Heterotopic Ossification in Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Heterotopic ossification (HO) following total ankle arthroplasty (TAA) is a known sequela and has been reported to contribute to reduced postoperative range of motion and poor patient functional outcomes. However, conflicting results have been reported in the literature with respect to the correlation between HO and clinical outcome. As new strategies and implants continue to be designed, it is important to understand what instruments for measuring the outcome of treatment are important to assess when evaluating outcome measures in TAA. The present study documents the incidence of HO and functional outcome for the novel 2 component fixed bearing Infinity Total Ankle System prosthesis at minimum of two year follow up and reports a systematic review of the literature. Methods: We reviewed the incidence, degree of severity, and functional outcome in 67 consecutive patients who underwent primary Infinity TAA at two North American tertiary medical centers between 2013 and 2015 in a prospective observational study. Radiographic and functional outcome data was collected preoperatively, at 6 to 12 months postoperatively, and annually thereafter. In addition, we conducted a systematic review of studies reporting the incidence of HO following TAA. We included peer-reviewed studies reporting on at least 20 TAAs with minimum follow up of two years. Results: While the incidence of HO was 68% at 2.4 years in the 67 patients who underwent primary Infinity TAA, there was no association between HO and AOFAS (HO 73.9, no HO 55.0), SF36-PCS (HO 50.1, no HO 45.2), FFI (HO 22.1, no HO 26.4), and VAS (HO 2.6, no HO 2.3). Fourteen studies with 1201 TAAs were included. The overall incidence of HO following TAA was approximately 56.6% at average 3.8 years with a wide range (range, 22.2-100%). Four studies (299 ankles) did not address functional outcomes. Nine studies (822 ankles) reported no association between functional outcomes and HO. One study (80 ankles) reported a statistically significant difference in range of motion of 7 degrees of dorsiflexion and a 7-point difference in AOFAS score. Conclusion: There was no association between HO and functional outcome in our observational cohort. Only one study demonstrated statistically significant differences in range of motion and functional outcome due to HO. Although the minimal clinical important difference in ankle dorsiflexion and AOFAS has not been established in TAA, these differences are below the minimal clinical important difference established in other foot and ankle procedures. Available data, including the results in our 67 patients, suggests that clinical function is independent of the presence of HO.

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Axial Rotational Alignment of Mobile-Bearing Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00216 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0021

Author(s):

Beat Hintermann ◽

Lukas Zwicky ◽

Christine Schweizer ◽

Alexej Barg ◽

Roxa Ruiz

Keyword(s):

Tibial Component ◽

Mobile Bearing ◽

Total Ankle Arthroplasty ◽

Axial Position ◽

Anterior Surface ◽

Ankle Arthroplasty ◽

Medial Border ◽

Wide Range ◽

Angle Of Rotation

Category: Ankle Arthritis Introduction/Purpose: In total ankle arthroplasty (TAA), component malpositioning is a major cause of implant failure, possibly due to the altered force patterns caused by the malpositioning which are then transmitted to the bone-implant interface or neighboring joints during physiological loading. Mobile-bearing TAA with their second interface, may allow the talus to adapt its position based upon the individual anatomy. However, no data exist on the change in component positioning after implantation. It is unclear whether it is the result of initial positioning during implantation or secondary adjustments such as possible soft tissue adaptions. We aimed to determine the relative axial rotation between the talar and tibial components at the end of surgery and after a minimum of 3 years follow-up. Methods: The relative rotation between the tibial and talar components was measured in two groups. First, intraoperatively before wound closure, in a consecutive series of 58 patients (60 ankles; age 61.8 [31 to 86] years; females 25, males, 35) who underwent TAA between February and November 2018. A K-wire inserted along the medial border of the tibial component and a rectangular marker positioned at the anterior surface of PE insert were used to determine the angle of rotation. Second, in 48 patients (48 ankles; age 60.2 [31 - 82] years; females, 24; males, 24) out of 1411 patients who underwent TAA between January 2003 and December 2015, and in whom a weight-bearing CT scan was taken for evaluation at 6.3 (range, 3.0 -16.3) years. The medial border of the tibial component and a perpendicular line to the anterior surface of the PE insert were used to determine the angle of rotation. Results: The angle of rotation, thus the relative position of the talar component compared to the tibial component, did not differ between the two groups (p = 0.2). While the talus was internally rotated by 1.7 (range, -14.0 - 14.0) degrees at the end of surgery, it was internally rotated by 1.5 (range, -13.0 – 19.5) degrees after a minimum follow-up of 3 years (Figure 1). Conclusion: Although there was no significant difference in average axial position measured intraoperatively compared to a 3- years follow-up, there was a wide range of rotational measurements. The possibility of the talar component to find its position as given by individual anatomy may be crucial in TAA to avoid non-physiological joint loads and shear forces which may otherwise result in increased PE wear. Due to the wide range of measurements, our data suggests that axial talar rotation cannot be predicted preoperatively or intraoperatively by surgical techniques that reference the transtibial axis, tibial tuberosity and transmalleolar axis as guidance for tibial component positioning.

