Conversion of painful ankle arthrodesis to total ankle arthroplasty

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.

Takedown of Ankle Arthrodesis and Conversion to Total Ankle Arthroplasty: A Systematic Review

Management of the nonunited or painful ankle arthrodesis remains a difficult challenge. The aim of this systematic review was to investigate the clinical outcomes and complications of conversion of an ankle fusion to a total ankle replacement (TAR). The PRISMA statement guidelines were followed. A literature search was performed in PubMed, Science Direct and Cochrane Central Register of Controlled Trails (CENTRAL) from their inception up to October 10th, 2023. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal tool and the Methodological Index for NonRandomized Studies (MINORS). Seven studies with 220 patients (223 ankles) with a mean follow-up of 64.9 months were included. Takedown of an ankle fusion and conversion to a TAR led to a significant improvement in all functional and clinical scores and with an acceptable range of motion. Most common complications were malleolar fractures (12.8%) and arthrofibrosis (5.6%). The revision rate was 8% and 4 cases resulted in a below-knee amputation. Cases with an insufficient fibula had a good outcome when a fibular reconstruction was performed. In conclusion, takedown of an ankle fusion and conversion to a TAR has satisfactory clinical outcomes and with a limited number of complications. Future well-designed studies are needed to validate the results of the present study.

Outcomes of Conversion of Ankle Fusion to Total Ankle Arthroplasty

With ankle replacements gaining popularity and documented good functional outcomes, there is an increasing number of patients inquiring about the possibility of converting an ankle fusion to a replacement. This could be due to pain, limited function, or increasing adjacent joint arthritis. There is an increasing body of evidence in the literature that a conversion to a replacement is possible and that the outcomes are positive. There are also absolute contradictions for a conversion. An absent fibula, pain of unknown origin, and recent infection fall in this category. Long-term follow-up is needed to see if conversions of ankle fusions to replacements have the same functional results and longevity as primary replacements.

[Postprimary early elective total arthroplasty in severe ankle fractures]

Treatment of the ankle joint with total ankle arthroplasty (TAA) is an established and safe surgical treatment for osteoarthritis of the ankle. Modern implants have low revision rates and are superior to ankle arthrodesis in terms of patient-reported outcomes. The importance of primary TAA treatment of ankle fractures is unclear. There are currently no studies in the literature on this topic. In view of the increasing number of cases of unstable ankle fractures, especially in older patients and with increasing functional demands also in old age, it is important to consider TAA in the management of these fractures in the future. Clinical studies are necessary to evaluate the treatment of ankle fractures using TAA.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

Takedown of Ankle Fusions and Conversion to Total Ankle Replacements

BACKGROUND

With ankle replacements gaining credibility, there is a small subset of patients who might benefit from a conversion of an ankle fusion to a replacement. The objective of this study is to present clinical and radiographic results of patients who had their ankle fusion converted to total ankle arthroplasty (TAA).

METHODS

Patients presented to the senior author with ongoing ankle pain following fusion or increasing pain after a period of relative comfort after an ankle fusion. Outcomes were evaluated preoperatively and postoperatively with the Veterans Rand Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) pain scale. A patient satisfaction survey was also distributed.

RESULTS

All ankle fusion conversions between April 2010 and December 2019 were included. Fifty-one patients (30 females) with the mean age of 62.6 (range, 37-83) years were followed. Mean follow-up was 4.2±2.3 (range, 2-11.5) years. Two patients were lost to follow-up (1 is deceased). Pre- and postoperative mean patient-reported outcome scores were all significantly different between groups except VR-12 mental subscale scores. VR-12 physical scores improved from 28.7±8.9 preoperatively to 38.9±9.9 (P < .001) postoperatively; VR-12 mental score was stable. AOS pain and disability subscales similarly improved: 55.9±24.4 to 27.9±25.4 (P < .001) and 61.7±21.1 to 31.1±25.7 (P < .001), respectively. VAS pain improved from a mean of 64.5±27.3 to 29.4±27.7 (P < .001). There was no tibiotalar dorsiflexion or plantarflexion with the ankle fusion. Initial postoperative visit revealed that average dorsiflexion was 10.9±5.93 degrees and average plantarflexion was 14.1±5.22 degrees. At the latest follow-up, dorsiflexion improved significantly to 15.5±6.33 degrees (P < .001), with no significant improvement in plantarflexion (P = .980).

CONCLUSION

In this single-surgeon longitudinal study of 51 patients with a painful, malaligned, or nonhealed ankle fusion treated with an ankle replacement, we found highly satisfactory functional outcomes at an average of 4.2 years. Continued long-term follow-up will reveal whether the longevity of these replacements is comparable to primary replacements.

Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?

