Total Ankle Arthroplasty: Ready for Prime Time Total Ankle Arthroplasty: Ready for Prime Time? Advances in Orthopaedic Trauma and Arthroplasty Steven B. Weinfeld, MD Chief; Foot and Ankle Service Associate Professor of Orthopaedic Surgery Mount Sinai Medical Center, NY

Osteoarthritis Can be post traumatic Degenerative May affect any joint in the foot and ankle

Inflammatory Arthritis Rheumatoid Systemic Lupus Erythematosis Psoriatic gout Others

Ankle Arthritis Most often post traumatic Swelling and pain with up and down motion of ankle, crepitance Pain with push off and up and down stairs May see swelling(effusion) of ankle May also have deformity

Treatment of Ankle Arthritis NSAIDS, Bracing, Shoewear modifications corticosteroid injection ankle joint debridement distraction arthrodesis arthroplasty

Results of Ankle Arthrodesis Many reports of successful results - good pain relief Pseudoarthrosis rates up to 50% difficult to obtain ideal position especially with bone loss 16% decreased gait velocity - Waters 1988 tibial stress fractures following ankle arthrodesis development of arthritis of adjacent joints-50%

Ankle Arthrodesis 75% loss of sagittal motion 70% loss of inversion/eversion Mann and Rongstad Foot Ankle 1998 Buck and Morrey JBJS 1987 19 patients with ankle arthrodesis Only 1 reported no pain All patients had difficulty on uneven terrain

Total Ankle Replacement “State of the Art”

History uniformly poor long term results Newton 1982- results of total ankle in RA so poor that procedure is contraindicated Bolton-Maggs 1985- arthrodesis treatment of choice for arthritis of ankle regardless of underlying condition Kitaoka et al 1996- reviewed 160 ankle replacements with 36% failure rate requiring removal of implant- Mayo Clinic

Total Ankle Replacement - Indications older patient with multiple joint problems normal alignment and ligamentous stability of ankle and foot no history of septic arthritis patient with reasonable expectations!!!

Contraindications to Ankle Replacement prior sepsis osteonecrosis or profound osteoporosis young, very active patient severe deformity of ankle or foot

First Ankle Replacement - 1970 inverted hip prosthesis failed miserably newer designs show improved results due to better understanding of ankle mechanics and modes of failure

Implant Design constrained prosthesis nonconstrained designs ICLH, Thompson-Parkridge-Richards, Mayo nonconstrained designs Richard Smith prosthesis, New Jersey Ankle semiconstrained Agility ankle STAR ankle Salto (Tornier) InBone Eclipse

Salto Talaris Anatomic Ankle (Tornier)

Inbone

Modes of Failure of Ankle Arthroplasty loosening 22-75% greater in constrained designs cemented prosthesis wound complications with subsequent infection amputation rate not insignificant ankylosis following arthroplasty difficult salvage including arthrodesis

“We no longer recommend ankle arthroplasty with the constrained Mayo implant for rheumatoid arthritis or osteoarthrosis of the ankle” Kitaoka and Patzer 1996

STAR Ankle- Scandinavia widely used in Europe 3 component design sliding polyethylene meniscus 70% suvivorship at 10 year follow up Kofoed JBJS 1998

STAR Ankle Replacement

STAR Ankle - continued Wood et al - Foot Ankle 2001 compared TPR ankle with STAR 14 arthroplasties in 12 patients with RA Average f/u 6 years 4 of 6 TPR radiographically loose within 2 years STAR remained satisfactory at 5 years

Wood et al JBJS Br 2003 200 STAR ankles with 46 month f/u 92.7% survivorship with 14 revisions or fusions Most common complication- wound healing and malleolar fracture

Uncemented STAR Ankle 51 consecutive ankles 1993-1999 12 revisions, 7 due to loosening Avg. 52 month follow up 70% survivorship Anderson et al JBJS July 2003

Functional Evaluation of STAR Ankle 9 patients had ankle function evaluated following arthroplasty External ankle dorsiflexion, inversion, and eversion moments all improved compared to pre-op Still decreased compared to controls Mann et al Foot Ankle June 2004

STAR Ankle Replacement 49 replacements in 47 patients Mean f/u 28 months 4 failures due to loosening Schutte and Louwerens Foot Ankle Int 2008

Buechel and Pappas- 1992 New Jersey Ankle reported 85 % good to excellent results 5% revision rate 6 year follow up

Buechel et al Foot Ankle 2003 49 Buechel Pappas ankles 88 % good to excellent results 93.5% survivorship at 10 years Revision due to malalignment, meniscal wear, and talar component subsidence No longer FDA approved in US

State of the Art-Agility Ankle semiconstrained design requires distal tib/fib fusion recent review of 100 arthroplasties JBJS 1998- Pyevich et al 26 with RA 2-12 year follow up- 93% patient satisfaction 83% reported no pain or mild pain 5 revisions, 21% radiographic loosening

Surgical Technique - Agility Ankle anterior approach to ankle application of external fixator for distraction resection of distal tibia and talus trial implantation implantation of components distal tibia/fibula fusion

Complications with Agility Ankle radiographic loosening delayed or nonunion of syndesmosis- 30% wound complications migration of tibial component

Agility Ankle 132 ankles in 126 patients with avg. 9 year follow up – 1 surgeon (F. Alvine) 90% reported satisfaction 14 ankles revised or fused (11%) 8% syndesmosis nonunion <25% progressive hindfoot arthritis as compared to >50% with ankle fusion Saltzman et al JBJS June 2004

Total Ankle Arthroplasty vs. Ankle Arthrodesis Haddad et al JBJS 2007 Meta analysis of 10 studies of total ankle with 852 patients and 39 studies of ankle arthrodesis with 1262 patients AOFAS scores 78.2 for total ankle and 75.6 for ankle arthrodesis with similar revision rates Intermediate outcome similar between the two groups

Complications and Failure After Total Ankle Arthroplasty 306 Agility Ankles Mean F/U 33 months 85 patients (28%) underwent 127 reoperations (168 procedures) Debridement of heterotopic bone, alignment correction, component replacement 8 Below knee amputations 5 year survival rate 80% Hansen S JBJS 2004

Salvage of Failed Ankle Replacement Arthrodesis Requires large bone graft to fill void Try to restore length Revision Often requires custom implant Bone graft to syndesmosis for nonunion (Agility) Amputation

64 y.o. female s/p distal tibial allograft for chondro- sarcoma

Conclusion total ankle replacement an option for the treatment of ankle arthritis careful patient selection and education new generation of prostheses may offer greater longevity complications common- Saltzman et al Foot Ankle June 2003

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