total ankle arthroplasty: ready for prime time? advances in orthopaedic trauma and arthroplasty...

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

OsteoarthritisOsteoarthritis

Can be post traumaticDegenerativeMay affect any joint in the foot and ankle

Inflammatory ArthritisInflammatory Arthritis

RheumatoidSystemic Lupus ErythematosisPsoriaticgoutOthers

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

Treatment of Ankle ArthritisTreatment of Ankle Arthritis

NSAIDS, Bracing, Shoewear modificationscorticosteroid injectionankle joint debridementdistractionarthrodesisarthroplasty

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%

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

Total Ankle ReplacementTotal Ankle Replacement““State of the ArtState of the Art””

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

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!!!

Contraindications to Ankle Contraindications to Ankle ReplacementReplacement

prior sepsisosteonecrosis or profound osteoporosisyoung, very active patientsevere deformity of ankle or foot

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

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

Salto Talaris Anatomic Ankle Salto Talaris Anatomic Ankle (Tornier)(Tornier)

Inbone

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

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

STAR Ankle- ScandinaviaSTAR Ankle- Scandinavia

widely used in Europe3 component designsliding polyethylene meniscus70% suvivorship at 10 year follow up

– Kofoed JBJS 1998

STAR Ankle ReplacementSTAR Ankle Replacement

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

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

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

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

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

Buechel and Pappas- 1992Buechel and Pappas- 1992

New Jersey Anklereported 85 % good to excellent results5% revision rate6 year follow up

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

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

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

Complications with Agility Complications with Agility AnkleAnkle

radiographic looseningdelayed or nonunion of syndesmosis- 30%wound complicationsmigration of tibial component

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

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

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

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

64 y.o. female s/p distaltibial allograft for chondro-sarcoma

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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