Intermediate results of Buechel Pappas unconstrained uncemented total ankle replacement for osteoarthritis

Medial malleolar osteotomy for the correction of tibiotalar varus deformity during total ankle arthroplasty: Results in 95 ankles

BACKGROUND

The importance of deformity correction before or during total ankle replacement (TAR) has been recognized for a long time. Our results of TAR, combined with medial malleolar lengthening osteotomy, for the reconstruction of osteoarthritic ankles with varus deformity are hereby reported.

METHODS

All ankles in which a medial malleolar osteotomy was performed during implantation of an ankle prosthesis during the period 1998-2018 were filtered out of our database. Preoperative coronal talar alignment was evaluated by measuring the angle between the tibial shaft and talar dome on the weightbearing mortise ankle radiograph. Patient-reported outcomes were measured with the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM). A Kaplan-Meier survival curve was constructed and the number of revisions per 100 observed component years was calculated for interprosthetic comparison.

RESULTS

A total of 95 TARs were included, consisting of the Alpha Ankle Arthroplasty (n = 22); Buechel-Pappas (n = 14) and the Ceramic Coated Implant Evolution (n = 59) prostheses. The preoperative average talar angle in these ankles was 12.4 degrees varus. In 33% (31/95) corrective procedures, in addition to the medial malleolar osteotomy, were performed. A reoperation rate of 44% (42/95) was found, including 28 revisions (revision rate 29% (4% septic; 25% aseptic) at an average follow-up of 5.9 years, resulting in a survival of 0.69 for the total cohort at 10 years of follow-up. At an average follow-up of 6.6 years the average FAOS scores were: FAOS_symptoms 66, FAOS_pain 73, FAOS_function 78, FAOS_sport 45 and FAOS_{quality of life} 56 respectively. The FAAM_adl score averaged 64.

CONCLUSION

This is the largest cohort of TAR combined with medial malleolar osteotomy to date. A 29% revision rate at 5.9 years of average follow-up compares unfavorably with regular cohort studies and with most other results in varus-deformed ankles. Scores on the FAOS and FAAM are comparable to those obtained in regular cohorts with similar length of follow-up. TAR in varus-deformed ankles necessitating medial malleolar osteotomy has an even higher failure rate than regular TAR. Obtaining a stable prosthesis with a neutrally-aligned hindfoot at the end of the procedure is of paramount importance.

LEVEL OF EVIDENCE

IV.

Positive and negative factors for the treatment outcomes following total ankle arthroplasty? A systematic review

BACKGROUND

Patient selection, surgeon's experience and implant design play an integral role and affect the treatment outcomes of total ankle arthroplasty (TAA). The aims of this study were to investigate the positive and negative attributes that correlate with different clinical and radiographic outcomes.

METHODS

Eight-nine studies matched the inclusion criteria: (1) studies of primary TAA with uncemented prosthesis; (2) mean follow-up of no less than 2-year; (3) reports of clinical and radiographic outcomes, and exclusion criteria: (1) non-English study; (2) more than one type of prosthesis without separated data; (3) kin studies with shorter follow-up or smaller cohort. Age, etiology, preoperative deformity, surgeon's experience, follow-up duration and prosthetic type were studied with respect to different outcomes by mixed-effects logistic regression analysis.

RESULTS

Patients factor: older patients reported less pain or stiffness and demonstrated less radiographic loosening which did not require additional surgical intervention. More traumatic arthritis experienced adjacent joints degeneration after TAA. Surgeon factor: less experienced surgeons had more intraoperative complications. Lack of experience for complications management without implant retrieval during early period might result in more revisions or fusion was done. Prosthetic factor: updated instrumentation decreased malalignment. If the polyethylene (PE) insert was significantly narrower than the metal components more implant instability and subsequent severe particulate wear was seen. Designs with flat-on-flat articulation and ridge at the center of the talar component associated with more PE fracture. Minimal bone resection reduced postoperative fractures. A flat cut of the tibial component and a flat undersurface with press-fit by two screws or pegs of the talar component demonstrated less postoperative fractures, whereas a syndesmosis fusion and a small triangular shape with one central fin of the talar component experienced more loosening which did not require additional surgery. Anatomic conical shape of the talar component seemed to reduce adjacent joint degeneration. Finally, fewer failures were found in patients who received HINTEGRA and Salto Talaris.

CONCLUSIONS

Based on our investigation, some positive and negative factors for different clinical and radiographic outcomes were found, which should be taken into consideration in clinical practice and ankle implant design.

