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Total Ankle Arthroplasty: Ready for Prime Time

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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


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