Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty Using the INBONE II Prosthesis

Traumatic Periprosthetic Fractures Following Total Ankle Replacement: A Systematic Review and Proposed Classification

Total ankle replacements (TAR) are increasingly utilized, but postoperative traumatic periprosthetic fractures remain a rare yet challenging complication. This systematic review aims to address the gap in literature by proposing a comprehensive classification system for these fractures, considering implant stability, fracture location, and surrounding bone quality. A systematic review identified 13 cases from 9 studies meeting inclusion criteria. Fractures were categorized using the proposed Hill-Brown classification: Type A (talus or fibula), Type B (distal tibial component), and Type C (diaphysis/proximal tibial metaphysis). Implant stability was a key factor, with Type B fractures further classified as B1 (stable), B2 (unstable with adequate bone stock), and B3 (unstable with poor bone stock). Most fractures occurred at or near the distal tibial component (Type B), with implant stability largely dependent on fracture location and bone quality. Surgical fixation, particularly minimally invasive plate osteosynthesis (MIPO) with locking plates, was the preferred treatment for stable implants, showing low complication rates. Unstable implants often required revision TAR or conversion to arthrodesis. Surgical intervention is recommended following all traumatic periprosthetic fractures in the setting of a TAR. Bone quality, particularly in patients with rheumatoid arthritis or osteoporosis, significantly impacted treatment decisions. Our findings emphasize the importance of fracture location, implant stability, and bone quality in managing these fractures. Future multicenter studies are necessary to validate this classification system and refine treatment protocols.Level of Evidence: Level III.

Indications and outcomes of revision total ankle arthroplasty

INTRODUCTION

Total ankle arthroplasty (TAA) has emerged as an alternative to ankle arthrodesis for managing end-stage ankle arthritis. However, the long-term survival of TAA remains inferior to that of hip and knee replacements, leading to a higher rate of revision TAA. Understanding the indications and outcomes of revision procedures is critical for orthopedic surgeons managing complex ankle pathology.

AREAS COVERED

This review explores the indications, surgical considerations, and outcomes associated with revision TAA. A structured literature search was conducted using PubMed and Scopus (January 2000-March 2024) with keywords including 'revision total ankle arthroplasty,' 'implant failure,' 'complications,' and 'biologic augmentation.'

EXPERT OPINION

Revision TAA presents unique surgical and biomechanical challenges that require individualized treatment approaches. While it offers pain relief and functional restoration for select patients, outcomes remain less favorable compared to primary TAA. Future advancements in implant technology may improve long-term success rates. Additionally, optimizing patient selection criteria and perioperative protocols will be essential to reducing complications and enhancing outcomes. Further research is needed to refine revision techniques and establish guidelines for managing failed TAA effectively.

Fate of revision total ankle arthroplasty: a meta-analysis of 999 cases

BACKGROUND

Revision total ankle arthroplasty (reTAA) is becoming more common. This meta-analysis aimed to evaluate its re-revision rate and factors affecting longevity.

METHODS

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and Assessing the Methodological Quality of Systematic Reviews guideline, we searched PubMed, Embase, Web of Science, and Cochrane Library databases from 1 January 2010 to 1 October 2024. Studies reporting survivorship of reTAA were included. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). The primary outcome was the re-revision rate. Pooled estimates with 95% confidence intervals (CIs) were calculated using a random-effects model. The annual re-revision rate was introduced for time-adjusted analysis. Heterogeneity was explored using meta-regression and subgroup analyses.

RESULTS

The analysis included 22 retrospective studies (cohort studies and case series) and one prospective cohort study. The NOS scores indicated moderate to high quality. A total of 999 reTAAs with a mean follow-up of 5 years were identified. The pooled re-revision rate was 9.9% (95% CI: 5.9% to 13.9%). The annual re-revision rate was 2.6% (95% CI: 1.8% to 3.6%). Subgroup analysis indicated that stemmed tibial components were potentially associated with a lower re-revision rate (5.5%) versus unstemmed tibial components (13.2%) ( P = 0.077). However, meta-regression model identified follow-up duration as the only significant factor influencing re-revision rates. The pooled complication rate following reTAA was 18.2%. Among those failed reTAAs, 64.9% underwent conversion to ankle fusion and 5.3% received below-knee amputation.

CONCLUSION

Although most included studies were low-level evidence, our meta-analysis revealed an overall re-revision rate of 9.9% at 5-year follow-up, with an annual rate of 2.6% for reTAA. Limited evidence suggested that revision systems using stemmed tibial components might reduce the risk of re-revision.