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.

Two-year outcomes of MOBILITY Total Ankle Replacement

BACKGROUND

There is little literature on patient-reported outcomes following total ankle replacement in patients with osteoarthritis, posttraumatic osteoarthritis, and rheumatoid arthritis. We compared the differences in demographic data and clinical and patient-reported outcomes among patients with those types of arthritis who underwent total ankle replacement performed with use of the MOBILITY Total Ankle System.

METHODS

Patients were divided into three groups based on the preoperative diagnosis of type of arthritis. We analyzed patient demographic data, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and patient-reported outcomes as measured with use of the Foot and Ankle Outcome Score (FAOS), the 36-item Short-Form (SF-36) Health Survey, and patient-satisfaction scores, collected preoperatively and at one and two years postoperatively.

RESULTS

The study included 106 consecutive patients who underwent total ankle replacement between March 2006 and December 2009. The posttraumatic osteoarthritis group, which had twenty-eight patients, was significantly younger (mean age, 54.8 yrs; p < 0.05) than the other groups; the rheumatoid arthritis group, which had twenty-two patients, had a significantly lower mean body mass index (24.5 kg/m(2); p < 0.05); and the osteoarthritis group, which had fifty-six patients, had a higher proportion of males (41 males; p < 0.05). The posttraumatic osteoarthritis group reported better scores for two of the eight domains of the SF-36 preoperatively. At one year postoperatively, the posttraumatic osteoarthritis group and the rheumatoid arthritis group had better FAOS results regarding pain than those of the osteoarthritis group, and the posttraumatic osteoarthritis group also reported better scores for the general health domain of the SF-36. At two years, the posttraumatic group continued to show significantly higher scores for the general health domain of the SF-36. There was no significant difference between the groups in terms of the AOFAS scores, other FAOS results, or the patient-satisfaction scores at one and two years postoperatively.

CONCLUSIONS

Our findings suggest that early outcomes after total ankle replacement for patients with posttraumatic osteoarthritis are comparable with those for patients with osteoarthritis and rheumatoid arthritis.

The outcome of total ankle replacement

We performed a systematic review and meta-analysis of modern total ankle replacements (TARs) to determine the survivorship, outcome, complications, radiological findings and range of movement, in patients with end-stage osteoarthritis (OA) of the ankle who undergo this procedure. We used the methodology of the Cochrane Collaboration, which uses risk of bias profiling to assess the quality of papers in favour of a domain-based approach. Continuous outcome scores were pooled across studies using the generic inverse variance method and the random-effects model was used to incorporate clinical and methodological heterogeneity. We included 58 papers (7942 TARs) with an interobserver reliability (Kappa) for selection, performance, attrition, detection and reporting bias of between 0.83 and 0.98. The overall survivorship was 89% at ten years with an annual failure rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean American Orthopaedic Foot and Ankle Society score changed from 40 (95% CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up of 8.2 years (7 to 10) (p < 0.01). Radiolucencies were identified in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The mean total range of movement improved from 23° (95% CI 19 to 26) to 34° (95% CI 26 to 41) (p = 0.01).

Our study demonstrates that TAR has a positive impact on patients’ lives, with benefits lasting ten years, as judged by improvement in pain and function, as well as improved gait and increased range of movement. However, the quality of evidence is weak and fraught with biases and high quality randomised controlled trials are required to compare TAR with other forms of treatment such as fusion.

Cite this article: Bone Joint J 2013;95-B:1500–7.

Mobile- and fixed-bearing total ankle prostheses: is there really a difference?

Approximately 1% of the world's adult population is affected by ankle osteoarthritis (OA). Therapeutic options include conservative and surgical measures. Because of substantial progress in total ankle replacement, ankle fusion is no longer the "gold standard" therapy for end-stage ankle OA. Various ankle prostheses have been designed and are currently available. This article reviews the in vitro studies addressing the biomechanics and kinematics of the replaced ankle. Furthermore, a systematic literature review was conducted to assess possible differences in clinical outcomes, including prosthesis survivorship and postoperative range of motion between mobile- and fixed-bearing total ankle prostheses.

Management of specific complications related to total ankle arthroplasty

Total ankle arthroplasty (TAA) has evolved over time and modern 3-component implants offer good and reliable clinical results. Despite recent improvements, TAA is still associated with a relatively high incidence of complications. Surgeon experience seems to play the most important role. This review highlights the most common intraoperative and postoperative complications, such as malleolar fracture, impingement, cyst formation, malalignment, and loosening, and offers a differentiated concept for their management.