Tibiotalar arthrodesis successfully treats ankle arthritis but carries risk of nonunion. It is unclear whether concurrent distal tibiofibular arthrodesis affects tibiotalar nonunion rate. The purpose of this study is to compare tibiotalar nonunion and complication rates in patients with versus without a distal tibiofibular arthrodesis. This is a retrospective review of 516 consecutive ankle arthrodesis performed between March 2002 and May 2016. A total of 319 ankles (312 patients) underwent primary, open tibiotalar arthrodesis (227 with distal tibiofibular arthrodesis, 92 without). Primary outcome measure was nonunion rate. Secondary outcome measures were time to tibiotalar union, rate of development of post-operative deep vein thrombosis (DVT)/pulmonary embolism (PE), rate of deep wound complications, and rate of return to operating room (OR). No differences in nonunion rates were observed in both cohorts of patients with versus without distal tibiofibular arthrodesis: 17/227 (7.5%) versus 11/92 (12%) (p = 0.2), respectively, odds ratio was 0.74, 95% CI: 0.29~2.08 (p = 0.55). There was no difference in deep wound complications (5.3% versus 10.9%, p = 0.42), time to union (3.7 months versus 4.1 months, p = 0.72), or rate of development of DVT/PE (5.2% versus 2.2%, p = 0.18) between patients with and without distal tibiofibular arthrodesis, respectively. This is the first study directly comparing nonunion and complication rates in primary, open ankle arthrodesis with and without distal tibiofibular arthrodesis. Inclusion of the distal fibular joint with the tibiotalar fusion was not associated with a change in tibiotalar nonunion rate, time to union, wound complications, or postoperative DVT/PE.

Total Talar Replacement With Custom-Made Vitallium Prosthesis for Talar Avascular Necrosis

Background: The current study investigated the application of three-dimensional (3D) printing technology in the treatment of talar avascular necrosis (TAN). Custom-made Vitallium talar prostheses were designed and generated via 3D printing. We hypothesized that these talar prostheses would facilitate more stable positioning, better ergonomically fit the ankle joint surfaces, and promote favorable long-term prognoses. Material and Methods: Computed tomography scans of both ankle joints were acquired from three patients diagnosed with TAN. The talar on the unaffected side was used as the design blueprint. Hence, with the aid of 3D printing technology a customized talar prosthesis made from a novel Vitallium alloy could be manufactured for each individual patient. Results: In all three cases there were no signs of prosthesis loosening or substantial degenerative change in the surrounding area of the joint, but small osteophytes were observed on the tibial side and navicular side. No chronic infection or other prosthesis-related complications were observed in any of the patients. All three were able to walk without pain at the most recent follow-up. Conclusion: With the aid of 3D printing and a novel Vitallium alloy, total talar replacement achieved encouraging results in 3/3 patients. All patients were satisfied with their joint function, and were able to return to their daily activities without limitations. Although more cases and longer-term follow-up periods are required, the success rate reported herein is encouraging.

Reconstruction of a missing or insufficient distal fibula in the setting of a total ankle replacement: The Milanese technique

BACKGROUND

The presence of an intact distal fibula is reported as a prerequisite when considering total ankle replacement and its lack is usually considered a contraindication. The purpose of the study was to describe the results of a surgical technique to reconstruct the distal fibula (Milanese fibular reconstruction technique) in the setting of a total ankle replacement and insufficient fibula.

METHODS

Retrospective analysis of 15 patients (15 ankles) who underwent rotational fibular reconstruction technique with minimum follow-up of 24 months. Patients were evaluated preoperatively and at the last follow-up with AOFAS Ankle and Hindfoot score, VAS pain scale, SF-12 and range of motion. Standard weightbearing radiographs were used for radiographic assessment.

RESULTS

The average of all clinical scores significantly improved (P<.001). The average radiographic parameters showed a neutral alignment. No cases of reabsorption of the new lateral malleolus were observed even in cases with complications that accounted for 2 superficial wound infection and 2 deep infections.

CONCLUSIONS

The Milanese fibular reconstruction technique can successfully reestablish a lateral strut and in the setting of an ankle prosthesis in patients with an insufficient fibula.

Comparison of Clinical Outcomes After Total Ankle Arthroplasty Between End-Stage Osteoarthritis and Rheumatoid Arthritis

BACKGROUND

Total ankle arthroplasty (TAA) is known to be a reliable operative option for end-stage rheumatoid arthritis. However, higher risk of postoperative complications related to chronic inflammation and immunosuppressive treatment is still a concern. With the use of a newer prosthesis and modification of anti-rheumatic medications, we compared clinical outcomes after TAA between patients with osteoarthritis and rheumatoid arthritis.

METHODS

Forty-five patients with end-stage osteoarthritis (OA group) and 19 with rheumatoid arthritis (RA group) were followed for more than 3 years after 3 component mobile-bearing TAA (Zenith^TM). Perioperative anti-rheumatic medications were modified using an established guideline used in total hip and knee arthroplasty. Clinical evaluations consisted of American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM).

RESULTS

In the preoperative and postoperative evaluation at final follow-up, there were no significant differences in AOFAS, FAOS, and FAAM scores between 2 groups. Despite statistical similarity in total scores, the OA group showed significantly better scores in FAOS sports and leisure (mean, 57.4 ± 10.1) and FAAM sports activity (mean, 62.5 ± 13.6) subscales than those in the RA group (mean, 52.2 ± 9.8, P = .004; and 56.4 ± 13.2, P < .001, respectively). There were no significant differences in perioperative complication and revision rates between 2 groups.

CONCLUSION

Patients with end-stage ankle RA had clinical outcomes comparable to the patients with OA, except for the ability related to sports activities. In addition, there were no significant differences in early postoperative complication rates, including wound problem and infection.

LEVEL OF EVIDENCE

Level III, prognostic, prospective comparative study.

