The Fate of Bone Graft for Periprosthetic Osteolysis in Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Periprosthetic osteolysis in total ankle arthroplasty (TAA) is a substantial problem. It may cause implant failure and has potential to affect long-term implant survival. To prevent major revisional arthroplasty, it is important to make an early diagnosis of osteolysis and decide an appropriate timing of surgical intervention such as bone graft. We report our experience of bone graft for osteolysis after TAA associated with clinical and radiologic outcome. Methods: Between May 2004 and Oct. 2013, 238 primary TAA were performed on 219 patients. We excluded 37 ankles with follow-up less than 24 months; thus, 201 ankles in 185 patients with mean follow-up of 61.9 (range, 24-130) months were included in the study. Nineteen patients were treated with a total of 21 bone graft procedures for periprosthetic osteolysis after TAA. Of these patients, 12 (57.1%) were males with mean follow-up length after bone graft 35.0 months. Location of osteolysis, bone grafting method and clinical outcome parameters using visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score were recorded. Results: Radiographs revealed total of 62 osteolysis lesions in 19 patients; 35 (56.5%) distal tibial lesions, 23 (37.0%) talar lesions. Autogenous iliac bone graft was used in 18 procedures (85.7%). The mean scores (and standard deviation) improved for the VAS from 4.8 ± 1.23 points before bone graft to 3.0 ± 0.94 points at the last follow-up (p<0.05); and for the AOFAS score from 76.8 ± 5.9 before bone graft to 84.3 ± 4.5 at the last follow-up (p<0.05). After 21 bone graft procedures, 6 demonstrated detection of newly developed osteolysis. One patient needed a repeat bone graft procedure with cementation after the primary bone grafting due to large cyst on distal tibia. There was no implant failure or major revisions after the bone graft. Conclusion: Bone graft for periprosthetic osteolysis may improve patient’s clinical outcome and give support to the structures surrounding the implant. Bone grafting in optimal timing may also improve implant survivorship. However, further study is needed for the etiology of newly developed painless osteolysis even after the bone graft.

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Management of Periprosthetic Osteolysis after Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00378 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0037

Author(s):

Yoo Jung Park ◽

Kwang Hwan Park ◽

Jae Han Park ◽

Seung Hwan Han ◽

Sang B. Kim ◽

...

Keyword(s):

Clinical Outcome ◽

Bone Graft ◽

Bone Grafting ◽

Distal Tibia ◽

Total Ankle Arthroplasty ◽

Implant Failure ◽

Time Interval ◽

Consecutive Series ◽

Periprosthetic Osteolysis ◽

Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: Periprosthetic osteolysis in total ankle arthroplasty (TAA) is a substantial problem. It may cause implant failure and has potential to affect long-term implant survival. To prevent major revisional arthroplasty, it is important to make an early diagnosis of osteolysis and decide an appropriate timing of surgical intervention such as bone graft. We report our updated result of bone graft for osteolysis after TAA associated with clinical and radiologic outcome. Methods: We retrospectively evaluated our consecutive series of 440 primary TAAs performed between May 2004 and August 2018 and identified those who had a subsequent bone graft procedure. A total of 38 bone graft procedures for periprosthetic osteolysis after TAA were performed. Mean time-interval between primary TAA and bone graft was 5.09 years (range 17.0 to 127.0 months). Location of osteolysis, bone grafting method and clinical outcome parameters using visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score were recorded. Results: Radiographs revealed periprosthetic osteolysis in 51.8% (58/112) of distal tibial lesions and 41.1% (46/112) of talar lesions. Autogenous iliac bone graft was used in most of procedures. Both mean VAS and AOFAS scores improved significantly at the last follow-up (p<0.05) One patient needed a repeat bone graft procedure with additional bone cementation after the primary bone grafting due to large cyst on distal tibia. There was no implant failure or major revisions after the bone graft. Conclusion: Bone graft for periprosthetic osteolysis may improve patient’s clinical outcome and give support to the structures surrounding the implant. Bone grafting in optimal timing may also improve implant survivorship. However, further study is needed for the etiology of newly developed painless osteolysis even after the bone graft.

