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Updated: May 26 2023

Total Ankle Arthroplasty

  • summary
    • Total Ankle Arthroplasty is an alternative to ankle arthrodesis for the treatment of end-stage ankle osteoarthritis.
    • The procedure attempts to preserve functional range of motion, which would otherwise be sacrificed with ankle arthrodesis.
    • Contraindications include active infection, peripheral vascular disease, charcot arthropathy, severe osteoporosis, osteonecrosis of the talus, and peripheral neuropathy.
  • History
    • History
      • first generation TAA
        • majority of designs were highly constrained, or semi-constrained two component prostheses
        • used cement fixation on both the talar and tibial sides
        • high incidence of loosening, wide osteolysis, subsidence, and mechanical failure of prosthesis components
      • second generation TAA
        • majority are two-component fixed-bearing systems with a polyethylene bearing surface incorporated into the talar or tibial component
        • more conservative bone cuts
        • elimination of bone cement in favour of press-fit designs with porous coating for bony ingrowth
      • third generation TAA
        • characterized by the addition of a third component, an independent polyethylene mobile-bearing meniscus
        • place a greater importance on the use of ligaments to retain stability, the need for anatomic balancing following component insertion, and minimal bone resection.
    • Implants approved by the FDA
      • Scandinavian Total Ankle Replacement (STAR; Small Bone Innovations, Morrisville, PA)
      • INBONE (Wright Medical Technology, Arlington, TN)
      • Agility (DePuy, Warsaw, IN)
      • Salto Talaris (Tornier, Montbonnot, France)
    • Outcomes
      • pain and function
        • significant improvement in pain and function
        • pre-operative ROM best predictor for post-operative ROM with minimal additional benefit in ROM gained from TAA
        • little high quality evidence comparing TAA vs. ankle arthrodesis
        • TAA with superior performance on uneven surfaces compared to ankle arthrodesis
      • survivorship
        • TAA survivorship at 10 years ranges from 70% to 90%
        • no evidence that three component designs are better than two component designs
  • Indications
    • Indications
      • diagnosis
        • unilateral or bilateral end-stage ankle OA
      • favorable patient factors
        • older (middle- to old-aged), low demand, reasonably mobile patient with no significant
        • normal or low body mass index
        • well-aligned and stable hindfoot
        • good soft tissues conditions
    • Contraindications
      • active infection
      • peripheral vascular disease
      • inadequate soft-tissue envelope
      • Charcot arthropathy
      • insufficient bone stock
      • severe osteoporosis
      • osteonecrosis of the talus
      • peripheral neuropathy
  • Preoperative Imaging
    • Radiographs
      • recommended views
        • weight-bearing AP and lateral views of the ankle
      • findings
        • extent of arthritis
    • MRI
      • findings
        • presence of osteonecrosis, amount of involvement, bone loss,and size of subchondral cysts
  • Surgical Technique
    • Approach
      • vast majority of systems utilize an anterior approach to the ankle, via the interval between tibialis anterior and extensor hallucis longus
    • Goals
      • to restore mechanical alignment to the ankle
        • achieved by alignment guides that allow for precise cuts of the tibia, talus, and in some systems the fibula
        • recent iterations of TAA systems have incorporated ligamentous balancing as a crucial part of the operative procedure
        • imperative to achieve a stable, neutrally aligned, plantigrade, weight-bearing position of the ankle and hindfoot
          • ligament reconstruction, tendon transfers, osteotomies, heel cord lengthening and arthrodesis may be necessary
    • Technical Considerations
      • soft tissue considerations
        • use a long incision to decrease the tension on the skin
        • perform thick skin flaps to maintain vascularity
        • minimize use of retractors has been emphasized in the literature
        • avoid the tibialis anterior sheath
          • prevents tendon bowstringing and its resultant wound complications
      • implant placement
        • common technical errors include
          • placing the prosthesis too lateral
          • using too small a prosthesis, which subsides
          • failing to solve preoperative varus or valgus malalignment and attempting to replace an ankle that is too anteriorly subluxated
  • Complications
    • Delayed wound healing
      • most common
      • reported in 4% to 17% of cases in the literature
    • Superficial wound infection
    • Deep wound infection
      • ranges from 0.5% to 3.5% of cases
      • studies have shown a low success rate of component reimplantation
      • painful TAA work-up should include CBC, ESR, and CRP
    • Sensory deficits
      • secondary to anterior incision and its proximity to the superficial and deep peroneal nerves
      • reported rates are as high as 21%
    • Intraoperative Fracture
      • medial > lateral malleolus
      • occur in the narrow bone bridge between the ankle joint and the outer cortex of the tibia or fibula
      • causes
        • overextending the plafond cut too medially or laterally
        • making a cut too proximal in the tibia
        • using an over-sized tibial component
        • distraction of the ankle with an external fixator
      • prevention
        • prophylactic K-wire pinning (or screw fixation) prior to osteotomy cut
    • Component loosening
      • talar component fails more commonly than the tibial component
    • Subsidence
      • may need to convert to ankle fusion
        • decide if there is infection
        • decide whether to fuse across subtalar joint (TTC fusion)
        • decide what bone graft to use
          • particulate cancellous graft (<2cm talar bone loss)
          • bulk allograft (>2cm bone loss)
            • femoral head allograft
              • graft of choice if TTC fusion is chosen
            • Cambell allograft graft (wedges of tricortical iliac crest)
            • fresh-frozen distal tibial allograft
        • decide what type of fixation
          • nail
          • plate
          • nail and plate
    • Osteolysis
      • polyethylene wear results in osteolysis, with large, expansive cystic lesions in the tibia or talus
      • CT with metal artifact reduction protocol is the best study to evaluate for extent of osteolysis
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