1. 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

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

6. Inflammatory Arthritis
Rheumatoid
Systemic Lupus Erythematosis
Psoriatic
gout
Others

7. 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

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

15. 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%

16. 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

20. Total Ankle Replacement “State of the Art”

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

22. 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!!!

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

24. 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

25. 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

27. Salto Talaris Anatomic Ankle (Tornier)

28. Inbone

29. 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

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

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

32. STAR Ankle Replacement

33. 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

37. 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

38. 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

39. 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

40. 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

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

43. 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

44. State of the Art-Agility Ankle
semiconstrained design
requires distal tib/fib fusion
recent review of 100 arthroplasties JBJS 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

46. 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

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

56. 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

69. 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

70. 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

71. 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

72. 64 y.o. female s/p distal
tibial allograft for chondro-
sarcoma

78. 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

79. THANK YOU