Takedown of Painful Ankle Arthrodesis to Total Ankle Arthroplasty: A Case Series of 77 Patients

Treatment of painful or malaligned ankle arthrodesis can present as a challenging issue. Several published studies have demonstrated that takedown of a painful ankle arthrodesis to total ankle arthroplasty can assist in restoring some sagittal plane motion and improving functional scores. The goal of this study was to contribute to the limited body of literature with the largest cohort and longest follow-up to date. A retrospective analysis was performed on patient and surgical characteristics of those who underwent a conversion of a painful ankle arthrodesis to a total ankle arthroplasty by 1 of 3 experienced total ankle arthroplasty surgeons from February 2003 to December 2016 with ≥2 years of follow up. Seventy-seven subjects were included for evaluation, with an implant retention rate of 88% (68 of 77) and mean follow-up of 8.3 years (range 2.6 to 15.8). Of the 11 (14%) failures (defined as retrieval or exchange of metallic components), 8 (10%) were revised to a total ankle replacement, 2 (2%) underwent revision arthrodesis, and 1 (1%) elected for below-the-knee amputation. The mean time since the primary arthrodesis was 8.6 years (range 1 to 44), and the longer time interval between primary arthrodesis to takedown total ankle arthroplasty did not correlate with poorer outcome scores or increased risk of failure. The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot, Buechel-Pappas, and visual analog pain scale scores improved from preoperative values, with less satisfaction noted in those who needed revision surgery. The conversion of a painful ankle arthrodesis to a total ankle implant is a viable option to obtain range of motion and improved patient satisfaction scores similar to primary total ankle replacement.

Converting Ankle Arthrodesis to a Total Ankle Arthroplasty

Several articles in the literature discuss the positive results of converting a painful ankle fusion to an ankle replacement. Our results confirm that in well-selected cases a conversion to a total ankle replacement is not only possible, but also significantly improves quality of life and reduces pain. The outcome of a total ankle replacement after an ankle fusion depends to a degree on the method of fusion. Less destructive fusion that is arthroscopic has better results than conventional transfibular open fusions. Absence of a fibula should be an absolute contraindication for a conversion.

Outcomes of Ankle Arthrodesis Conversion to Total Ankle Arthroplasty: A Systematic Review

Ankle arthrodesis (AA) provides reliable pain relief, good patient satisfaction scores, and improved overall function. However, this procedure has been associated with numerous complications and sequelae, such as pseudoarthrosis, malunion, gait abnormalities, increased demand on surrounding joints, and a long period of convalescence. Conversion to total ankle arthroplasty (TAA) is a potential option in the management of these complex and challenging situations. The purpose of this study is to investigate the outcomes of AA conversion to TAA. A systematic review of electronic databases was performed. Six studies involving 172 ankles met inclusion criteria. The weighted mean preoperative Visual Analogue Scale (VAS) score at the time of TAA conversion was 7.8 and the weighted mean postoperative VAS score at the time of final follow-up was 2.5. The weighted mean preoperative AOFAS score at the time of TAA conversion was 32 and the weighted mean postoperative AOFAS score at the time of final follow-up was 72.4. The rate of salvage tibiotalocalcaneal arthrodesis was 2.3% and rate of transtibial amputation was also 2.3% after attempted conversion from initial AA to TAA. Conversion of AA to TAA appears to be a viable option to improve patient outcomes and prevent extensive hindfoot arthrodesis and transtibial amputation. More prospective studies with consistent reporting of outcomes, complications, and revision rates with long-term follow-up are needed.

A modified transfibular technique of ankle arthrodesis using partial fibular resection and onlay bone graft

The transfibular approach is a common procedure for tibiotalar fusion. However, this technique has several concerns: inadequate stability to resist rotational and shearing forces, a fibula is suboptimal for bone grafting, and an onlay fibular graft that might prevent impacting and cause distraction. We present a modified transfibular technique using partial fibular resection and onlay bone graft, which may address these potential problems. This study aimed to evaluate whether the ankle joint is well fused with neutral alignment and functionally improved at the final follow-up. For this study, 27 consecutive patients (mean age, 68.5 years; range, 58–83) who underwent tibiotalar fusion with a follow-up period of >1 year were retrospectively included. A modified transfibular lateral approach was performed, in which the distal anterior half fibula was resected and fixed as an onlay graft to achieve fusion between the tibia, fibula, talus, and fibular onlay graft simultaneously. Radiographic outcomes were assessed using computed tomography at 4 months after operation and serial follow-up radiographs. Functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot scale and Foot and Ankle Outcome Score. The mean follow-up period was 17.3 (range, 12–32) months. Four months after operation, complete union was achieved in 13 patients, near-complete union in 8 patients, and partial union in the remaining 6 patients. At the final follow-up, all the patients achieved complete union and maintained neutral ankle alignment. The functional outcome showed a significant increase between the preoperative and postoperative periods. One minor complication occurred, in which medial side ankle pain was relieved after screw removal. This modified technique is safe and effective, and has several merits, including saving the soft tissue of the anterior ankle, saving the course of the peroneal tendons by leaving the posterior half of the fibula, resected fibula serving as a good bone stock, and reducing the likelihood of valgus deformity after fibulectomy.

Revision of the Malaligned Ankle Arthrodesis

A malaligned ankle arthrodesis is a painful and complicated pathology. Deformities may be present in the frontal, sagittal, or transverse plane or a combination of planes. Thorough preoperative evaluation of the deformity and the patient as a whole is crucial to successful revision. Surgical site for revision should be based on center of rotation of angulation, when possible. Revision commonly is performed through opening wedge osteotomy. Closing wedge and focal dome osteotomies, however, are excellent options. Revision also may be performed through external fixation or total ankle replacement. Although the literature is not rich with data, the options discussed provide favorable results.