A systematic review of outcomes of total ankle arthroplasty with INBONE II

BACKGROUND

This study systematically reviews the literature and reports on outcomes of total ankle arthroplasty (TAA) with the INBONE II fixed-bearing implant.

METHODS

PubMed, SCOPUS and CINAHL were searched for clinical studies reporting INBONE II specific outcomes from database inception through July 13th, 2024, according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines.

RESULTS

Seven primary TAA studies and 4 revision TAA studies were included with 406 and 114 patients respectively. Survivorship was 96.5 % (mean follow-up 44.8 months) and 93.9 % (mean follow-up=37.3 months) for primary and revision TAA, respectively. The mean reoperation rate was 11.4 % with a 3.2 % rate of major complications for primary TAA. Meanwhile, the reoperation rate was 9.1 % with a major complication rate of 12.2 % for revision TAA.

CONCLUSIONS

Primary and revision TAA with this implant results in over 93 % survival at mid-term follow-up with an acceptable complication rate, supporting its continued use.

LEVEL OF EVIDENCE

Level IV: Systematic Review of Level I-IV Studies.

[Treatment of ankle osteoarthritis : Analysis of a German nationwide survey]

BACKGROUND

In most cases osteoarthritis of the ankle is of posttraumatic origin. Younger people are more frequently affected, which makes treatment a particular challenge. In addition to conservative treatment numerous surgical procedures are available for the treatment of advanced arthrosis. The aim of this nationwide survey was to document the current status of the diagnostics and treatment of ankle arthritis in Germany.

MATERIAL AND METHODS

Members of the German Society for Orthopedics and Trauma Surgery (DGOU) were invited to participate in an anonymous online survey on the treatment of ankle joint osteoarthritis. The survey included 69 questions on the person, on the diagnostic and treatment approaches as well as 3 clinical and radiological patient cases. The evaluation of the results of the survey included differences in the subgroups of participants based on the discipline, the location of activity, position and certification.

RESULTS

From November 2019 to February 2020 a total of 343 members participated in the survey. For the diagnostics 96% requested conventional radiographs in a standing position and in 2 levels. Other native radiographs were considered necessary by less than half of respondents. Less than one third of participants sometimes (n = 87) or always (n = 18) use an outcome score. The therapeutic repertoire included supramalleolar osteotomy (n = 106), ankle arthroplasty (n = 100) and arthrodesis (n = 248). Open arthrodesis using screws through an anterior approach was the most frequently used surgical procedure.

CONCLUSION

Diagnostic standards were regularly used in the treatment of ankle arthrosis. With respect to the surgical treatment there was a wide heterogeneity due to the pathological anatomy and preferences of the participants. Open arthrodesis was the most frequently selected procedure.

Morselized Femoral Head Impaction Bone Grafting of Large Defects in Ankle and Hindfoot Fusions

BACKGROUND

Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. The purpose of this study was to evaluate outcomes of patients who underwent ankle-hindfoot fusions with impaction bone grafting (IBG) with morselized femoral head allograft to fill large bony void defects.

METHODS

This was a 3-center, retrospective review of a consecutive series of 49 patients undergoing ankle or hindfoot fusions with femoral head IBG for filling large bony defects. Union was assessed clinically and radiologically with radiography or computed tomography. Graft stability/collapse was identified on radiographs as loss of graft height across the fusion interface. Indications included 35 failed total ankle arthroplasty, talar osteonecrosis and collapse (7 patients), failed ankle fusion (4 patients), trauma with bone loss or fracture nonunion (1 patients), and other (2 patients). Tibiotalocalcaneal (TTC) fusion was performed in 36 (73%) patients and ankle (TT) fusion in 13 (27%).

RESULTS

Mean age was 59.3 (19-78) years. Mean follow-up was 22.9 ± 8.3 months. Eighteen percent were smokers. Mean depth of the bone defect was 35.2 ±8.7 mm, and mean volume of the defect was 62.2 ±5.8 cm3. Symptomatic nonunion rate was 14% (7/49). The mean time to radiologic union was 7.6 ±3.2 months. Complete radiologic union rate occurred in 73% (36/49). Eight TTC fusion patients (22.2%) united at the tibiotalar joint but not at the subtalar joint, of which 6 were asymptomatic. There was no graft collapse, even in patients developing nonunion, with all patients maintaining bone incorporation and leg length.

