are mandatory to anticipate potential problems during TAR surgery and complications.

Effects of Patient-Specific Instrumentation and Ancillary Surgery Performed in Conjunction With Total Ankle Implant Arthroplasty: Postoperative Radiographic Findings

Accuracy and reproducibility when performing total ankle implant arthroplasty (TAA) are essential for longevity of the implant, maintaining relative stability of the joint, and theoretically reducing the formation of adjacent joint arthritis in the subtalar and knee joints. Studies have helped to illustrate the accuracy of implantation when using patient-specific instrumentation in both knee and ankle implant arthroplasty. Despite the findings of these studies, few have gone on to evaluate the effects of ancillary procedures on TAA; particularly their effects on postoperative implant congruity when performed simultaneously with joint replacement surgery. In this study, preoperative plans on implant alignment based on patient-specific computed tomography images were compared with the alignment observed on immediate postoperative radiographs. Additionally, postoperative joint congruity was measured, and operative reports were assessed to determine if concomitant procedures performed with total ankle replacement had a significant effect on overall alignment. In our population, 46/47 implants were within 1.5° of their anticipated placement in the coronal plane, and 100% were within 2° of anticipated placement in the sagittal plane. Using a spearman's rank-order correlation, our data failed to show any significant relationship between conducting additional procedures in conjunction with TAA (rho = 0.178; p value = .232) and postoperative congruency of the implant. These findings help support the accuracy of ankle implantation using patient-specific instrumentation, while also supporting the appropriate use of indicated procedures in conjunction with total ankle replacement to help obtain a congruent joint postoperatively.

Patient-specific instrumentation in total ankle arthroplasty

The recent increase in the adoption of total ankle arthroplasty (TAA) reflects the improvements in implant designs and surgical techniques, including the use of preoperative navigation system and patient-specific instrumentation (PSI), such as custom-made cutting guides. Cutting guides are customized with respect to each patient's anatomy based on preoperative ankle computed tomography scans, and they drive the saw intra-operatively to improve the accuracy of bone resection and implant positioning. Despite some promising results, the main queries in the literature are whether PSI improves the reliability of achieving neutral ankle alignment and more accurate implant sizing, whether it is actually superior over standard techniques, and whether it is cost effective. Moreover, the advantages of PSI in clinical outcomes are still theoretical because the current literature does not allow to confirm its superiority. The purpose of this review article is therefore to assess the current literature on PSI in TAA with regard to current implants with PSI, templating and preoperative planning strategies, alignment and sizing, clinical outcomes, cost analysis, and comparison with standard techniques.

Correction of Sagittal Plane Deformity of the Distal Tibia

Distal tibia sagittal plane deformities are a frequent finding in tibial malunions (antecurvatum or recurvatum) or ankle posttraumatic arthritis (anterior or posterior ankle arthritis). They should be evaluated in all deformities using long leg and tibia radiographs. Measuring the anterior distal tibia angle is necessary to evaluate the deformity severity. To evaluate the magnitude of secondary talar anterior or posterior displacement, the tibial axis to talus ratio and/or the talar lateral process position relative to the tibia axis should be measured. Anterior closing or opening wedge osteotomies are the recommended treatment options for posterior ankle arthritis or anterior ankle arthritis, respectively.