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Role of Total Ankle Arthroplasty in Stiff Ankles – Long Term Follow-Up

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00013 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0001

Author(s):

James W. Brodsky ◽

Justin M. Kane ◽

Andrew W. Pao ◽

David D. Vier ◽

Scott Coleman ◽

...

Keyword(s):

Range Of Motion ◽

Step Length ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Ankle Arthroplasty ◽

Post Surgery ◽

Long Term Follow Up ◽

Gait Function

Category: Ankle, Ankle Arthritis Introduction/Purpose: Operative treatment of end-stage ankle arthritis involves either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The theoretical benefit of TAA is the ability to preserve range of motion (ROM) at the tibiotalar joint. Previous studies have questioned whether it is justified to perform TAA over AA in stiff, arthritic ankles. However, a recent study showed that patients who underwent TAA with stiff ankles preoperatively experienced significant clinical improvement in range of motion and gait function compared to more flexible groups at 1-year follow-up. We retrospectively assessed these same gait and functional parameters to see if these improvements held up in long-term follow-up. Methods: A retrospective study of long-term, prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 years postoperatively (range 4.8-13.3) used a multivariate regression model to determine the effect of ankle stiffness on the long- term, objective outcomes of TAA. Data was analyzed by quartiles (Q1, Q2+Q3, Q4) of preoperative sagittal ROM using one-way analysis of variance (ANOVA) to compare both preop and postop gait parameters. The two middle quartiles were combined to conform to distribution of the data. The multivariate analysis determined the independent effect of age, gender, BMI, years post- surgery, and preop ROM on every preop and postop parameter of gait. Results: Statistically significant differences were found in all three gait parameter categories, including temporal-spatial (step length and walking speed), kinematic (total sagittal ROM and maximum plantarflexion), and kinetic (peak ankle power). The stiffest ankles preoperatively (Q1) had the greatest absolute increase in total sagittal ROM postoperatively, +5.3o, compared to -1.3o (p<0.0174) in Q4 (most flexible). However, Q1 had the lowest absolute total postoperative sagittal ROM of 13.1 o, compared to 19.7 o (p<0.0108) in Q4. Q1 also had the lowest preoperative step length, walking speed, maximal plantarflexion, and peak ankle power when compared to the other subgroups. There was no difference in any of these same parameters postoperatively. BMI and years post-surgery had no effect on outcomes, while age and gender had a minimal effect. Conclusion: Preoperative range of motion was once again predictive of overall postoperative gait function in long-term follow-up at an average of 7.2 years. A greater degree of preoperative sagittal range of motion was predictive of greater postoperative sagittal range of motion in long-term follow-up. Patients with the stiffest ankles preoperatively once again had a statistically and clinically greater improvement in function as measured by multiple parameters of gait. This shows that the clinically meaningful improvement in gait function after total ankle arthroplasty holds up in long-term follow-up, even in the setting of limited preoperative sagittal range of motion.

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Clinical Outcomes of Total Ankle Arthroplasty With Total Talar Prosthesis

Foot & Ankle International ◽

10.1177/1071100719847135 ◽

2019 ◽

Vol 40 (8) ◽

pp. 948-954

Author(s):

Noriyuki Kanzaki ◽

Nobuaki Chinzei ◽

Tetsuya Yamamoto ◽

Takahiro Yamashita ◽

Kazuyuki Ibaraki ◽

...

