Rheumatoid arthritis (RA) frequently leads to progressive joint destruction, most commonly affecting the forefoot and hindfoot through inflammatory changes. RA is a chronic autoimmune disease that causes a cascade of inflammation-driven changes, creating pannus formation, cartilage damage, and osteoclast-mediated erosion of bone Although less common, end-stage ankle arthritis from RA can cause severe pain, gait disturbance, and substantial functional disability. Historically, surgical treatment has relied on ankle arthrodesis, which reliably alleviates pain but eliminates motion and may accelerate adjacent joint degeneration. Total ankle replacement (TAR) offers a motion-preserving alternative with favorable functional outcomes; however, the long-term survivorship of metallic implants remains a concern in relatively younger patients.

Osteochondral allograft reconstruction has emerged as a biologic alternative to metallic components, demonstrating success in younger, active patients with severe post-traumatic ankle arthritis in short-, mid-, and long-term follow-up. ^, Osteochondral allograft transplantation is described in the knee literature. Contraindications include end-stage osteoarthritis and inflammatory joint disease, as inflammatory disease may decrease graft survival by affecting chondrocyte viability. This report describes the use of bipolar osteochondral allograft reconstruction for total ankle replacement in a relatively young patient with RA and end-stage ankle arthritis with greater than 3 years of follow-up.

A 43-year-old female with RA presented with a 2-year history of progressive left ankle pain and functional decline. Informed consent for participation in this study was obtained and signed by the patient. She was dependent on a knee scooter for ambulation, with a visual analog scale (VAS) score of 9 and a Foot Function Index (FFI) score of 79.4. Conservative management had failed, and ankle arthrodesis had previously been recommended by another surgeon. At presentation, she was not receiving disease-modifying antirheumatic therapy or chronic corticosteroids due to disease remission, per the treating rheumatologist. This is an important consideration in patient selection, as uncontrolled RA or DMARDs can affect graft survival and postoperative complications.

Physical examination revealed an antalgic gait with excessive external rotation and <10° of total ankle motion, accompanied by crepitus, pain, and guarding. Hindfoot and midfoot motion were absent due to ankylosis of the talonavicular, subtalar, calcaneocuboid, and naviculocuneiform joints. The anterior ankle was tender to palpation with mild edema, without gross instability or deformity. Radiographs demonstrated advanced degenerative changes of the ankle with mild congruent varus alignment ( Fig. 1 ). Given her age, activity level, and desire to preserve motion, bipolar osteochondral allograft TAR was recommended.

Pre Op X-ray imaging of the left ankle demonstrating end-stage arthritic changes, anterior-posterior ankle view (a), medial oblique ankle view (b), lateral ankle view (c).

The patient was placed supine on the operating table utilizing a hip bump and bone foam for optimal positioning. The operative extremity was prepared and draped in standard sterile fashion. The standard anterior approach was utilized; the operative ankle was incised with a longitudinal midline incision following the course of the long extensor tendon to the great toe. The incision was deepened carefully through the subcutaneous tissue, with the intermediate dorsal cutaneous nerve being identified and reflected laterally. The fascia was identified and split longitudinally, followed by division of the anterior compartment structures. The tibialis anterior was reflected, along with the rest of the structures laterally, including the neurovascular bundle. Next, the joint capsule and periosteum were incised and reflected. The periosteum was elevated off the anterior tibia and talus, and the ankle joint was exposed, which was filled with hypertrophic synovium and scar tissue. The synovium, scar tissue, and anterior hyperostosis to the distal tibia and talus were resected with a combination of hand and power instrumentation to expose the full width of the medial, anterior, and lateral joint line.

Manual jig-cut blocks from the Salto Talaris Total Ankle Arthroplasty System (Smith & Nephew, Inc., Memphis, Tennessee, USA.) were positioned carefully to resect the joint surfaces, and size-matched allografts were contoured to fit the recipient sites ( Fig. 2 ). Fixation of the tibial and talar allografts, along with medial malleolar reinforcement, was achieved using 2.0 mm headless compression screws, two anterior in the tibia, one posterior in the tibia, and two in the talus, placed outside the weightbearing zone or buried beneath the cartilage to avoid impingement ( Fig. 3 a).

Intraoperative images showing intraoperative allograft osteotomy alignment (a), the allograft compared to arthritic tibial and talar articular surface (b), and final clinical appearance following implantation (c).