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A Comparison of Cyst Formation and Management in Mobile-Bearing and Fixed-Bearing Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00005 ◽

2019 ◽

Vol 4 (2) ◽

pp. 2473011419S0000

Author(s):

James Lachman ◽

Michel Taylor ◽

Elizabeth Cody ◽

Daniel Scott ◽

James A. Nunley ◽

...

Keyword(s):

Bone Grafting ◽

Patient Reported Outcomes ◽

Mobile Bearing ◽

Cyst Formation ◽

Total Ankle Arthroplasty ◽

Fixed Bearing ◽

Ankle Arthroplasty ◽

Ankle Replacement ◽

Patient Reported

Category: Ankle Arthritis Introduction/Purpose: The Scandinavian Total Ankle Replacement(STAR) system and Salto Talaris(ST) total ankle system are two of the more commonly studied total ankle implants. As the STAR is one of the oldest total ankle arthroplasty (TAA) implants still in use today, most studies focus on longevity and survivorship. Reported rates of cyst formation for these two prosthesis in most series vary from 11-22% but no large study has focused on surgical management of these cysts or included patient reported outcomes after surgery. In this series, we aimed to investigate rates of cyst formation between mobile(MB) and fixed-bearing(FB) TAA and examine clinical and patient reported outcomes of bone grafting or cementing of large cysts surrounding the STAR and ST implants. Methods: A prospectively collected database at a high volume total ankle replacement center was retrospectively reviewed to identify patients who underwent TAA with either the STAR or the ST total ankle system between 2007 and 2015. Cysts were identified and measured on standard weight bearing radiographs and confirmed on computed tomography(CT) when available. Visual analog scale (VAS) score, Short Form-36 (SF-36) physical and mental component scores, Short Musculoskeletal Function Assessment(SMFA), and AOFAS hindfoot scores were collected from all patients preoperatively and then at 6 months, 1 year and annually postoperatively. Patients with a minimum 2 years follow-up who underwent revision TAA secondary to catastrophic bone cysts or who were managed with either curettage and bone grafting or curettage and cementing of bone cysts surrounding the TAA prosthesis were included in the patient reported outcomes (PRO) analysis Results: Excluding 53 patients for inadequate follow-up, 232 patients (29% female, 71% male; follow-up 6.7 years) who underwent STAR-TAA and 147 patients (26.6% female, 73.5% male; follow-up 7 years) who underwent ST-TAA were identified. Cysts <20 mm diameter occurred more often in the MB TAAs, and more often in the tibia than talus (table). Cysts >10 mm were identified in 95/232 (41%) STAR and 24/147 (16%) ST ankles. In the STAR group, 24 patients underwent cyst bone grafting (13), cementing (6) or both (8) at a mean 4.8 years. In the ST group, 14 patients underwent cyst bone grafting (6), cementing (4), or both (4) at a mean of 2.7 years. PRO data improved significantly for both the STAR and ST group in all questionnaires (p<0.05 for all). Conclusion: Mobile-bearing total ankle arthroplasty in this cohort had a higher rate of cyst formation greater than 10 mm (95/232 patients, 41%) when compared to a fixed-bearing TAA (24/147, 16.3%). Only 24/95 (25%) of STAR patients and 14/24 (58%) of ST patients required surgical intervention for cyst management. Patient reported outcomes after cyst surgery improved significantly when compared to pre-cyst management surgery and did not differ between MB and FB cohorts (p=0.424). Successful surgical management of large cyst surrounding either mobile-bearing or fixed-bearing total ankle systems can be expected based on the results of this study. [Table: see text]

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Effect of age on outcome and revision in total ankle arthroplasty

The Bone & Joint Journal ◽

10.1302/0301-620x.102b7.bjj-2019-1263.r2 ◽

2020 ◽

Vol 102-B (7) ◽

pp. 925-932 ◽

Cited By ~ 1

Author(s):

Mario Gaugler ◽

Nicola Krähenbühl ◽

Alexej Barg ◽

Roxa Ruiz ◽

Tamara Horn-Lang ◽

...