Anteroposterior Translational Malalignment of Ankle Arthrodesis Alters Foot Biomechanics in Cadaveric Gait Simulation

Tibiotalar arthrodesis is a common surgical treatment for end-stage ankle arthritis. Proper ankle alignment is important as malalignment can lead to complications that may require revision surgery. This study aimed to determine how anteroposterior (AP) translational malalignment of ankle arthrodesis affects distal foot joint kinematics and plantar pressure. Ankle arthrodesis was performed on 10 cadaveric foot specimens using a custom fixture that could fuse the ankle neutrally and induce discrete malalignments (3, 6, and 9 mm) anteriorly and posteriorly. Gait was simulated under each alignment with a robotic gait simulator, and foot bone motion and plantar pressure were quantified. AP translational malalignment did not substantially affect plantar pressure or joint range of motion, but there were several significant differences in joint position throughout stance phase. Differences were seen in five joints (talocalcaneal, talonavicular, calcaneocuboid, fifth tarsometatarsal, and first metatarsophalangeal) and in the position of the first metatarsal relative to the talus. The most extreme effects occurred when the talus was displaced 6 mm or more posteriorly. In vivo, this may lead to aberrant joint loading, which could negatively impact patient outcomes. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:450-458, 2020.

[Development and clinical application of ankle prosthesis]

OBJECTIVE

To review the development and clinical application of ankle prosthesis.

METHODS

The recent literature on ankle prosthesis design and clinical application was reviewed and analyzed.

RESULTS

Compared with the hip and knee prostheses, the ankle prosthesis develops slowly and has been developed to the third generation. The ankle joint has a special structure of multi-axis movement. The design of the first and second generations of prostheses is not conformed to the biomechanics of the ankle. The third generation of prosthesis is more conform to the characteristics of ankle biomechanics, with high postoperative survival rate and satisfactory clinical outcome.

CONCLUSION

At present, the survival rate of ankle prosthesis is low, and there is still much room for improvement in biomechanics, materials, and other aspects.

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BACKGROUND

The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.

METHODS

Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4±1.9years (range 1.0-6.5).

RESULTS

One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.

CONCLUSION

In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.

Risk Factors for Failure of Total Ankle Arthroplasty With a Minimum Five Years of Follow-up

BACKGROUND:

As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which patient factors are associated with implant failure. In this study, we aimed to use a large total ankle database to identify independent risk factors for implant failure at mid- to long-term follow-up.

METHODS:

A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 5 years' follow-up. The primary outcome was revision, defined as removal of one or both metal components; failures due to infection were excluded. Patient and clinical factors analyzed included age, sex, body mass index (BMI), smoking status, presence of diabetes, indication for TAA, implant, tourniquet time, and presence of ipsilateral hindfoot fusion. Preoperative coronal deformity and sagittal talar translation were assessed, as were postoperative coronal and sagittal tibial component alignment. Univariable and multivariable analyses were performed to identify predictors of implant failure. After excluding 5 ankles that failed because of deep infection, 533 ankles with a mean 7 (range, 5-11) years of follow-up met the inclusion criteria. Four implants were used: INBONE I, INBONE II, STAR, and Salto-Talaris.

RESULTS:

Thirty-four ankles (6.4%) were revised or removed a mean 4 (range, 1-9) years postoperatively. The only independent predictors of failure were the INBONE I prosthesis and ipsilateral hindfoot fusion ( P = .006 and P = .023, respectively).

CONCLUSIONS:

This is among the largest studies to analyze the relationship between TAA failure rates and multiple different patient, operative, and radiographic factors. Of note, age, BMI, and amount of deformity were not associated with higher failure rates. Only patients with ipsilateral hindfoot fusion or who received the INBONE I prosthesis were at significantly higher risk of implant failure.

LEVEL OF EVIDENCE:

Level III, retrospective cohort study.

Takedown of Ankle Arthrodesis With Insufficient Fibula: Surgical Technique and Intermediate-Term Follow-Up

Conversion of ankle arthrodesis to total ankle arthroplasty has recently gained popularity. However, technical challenges are present when treating patients without a sufficient fibular buttress. We describe a technique for restoration of an adequate fibular buttress using an iliac crest bone graft or malleolar relocation. The results of 10 patients with an average follow-up period of 56 (range 24 to 123) months are presented. Of the 10 patients, 3 underwent tricortical iliac bone augmentation of the fibula, 4 underwent repositioning of the remnant fibula, and in 3, the in situ fibula was used. The average interval from fusion to takedown was 15.1 (range 5 to 35) years, and the average age at takedown was 52.8 (range 33 to 75) years. The average improvement in the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale and Buechel-Pappas scale scores was 35.8 (range 30 to 46) and 34 (range 25 to 42), respectively. Three patients underwent a total of 7 subsequent operations related to the ankle implant. Only 1 of the patients had any residual frontal plane deformity. None of the patients exhibited any component subsidence; however, 2 patients experienced asymptomatic lateral talar component overgrowth. The improvement in the clinical scores in this group of patients suggests that takedown of an ankle arthrodesis with an insufficient fibula is a viable option to improve function. Various techniques to restore the lateral buttress can be used even with complete absence of the distal fibula.