Keyword(s):

Range Of Motion ◽

Case Series ◽

Total Ankle Arthroplasty ◽

Medial Malleolus ◽

Level Of Evidence ◽

Ankle Arthroplasty ◽

The Mean ◽

End Stage ◽

Medial Malleolus Fracture

Background: Total ankle arthroplasty (TAA) has been developed to treat patients with end-stage ankle osteoarthritis (OA). However, there is often difficulty in treating complicated pathologies such as ankle OA with subtalar joint OA and severe talar collapse. Therefore, this study aimed to explore the short-term results and complications of TAA with total talar prosthesis, known as combined TAA, as the new techniques to treat such complicated pathology. Methods: We examined postoperative results including ankle range of motion, Japanese Society for Surgery of the Foot (JSSF) scale, and complications. There were 22 patients (15 women), with mean follow-up of 34.9 (range, 24–53 months), and the mean age was 72 (range, 62–80) years. The main indications for combined TAA included osteoarthritis (18 patients), rheumatoid arthritis (3 patients), and talar osteonecrosis with osteoarthritis (one patient). Results: The mean range of motion improved from 4.0 to 14.4 degrees in dorsiflexion and from 23.8 to 32.0 degrees in plantarflexion. The JSSF scale improved from 50.5 to 91.5 points. Prolonged wound healing occurred in 3 patients, and medial malleolus fracture occurred in 4 patients. Conclusion: Combined TAA was a reliable procedure for the treatment of not only ankle OA following avascular necrosis of talus but also of degeneration of both ankle and subtalar joints. Level of Evidence: Level IV, case series.

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Heterotopic Ossification Following Total Ankle Arthroplasty With Fourth-Generation Prostheses

Foot & Ankle Specialist ◽

10.1177/1938640020970013 ◽

2020 ◽

pp. 193864002097001

Author(s):

Calvin J. Rushing ◽

James Steriovski ◽

Christopher F. Hyer ◽

Gregory C. Berlet

Keyword(s):

Heterotopic Ossification ◽

Reoperation Rate ◽

Total Ankle Arthroplasty ◽

Fourth Generation ◽

Class Iii ◽

Level Of Evidence ◽

Ankle Arthroplasty ◽

High Incidence

Background The purpose of the present study was to assess the radiographic incidence, location, and classification of heterotopic ossification (HO) in patients who underwent total ankle arthroplasty (TAA) with a 4th generation prostheses at a minimum of 1-year follow up. Baseline demographic, radiographic, and operative factors between patents with and without HO were compared. Methods Ninety ankles that underwent TAA with a 4th generation protheses, INFINITY (n = 62) or CADENCE (n = 28) were followed for an average of 23.7 (range, 12-49) months. Incidence and location of HO was assessed on weightbearing radiographs, and severity graded according to the modified Brooker classification. Data was compared between patents with and without HO to identity any predisposing factors. Results In 90 ankles that underwent 4th generation TAA, HO incidence was 55.6% (n = 50); 56.5% (n = 35) for INFINITY, and 53.6% (n = 15) for CADENCE. Twenty-five cases of HO were observed posteriorly, 16 anteriorly, and 9 combined. Severity was as follows; class I in 19 cases (38%), class II in 20 (40%), class III in 9 (18%) and class IV in 2 (4%). A single ankle required a non-revisional reoperation for HO debridement; reoperation rate of 2%. Conclusion The present study suggests a similarly high incidence of HO after TAA with two different 4th generation protheses (INFINITY 56.5%, CADENCE 53.6%). A trend for differences in location and severity between the protheses may also be present. Given the paucity of literature, additional studies with longer follow-up are warranted to discern the significance of HO following TAA with 4th generation protheses. Level of Evidence Level III: Retrospective cohort study

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Functional Outcomes of Total Ankle Arthroplasty at a Mean Follow-up of 7.6 Years

The Journal of Bone and Joint Surgery (American) ◽

10.2106/jbjs.20.00659 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

James W. Brodsky ◽

Daniel J. Scott ◽

Samuel Ford ◽

Scott Coleman ◽

Yahya Daoud

Keyword(s):

Functional Outcomes ◽

Total Ankle Arthroplasty ◽

Ankle Arthroplasty

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The HINTEGRA total ankle arthroplasty

