Long-Term Clinical Outcomes and Implant Survivorship of 151 Total Ankle Arthroplasties Using the HINTEGRA Prosthesis: A Minimum 10-Year Follow-up

Effects of Parallax and Distortion in Total Ankle Arthroplasty

BackgroundSurgeons rely on intraoperative fluoroscopy to assist in placement of implant components during total ankle arthroplasty (TAA). Parallax alters the direction of an object when viewed from two different points, resulting in image distortion. The purpose of this study was to evaluate parallax/distortion in intraoperative fluoroscopic images during TAA.MethodsA retrospective review of all TAAs performed by two surgeons (R.W.M. and B.S.) from August 2019 to April 2023 were reviewed. Intraoperative fluoroscopic anteroposterior (AP) ankle views were evaluated for any obvious parallax image distortion. Cases with obvious parallax distortion were included for angular evaluation of AP intraoperative fluoroscopic and first postoperative plain films. The tibia was marked at 2-centimeter intervals to create zones from the proximal stem of the implant. The anatomical axis of the tibia (AAT) was drawn at the mid-diaphysis. The anatomic lateral distal tibial angle (aLDTA) and anatomic axis deviation (AAD) were measured for each zone.ResultsA total of 22 TAAs were performed during the study period. Four cases were excluded due to inadequate imaging, leaving a total of 18 TAAs for review. We found 6 of 18 (33.3%) cases had obvious parallax distortion. We found the average aLDTA was 90.9° (84°-101°). At the most proximal tibial zone, the average aLDTA was 94° (91°-101°). We found the average AAD was 4.7 (0.5-17.2) mm. The AAD ranged from 0.5 to 17.2 mm lateral to 0.8 to 8.2 mm medial. Postoperative plain film radiographs displayed a normal aLDTA and an AAT centered within the ankle joint.ConclusionParallax can distort the appearance of the tibia on fluoroscopic images. Deviation from the normal aLDTA and anatomical axis should be anticipated. Surgeons should be aware of the potential impact of parallax and ways to mitigate these effects.

Hintegra® total ankle replacement. Five and 10 year survivorship analysis, clinical outcomes, complications and satisfaction rates

Background

This study retrospectively evaluated a consecutive series of patients who underwent Total Ankle Replacement (TAR) with the third-generation mobile bearing Hintegra® prosthesis performed by a single non-designer surgeon. Few studies reporting outcomes from total ankle replacement (TAR) have been published by non-designer investigators. Clinical outcomes, complication and satisfaction rates have also been analysed.

Method

A consecutive series of 52 patients that received 55 TAR were reviewed between 2008 and 2016. Kaplan-Meier survival analysis was performed on all of the 55 TAR. Change in AOFAS hind foot scores from pre to post surgery and self-reported satisfaction scores were analysed.

Results

The 10 year survival analysis group had a minimal mean follow up of 10 years (SD 1.5, median 8.5, min 7.0. max 12.9), with a survival rate of 87 % (CI 0.74 to 0.94). Five-year survival rate was 93 % (CI 0.82 to 0.97). Six ankles (11 %) had to be revised. One having a talar component revision with polyethylene exchange and the remaining five with a conversion to arthrodesis. Only thirty-eight of the original 55 TAR were analysed for outcome measures. Seventeen patients were lost to follow up and 19 patients were deceased. In total 79 % (30) patients were satisfied with the TAR procedure with sixteen patients reporting to be extremely satisfied. Sixteen per cent (6) patients reported to be neutral and only 5 % (2) patients stated that they were not satisfied with the TAR procedure.

Conclusions

Our results show that the Hintegra® TAR prosthesis leads to good medium to long term survivorship and acceptable patient satisfaction rates. The results of these cases, all treated by a single non-designer surgeon in a low-volume practice, demonstrate that acceptable outcomes may be achieved outside of high-volume TAR centres.

Level of evidence

Retrospective analysis - Level III.

Outcomes of Autogenous Bone Grafting for Periprosthetic Osteolysis After Total Ankle Arthroplasty: Clinical and 3-Dimensional Computed Tomography Results

BACKGROUND

Periprosthetic osteolysis after total ankle arthroplasty (TAA) is a substantial problem. Bone grafting may be beneficial in the treatment of large osteolytic cysts; however, the literature regarding the outcomes of bone grafting is limited. This study analyzed the outcomes of autogenous bone grafting performed for the management of periprosthetic osteolysis following TAA.