Revision and Salvage Management: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article was to report on the consensus statements on "Revision and Salvage Management" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 8 statements on revision and salvage management reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). All statements reached at least 85% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with revision and salvage management in the cartilage repair of the ankle.

Can a Three-Component Prosthesis be Used for Conversion of Painful Ankle Arthrodesis to Total Ankle Replacement?

BACKGROUND

In patients with painful ankle arthrodesis, the surgical treatment is challenging, and may include takedown of ankle arthrodesis and conversion to a total ankle replacement (TAR). This procedure is technically demanding given the altered anatomy after arthrodesis. Few studies have evaluated TAR in the setting of prior arthrodesis.

QUESTIONS/PURPOSES

(1) What intraoperative and perioperative complications were observed in patients who underwent conversion of an ankle arthrodesis to a TAR? (2) Was durable fixation achieved at short term, and what was the alignment of the components? (3) What subsequent surgical procedures were performed, including revisions? (4) What improvements were observed in pain, tibiotalar range of motion (ROM), and quality of life?

METHODS

Between January 2007 and December 2014, 18 patients with a painful ankle arthrodesis underwent conversion to TAR at our tertiary referral center. During this period, the indications for conversion of ankle arthrodesis to TAR were tibiotalar nonunion or malunion after attempted arthrodesis in patients who declined revision ankle arthrodesis. The goal of revision surgery was to help patients regain hindfoot mobility and to decrease pain. During the study period, all patients who met indications were treated with a conversion procedure. Of the 18 patients included, 14 were men and four were women. The mean age of the patients was 51 ± 7 years. The mean followup was 54 ± 27 months, with no loss to follow up observed. The initial ankle arthrodesis was performed 6 ± 3.5 years before conversion to TAR. In all patients, the conversion to TAR was performed using a nonconstrained cementless three-component prosthesis. Intraoperative and postoperative complications, revision procedures, and prosthesis component loosening were evaluated. Weightbearing radiographs were used to determine the angular alignment of the tibial and talar components using α/β/γ angles and to analyze the bone-implant interface. Osseointegration was defined as visible trabecular structures at the bone-implant interface without radiolucent lines. The criteria for radiographic loosening was defined as subsidence or migration of prosthesis components and/or a cystic lesion with a diameter at least 2 mm. Clinical assessment included pain evaluation, measurement of ankle ROM, and quality of life.

RESULTS

Two of the 18 patients sustained an intraoperative medial malleolar fracture. In three patients, delayed wound healing was observed. At latest followup, four patients had incomplete osseointegration (posterior quarter of the bone-prosthesis interface on the tibial side). None of the 18 patients had prosthesis loosening. In all patients, both components were neutrally aligned. Two patients had painful arthrofibrosis with reduced ROM, which we treated with an open arthrolysis and exchange of mobile-bearing inlay; one other patient is considering a revision for substantial tibial component medial tilt with collapse of the medial arch. At the latest followup, the mean dorsiflexion and plantar flexion were 8.5° ± 3° and 15° ± 5°, respectively. The mean visual analog scale (VAS) score decreased from 9 ± 0.8 to 1.7 ± 1.6 (p < 0.001). The Short Form Health Survey questionnaire (SF-36) physical and mental outcome scores improved from 34 ± 5 to 74 ± 11 (p < 0.001) and from 49 ± 4 to 75.5 ± 7 (p < 0.001).

CONCLUSIONS

Conversion of an ankle arthrodesis to a TAR is a technically challenging procedure. In this small series, it was associated with frequent complications including arthrofibrosis, and functional outcomes including postoperative ROM were lower than reported for primary TAR. However, pain and function did improve. Further studies are necessary to address long-term clinical and radiographic outcomes in this patient cohort.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Dealing with the Stiff Ankle: Preoperative and Late Occurrence

In patients with a stiff ankle replacement, appropriate resection of scarred capsular structures, hypertrophic bone debridement, and careful release of tendons should be performed to achieve good outcomes. Appropriately sized and correctly implanted components are required to restore ankle function to as normal as possible. Although not proven, the better a total ankle replacement is balanced, the less likely scar and heterotopic bone formation will occur. In patients with a stiff and painful ankle replacement, a preoperative diagnostic workup is mandatory to understand the underlying pathologic process and plan appropriate treatment. All underlying causes should be addressed.

Obtaining Correct Ankle Alignment Using Intraoperative External Fixation for Ankle Arthrodesis

Ankle arthrodesis remains an important treatment option for patients with ankle arthritis. Many methods have been described; however, no consensus has been reached regarding the best technique to achieve both successful fusion and a good position for optimal foot mechanics. Furthermore, as arthroplasty has become more popular, preservation of the fibula to allow for future arthroplasty has become critical. The present report describes an innovative technique in which temporary external fixation at operative fixation is used, along with internal fixation, to achieve both an optimal foot position and high fusion rates, while maintaining the integrity of the fibula. Seventeen patients were identified who met the criteria for inclusion. Their medical records, including pre- and postoperative radiographs, were reviewed retrospectively. Preoperative and postoperative coronal and sagittal alignment was determined. All patients achieved successful fusion, although 1 (5.9%) patient experienced delayed union. The average tibial/talar ratio preoperatively was 21% (range 8% to 33%), demonstrating anterior subluxation. Postoperatively, this ratio improved to 33% (range 26% to 40%), approximating the normal anatomic ratio. Of the 17 patients, 5 (29.4%) had preoperative varus or valgus alignment of the talas >5°. All 5 cases were successfully corrected to within 2° of normal anatomic alignment. This technique allows the surgeon to achieve good visualization of the joint for preparation and to obtain the optimal position of the foot at arthrodesis without compromising the lateral column significance of the fibula. All patients obtained fusion, and minimal complications were associated with the use of this technique.