Keyword(s):

Pain Relief ◽

Clinical Outcome ◽

Revision Surgery ◽

Preoperative Assessment ◽

Total Ankle Arthroplasty ◽

Consecutive Series ◽

Ankle Arthroplasty ◽

Major Revision ◽

Effect Of Age

Aims To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA). Methods A consecutive series of 811 ankles (789 patients) that underwent TAA between May 2003 and December 2013 were enrolled. The influence of age on clinical outcome, including the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and pain according to the visual analogue scale (VAS) was assessed. In addition, the risk for revision surgery that includes soft tissue procedures, periarticular arthrodeses/osteotomies, ankle joint debridement, and/or inlay exchange (defined as minor revision), as well as the risk for revision surgery necessitating the exchange of any of the metallic components or removal of implant followed by ankle/hindfoot fusion (defined as major revision) was calculated. Results A significant improvement in the AOFAS hindfoot score and pain relief between the preoperative assessment and the last follow-up was evident. Age had a positive effect on pain relief. The risk for a minor or major revision was 28.7 % at the mean follow-up of 5.4 years and 11.0 % at a mean follow-up of 6.9 years respectively. The hazard of revision was not affected by age. Conclusion The clinical outcome, as well as the probability for revision surgery following TAA, is comparable between younger and older patients. The overall revision rate of the Hintegra total ankle is comparable with other three component designs. TAA should no longer be reserved for low demand elderly patients, but should also be recognized as a viable option for active patients of younger age. Cite this article: Bone Joint J 2020;102-B(7):925–932.

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Survivorship and Long-term Results of Consecutive Series of 118 Hintegra Total Ankle Arthroplasties

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00334 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0033

Author(s):

Jae Han Park ◽

Yeok Gu Hwang ◽

Jae Bum Kwon ◽

Dong Woo Shim ◽

Kwang Hwan Park ◽

...

Keyword(s):

Clinical Outcomes ◽

Mobile Bearing ◽

Total Ankle Arthroplasty ◽

Long Term Outcomes ◽

Metal Component ◽

Aofas Score ◽

Ankle Arthroplasty ◽

The Mean

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) has been more suggested to patients with end-stage ankle osteoarthritis. However, there were few studies which had investigated long-term clinical outcomes with mobile bearing system. The purpose of this study is to evaluate the long-term outcomes of total ankle arthroplasty with use of the Hintegra prosthesis and to identify prognostic factors that affect the outcome. Methods: Between September 2004 and December 2009, 118 ankles underwent total ankle arthroplasty with Hintegra prosthesis. Clinical outcomes were assessed annually after operation using visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) scores, plain radiographs and re-operation. Kaplan-Meier survival plot showed survival outcomes of TAA in long-term follow-up. Results: The mean follow-up period was 10.9 years (range 9.0-14.3). The mean change from baseline to final follow-up was -6.7 ± 4.3 points for VAS, and 26.1 ± 10.3 points for the AOFAS score. Three (2.5%) of the ankles required metal component revision at a mean of 2.9 ± 1.8 years (range, 0.5 to 5.8 years) after primary surgery. Five (4.2%) ankles underwent conversion to arthrodesis. Cystic osteolysis that needed surgery was 19 (16.1%) cases, most frequent lesion was posterior aspect of distal tibia. 65 ankles (55.1%) showed heterotopic ossifications but the degree of heterotopic ossification was not significantly correlated with VAS and AOFAS score. Revision with metal component as the end point of prosthesis was 86% at 10 years of follow up. Conclusion: Long term outcomes were satisfactory after mobile-bearing total ankle arthroplasty. Further study to elucidate possible reasons for osteolysis and subjective pain after TAA is warranted.

