Periprosthetic Fracture of the Talus following Total Ankle Replacement: A Case Series

Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: Although total ankle replacement (TAR) for the treatment of end-stage ankle arthritis has been shown to have excellent radiographic and clinical outcomes, there is a risk for complications such as periprosthetic fractures. While periprosthetic fractures of the tibia are well described in the literature, little is known about such fractures involving the talus. The purpose of this case series is to describe the radiographic findings and surgical management of talar fractures sustained after placement of total ankle prostheses. Methods: We retrospectively reviewed 489 patients who underwent total ankle replacement from June 2015 to March 2019, and identified five cases (2 males, 3 females, average age 45.7 years) in which patients sustained a periprosthetic fracture of the talus. All patients presented symptomatically with ankle pain during postoperative follow-up, and fractures of the talus were confirmed on computed tomography (CT) imaging. One patient had psoriatic arthritis and four patients had primary osteoarthritis of the ankle. CTs were reviewed to confirm location and pattern of the fracture, as well as related pathology such as osteolysis and subsidence. Hospital charts and operative reports were reviewed to record patient demographics and postoperative management including reoperations. Results: Overall the incidence of talar fractures was 1% (5/489) and all occurred in implants with a talar stem (4 INBONE II, 1 Salto Talaris). All fractures extended from the stem of the talar component into the subtalar joint, with one case of a non- displaced fracture. Osteolysis surrounding the talar stem was observed in all cases, with subsidence of the talar component observed in four out of five patients on CT. All five patients presented symptomatically and underwent reoperation (1 revision of talar component with ORIF, 3 subtalar fusions, 1 tibiotalar fusion). Conclusion: The findings in this case series suggest that periprosthetic fractures of the talus following total ankle replacement is a possible complication of stemmed implants and is associated with poor clinical outcomes requiring reoperation. Therefore, a periprosthetic fracture of the talus should be considered in a patient with unexplained pain and evidence of radiographic osteolysis around the stemmed component. [Table: see text]

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Total Ankle Arthroplasty Survivorship, Complication, and Revision Rates in Patients Younger Than 55 Years

Foot & Ankle Specialist ◽

10.1177/1938640020980925 ◽

2021 ◽

pp. 193864002098092

Author(s):

Devon W. Consul ◽

Anson Chu ◽

Travis M. Langan ◽

Christopher F. Hyer ◽

Gregory Berlet

Keyword(s):

Case Series ◽

Ankle Arthrodesis ◽

Total Ankle Replacement ◽

Implant Survival ◽

Ankle Arthritis ◽

Single Institution ◽

Retrospective Case ◽

Ankle Replacement ◽

End Stage

Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical management of advanced ankle arthritis. Total ankle replacement has generally been reserved for patients who are older and for those who will have a lower demand on the replacement. The purpose of the current study is to review patient outcomes, complications, and implant survival in patients younger than 55 years who underwent total ankle replacement at a single institution. A single-center chart and radiographic review was performed of consecutive patients who underwent total ankle replacement for treatment of end-stage ankle arthritis. All surgeries were performed by 1 of 5 fellowship-trained foot and ankle surgeons at a single institution. A total of 51 patients met inclusion criteria with a mean follow-up of 31.2 months (SD = 16.2). Implant survival was 94%, There were 7 major complications (13%) requiring an unplanned return to the operating room and 8 minor complications (15%) that resolved with conservative care. The results of this study show that total ankle replacement is a viable treatment option for patients younger than 55 years. Levels of Evidence: A retrospective case series

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Prospective Randomized Trial Comparing Mobile-bearing and Fixed-bearing Total Ankle Replacement

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00093 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0009

Author(s):

James Nunley ◽

Samuel Adams ◽

James DeOrio ◽

Mark Easley

Keyword(s):