Tibiotalar Arthrodesis Conversion to Total Ankle Arthroplasty

Introduction

Although conversion of the painful ankle arthrodesis to total ankle arthroplasty remains controversial, this surgical modality has satisfactorily expanded the treatment armamentarium for addressing this pathology.

Indications & Contraindications

Step 1 Preoperative Preparation and Surgical Planning

Preoperative preparation and planning is similar to that for a primary total ankle arthroplasty, and implants designed for primary arthroplasty can be used in most patients managed with conversion to total ankle replacement.

Step 2 Patient Positioning

Position the patient as for a primary total ankle replacement.

Step 3 Remove Hardware and Insert Prophylactic Malleolar Screws

Preserve exsanguination time by removing hardware prior to inflating the tourniquet.

Step 4 Recreate the Tibiotalar Joint

Recreate the native joint line, which can be relatively easy in selected patients and challenging in others.

Step 5 Set the Optimal Talar Slope

Set the optimal talar slope, which can be challenging, particularly when the ankle arthrodesis is malunited in equinus.

Step 6 Recreate the Medial and Lateral Gutters

Because the former medial and lateral articulations between the talus and the malleoli can be difficult to define, use careful surgical technique to avoid compromise of the malleoli and excessive talar resection.

Step 7 Mobilize the Ankle and Use Bone Graft in Defects from Previous Hardware

To avoid potential malleolar fractures, mobilize the ankle only after the prophylactic malleolar screws have been placed; the tibial and talar cuts, completed; the gutters, reestablished; all resected bone, removed; and scar tissue from the posterior aspect of the ankle, excised; thereafter, conversion total ankle arthroplasty is similar to a primary total ankle replacement, with the exception of potential bone defects where prior hardware was positioned.

Step 8 Talar Preparation

Perform the routine steps for primary total ankle arthroplasty, often ignoring bone defects from the ankle arthrodesis hardware, but plan to repair the defects with bone-grafting before implanting the final talar component.

Step 9 Tibial Preparation and Definitive Components

Perform tibial preparation in a manner similar to that used for primary total ankle arthroplasty.

Results

We performed 23 conversion total ankle arthroplasties in patients who had an ankle arthrodesis, including those with pain despite successful fusion and those with painful nonunions⁹.

Pitfalls & Challenges

Conversion of ankle autofusion to total ankle replacement using the Salto XT revision prosthesis

Few reports in the literature have described the conversion of a surgically fused ankle to a total ankle replacement. The takedown of an autofusion and conversion to a prosthesis has not been described. We report the case of a patient with severe rheumatoid arthritis with an ankle autofusion fixed in equinus and severe talonavicular arthritis that was converted to ankle replacement using the Salto XT revision system. We describe the reasons why the decision was made to perform total ankle arthroplasty while concomitantly fusing the talonavicular joint, and discuss the rationale of the various surgical treatment options considered. We describe the clinical and radiographic outcomes achieved in this case. At 12 months post-operatively the patient reported significant reduction of pain, increased FAOS scores and had increased ankle range of motion.

Total Ankle Arthroplasty for the Treatment of Symptomatic Nonunion Following Tibiotalar Fusion

Background Nonunion of an ankle arthrodesis is associated with significant pain and morbidity. Revision arthrodesis presents greater short-term morbidity and long-term sequelae. 1-6 Recent reports have demonstrated the feasibility of converting a symptomatic nonunion of an ankle arthrodesis to a total ankle arthroplasty.7-9 The objective of the present study was to evaluate the short-term outcome associated with take down of symptomatic nonunions of ankle arthrodeses and conversion to a fixed bearing, intramedullary total ankle arthroplasty. Methods Five patients with symptomatic, aseptic tibiotalar arthrodesis nonunions (average age, 62.2 years), who underwent conversion to a total ankle arthroplasty were retrospectively identified and assessed at a prospective office visit. Minimum follow-up was 12 months (average, 21.3 months). Clinical outcomes were assessed on the basis of the American Foot and Ankle Society (AOFAS) ankle-hindfoot score10 and the Foot Function Index.11,12 Radiographic analysis, patient satisfaction and pain levels were also evaluated. Results The average post-operative AOFAS ankle-hindfoot score was 82.6, while the FFI was 28.2%. The average clinical range of motion was 35 degrees. Visual analog scale (VAS) pain scores averaged 31.1 out of 100. Four out of the five patients were very satisfied or satisfied. Radiographically, the tibial and talar components were stable in all patients without evidence of loosening, migration, or subsidence. There were no complications requiring additional procedures. Conclusions Patients undergoing ankle arthrodesis that is complicated by an aseptic nonunion pose a difficult clinical problem. Conversion to a total ankle arthroplasty with a fixed bearing, intramedullary implant is a viable treatment option with reliable short-term results.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Transfibular ankle arthrodesis using burring, curettage, multiple drilling, and fixation with two retrograde screws through a single lateral incision

PURPOSE

To review the outcome of 23 ankle arthrodeses using burring, curettage, multiple drilling, and fixation with 2 retrograde screws through a single lateral incision.