The Bone & Joint Journal ◽

10.1302/0301-620x.101b6.bjj-2018-1578.r1 ◽

2019 ◽

Vol 101-B (6) ◽

pp. 695-701 ◽

Cited By ~ 15

Author(s):

H-Y Yang ◽

S-H Wang ◽

K-B Lee

Keyword(s):

Functional Outcome ◽

Short Form ◽

Major Complication ◽

Mobile Bearing ◽

Total Ankle Arthroplasty ◽

Range Of Movement ◽

Ankle Arthroplasty ◽

Implant Survivorship ◽

American Orthopaedic

Aims The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon. Patients and Methods We reviewed 205 consecutive patients (210 ankles) who had undergone mobile-bearing TAA (205 patients) for osteoarthritis of the ankle between January 2005 and December 2015. Their mean follow-up was 6.4 years (2.0 to 13.4). Functional outcome was assessed using the Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, 36-Item Short-Form Health Survey (SF-36) score, visual analogue scale, and range of movement. Implant survivorship and complications were also evaluated. Results There were significant improvements in all functional outcome categories between the preoperative and final follow-up assessments (p < 0.001). Patients showed marked improvement in clinical outcomes in terms of pain, function, and quality of life. The overall implant survivorship was 91.7% at a mean follow-up of 6.4 years. In all, 33 major complications were identified with a 15.7% rate, resulting in 12 prosthesis failures (5.7%). Periprosthetic osteolysis (19 cases; 9.0%) was the most frequent complication. Conclusion Mobile-bearing TAA resulted in improved functional outcomes, a low major complication rate, and excellent implant survivorship at a mean follow-up of 6.4 years. Cite this article: Bone Joint J 2019;101-B:695–701.

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Long Term Functional Outcomes after Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00145 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0014

Author(s):

James W. Brodsky ◽

Daniel J. Scott ◽

Samuel E. Ford ◽

Scott Coleman ◽

Yahya Daoud

Keyword(s):

Gait Analysis ◽

Functional Outcomes ◽

Walking Speed ◽

Step Length ◽

Total Ankle Arthroplasty ◽

Initial Contact ◽

Ankle Arthroplasty ◽

Objective Functional

Category: Ankle; Ankle Arthritis; Hindfoot Introduction/Purpose: In vivo gait analysis is the objective functional measurement compared to subjective patient-reported outcomes. Intermediate-term gait studies showed positive results of Total Ankle Arthroplasty (TAA). To date, there are no published Long-Term functional outcomes of TAA. Methods: Three-dimensional gait analysis with twelve-camera digital-motion capture system and double force plates recorded temporal-spatial (TS), kinematic (KM), and kinetic (KN) measures, in 33 patients who had STAR (28) or Salto Talaris (5) TAA, done pre-operatively and at intervals post-operatively, with last testing at a mean of 7.6 years. Almost half the patients had 8-13 year follow up. Results: Improvements were found in multiple gait parameters, with TS increases in cadence, (+9.5 steps/min; P <0.001), step length (+4.4 cm; P = 0.001) and walking speed (+0.2 m/s; P<0.001), KM increases in total ROM (+2.0 deg; P = 0.026), plantarflexion at initial contact (+2.7 deg; P=0.004), and maximum plantarflexion (+2.0 deg; P=0.049), and KN analysis showed no loss of ankle power, despite patients’ aging. When examining 15 patients with 8 to 13 year follow-up (mean 10.3 years), there were gains in cadence (+9.8 steps/min, p=0.003), step length (3.6 cm, p=0.024), and walking speed (0.17 m/s, p=0.003), and preservation of the increased sagittal ROM of 2.0 deg. The only difference between prostheses was increased dorsiflexion at initial contact in the STARs vs SALTOs (5.9 degrees, p=0.014). Conclusion: This is the first study to report long-term, objective, functional outcomes of TAA, as measured by 3-D digital gait analysis. Even at a decade or more after TAA, patients had sustained improvement in multiple, objective parameters of gait compared to their preoperative function.

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Outcome after total ankle arthroplasty with a minimum of five years follow-up: A systematic review and meta-analysis

Foot and Ankle Surgery ◽

10.1016/j.fas.2019.07.006 ◽

2020 ◽

Vol 26 (5) ◽

pp. 556-563 ◽

Cited By ~ 2

Author(s):

James Randolph Onggo ◽

Mithun Nambiar ◽

Kevin Phan ◽

Benjamin Hickey ◽

Michael Galvin ◽

...