10-month post-op x-rays (a) and 3-month CT scan demonstrating stable allograft incorporation (b).

Copious irrigation throughout the operation with a pulsatile lavage system was utilized. The wound was soaked in diluted betadine solution following allograft insertion as well. Final irrigation followed by closure with 0 Vicryl, 2–0 Vicryl, 3–0 Vicryl, 3–0 Monocryl, and 3–0 nylon and skin staples were used in the capsule, fascia, subcutaneous tissue, and skin, respectively. The patient’s wounds were dressed with a multilayered compression dressing, and the leg was placed in a short leg splint.

The patient remained non-weightbearing for 12 weeks in a cast, followed by progressive weightbearing in a controlled ankle motion (CAM) boot for 4 weeks. Computed tomography (CT) at 3 months confirmed stable fixation and osseous incorporation ( Fig. 3 b). At 5 months, she transitioned to supportive shoe gear with an ankle-stabilizing orthosis, and by 8 months reported marked pain relief and independent ambulation without assistive devices (VAS 0, FFI 21.2). Post-operative radiographs were taken at 10 months ( Fig. 3 a). The patient continues to have pain relief for over 3-years, with the most recent VAS of 0 and FFI of 8.2.

The progressive nature of RA can lead to early-onset end-stage ankle arthritis. These patients are often younger and remain active, yet surgical options are typically limited to ankle arthrodesis or metallic TAR. ^, In RA patients undergoing metallic TAR, reported survivorship ranges from 88.5% at 5 years to 74.7% at 10 years ^, , with most cohorts averaging older than 60 years of age. More recent studies with TAR implants in RA patients have reported improved survivorship up to 97.4% at 10 years, although the revision-free survivorship was 81.5% at 5 years and 74.7% at 10 years. A large single-institution study of 1071 primary TARs was performed, including patients with RA. This study found that although RA patient-reported outcome scores did not improve as much as the OA and posttraumatic groups, they did have functional improvement from baseline with no increased risk to implant failure. The National Joint Registry (NJR) Data and National Health Service (NHS) data were utilized to evaluate risk factors for TAR failure. Within this study, they reported that RA was not a significant risk factor for failure; in fact, those patients had higher survivorship than OA patients. These findings highlight the changes in TAR management and the role of alternative treatment strategies in younger patients with RA and advanced ankle arthritis.

This case highlights the potential role of bipolar osteochondral allograft reconstruction as a biologic, motion-preserving alternative in this population. Bipolar allograft TAR has demonstrated favorable early outcomes and meaningful pain reduction in multiple series. ^,,,, Reported graft survival ranges vary across the literature. The largest reported series of bipolar osteochondral allograft transplantation was reported by Bugbee et al., which consisted of eighty-four patients and eighty-eight ankles with a reported 76% survivorship at 5 years and 44% survivorship at 10 years. Similarly, mid-term follow-up survivorship on eighty-six ankles was reported by French et al., showing bipolar osteochondral allograft transplantation survivorship of 74.8% at 5 years and 56% at 10 years. While a 10-year survivorship of 70.8% was reported by Giannini et al. on a smaller cohort of forty-eight ankles. Providing evidence for the utilization of bipolar allografts for total ankle reconstruction.

Total ankle reconstruction using bipolar osteochondral allograft is technically demanding and depends on surgical precision and graft viability, which likely contribute to the relatively high failure rate reported in the literature. ^, Chondrocyte viability is a critical determinant of graft incorporation, with thresholds of approximately 70% considered necessary for successful biologic integration. Conventional storage techniques are associated with substantial loss of viability within 4 weeks, and fresh grafts are typically available only for 14 to 21 days, with marked degradation after 14 days of storage. One study reported chondrocyte viability decreased by 1.7% at 14 days and 28.5% by day 28. ^,,,,,

The Missouri Osteochondral Preservation System (MOPS) has been shown to better maintain chondrocyte viability and may extend graft shelf life up to 60 days, with reported 90% viability at 60 days compared with 53% in controls. This advancement may improve the durability and reliability of biologic ankle reconstruction.

To our knowledge, this is the first report describing bipolar osteochondral allograft TAR in a relatively young patient with RA and end-stage ankle arthritis. This motion-preserving approach resulted in substantial improvement in pain and function and may represent an alternative to metallic TAR or ankle arthrodesis in carefully selected patients. Long-term follow-up will be crucial for monitoring progressive RA-related degenerative changes to the allograft ankle components.