METHODS

We retrospectively reviewed 42 ankles (41 Korean patients) that underwent autogenous bone grafting for periprosthetic osteolysis following TAA. Clinical outcomes were evaluated using visual analog scale for pain scores, Ankle Osteoarthritis Scale pain and disability scores, and American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores. Computed tomography (CT) was performed preoperatively and for at least 2 years postoperatively in order to evaluate the treatment response. Histology, prosthesis survivorship, reoperations, and complications were also evaluated.

RESULTS

The mean time to autogenous bone grafting was 64.4 months (range, 10 to 128 months), and the mean follow-up duration after autogenous bone grafting was 70.7 months (range, 24 to 137 months). All clinical scores significantly improved from preoperatively to the last follow-up visit. The mean osteolytic cyst volume improved from 4.8 cm 3 (range, 1.1 to 19.4 cm 3 ) to 0.8 cm 3 (range, 0 to 6.5 cm 3 ). A Kaplan-Meier survival analysis revealed that TAA with subsequent bone grafting was associated with similar prosthesis survivorship (100% and 85.7% at 5 and 10 years, respectively) but inferior reoperation-free survivorship (93.4% and 68.4% at 5 and 10 years, respectively) compared with TAA without osteolysis or with non-progressive osteolysis.

CONCLUSIONS

Autogenous bone grafting performed for the management of periprosthetic osteolysis after TAA produced favorable clinical and radiographic outcomes. However, there was still a higher risk of subsequent surgery even after successful bone grafting, compared with TAA without osteolysis or with non-progressive osteolysis. Our results suggest that autogenous bone grafting and serial CT scan monitoring over time may prolong the survivorship of TAA prostheses in ankles with periprosthetic osteolysis.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Indications, Functional Outcomes, Return to Sport and Complications of Anterior and Lateral Approaches for Total Ankle Arthroplasty: A Comprehensive Review

Ankle osteoarthritis (OA) is a degenerative condition that impacts quality of life. Total ankle replacement (TAR) represents a significant advancement in orthopedic surgery. Objectives: The purpose was to provide an overview of the indications, outcomes, and complications of anterior and lateral surgical approaches in TAR, as well as return to sport following surgery. Methods: The PubMed, MEDLINE, Scopus, and Cochrane Central databases were searched. The keywords used were "total ankle arthroplasty", "total ankle replacement", "ankle anterior approach", "ankle lateral approach", "outcomes", "return to sport", and "complications", and the search included articles published from 2014 to 2024. Results: Successful functional outcomes, return to athletic activity, and return to the previous level of sports performance after surgery have been reported at rates of over 60%. The anterior approach restores the normal tibial slope but presents a high risk of wound-healing complications and medial malleolar fractures. The lateral approach allows an anatomic placement of the implant, but it is associated with fibular complications and a high risk of revision surgery. Return to sport is feasible in low-impact sports such as cycling, swimming, and dancing. Conclusions: The anterior and lateral approaches for TAR yielded satisfactory functional outcomes and rates of return to athletic activity. Different intra- and post-operative complications and revision surgery should be managed properly to optimize outcomes.

The Salto Mobile-Bearing Total Ankle Arthroplasty: Survivorship, Radiologic, and Clinical Outcomes at an Average 9-Year Follow-Up

BACKGROUND

Total ankle arthroplasty (TAA) remains an excellent treatment option for end-stage ankle osteoarthritis. Questions remain regarding the superiority of either fixed- or mobile-bearing implants because of equipoise in the literature and a paucity of long-term follow-up. We present results of the Salto mobile-bearing TAA, aiming to add to the literature for longer-term follow-up of this mobile-bearing TAA and investigate the survivorship and patient satisfaction with this implant.

METHODS

TAA was performed in 91 consecutive ankles (87 patients) in an independent, prospective, single-surgeon study. The minimum follow-up was set at 5 years. Implant survival, patient-reported outcome measures (PROMs), and radiographic outcomes are presented at a mean of 9.1 years (range 5-18 years).

RESULTS

Nine ankles (9 patients) were lost to follow-up or were unable to comply. Eighty-two ankles (78 patients) were included with a mean age of 69.5 years at the time of their operation. Six of 82 ankles (7.3%) underwent revision of any of the components. Four were revisions involving the metallic components to fusion or revision TAA, all within 5 years of the index procedure. Three ankles (3.7%) underwent reoperations. With all-cause revision of any component (including the polyethylene liner) as an endpoint, implant survival was calculated using Kaplan-Meier curves as 95.0% at 5 years and 93.2% at 10 years. Reported PROMs were very high and we found no progressive linear lucencies, cysts, or subsidence in TAAs other than in those that underwent revision or reoperation.