Clinical Outcomes ◽

Mobile Bearing ◽

Cyst Formation ◽

Total Ankle Replacement ◽

Fixed Bearing ◽

Ankle Arthritis ◽

Ankle Replacement ◽

Significant Difference ◽

End Stage

Category: Ankle Arthritis Introduction/Purpose: Outcomes of total ankle replacement for the treatment of end-stage ankle arthritis continue to improve. Debate continues whether a mobile-bearing total ankle replacement (MB-TAR) or a fixed-bearing total ankle replacement (FB-TAR) is superior, with successful outcomes reported longterm for MB-TAR and at intermediate-to-longterm follow-up for newer generation FB-TAR. Although comparisons between the two total ankle designs have been reported, to our knowledge, no investigation has compared the two designs with a high level of evidence. This prospective, randomized controlled trial conducted at a single institution compares patient satisfaction, functional outcomes and radiographic results of the mobile-bearing STAR and the fixed-bearing Salto-Talaris in the treatment of end-stage ankle arthritis. Methods: This investigation was approved by our institution’s IRB committee. Between November 2011 and November 2014, adult patients with end-stage ankle osteoarthritis failing nonoperative treatment were introduced to the study. With informed consent, 100 patients (31 male and 69 female, average age 65, range 35 to 85) were enrolled; demographic comparison between the two cohorts was similar. Exclusion criteria included inflammatory arthropathy, neuropathy, weight exceeding 250 pounds, radiographic coronal plane deformity greater than 15 degrees or extensive talar dome wear pattern (“flat top talus”). Prospective patient-reported outcomes, physical exam and standardized weightbearing ankle radiographs were obtained preoperatively, at 6 and 12 months postoperatively, and then at yearly intervals. Data collection included visual analog pain score (VAS), short form 36 (SF-36), foot and ankle disability index (FADI), short musculoskeletal functional assessment (SMFA) and AOFAS ankle-hindfoot score. Surgeries were performed by non-design team orthopaedic foot and ankle specialists with total ankle replacement expertise. Statistically analysis was performed by a qualified statistician. Results: At average follow-up of 4.5 years (range 2-6 years) complete clinical data and radiographs were available for 84 patients; 7 had incomplete data, one had died, 4 were withdrawn after enrolling but prior to surgery and 4 were lost to follow-up. In all outcome measures, the entire cohort demonstrated statistically significant improvements from preoperative evaluation to most recent follow-up. There was no statistically significant difference in improvement in clinical outcomes between the two groups. Radiographically, tibial lucency/cyst formation was 26.8% and 20.9% for MB-TAR and FB-TAR, respectively. Tibial settling/subsidence occurred in 7.3% of MB-TAR. Talar lucency/cyst formation occurred in 24.3% and 2.0% of MB-TAR and FB-TAR, respectively. Talar subsidence was observed in 21.9% and 2.0% of MB-TAR and FB-TAR, respectively. Re-operations were performed in 8 MB-TAR and 3 FB-TAR, with the majority of procedures being to relieve impingement or treat cysts and not to revise or remove metal implants. Conclusion: For the first time, with a high level of evidence, our study confirms that patient reported and clinical outcomes are favorable for both designs and that there is no significant difference in clinical improvement between the two implants. The incidence of lucency/cyst formation was similar for MB-TAR and FB-TAR for the tibial component, but the MB-TAR had greater talar lucency/cyst formation and tibial and talar subsidence. As has been suggested in previous studies, clinical outcomes do not correlate with radiographic findings. Re-operations were more common for MB-TAR and in the majority of cases were to relieve impingement or treat cysts rather than revise or remove metal implants.

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Clinical and Radiological Outcomes of Transfibular Total Ankle Arthroplasty

Foot & Ankle International ◽

10.1177/1071100718798851 ◽

2018 ◽

Vol 40 (1) ◽

pp. 24-33 ◽

Cited By ~ 11

Author(s):

Federico G. Usuelli ◽

Camilla Maccario ◽

Francesco Granata ◽

Cristian Indino ◽

Venus Vakhshori ◽

...