J. Leonard Goldner Award 2011: changes in pain, function, and gait mechanics two years following total ankle arthroplasty performed with two modern fixed-bearing prostheses

BACKGROUND

Total ankle replacement (TAR) continues to grow as an alternative to arthrodesis for patients who suffer from end-stage ankle arthritis. The purpose of this study was to examine changes in gait mechanics from before surgery to 1 and 2 years after surgery in patients who received a fixed-bearing TAR.

METHODS

Fifty-one patients with a primary fixed-bearing TAR and no complications requiring further surgery were identified from a database and enrolled in this non-randomized study. Subjects were examined preoperatively, and at 1 and 2 years postoperatively. Three-dimensional joint mechanics and ground reaction forces (GRF) were collected during level walking. The Four Square Step Test, Timed Up and Go (TUG), VAS, and the AOFAS-Hindfoot score were assessed for each subject at each time point.

RESULTS

TUG, VAS and AOFAS-Hindfoot score along with all measured kinetic parameters demonstrated significant improvements across all of the time points (p < 0.05). Four Square Step Test time was significantly improved between the preoperative and 2-year postoperative time point (p < 0.05). Measured ankle dorsiflexion angles did not demonstrate significant change between any time points.

CONCLUSIONS

All of the observed changes suggest improved or maintained functioning in patients who received a TAR with the greatest improvement occurring within the first year. Sagittal plane ankle range of motion and dorsiflexion angle at heel strike were unchanged across all of the time points. The results of this study indicate that patients with end-stage osteoarthritis demonstrate improvements in pain and gait up to 2 years following surgery while maintaining ankle range of motion.

Total ankle replacement with use of a new three-component implant

BACKGROUND

Total ankle arthroplasty has evolved over the past decade, and newer three-component implants have demonstrated favorable clinical results and improved survivorship. The present study analyzed the clinical and radiographic results of the first 240 total ankle arthroplasties performed by the authors with one of these new three-component prostheses.

METHODS

Two hundred and forty consecutive primary total ankle arthroplasties were performed in 233 patients (115 women and 118 men; mean age, 61.6 years) between November 2003 and October 2007 with the Mobility prosthesis. Intraoperative and postoperative complications, reoperations, and failures were recorded. The American Orthopaedic Foot & Ankle Society hindfoot score and a visual analog scale score assessment of pain were determined at each follow-up visit. Range of ankle motion was measured on functional radiographs, and the radiographs were studied to assess component positioning, radiolucencies, new bone formation, and periprosthetic bone cysts.

RESULTS

Two hundred and thirty-three of the arthroplasties were available for follow-up at least one year after surgery. The mean duration of follow-up was 32.8 ± 15.3 months. There were ten intraoperative complications (4.2%) and twenty postoperative complications (8.6%). A reoperation was necessary in eighteen ankles (7.7%). Five arthroplasties (2.1%) failed at a mean of twenty-seven months after surgery. The mean American Orthopaedic Foot & Ankle Society hindfoot score improved from 48.2 to 84.1 points (p < 0.001). The mean pain level decreased from 7.7 to 1.7 points (p < 0.001). The mean total range of ankle motion improved from 19.8° to 21.9° (p < 0.001). The tibial component had a mean of 2.1° of varus and a mean posterior slope of 6.0° relative to the tibial axis. The prevalence of nonprogressive radiolucency ranged from 1.8% to 37.3% in the ten zones surrounding the tibial component, and from 0 to 2.2% in the three zones surrounding the talar component.

CONCLUSIONS

The short-term clinical and radiographic results after Mobility total ankle arthroplasty are encouraging and are at least comparable with those associated with other modern three-component implants. The minimum duration of follow-up of one year is short, and studies with longer follow-up are needed to confirm our findings.

Results of total ankle arthroplasty

Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence. Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis. On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years. Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or soft-tissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange. A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.

Revision rates after total ankle arthroplasty in sample-based clinical studies and national registries

BACKGROUND

The aim of this study was to evaluate the outcome of specific implants in total ankle arthroplasty as reported in clinical studies and determined by national registries.

MATERIALS AND METHODS

A structured literature review was conducted regarding sample-based clinical studies and national registry data. To allow for comparative analyses, registry data had to be available for the implants included. These were STAR Ankle, Büchel-Pappas, Hintegra, Mobility, Agility, and Ramses Total Ankle Arthroplasty. The revision rate was used as the main outcome parameter.