METHODS

Records of 22 consecutive patients aged 39 to 79 (mean, 62.4) years who underwent 23 ankle arthrodeses for end-stage ankle arthritis were reviewed. Through a single lateral incision, articular cartilage was removed using burring and curettage, and multiple holes were drilled using a Kirschner wire, followed by fixation with 2 retrograde screws. The resected distal fibula was fixed to the distal part of the talus and tibia. The position of the ankle and subtalar joint arthrosis was assessed by 2 orthopaedic specialists. Pre- and post-operative American Orthopaedic Foot and Ankle Society (AOFAS) scores were evaluated.

RESULTS

The mean operating time was 122 minutes. The mean follow-up period was 41 months. The mean postoperative ankle alignment was suboptimal: 2.7º varus, 6.7º plantar flexion, and 2.9º internal rotation. The mean AOFAS score improved from 30 to 71 (p<0.01). The postoperative varus ankle alignment was not associated with the AOFAS score (r= -0.13, p=0.569). Of the 23 cases, one was nonunion and 22 achieved bone union after a mean of 5.4 (range, 2-16) months; 3 of them were delayed union. Despite bone union, 7 patients complained of persistent pain; 4 of them had progressive arthrosis of the adjacent subtalar joints (n=2) or subtalar and talonavicular joints (n=2).

CONCLUSION

Ankle arthrodesis using burring, curettage, multiple drilling, and fixation with 2 retrograde screws achieved a high union rate and acceptable functional score without serious complications.

Total ankle joint replacement

Ankle arthritis results in a stiff and painful ankle and can be a major cause of disability. For people with end-stage ankle arthritis, arthrodesis (ankle fusion) is effective at reducing pain in the shorter term, but results in a fixed joint, and over time the loss of mobility places stress on other joints in the foot that may lead to arthritis, pain and dysfunction. Another option is to perform a total ankle joint replacement, with the aim of giving the patient a mobile and pain-free ankle. In this article we review the efficacy of this procedure, including how it compares to ankle arthrodesis, and consider the indications and complications.

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.

Current Concepts in the Management of Ankle Osteoarthritis: A Systematic Review

Ankle osteoarthritis is less common than hip or knee osteoarthritis; however, it is a relatively common presentation and is predominantly related to previous trauma. Treatments have traditionally consisted of temporizing measures such as analgesia, physiotherapy, and injections until operative treatment in the form of arthrodesis is required. More recently, interest has been increasing in both nonoperative and alternative operative options, including joint-sparing surgery, minimal access arthrodesis, and new arthroplasty designs. The present systematic instructional review has summarized the current evidence for the treatment options available for ankle osteoarthritis.

Conversion of a surgical elbow arthrodesis to total elbow arthroplasty

Arthrodesis of the elbow joint addresses pain due to intra-articular pathology, but with significant functional limitations. Loss of motion at the elbow is not completely compensated by the wrist and shoulder joints and elbow fusion is thus purely a salvage procedure. Advances in joint arthroplasty have allowed surgeons to address the functional limitations of arthrodesis, but despite these advances the elbow is still one of the joint replacements with higher complication rate. Conversion of a joint fusion to arthroplasty has been reported for the hip, knee, shoulder, and ankle. The takedown of a surgically fused elbow was reported in German literature in 2013. We present the first such case report in the English literature with a 49-year-old male whose status is elbow fusion performed for trauma 31 years prior.

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.

Short-term and mid-term outcome of total ankle replacement in haemophilic patients

BACKGROUND

Ankle arthropathy is very frequent in haemophilic patients. Prostheses are valuable alternatives to arthrodesis in non-haemophilic patients. We report the experience of a single centre in France on the use of prostheses in haemophilic patients.

METHODS

Retrospective study of 21 patients with haemarthropathy who underwent ankle arthroplasty (32 ankles), with additional surgery, if needed, from July 2002 to September 2009 (mean follow-up 4.4±1.7 years). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale was used to evaluate pain, function, ankle mobility and alignment.

RESULTS

The overall AOFAS score improved from 40.2±19.4 (pre-surgery) to 85.3±11.4 (post-surgery). The function score increased from 23.6±7.7 to 35.9±6.7 and dorsiflexion from 0.3°±5.0° to 10.3°±4.4°. Two patients underwent further ankle arthrodesis. On X-ray, both tibial and talar components were stable and correctly placed in all ankles. Alignment was good.

CONCLUSION

Ankle arthroplasty is a promising alternative to arthrodesis in haemophilic patients.

Ankle arthritis: review of diagnosis and operative management

The diagnostic and therapeutic options for ankle arthritis are reviewed. The current standard of care for nonoperative options include the use of nonsteroidal antiinflammatory drugs, corticosteroid injections, orthotics, and ankle braces. Other modalities lack high-quality research studies to delineate their appropriateness and effectiveness. The gold standard for operative intervention in end-stage degenerative arthritis remains arthrodesis, but evidence for the superiority in functional outcomes of total ankle arthroplasty is increasing. The next few years will enable more informed decisions and, with more prospective high-quality studies, the most appropriate patient population for total ankle arthroplasty can be identified.

Total Ankle Arthroplasty with a Modern Fixed-Bearing System: The Salto Talaris Prosthesis

Introduction

The Salto Talaris total ankle replacement is a fixed-bearing system that integrates a mobile tibial trial component that allows self-alignment on the distal tibial resected surface, as guided by the talar component.

