Updated: 6/8/2021

Total Ankle Arthroplasty

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  • 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
Flashcards (2)
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Questions (7)
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(OBQ18.100) A 66-year-old patient with diabetes underwent a left total ankle arthroplasty 2 years ago. The patient has developed left ankle erythema, swelling, and pain over the last 5 weeks. His radiographs are shown in Figures A and B, while a joint aspiration reveals 70K WBCs with gram-positive cocci in clusters. What is the most appropriate treatment and the expected outcome?

QID: 212996

IV antibiotics; prosthesis retention



Irrigation and debridement with polyethylene exchange; prosthesis retention



Antibiotic spacer; successful re-implantation of arthroplasty components



Amputation; successful infection eradication



Antibiotic spacer; unlikely for reimplantation of prosthesis



L 3 A

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(OBQ18.26) A 56-year-old patient presents with 3 months of right ankle pain. The patient underwent a total ankle arthroplasty 6 years ago and has remained relatively painless since the procedure. The patient denies any fevers or chills. Serum ESR and CRP are 19 mm/hr and 1.1 mg/L, respectively. Complete blood count revealed a white blood cell count of 9K cells/mL. Physical examination of the surgical wound reveals a well-healed incision and no evidence of drainage or sinus tracts. Synovial fluid analysis from the ankle consisted of 900 nucleated cells/mL, 44% neutrophils, negative gram stain, and no growth on cultures. Figures A and B are AP and lateral radiographs of the right ankle. What is the most appropriate next step?

QID: 212922

Bone scan



CT with metal artifact-reducing protocol



Repeat aspiration



Routine follow-up



Two-stage revision




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(OBQ17.188) A 67-year-old patient presents with a several year history of chronic right medial ankle pain that has failed conservative treatment. Despite the use of orthotics and Arizona bracing, the patient's foot has become flatter over time. There is tenderness along the joint line and pain with passive dorsiflexion and plantarflexion of the tibiotalar joint. Weakness and pain are appreciated with resisted foot inversion. The patient has a rigid hindfoot and is unable to perform a single heel raise. Figures A, B, and C are current radiographs. What is the most appropriate treatment?

QID: 210275

Medial slide calcaneal osteotomy, FDL transfer to the navicular, lateral column lengthening, cotton osteotomy, calcaneonavicular ligament reconstruction with peroneus longus tendon, deltoid ligament reconstruction



Supramalleolar osteotomy



Pantalar arthrodesis



Total ankle arthroplasty



Triple arthrodesis with deltoid ligament reconstruction



L 4 A

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