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Volume and Distribution of Periprosthetic Bone Cysts in the Distal Tibia and Talus before Early Revision of Total Ankle Arthroplasty

Applied Sciences ◽

10.3390/app11167242 ◽

2021 ◽

Vol 11 (16) ◽

pp. 7242

Author(s):

Seoyeong Kim ◽

Jinju Jang ◽

Jae-Hyuk Choi ◽

Hai-Mi Yang ◽

Heoung-Jae Chun ◽

...

Keyword(s):

Distal Tibia ◽

Three Dimensional ◽

Total Ankle Arthroplasty ◽

Periprosthetic Osteolysis ◽

Periprosthetic Bone ◽

Careful Planning ◽

Ankle Arthroplasty ◽

Early Revision ◽

Further Development ◽

Stress Flow

Periprosthetic osteolysis is a common complication following total ankle arthroplasty (TAA). However, understanding of osteolysis volume and distribution is still evolving, undermining efforts to reduce the incidence of osteolysis via bone remodeling. We obtained data on the characteristics of osteolysis developing within the distal tibia and talus after TAA. Three-dimensional computed tomography (3D-CT) reconstructions of 12 patients who underwent HINTEGRA TAA were performed. We identified 27 volumes of interest (VOIs) in the tibia and talus and used statistical methods to identify the characteristics of osteolysis in the VOIs. The osteolysis volume was significantly larger in the talus than in the tibia (162.1 ± 13.6 and 54.9 ± 6.1 mm3, respectively, p = 0.00). The extent of osteolysis within the peri-prosthetic region was greater than within other regions (p < 0.05). Particularly, in the talus, the region around the talar pegs exhibited 24.2 ± 4.5% more osteolysis than any other talar region (p = 0.00). Our results may suggest that extensive osteolysis within the peri-prosthetic region reflects changes in stress flow and distribution, which vary according to the design and placement of the fixation components. This is the first study to report 3D osteolysis patterns after TAA. Careful planning of TAA design improvements may reduce the incidence of osteolysis. Our results will facilitate the further development of TAA systems.

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Influence of Depressive Symptoms on Clinical Outcomes of Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00041 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0004

Author(s):

Tae Yong Kim ◽

Jungtae Ahn ◽

Bi O Jeong

Keyword(s):

Depressive Symptoms ◽

Clinical Outcome ◽

Statistical Difference ◽

Distal Tibia ◽

Ankle Arthritis ◽

Ankle Arthroplasty ◽

The Relationship ◽

Depressive Group ◽

Surface Angle

Category: Ankle Arthritis Introduction/Purpose: Recently, there have been many reports on the relationship between depression and clinical outcome of knee or hip arthroplasty. However, there is no study on the association between depression and total clinical outcome of total ankle arthroplasty (TAA). This study investigated the relationship between depressive symptoms and clinical outcome after TAA. Methods: Forty patients who underwent TAA for end-stage ankle arthritis from July 2014 to July 2017 and were able to follow- up at least 12 months were selected. Depressive symptoms were evaluated using Center for Epidemiologic Studies Depression Scale (CES-D) and Patient Health Questionnaire-9 (PHQ-9). The subjects were divided into Depressive group and Non-depressive group, and the preoperative and postoperative clinical results were compared using a visual analogue scale (VAS), American orthopedic foot and ankle-hindfoot score (AOFAS). The preoperative and postoperative radiological results were also compared using anterior surface angle of distal tibia (TAS), talar tilt of ankle joint (TT), lateral surface angle of distal tibia (TLS), and heel alignment distance (HD). Results: The mean age of the patients was 61.6±18.2 years and the average follow-up period was 24.3±7.3 months. 13 subjects were in Depression group and 27 subjects were in Non-depression group. There was no statistical difference in baseline characteristics between the two groups. Additionally, there was no statistical difference in preoperative VAS and AOFAS between the two groups (p>.05). Preoperative and postoperative VAS and AOFAS showed statistically significant improvement in both groups (p<.05). However, the depressive group showed higher result in postoperative VAS than the Non-depressive group significantly (3.1±2.4 vs 1.4±2.3, p<.05). The postoperative AOFAS was also higher in the non-depressive group significantly (89.3±13.4 vs 95.0±8.1, p<.05). Both groups showed improvement in postoperative radiologic index. Preoperative and postoperative radiologic index showed no difference in both groups. Conclusion: The clinical outcome after TAA was poor in patients with depressive symptoms when compared to patients without depressive symptoms. Since depressive symptoms is a patient-specific factor that result in less improvement in clinical outcomes after TAA, clinical considerations for depressive symptoms are needed prior to TAA surgery.