Step 1 Preoperative Planning

A thorough preoperative assessment is crucial.

Step 2 Anterior Approach

Meticulous soft-tissue handling is essential.

Step 3 Tibial Preparation

Use intraoperative fluoroscopy and direct inspection to determine the appropriate alignment, tibial component size, and resection level as guided by the external tibial alignment and cutting guides.

Step 4 Talar Preparation

Use the largest talar component that does not impinge on either malleolus.

Step 5 Implant Trialing

Careful assessment of ankle range of motion and stability in conjunction with selection of an appropriately sized polyethylene insert and consideration of additional soft-tissue balancing procedures are key to implantation of a well-balanced stable ankle replacement.

Step 6 Final Implant Placement and Closure

Completion of a meticulous, layered soft-tissue closure over a drain and placement of a well-padded short leg cast are key to soft-tissue stability and wound-healing.

Step 7 Postoperative Care

Wound and soft-tissue healing drive the initial postoperative management.

Results

Published, prospective studies of the clinical outcomes of modern fixed-bearing total ankle systems are limited in the United States, mainly because FDA approval of these systems is more recent than that of other mobile-bearing options.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Ankle osteoarthritis: etiology, diagnostics, and classification

Osteoarthritis (OA) is defined as the syndrome of joint pain and dysfunction caused by substantial joint degeneration. In general, OA is the most common joint disease and is one of the most frequent and symptomatic health problems for middle-aged and older people: OA disables more than 10% of people who are older than 60 years. This article reviews the etiology of ankle OA, and describes the onset and development of posttraumatic ankle OA, the most common form of OA in the tibiotalar joint. Various methods of clinical and radiographic assessment are described in detail.

Total ankle arthroplasty: a radiographic outcome study

OBJECTIVE

Total ankle arthroplasty (TAA) is becoming a popular alternative to arthrodesis for patients with end-stage ankle arthrosis. Prior outcome studies have primarily focused on surgical findings. Our purpose is to determine the radiographic outcome of TAA and to correlate it with clinical outcome.

MATERIALS AND METHODS

In a 9-year retrospective review of patients with TAA, all available ankle radiographs and clinical data were reviewed. Data analysis included descriptive statistics, Fisher exact test, and Kaplan-Meier survival curves for radiographic and clinical survival.

RESULTS

Two hundred sixty-two TAAs in 260 patients were reviewed; 55% were in women, and the mean patient age was 61.5 years. The mean radiographic follow-up was 142 weeks, with an average of six radiographs per patient. One hundred sixty-three patients (62.2% of TAAs) developed one or more radiographic complications, including periprosthetic lucency (34.0%), hardware subsidence (24.4%), perihardware fracture (11.1%), syndesmotic screw loosening (10.3%), and screw fracture (6.5%). One hundred nineteen patients (45.4% of TAAs) developed symptoms of ankle pain or instability, and 71 patients (27.1% of TAAs) underwent at least one reoperation. In patients with radiographic complications, 41.7% developed ankle pain and 5.1% developed ankle instability, compared with 23.7% and 2.2%, respectively, of patients with no radiologic complications (p < 0.05). Of the patients with radiographic complications, 33.1% had at least one additional surgery compared with 17.1% of patients without radiographic complications (p < 0.05).

CONCLUSION

Radiographic complications are common in patients after total ankle arthroplasty. There is a strong positive association between postoperative radiographic findings and clinical outcome. Knowledge of common postoperative radiographic findings is important for the practicing radiologist.

HINTEGRA revision arthroplasty for failed total ankle prostheses

BACKGROUND

When a total ankle replacement fails, arthrodesis has been advocated as the treatment of choice. With the availability of a wide spectrum of implants, revision arthroplasty may become a viable alternative.

METHODS

We reviewed a consecutive series of 117 cases (116 patients [fifty-six female and sixty male]; mean age, 55.0 ± 12.0 years) in which a total ankle arthroplasty failed after a mean of 4.3 years and was revised with use of the HINTEGRA three-component total ankle prosthesis. The reason for revision involved the metallic components in sixty ankles (51%), the bone in twenty-eight (24%), the soft tissues in twenty (17%), and infection in nine (8%). The talar component was revised in 104 ankles (89%) and the tibial component, in 106 (91%).

RESULTS

Early complications included a fracture of the malleoli in two ankles and a dislocation of the polyethylene insert in one. Seventeen (15%) of the revision arthroplasties required further revision surgery, in most cases for loosening of one or two of the prosthetic components. The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score for the remaining 100 ankles (85%) improved from 44 ± 18 preoperatively to 72 ± 19 (p < 0.01) at the time of the latest follow-up (mean, 6.2 years). The estimated survival of the revision arthroplasties at nine years, with loosening of components as the end point, was 83%. The prevalence of component loosening was higher (p < 0.005) with the use of single-coated hydroxyapatite components (six of twenty-three ankles, 26%) than with double-coated components (five of ninety-four ankles, 5%). The correlation between the extent of bone loss at the resection surface and the prevalence of component failure was weak and not significant.

CONCLUSIONS

The medium-term results of revision arthroplasty after a failed total ankle arthroplasty were similar to those after primary arthroplasty. The key to success was firm anchorage of the components to primary bone stock. A single hydroxyapatite component coating should no longer be used for revision total ankle arthroplasty.

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.