RESULTS

On average, the revision rates published in sample-based clinical studies were about half the value found in registries. Implant developers represent a share of almost 50% of the published content and are therefore over-represented in scientific publications. The inventors of STAR Ankle and BP total ankle implants published data which was statistically significantly superior to the outcome achieved in average patients as documented in registries. Irrespective of the implant, the average revision rate to be expected according to the registry data available is 21.8% after 5 years, and 43.5% after 10 years.

CONCLUSION

The average revision rate published in peer-reviewed scientific articles was significantly lower than the outcome achieved according to national arthroplasty registry data, which reflect actual average patient care in the respective countries. Publications by some research groups, particularly by implant inventors, show a deviation from the outcome published by other users and those shown in registry data.

Avoiding Wound Complications in Total Ankle Arthroplasty: Surgical Technique and Tips

Introduction

This technique guide is intended to help surgeons to avoid pitfalls and optimize the surgical technique for implantation of a total ankle prosthesis.

Step 1 Preoperative Planning

Obtain radiographs and other relevant images and perform accurate templating.

Step 2 Patient Positioning

Position the patient with the foot and patella facing directly forward, and mark the anterior tibial crest.

Step 3 Surgical Approach

Incise the ankle, taking care to avoid injury to the superficial peroneal nerve and to protect the deep neurovascular bundle.

Step 4 Bone Cuts and Component Implantation

Make the bone cuts in the distal part of the tibia and the talar dome, taking care to avoid excessive bone resection from the distal part of the tibia, fracture of the malleoli, or penetrating too deeply.

Step 5 Soft-Tissue Balancing

Make adjustments as needed for optimal range of motion, alignment, and joint balancing; then remove the trial components and insert the final components.

Step 6 Wound Closure

Repair the extensor retinaculum and close the wound, taking measures that help avoid wound-related complications.

Results & Preop/Postop Images

Despite careful patient selection and surgical technique in our series of 106 consecutive total ankle arthroplasties performed with the Agility system, twenty-seven ankles (25%) had problems related to the anterior incision that required local wound care or oral antibiotics and then healed without subsequent consequences.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement

BACKGROUND

Major modifications in the design and techniques of total ankle replacement have challenged the perception that ankle arthrodesis is the treatment of choice for end-stage ankle arthritis. High complication and revision rates have been reported after both procedures.

METHODS

We performed radiographic evaluations at a mean of thirty-nine months following 114 total ankle replacements done with use of commonly used implants and at a mean of thirty-seven months following forty-seven ankle arthrodeses. The mean age was sixty-four years for the patients (fifty-one female and sixty-three male) who underwent total ankle replacement and fifty-nine years in the patients (fifteen female and thirty-two male) who underwent ankle arthrodesis. The impact of complications was analyzed with use of the Ankle Osteoarthritis Scale (AOS), a validated outcome instrument.

RESULTS

Both groups had significant improvement in the mean AOS score (p < 0.001). There was no significant difference in the mean improvement between the two groups (p = 0.96). The complication rate was 54% following total ankle replacement and 26% following ankle arthrodesis, which was a significant difference (p = 0.003). The impact of major complications on the AOS outcome score was significant in both the total ankle replacement group (p = 0.031) and the ankle arthrodesis group (p = 0.02).

CONCLUSIONS

At the time of follow-up, at a minimum of two years postoperatively, the outcomes of total ankle replacement and ankle arthrodesis, with regard to pain relief and function, were comparable. While the rate of complications was significantly higher following total ankle replacement, the impact of complications on outcome was clinically relevant in both groups.

Minimally invasive plate osteosynthesis (MIPO) for periprosthetic fracture after total ankle arthroplasty: a case report

Level of Evidence: V, Expert Opinion

Risk factors for incision-healing complications following total ankle arthroplasty

BACKGROUND

The anterior incision used for the insertion of total ankle arthroplasty systems is at high risk for wound complications, and little has been documented regarding who is at risk for the development of these complications.

METHODS

We conducted a retrospective chart review of 106 total ankle arthroplasties. Independent risk variables, including age, sex, body-mass index, diabetes, smoking, medications, preoperative diagnosis, implant size, tourniquet time, closure method, and anticoagulation status, were recorded. Postoperative office notes were reviewed for wound-related complications. Outcomes were divided into three categories: no complications (uncomplicated wound-healing), minor complications (wounds requiring only local care/oral antibiotics), and major complications (requiring a return to the operating room for treatment). Simultaneously, categorical variables were compared with use of chi-square analysis. Multivariate logistic regression and odds ratio assessment were performed as well.