Keyword(s):

Short Form ◽

Case Series ◽

Total Ankle Replacement ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Plate Removal ◽

Ankle Arthroplasty ◽

Ankle Replacement ◽

Patient Reported

Background: Ankle arthritis is a highly limiting pathology that causes pain and functional limitation with subsequent deterioration of quality of life. With recent advances in surgical instrumentation and techniques, prosthetic replacement of the ankle has proven to be a valid alternative to arthrodesis with comparable outcomes. The purpose of this study was to evaluate clinical and radiological findings in a transfibular total ankle replacement with follow-up of at least 2 years. Methods: This prospective study included 89 patients who underwent transfibular total ankle arthroplasty from May 2013 to February 2016. The mean age was 53.2 ± 13.5 years. All patients were followed for at least 24 months postoperatively with an average follow-up of 42.0 ± 23.5 months. Patients were assessed clinically and radiographically preoperatively and at 6, 12, and 24 months postoperatively. Results: At 24 months postoperatively, patients demonstrated statistically significant improvement in the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score from 33.8 ± 14.3 to 88.5 ± 6.6 ( P < .001), visual analog scale (VAS) from 80.5 ± 17.0 to 14.1 ± 9.2 ( P < .001), and Short Form-12 Physical and Mental Composite Scores from 29.9 ± 6.7 and 43.3 ± 8.6 to 47.0 ± 7.6 and 53.3 ± 8.1, respectively ( P < .001). In addition, ankle dorsiflexion and plantarflexion improved from 6.2 ± 5.5 and 9.6 ± 5.8 degrees to 24.2 ± 7.9 and 18.1 ± 7.6 degrees, respectively ( P < .001). Radiographically, patients demonstrated maintained neutral alignment of the ankle at 24 months. No patient demonstrated any radiographic evidence of tibial or talar lucency at final follow-up. Seven patients underwent reoperation for removal of symptomatic hardware (6 fibular plates, 1 syndesmotic screw); 2 patients experienced delayed wound healing. The first one was treated with plate removal and flap coverage. The second one required fibular plate removal. One patient developed a postoperative prosthetic infection requiring operative debridement, removal of implants, and placement of an antibiotic spacer. Conclusion: This study found that transfibular total ankle replacement was a safe and effective option for patients with ankle arthritis resulting in improvements in patient-reported outcomes, range of motion, and radiographic parameters. However, further studies are required to determine the mid- and long-term performance of these implants. Level of Evidence: Level IV, case series.

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Indications of Total Ankle Replacement for Ankle Arthritis: The Evaluation of Quality of Life and Radiographic Findings

Clinical Research on Foot & Ankle ◽

10.4172/2329-910x.1000139 ◽

2014 ◽

Vol 02 (03) ◽

Author(s):

Chayanin Angthong

Keyword(s):

Quality Of Life ◽

Total Ankle Replacement ◽

Ankle Arthritis ◽

Radiographic Findings ◽

Ankle Replacement

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Living With Both a Total Ankle Replacement and an Ankle Fusion: A Qualitative Study From the Patients’ Perspective

Foot & Ankle International ◽

10.1177/10711007211004447 ◽

2021 ◽

pp. 107110072110044

Author(s):

Catherine Conlin ◽

Ryan M. Khan ◽

Ian Wilson ◽

Timothy R. Daniels ◽

Mansur Halai ◽

...

Keyword(s):

Hospital Setting ◽

Case Series ◽

Total Ankle Replacement ◽

Qualitative Description ◽

Level Of Evidence ◽

Foot Placement ◽

Advantages And Disadvantages ◽

Ankle Fusion ◽

Ankle Replacement ◽

Patient Reported

Background: Total ankle replacement (TAR) and ankle fusion are effective treatments for end-stage ankle arthritis. Comparative studies elucidate differences in treatment outcomes; however, the literature lacks evidence demonstrating what outcomes are important to patients. The purpose of this study was to investigate patients’ experiences of living with both a TAR and ankle fusion. Methods: This research study used qualitative description. Individuals were selected from a cohort of patients with TAR and/or ankle fusion (n = 1254). Eligible patients were English speaking with a TAR and contralateral ankle fusion, and a minimum of 1 year since their most recent ankle reconstruction. Surgeries were performed by a single experienced surgeon, and semistructured interviews were conducted by a single researcher in a private hospital setting or by telephone. Ankle Osteoarthritis Scale (AOS) scores, radiographs, and ancillary surgical procedures were collected to characterize patients. Themes were derived through qualitative data analysis. Results: Ten adults (8 men, 2 women), ages 59 to 90 years, were included. Average AOS pain and disability scores were similar for both surgeries for most patients. Participants discussed perceptions of each reconstructed ankle. Ankle fusions were considered stable and strong, but also stiff and compromising balance. TARs were considered flexible and more like a “normal ankle,” though patients expressed concerns about their TAR “turning” on uneven ground. Individuals applied this knowledge to facilitate movement, particularly during a first step and transitioning between positions. They described the need for careful foot placement and attention to the environment to avoid potential challenges. Conclusion: This study provides insight into the experiences of individuals living with a TAR and ankle fusion. In this unusual but limited group of patients, we found that each ankle reconstruction was generally perceived to have different characteristics, advantages, and disadvantages. Most participants articulated a preference for their TAR. These findings can help clinicians better counsel patients on expectations after TAR and ankle fusion, and improve patient-reported outcome measures by better capturing meaningful outcomes for patients. Level of Evidence: Level IV, case series.