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Comparison of Preoperative Bone Density in Patients With and Without Periprosthetic Osteolysis Following Total Ankle Arthroplasty

Foot & Ankle International ◽

10.1177/1071100720976096 ◽

2020 ◽

pp. 107110072097609

Author(s):

Gun-Woo Lee ◽

Hyoung-Yeon Seo ◽

Dong-Min Jung ◽

Keun-Bae Lee

Keyword(s):

Bone Density ◽

Ankle Joint ◽

Bone Ingrowth ◽

Distal Tibia ◽

Reference Points ◽

Total Ankle Arthroplasty ◽

Coronal Plane ◽

Periprosthetic Osteolysis ◽

Ankle Arthroplasty ◽

Press Fit

Background: Modern total ankle arthroplasty (TAA) prostheses are uncemented press-fit designs whose stability is dependent on bone ingrowth. Preoperative insufficient bone density reduces initial local stability at the bone-implant interface, and we hypothesized that this may play a role in periprosthetic osteolysis. We aimed to investigate the preoperative bone density of the distal tibia and talus and compare these in patients with and without osteolysis. Methods: We enrolled 209 patients (218 ankles) who underwent primary TAA using the HINTEGRA prosthesis. The overall mean follow-up duration was 66 (range, 24-161) months. The patients were allocated into 2 groups according to the presence of periprosthetic osteolysis: the osteolysis group (64 patients, 65 ankles) and nonosteolysis group (145 patients, 153 ankles). Between the 2 groups, we investigated and compared the radiographic outcomes, including the Hounsfield unit (HU) value around the ankle joint and the coronal plane alignment. Results: HU values of the tibia and talus measured at 5 mm from the reference points were higher than those at 10 mm in each group. However, comparing the osteolysis and nonosteolysis groups, we found no significant intergroup difference in HU value at every measured level in the tibia and talus ( P > .05). Concerning the coronal plane alignment, there were no significant between-group differences in the tibiotalar and talar tilt angles ( P > .05). Conclusions: Patients with osteolysis showed similar preoperative bone density of the distal tibia and talus compared with patients without osteolysis. Our results suggest that low bone density around the ankle joint may not be associated with increased development of osteolysis. Level of Evidence: Level III, retrospective cohort study.

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

Foot & Ankle International ◽

10.1177/1071100718806474 ◽

2018 ◽

Vol 40 (3) ◽

pp. 249-258 ◽

Cited By ~ 12

Author(s):

Elizabeth A. Cody ◽

Lorena Bejarano-Pineda ◽

James R. Lachman ◽

Michel A. Taylor ◽

Elizabeth B. Gausden ◽

...

Keyword(s):

Risk Factors ◽

Smoking Status ◽

Total Ankle Arthroplasty ◽

Implant Failure ◽

Failure Rates ◽

Level Of Evidence ◽

Tourniquet Time ◽

Ankle Arthroplasty ◽

Hindfoot Fusion

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.

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