CONCLUSION

Our study of 82 Salto mobile-bearing TAAs found commendable survivorship, along with robust radiographic and patient-reported outcomes at an average of 9 years, with survivorship rates comparable to those reported for fixed-bearing implants.

Design Rational for Total Ankle Arthroplasty: An Update

The design of total ankle arthroplasty (TAA) systems is rapidly evolving as device companies try to keep pace with the expansion of surgical indications and a refinement of techniques for TAA. Even since the publication of the latest "update," published in 2018, three new designs and three updates on preexisting third-generation implants came onto the market. Improvements in third-generation TAA systems include minimal bone resection, retaining ligamentous support, and anatomic balancing. Fourth-generation systems use 3D printing technology, improved talus and tibia designs based on CT scans of arthritic and normal ankles, and include patient-specific instrumentation. We will then explore the short-term and mid-term outcomes of the previously discussed six TAA systems-INBONE, INFINITY, INVISION (Stryker), Salto-Talaris (Smith and Nephew), Scandinavian Total Ankle Arthroplasty (Enovis), Trabecular Metal Total Ankle (Zimmer Biomet), and VANTAGE (Exactech). As more research pours in regarding mid- to long-term outcomes of these implants, it is important to assess the design rationale and summarize current outcome data for these implants.

The Role of Receptor Activator of Nuclear Factor-κB Ligand/Osteoprotegerin Ratio in Synovial Fluid as a Potential Marker for Periprosthetic Osteolysis Following Total Ankle Arthroplasty

Background

Periprosthetic osteolysis is a prevalent complication following total ankle arthroplasty (TAA), implicating various cytokines in osteoclastogenesis as pivotal in this process. This study aimed to evaluate the relationship between osteolysis and the concentrations of osteoclastogenesis-related cytokines in synovial fluid and investigate its clinical value following TAA.

Methods

Synovial fluid samples from 23 ankles that underwent revision surgery for osteolysis following TAA were analyzed as the osteolysis group. As a control group, we included synovial fluid samples obtained from 23 ankles during primary TAA for osteoarthritis. The receptor activator of nuclear factor-κB ligand (RANKL)/osteoprotegerin (OPG) ratio in these samples was quantified using sandwich enzyme-linked immunosorbent assay techniques, and a bead-based multiplex immunoassay facilitated the detection of specific osteoclastogenesis-related cytokines.

Results

RANKL levels averaged 487.9 pg/mL in 14 of 23 patients in the osteolysis group, with no detection in the control group's synovial fluid. Conversely, a significant reduction in OPG levels was observed in the osteolysis group (p = 0.002), resulting in a markedly higher mean RANKL/OPG ratio (0.23) relative to controls (p = 0.020). Moreover, the osteolysis group had increased concentrations of various osteoclastogenesis-related cytokines (tumor necrosis factor-α, interleukin [IL]-1β, IL-6, IL-8, IP-10, and monocyte chemotactic protein-1) in the synovial fluid relative to the control group.

Conclusions

Our results demonstrated that periprosthetic osteolysis was associated with osteoclastogenesis activation through an elevated RANKL/OPG ratio following TAA. We assume that RANKL and other osteoclastogenesis-related cytokines in the synovial fluid have clinical value as a potential marker for the development and progression of osteolysis following TAA.

Fixed-bearing versus mobile-bearing total ankle replacement survivorship. A meta-analysis

BACKGROUND

Main objective of this research is to know if there is a different survival rate between fixed bearing (FB) and mobile bearing (MB) total ankle replacement (TAR). We hypothesized that there are no differences between the survival rates of both implants.

METHODS

A systematic search was performed in PubMed, Cochrane, EMBASE and ClinicalTrials.gov databases‎ to identify published studies from August 2018 to September 2022 including results for FB and MB TAR survivorship. Inclusion criteria included 1) primary TAR in one or both feet in which implant could be identified‎, 2) a minimum of 20 procedures reported, 3) reported implant survivorship or calculable and 4) a minimum of 12 months follow-up for level 1-3 studies or 60 months for level 4 studies.