CONCLUSION

Impaction of morselized femoral head allograft can fill large bony voids around the ankle or hindfoot during fusion, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory and comparable union outcomes without limb shortening or expensive custom 3D-printed metal cages.

Outcomes of Total Ankle Replacement

Total ankle replacement (TAR) is an effective operative treatment of end-stage ankle osteoarthritis (OA) in the appropriate patient, conferring improved kinematic function, decreased stress across adjacent joints, and offering equivalent pain relief in comparison to ankle arthrodesis (AA). It is important to consider patient age, weight, coronal tibiotalar deformity, joint line height, and adjacent joint OA to maximize clinical and patient outcomes. Both mobile-bearing and fixed-bearing implants have demonstrated favorable clinical outcomes, marked improvement in patient-reported outcomes, and good survivorship; however, implant survivorship decreases with longer term follow-up, necessitating constant improvement of primary and revision TAR options.

Lessons From Revision Total Ankle Replacement: Tibias Fail Earlier, and Taluses Fail Later (and Fail Again)

BACKGROUND

The literature on survivorship and outcomes after revision total ankle replacement (TAR) in the modern era is limited. This study aimed to describe the timing to revision and survivorship after revision TAR. We hypothesized that tibial-sided failures would occur earlier after the primary TAR, and secondary revisions after failure of revision TAR would occur more due to talar-sided failures than tibial-sided failures.

METHODS

This is a single-institution retrospective study of TAR patients with minimum 2-year follow-up. Revision TARs (defined as exchange of tibial and/or talar components) for aseptic causes with any implant were included. Etiology of failure necessitating revision and ultimate outcomes after revision (survival of TAR revision, additional revision, conversion to fusion, and below-knee amputation [BKA]) were recorded.

RESULTS

There were 46 revision TARs, with mean age of 60.6 (range: 31-77) years and mean 3.5 years' follow-up postrevision. Revisions for tibial failure occurred significantly earlier (n = 22, 1.3 ± 0.5 years after index procedure) than those for talar failure (n = 19, 2.3 ± 1.7 years after index procedure) or combined tibial-talar failure (n = 5, 3.4 ± 3.4 years after index procedure) (P = .015). Revisions for tibial-only failure had better survival (95.5%) than revisions for talar or combined tibial-talar failures: 26% of talar failures and 20% of combined tibial-talar failures underwent ≥1 revisions. Of the 6 additional revisions after failure of the talar component, 1 ultimately underwent BKA, 2 were converted to total talus replacement, 2 were revised to modular augmented talar components, and 1 was treated with explant and cement spacer for PJI after the revision.

CONCLUSION

TAR tibial failures occurred earlier than talar failures or combined tibial-talar failures. Revisions for talar failures and combined tibial-talar failures were more likely to require additional revision or ultimately fail revision treatment. This is important given the consequences of talar implant subsidence, bone necrosis, loss of bone stock, and limited salvage options.

The INVISION Talar Component in Revision Total Ankle Arthroplasty: Analysis of Early Outcomes

INTRODUCTION

Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component.

METHODS

This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus.

RESULTS

The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively.

CONCLUSIONS

In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Revision Total Ankle Arthroplasty Using the INBONE II System

BACKGROUND

The utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, leading to a higher occurrence of revision TAA procedures because of failure of primary TAA. This study aims to examine the clinical results associated with revision TAA using the INBONE II system. Given the growing number of TAA revision procedures and a focus on motion-preserving salvage options, we evaluated our early experience with revision TAA.

METHODS

A retrospective analysis was conducted on a group of 60 presumed noninfected patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis.

RESULTS

The study revealed high complication rates but generally fair clinical outcomes for revision TAA using the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n = 6), nerve injury/impingement (n = 5), infection (n = 3), fracture (n = 3), implant failure (n = 3), impaired wound healing (n = 2), and osteolysis (n = 3). The 3-year survivorship rate from reoperation was 92.0% (82.7%-100.0%) whereas the 3-year survivorship rate from major complications was 90.4% (80.8%-100.0%).

CONCLUSION

We report high complication rates but generally fair clinical results for revision TAA utilizing the INBONE II system.

Revision Total Ankle Arthroplasty Using a Novel Modular Fixed-Bearing Revision Ankle System

INTRODUCTION

Large bone defects such as those encountered after failed total ankle replacement have previously been a relative contraindication to revision ankle replacement due to inadequate bone stock. We describe our experience and patient reported outcomes with a modular ankle replacement system with tibial and talar augments.

