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Total Ankle Arthroplasty: Total Ankle Arthroplasty: Ready for Prime Time?Ready for Prime Time?
Advances in Orthopaedic Trauma and Advances in Orthopaedic Trauma and ArthroplastyArthroplasty
Steven B. Weinfeld, MD
Chief; Foot and Ankle Service
Associate Professor of Orthopaedic Surgery
Mount Sinai Medical Center, NY
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OsteoarthritisOsteoarthritis
Can be post traumaticDegenerativeMay affect any joint in the foot and ankle
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Inflammatory ArthritisInflammatory Arthritis
RheumatoidSystemic Lupus ErythematosisPsoriaticgoutOthers
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Ankle ArthritisAnkle Arthritis
Most often post traumaticSwelling and pain with up and down motion
of ankle, crepitancePain with push off and up and down stairsMay see swelling(effusion) of ankleMay also have deformity
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Treatment of Ankle ArthritisTreatment of Ankle Arthritis
NSAIDS, Bracing, Shoewear modificationscorticosteroid injectionankle joint debridementdistractionarthrodesisarthroplasty
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Results of Ankle ArthrodesisResults 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%
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Ankle ArthrodesisAnkle Arthrodesis
75% loss of sagittal motion70% 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
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Total Ankle ReplacementTotal Ankle Replacement““State of the ArtState of the Art””
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HistoryHistory
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
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Total Ankle Replacement - Total Ankle Replacement - IndicationsIndications
older patient with multiple joint problemsnormal alignment and ligamentous stability
of ankle and footno history of septic arthritispatient with reasonable expectations!!!
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Contraindications to Ankle Contraindications to Ankle ReplacementReplacement
prior sepsisosteonecrosis or profound osteoporosisyoung, very active patientsevere deformity of ankle or foot
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First Ankle Replacement - First Ankle Replacement - 19701970
inverted hip prosthesisfailed miserablynewer designs show improved results due to
better understanding of ankle mechanics and modes of failure
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Implant DesignImplant Design
constrained prosthesis– ICLH, Thompson-Parkridge-Richards, Mayo
nonconstrained designs– Richard Smith prosthesis, New Jersey Ankle
semiconstrained– Agility ankle– STAR ankle– Salto (Tornier)– InBone– Eclipse
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Salto Talaris Anatomic Ankle Salto Talaris Anatomic Ankle (Tornier)(Tornier)
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Inbone
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Modes of Failure of Ankle Modes of Failure of Ankle ArthroplastyArthroplasty
loosening 22-75%– greater in constrained designs– cemented prosthesis
wound complications with subsequent infection– amputation rate not insignificant
ankylosis following arthroplastydifficult salvage including arthrodesis
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“We no longer recommend ankle arthroplasty with the constrained Mayo implant for rheumatoid arthritis or osteoarthrosis of the ankle” Kitaoka and Patzer 1996
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STAR Ankle- ScandinaviaSTAR Ankle- Scandinavia
widely used in Europe3 component designsliding polyethylene meniscus70% suvivorship at 10 year follow up
– Kofoed JBJS 1998
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STAR Ankle ReplacementSTAR Ankle Replacement
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STAR Ankle - continuedSTAR Ankle - continued
Wood et al - Foot Ankle 2001compared TPR ankle with STAR14 arthroplasties in 12 patients with RAAverage f/u 6 years4 of 6 TPR radiographically loose within 2
yearsSTAR remained satisfactory at 5 years
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Wood et al JBJS Br 2003Wood et al JBJS Br 2003
200 STAR ankles with 46 month f/u92.7% survivorship with 14 revisions or
fusionsMost common complication- wound
healing and malleolar fracture
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Uncemented STAR AnkleUncemented STAR Ankle
51 consecutive ankles 1993-199912 revisions, 7 due to looseningAvg. 52 month follow up70% survivorship
– Anderson et al JBJS July 2003
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Functional Evaluation of Functional Evaluation of STAR AnkleSTAR 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
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STAR Ankle ReplacementSTAR Ankle Replacement
49 replacements in 47 patientsMean f/u 28 months4 failures due to loosening
– Schutte and Louwerens Foot Ankle Int 2008
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Buechel and Pappas- 1992Buechel and Pappas- 1992
New Jersey Anklereported 85 % good to excellent results5% revision rate6 year follow up
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Buechel et al Foot Ankle 2003Buechel et al Foot Ankle 2003
49 Buechel Pappas ankles88 % good to excellent results93.5% survivorship at 10 yearsRevision due to malalignment, meniscal
wear, and talar component subsidenceNo longer FDA approved in US
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State of the Art-Agility AnkleState 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
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Surgical Technique - Agility Surgical Technique - Agility AnkleAnkle
anterior approach to ankleapplication of external fixator for
distractionresection of distal tibia and talustrial implantationimplantation of componentsdistal tibia/fibula fusion
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Complications with Agility Complications with Agility AnkleAnkle
radiographic looseningdelayed or nonunion of syndesmosis- 30%wound complicationsmigration of tibial component
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Agility AnkleAgility Ankle
132 ankles in 126 patients with avg. 9 year follow up – 1 surgeon (F. Alvine)
90% reported satisfaction14 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
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Total Ankle Arthroplasty vs. Total Ankle Arthroplasty vs. Ankle ArthrodesisAnkle 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
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Complications and Failure Complications and Failure After Total Ankle ArthroplastyAfter 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
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Salvage of Failed Ankle Salvage of Failed Ankle ReplacementReplacement
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
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64 y.o. female s/p distaltibial allograft for chondro-sarcoma
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ConclusionConclusion
total ankle replacement an option for the treatment of ankle arthritis
careful patient selection and educationnew generation of prostheses may offer
greater longevitycomplications common- Saltzman et al Foot
Ankle June 2003
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THANK YOUTHANK YOU