RESULTS

When patients who had no complications were compared with those who had minor complications, a history of diabetes was the only variable that was identified as resulting in a significant risk increase (p = 0.04). When patients who had no wound complications or minor wound complications were compared with those who had major wound complications, female sex, a history of corticosteroid use, and underlying inflammatory arthritis were all associated with increased risk. Multivariate logistic regression demonstrated underlying inflammatory arthritis (p = 0.004) to be the only significant risk factor for major wound complications, with an odds ratio demonstrating a 14.03 times increased risk of requiring reoperation.

CONCLUSIONS

We recommend that caution be used when selecting and educating patients with inflammatory arthritic conditions who are potential candidates for total ankle arthroplasty.

Evidence-based classification of complications in total ankle arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) has become a viable treatment for end-stage ankle arthrosis. Current literature on survival rates and complications of TAA consist of mostly retrospective Level IV papers that do not provide a system for classifying complications. The aim of the current review is to provide a summary of TAA implant survival and complication rates from current literature on outcomes of second or third generation ankle prostheses and subsequently propose a classification system.

METHODS

A literature review was used to identify articles reporting complications and failures of TAA ankle prostheses. Inclusion criteria included studies with at least 25 cases and a minimum of 24 months followup.

RESULTS

Twenty studies met the inclusion criteria. The percentage of failed TAA reported for the short- and intermediate-term followup in this review ranged from 1.3 to 32.3 % with an overall mean of 12.4 % failure at 64 months. Nine main complications of TAA were identified.

CONCLUSION

Deep infection, aseptic loosening and implant failure should be considered ;;high-grade'' complications since they will result in failure greater than 50% of the time. Technical error, subsidence and postoperative bone fracture should be considered "medium-grade'', while intra-op bone fractures and wound healing problems should be considered "low-grade''. We believe this review provides the groundwork for uniform complication reporting in TAA and allows the development of a classification system that will provide prognostic information that may serve to guide postoperative care of patients receiving TAA.

History and evolution in total ankle arthroplasty

INTRODUCTION

The current study provides an overview of history and evolution in total ankle arthroplasty.

METHODS

We conducted a comprehensive literature search without limitations to language. Information from any source, providing evidence of the use ankle of prostheses (e.g. biomechanical testing, cadaveric implantations or clinical use) was evaluated. Data regarding biomechanical concepts, design considerations, published results (patient numbers, surgical method, follow-up, complications and survival rates) were collected.

RESULTS

Only level IV studies were found. Mobile-bearing prostheses are mainly used in Europe, and fixed-bearing implants are mainly used in the USA. The current designs' failure rate is 10-12% at approximately 5 years. Survival rates vary among different institutions. Increased surgeons' experience is associated with better outcomes.

DISCUSSION

Biomechanical studies and review of previous implant failures has led to the development of a new generation of implants.

CONCLUSIONS

Results show that ankle arthroplasty is a viable alternative for the management of ankle arthritis in selected patients.

Moderne 3-Komponenten-Sprunggelenkprothesen

Luxation and excessive wear of the mobile bearing in modern three-piece total ankle replacement (TAR) is reported. We conducted a systematic review of studies to explore and discuss the rate and causes of these complications.A systematic review of studies since 2000 showed 26 studies with altogether 1,318 followed up TARs which we analyzed. Of these 1,318 TARs, 188 (14.3%) were revised and 56 (4.2%) complications with the mobile bearing were reported. A total of 39 cases (3%), i.e., 20.7% of all revisions, were revised due to failure of the mobile bearing, including 17 cases with subluxation (1.3%), 15 with asymmetric load of the bearing (1.1%), 10 with fracture of the polyethylene (PE) inlay (0.76%), 7 with massive PE wear (0.53%), and 7 with luxation of the meniscal bearing (0.53%).Complications due to the meniscal mobile bearing in TARs such as luxation, subluxation, massive wear, and fracture of the PE inlay are rare complications. The cause of these complications is regularly not found in the design of this three-piece total ankle replacement. Causes of failure of the mobile bearing are mostly found in incorrect indication, incorrect soft tissue balancing, incorrect positioning of components, implantation in ankles with hindfoot malalignment and ankle instability.