METHODS

This is a retrospective case series analysis of patients who underwent a total ankle replacement using the INVISION system across 2 centers between 2016 and 2022. Patients completed the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS), and EQ-5D pre-operatively and then post-operatively at 6 months, 1 year, 2 years, 3 years, and 5 years. Medical records were reviewed for complications and re-operations. X-rays were reviewed for lucencies and alignment.

RESULTS

A total of 17 patients were included in the study; 14 men and 3 women with an average age at the time of surgery of 67.9 years (range 56-80 years). The average follow-up post-operatively was 40.5 months (range 7-78) at the time of this study. The indication for surgery was revision of failed total ankle replacement (TAR) in 16 and revision of failed ankle fusion in 1. An augmented tibia was used in 13, an augmented talus in 13, and both augmented tibia and talus in 9 cases. There were no early surgical complications. One patient required debridement and implant retention for late deep infection. No implants have been revised. The average MOXFQ score improved by 19.3 points at most recent follow-up. The average AOS score improved by 25.2 points.

CONCLUSION

The early results of a modular augmented ankle arthroplasty system have shown satisfactory patient outcomes with a low complication and re-operation rate and present another option for patients with larger bone defects. This is a small series, and a larger series with long-term follow-up would be beneficial.

LEVELS OF EVIDENCE

Level IV: Case series.

The significance of heterotopic ossification following total ankle arthroplasty: a systematic review and meta-analysis

PURPOSE

The purpose of this systematic review and meta-analysis was to evaluate the prevalence and clinical significance of heterotopic ossification (HO) following total ankle replacement (TAR).

METHODS

During August 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies reporting HO following TAR. Data regarding surgical characteristics, pathological characteristics, subjective clinical outcomes, ankle range of motion, radiographic outcomes, reoperation rates were extracted and analysed.

RESULTS

Twenty-seven studies with 2639 patients (2695 ankles) at a weighed mean follow-up time of 52.8 ± 26.9 months were included. The pooled prevalence rate was 44.6% (0.25; 0.66). The implant with the highest rate of HO was the INBONE I (100%) and BOX (100%) implants. The most common modified Brooker staging was grade 1 (132 patients, 27.0%). Random effects models of standardized mean differences found no difference in American orthopedic foot and ankle society (AOFAS) scores, visual analog scale scores (VAS) and ankle range of motion (ROM) between patients with HO and patients without HO. Random effects models of correlation coefficients found no correlation between AOFAS, VAS and ROM and the presence of HO. The surgical intervention rate for symptomatic HO was 4.2%.

CONCLUSION

This systematic review and meta-analysis found that HO is a common finding following TAR that is not associated with inferior clinical outcomes. Surgical intervention was required only for moderate-to-severe, symptomatic HO following TAR. This study is limited by the marked heterogeneity and low level and quality of evidence of the included studies. Further higher quality studies are warranted to determine the precise prevalence and impact of HO on outcomes following TAR.

Clinical Outcomes and Registry Data in Total Ankle Arthroplasty

Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis consistently demonstrating good to excellent outcomes, even when considering factors such as deformity, patient age, bilaterality, and arthritis etiology. There is little consensus in the literature with regard to preferred patient-reported outcome metrics (PROMs) for assessing outcomes, although all metrics generally improve following TAA. Several countries have successful registries to track longevity of TAA in populations; however, PROMs are generally not successfully tracked in registries. A trend toward consensus on outcome metrics and collaborative registries is warranted to optimize patient selection and outcomes in TAA.

Outcomes of Revision Total Ankle Replacement

The objective of this study is to provide an up-to-date review of the outcomes of revision total ankle arthroplasty (TAA). Relevant studies published over the last decade were reviewed. Twelve studies were included. At a median follow-up of 4 years, the median survival and reoperation rates were 86% and 16%, respectively. Significant postoperative improvements in patient-reported outcome measures were recorded in 6 studies. Significant improvement in alignment was documented in 1 study only. Revision TAA is a safe procedure that can produce good outcomes. Nevertheless, data relating to long-term outcome are still limited in quantity and duration.