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Total Ankle Arthroplasty ◽

Ankle Arthroplasty

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Heterotopic Ossification in Total Ankle Arthroplasty: Case Series and Systematic Review

The Journal of Foot & Ankle Surgery ◽

10.1053/j.jfas.2019.12.003 ◽

2020 ◽

Vol 59 (4) ◽

pp. 716-721 ◽

Cited By ~ 3

Author(s):

Thomas B. Bemenderfer ◽

W. Hodges Davis ◽

Robert B. Anderson ◽

Kevin Wing ◽

Mario I. Escudero ◽

...

Keyword(s):

Systematic Review ◽

Heterotopic Ossification ◽

Case Series ◽

Total Ankle Arthroplasty ◽

Ankle Arthroplasty

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Functional Outcome Risk Score for Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00086 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0008

Author(s):

Elizabeth McDonald ◽

Kristen Nicholson ◽

Max Greenky ◽

Benjamin Hendy ◽

Abhay Mathur ◽

...

Keyword(s):

Logistic Regression ◽

Functional Outcome ◽

Risk Score ◽

Functional Outcomes ◽

Ligament Reconstruction ◽

Total Ankle Arthroplasty ◽

Coronal Plane ◽

Ankle Arthroplasty ◽

Calculated Risk ◽

Plane Deformity

Category: Ankle Introduction/Purpose: Postoperative functional outcomes are important measures as the orthopaedic community responds to pay-for-performance and bundled payments. Considering the 1000-fold growth of total ankle arthroplasty (TAA) procedures in the Medicare population in the past two decades, this procedure will likely undergo increasing scrutiny of quality under Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015(MACRA). While BMI, coronal plane deformity, age, and rheumatoid arthritis influence outcomes and rate of complications after TAA, there has been no single identifiable factor that predicts poor functional outcomes. The aim of this study is to identify independent patient factors that are associated with lower functional outcomes at two years after TAA and compound these predictive factors into an easily calculable score to preoperatively stratify patients undergoing modern TAA. Methods: 134 consecutive patients (136 ankles) with a mean age of 64 years (range, 31 to 79 years) and 70 (51%) men that had undergone TAA by a single surgeon from May 2011 to May 2015 were retrospectively enrolled. In addition to 2-year functional outcomes for each patient, 22 data point were collected including preoperative range of motion; baseline functional scores; and a comprehensive health history. FAAM ADL scores at 2-years were grouped into excellent (>90 points), good (75-90), or fair (<75). Univariable analyses tested for the association between demographics, medical history, functional outcomes, and procedure factors using chi-squared tests for categorical variables and either one-way ANOVAs or Kruskal Wallis tests for continuous variables. Model coefficients from a multivariable ordinal logistic regression analysis for the significant predictors of excellent, good, or fair outcomes were used to create a summed risk score to predict inferior 2-year outcome scores. Results: Ninety-one patients met the inclusion criteria. The only predictors associated with inferior functional outcomes were (1) baseline ADL score (2) no calcaneal osteotomy for coronal plane deformity (3) lateral or deltoid ligament reconstruction and (4) post-traumatic/chronic sprain etiology and BMI >30. From the multivariable ordinal logistic regression, baseline ADL scores less than 40 had a weight of 2 while an ADL score of 40-55 had a weight of 1. The remaining factors were weighted 3, 2, 1 for ligament reconstruction, no calcaneal osteotomy, and obese+sprain. Of the 23 patients with a calculated risk of 0-2, 18 did excellent and 2 did fair. Conversely, of the 22 patients with a calculated risk score of 4+, only 2 did excellent and 15 did fair (Table 1). Conclusion: Over twenty baseline and surgical factors were considered when creating a clinical scoring system that compounds the effect of risk factors on postoperative foot and ankle functional outcome measures at two years. Ligament reconstruction was the highest weighted factor(3-points), which suggests soft tissue stabilization needs to be considered in conjunction with boney correction. As previous literature supports, preoperative coronal plane deformity when corrected appropriately can lead to greater likelihood for superior outcomes when compared to patients without this deformity. This novel risk score takes into account 5 easily-obtainable factors and may help to better set patient expectations prior to TAA.

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