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Adverse Events in Total Ankle Arthroplasty, Analysis of the FDA Medical and User Facility Device Experience Database

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00285 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0028

Author(s):

Karim Mahmoud ◽

Sreenivasulu Metikala ◽

Kathryn O’Connor ◽

Daniel Farber

Keyword(s):

Adverse Events ◽

Aseptic Loosening ◽

Mandatory Reporting ◽

Total Ankle Replacement ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Ankle Arthroplasty ◽

Ankle Replacement ◽

Mode Of Failure ◽

User Facility

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement has become a popular treatment option for end stage ankle arthritis. Most of the reports of adverse events following total ankle replacement have been from high volume institutions and are subject to either observational or selection bias as well as potential under-reporting as they do not include the experience of community and lower volume centers and surgeons. The FDA’s Medical and User Facility Device Experience (MAUDE) Database provides a more complete scope of adverse events due to the mandatory reporting requirements by the FDA of implant manufactures. We reviewed the database to identify the common modes of failure and complications of total ankle implants Methods: We retrospectively reviewed reports of the MAUDE database from November 2011 to September 2018 regarding all total ankle implants. Each device in the MAUDE database is classified with a 3-letter code, we identified the 2 codes assigned to total ankle arthroplasty devices, and manually searched the FDA’s published Device Classification list for adverse events. All events were reviewed and classified. Data related to patient age or sex, surgeon, medical center location are not available in the database Results: We identified 1000 adverse reports in the period between November 2011 and September 2018. After exclusion of duplicate reports for single events or reports irrelevant to total ankle arthroplasty, a total of 697 adverse event reports were noted. The most common mode of failure was aseptic loosening (21%), followed by infection (16%), alignment and mechanical issues (instability, malalignment, malposition, stiffness, impingement) (15%), implantation issues (pin, screw or drill breakage, alignment guide problems) (9%), polyethylene related problems (wear, displaced or fractured implants) (7%), bony and soft tissue overgrowth (6%), and peri-prosthetic fractures (5%). Conclusion: Our analysis reveals that the most reported mode of failure was aseptic loosening followed by infection. However, it is notable that there are a significant number of issues with implant alignment and mechanics, complications during implantation and polyethylene component failure that are under-reported in the literature. Knowledge of these adverse events may help surgeons avoid similar complications as well as lead to improvement in component implantation and design

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Perspectives in Treatments of End-Stage Ankle Arthritis Among Orthopaedic Surgeons

Foot & Ankle Orthopaedics ◽

10.1177/2473011418779976 ◽

2018 ◽

Vol 3 (3) ◽

pp. 247301141877997

Author(s):

Phinit Phisitkul ◽

Natalie Glass ◽

Patrick B. Ebeling ◽

Sandra E. Klein ◽

Jeffrey E. Johnson

Keyword(s):

United States ◽

The United States ◽

Total Ankle Replacement ◽

Ankle Arthritis ◽

Cross Sectional Survey ◽

Level Of Evidence ◽

Cross Sectional ◽

Orthopaedic Surgeons ◽

Ankle Replacement ◽

End Stage

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role ( P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon’s experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. Level of Evidence: Level III, therapeutic.