Lack of Consensus on the Definition of Aseptic Loosening in Total Ankle Replacement: A Narrative Systematic Review

Background: Aseptic loosening is one of the most common modes of failure of total ankle replacement (TAR). However, a precise definition of aseptic loosening is still lacking. This systematic review aimed to identify the variations of applied definitions and offer insights into the lack of consensus. Methods: Human studies reporting aseptic loosening of TAR published in peer-reviewed journals within the last decade were considered. The search strategy involved specific terms in Embase, MEDLINE ALL, and the Cochrane Library. Variations in aseptic loosening definitions were analysed. Results: Of 767 studies, 88 were included in this study. Only nine studies precisely defined aseptic loosening with significant variations. Twenty-two studies referenced the term and fifty-seven reported it as a complication but neither defined nor referenced it. Conclusions: Significant uncertainty exists regarding the universal definition of aseptic loosening of TAR, and many variations occur in terms of the assessment approach and criteria.

Comparison of Radiographic Talar Loosening Rates Between Salto-Talaris and INBONE II

BACKGROUND

Despite substantial increase in total ankle arthroplasty (TAA) nationwide, there are few studies comparing flat-cut vs chamfer-cut talar systems in TAA with regard to radiographic aseptic loosening rates of the implant.

METHODS

This retrospective study included 189 Salto-Talaris TAA and 132 INBONE II primary TAA with a minimum 1-year follow-up. Patient characteristics were obtained including gender, age at surgery, body mass index (BMI), smoking status, primary diagnosis, surgical time, and the presence of diabetes. Radiographic evidence for aseptic loosening was assessed. Statistical analysis was performed for comparison in outcomes between Salto-Talaris and INBONE II.

RESULTS

The mean age of the study population was 63.5 ± 9.8 years at surgery. Mean follow-up was 4.9 ± 3.0 years. Radiographic aseptic loosening of the tibial implant showed no significant difference between the 2 groups: Salto-Talaris, 18%, and INBONE II, 18.9% (P = .829). Aseptic loosening of the talar implant also showed no significant difference between the 2 groups: Salto-Talaris, 1.6%, and INBONE II, 1.5% (P = .959). No variables, including the implant type, were found to contribute to the aseptic loosening rate of either the tibia or talus.

CONCLUSION

In our cohort, we observed no difference in radiographic implant aseptic loosening between Salto-Talaris and INBONE II systems.

LEVEL OF EVIDENCE

Level IV, retrospective case series study.

Hybrid-Total Ankle Arthroplasty (H-TAA) for Failed Talar Component in Mobile-Bearing Total Ankle Arthroplasty

INTRODUCTION

Revision Total Ankle Arthroplasty (TAA) surgery due to TAA aseptic loosening is increasing. It is possible to exchange the talar component and inlay to another system for isolated talar component loosening in a primary mobile-bearing TAA: Hybrid-Total Ankle Arthroplasty (H-TAA). The purpose of this study was to analyze the results of the revision surgery of an isolated aseptic talar component loosening in a mobile-bearing three-component TAA with a H-TAA solution.

METHODS

In this prospective case study, nine patients (six women, three men; mean age 59.8 years; range 41-80 years) with symptomatic isolated aseptic loosening of the talar component of a mobile-bearing TAA were treated with an isolated talar component and inlay substitution. In all nine cases, a hybrid TAA revision surgery was performed by implanting a VANTAGE TAA talar and insert component (Flatcut talar component: six cases, standard talar component: three cases). The patients were reviewed with the pain score (VAS Pain Score 0-10), Dorsiflexion/Plantarflexion (DF/PF) Range of Motion (ROM; degrees), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot Score (0-100 points), Sports Frequency Score (Level 0-4), and subjective Patients' Satisfaction Score (0-10 points).

RESULTS

The average Pain score improved significantly from preoperative 6.7 points to postoperative 1.1 points (p < 0.001). Average Dorsiflexion/Plantarflexion ROM values increased significantly post-surgery: 21.7° preoperative to 45.6° postoperative (p < 0.001). The postoperative AOFAS scores were significantly greater than the preoperative values: 47.7 points preoperative, 92.3 points postoperative (p < 0.001). The sports activity improved from preoperative to postoperative where, preoperative, none of the patients were able to perform sports. Postoperative, eight patients were able to be sports-active again. The overall average postoperative level of sports activity was 1.4. The postoperative average patient's satisfaction was 9.3 points.

CONCLUSIONS

In painful talar component aseptic loosening of a three-component mobile-bearing TAA, H-TAA is a good surgical solution for reducing pain, restoring ankle function, and improving patients' life quality.