RESULTS

3902 ankles in 28 studies were included. 719 were FB and 3104 MB with an overall survivorship of 94% (95% CI [0.89; 0.97]) and 89% (95% CI [0.86; 0.92]) respectively. After subgroup analysis, we did not find differences among both groups (p = ‎0.429‎). Meta-regression analysis showed that longer follow-up was associated with lower survival rates in MB group (p = 0.000) while no other relationships were found with other factors (age, level of evidence or conflict of interests).

CONCLUSIONS

No differences in survival rates between both groups were found. Age and other studied confounders were not found to be related with implant survivorship. However, longer follow-up was found to be related with lower survival rates. Studies with longer follow-up and higher level of evidence are needed to confirm results.

LEVEL OF EVIDENCE

IV, systematic review of level I to IV studies.

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.

Results of Total Ankle Arthroplasty Versus Ankle Arthrodesis

No differences have been found between total ankle arthroplasty (TAA) and ankle arthrodesis (AA) with respect to patient-reported outcome measures (PROMs), although both interventions were shown to improve PROMs with respect to the preoperative situation. That is, both interventions (AA and TAA) were effective in improving preoperative symptoms. On the other hand, 2-year complication rates were higher after AA (27%) than after TAA (16%); however, infection rates were similar (4%). The published revision rate after AA is 16% versus 11% after TAA. In short, TAA and AA appear to offer the same PROMs, but TAA has a lower rate of complications (except for infection) and revisions.

Outcomes after total ankle arthroplasty with an average follow-up of 10 years: A systematic review and meta-analysis

BACKGROUND

The literature demonstrating positive outcomes after total ankle arthroplasty (TAA) is mounting. However, the long-term outcomes of TAA (≥ 10 years) remain minimally reported. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics over multiple TAA studies with greater than 10 years of average follow-up.

METHODS

TAA studies were searched in Medline, Embase, and Scopus from the date of inception to September 12, 2022. Inclusion criteria included 1) studies of patients that underwent uncemented TAA, and 2) studies with an average follow-up time of at least ten years. Manuscripts in non-English languages and isolated abstracts were excluded. We collected American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) scores from the included studies for pooled meta-analysis. Due to the varying definition of survivability between studies, this metric was not assessed in our final evaluation.

RESULTS

Our data included approximately 3651 patients (3782 ankles). Of the 25 studies with an average follow-up of 10 years included in the systematic review, 5 provided pre- and post-operative AOFAS means and 5 provided pre- and post-operative VAS means with associated measures of variability and were included in our meta-analysis. The weighted mean difference between pre-and post-operative AOFAS and VAS scores was -40.36 (95% CI -47.24 to -33.47) and 4.52 (95% CI: 2.26-6.43), respectively. The risk of bias was low to moderate for the included studies.

CONCLUSION

Outcomes following TAA are favorable and indicate patient-reported outcome improvement over long-term follow-up. However, a significant amount of heterogeneity exists between studies. Future, prospective, randomized research should focus on standardizing outcome measures, survivorship, and complication reporting methodologies to allow for pooled meta-analyses of these important outcome metrics.

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.

Early Outcomes of Combined Total Ankle Total Talus Replacement Using a 3D-Printed Talus Component With Hindfoot Arthrodesis

Late-stage talar avascular necrosis (AVN) results in devascularization of the talus with osteonecrosis and subchondral collapse. A combined total ankle and total talus replacement (TATTR) with hindfoot arthrodesis may be utilized for end-stage talar AVN with tibiotalar and hindfoot joint arthritis. The purpose of this study is to evaluate the short-term outcomes of combined TATTR with hindfoot arthrodesis. Patients who underwent a combined TATTR or TTR with a hindfoot arthrodesis (subtalar with or without talonavicular arthrodesis) from 2016 to 2020 were retrospectively reviewed. Patient demographics, comorbidities, and surgical data were collected. Outcomes included the Visual Analog Scale (VAS) scores, range of motion, radiographic parameters, union rates, and complications. A total of 18 patients were reviewed. Nine patients were included with an average of 19.4 months follow-up. Significant postoperative improvements were observed in VAS scores (P < .001), ankle plantarflexion (P = .04), talocalcaneal height (P = .03), and tibiotalar alignment (P = .02). All patients achieved a successful union of their subtalar and talonavicular joints arthrodesis. There was one reoperation for a persistent varus ankle deformity. This is the first study to evaluate the clinical outcomes, radiographic outcomes, and union rate in combined TATTR with hindfoot arthrodesis. The early results demonstrated significant clinical improvement with 100% hindfoot union rate and no prosthetic failure.Level of Evidence: IV.