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The Role of Axial Rotation in Total Ankle Replacement

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00090 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0009

Author(s):

Ali-Asgar Najefi ◽

Andrew Goldberg

Keyword(s):

Surgical Techniques ◽

Axial Rotation ◽

Total Ankle Replacement ◽

Tibial Tuberosity ◽

Ct Scans ◽

Patient Specific ◽

Ankle Arthritis ◽

Ankle Replacement ◽

Wright Medical Technology ◽

The Mean

Category: Ankle Arthritis Introduction/Purpose: The importance of implant orientation in the axial rotational plane is ill understood. No Total ankle replacement (TAR) implant deals specifically with rotation as part of the surgical technique. Preoperative computed tomography (CT) scan–derived patient-specific plans and guides (PROPHECY, Wright Medical Technology, Memphis, TN) have been developed for TAR scanning the knee and ankle for the purposes of patient specific instrumentation. The objectives of this study were to establish the range and relationship between the transtibial axis at the knee, the tibial tuberosity, and the transmalleolar axis using these CT scans in an adult population with ankle arthritis. Methods: 150 CT Scans of patients with end stage ankle osteoarthritis undergoing Psi, we measured the relationship between the transtibial axis, the tibial tuberosity and the transmalleolar axis (Figure 1). All CT scans were analysed using the Solidworks software (Dassault Systèmes). Varus or valgus arthritis, tibiotalar angle and presence of deformity was also recorded. Results: The mean difference in the axial plane between the transmalleolar axis and the tibial tuberosity was 17.9 ± 9.3 degrees externally rotated. There was a large range which was between -5 and 53 degrees of external rotation. The mean foot angle was 15.4 ± 11.1 degrees relative to the implant position. All planned implant positions were mean 1.0 ± 1.8 degrees (range -3.8 – 1.7 degrees) internally rotated to the transmalleolar axis. Varus or valgus ankle arthritis did not correlate with rotation of the tibial axis (p=0.4). Conclusion: There is a wide variation in rotational alignment of the tibia, which cannot be accurately assessed clinically or using plain radiographs. Surgical techniques that reference the tibial tuberosity to plan component alignment can be misleading and lead to implant malalignment. We recommend routine preoperative CT scanning prior to ankle replacement surgery and recommend research to assess the effects of axial rotation of implant performance and survival.

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Nationwide Analysis of Total Ankle Replacement and Ankle Arthrodesis in Medicare Patients: Trends, Complications, and Cost

Foot & Ankle Specialist ◽

10.1177/1938640020950181 ◽

2020 ◽

pp. 193864002095018

Author(s):

William A. Tucker ◽

Brandon L. Barnds ◽

Brandon L. Morris ◽

Armin Tarakemeh ◽

Scott Mullen ◽

...

Keyword(s):

Surgical Intervention ◽

Ankle Arthrodesis ◽

Total Ankle Replacement ◽

Complication Rates ◽

Ankle Arthritis ◽

Ankle Replacement ◽

Procedure Cost ◽

Medicare Patients ◽

Retrospective Comparative Study ◽

End Stage

Background Surgical management of end-stage ankle arthritis consists of either ankle arthrodesis (AA) or total ankle replacement (TAR). The purpose of this study was to evaluate utilization trends in TAR and AA and compare cost and complications. Methods Medicare patients with the diagnosis of ankle arthritis were reviewed. Patients undergoing surgical intervention were split into AA and TAR groups, which were evaluated for trends as well as postoperative complications, revision rates, and procedure cost. Results A total of 673 789 patients were identified with ankle arthritis. A total of 19 120 patients underwent AA and 9059 underwent TAR. While rates of AA remained relatively constant, even decreasing, with 2080 performed in 2005 and 1823 performed in 2014, TAR rates nearly quadrupled. Average cost associated with TAR was $12559.12 compared with $6962.99 for AA ( P < .001). Overall complication rates were 24.9% in the AA group with a 16.5% revision rate compared with 15.1% and 11.0%, respectively, in the TAR group ( P < .001). Patients younger than 65 years had both higher complication and revision rates. Discussion TAR has become an increasingly popular option for the management of end-stage ankle arthritis. In our study, TAR demonstrated both lower revision and complication rates than AA. However, TAR represents a more expensive treatment option. Levels of Evidence: Level III: Retrospective comparative study

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