Abstract
Revision total ankle arthroplasty (TAA) frequently requires removal of well-fixed tibial components. Modular intramedullary stem systems provide strong metaphyseal and diaphyseal fixation but can present substantial challenges during revision surgery. Standard extraction techniques relying on axial traction may fail when significant osseous integration occurs. We describe a stepwise technique for removal of a well-fixed modular tibial stem utilizing fluoroscopically guided flexible osteotomes combined with distal and proximal anteromedial tibial corticotomies. This staged approach allows controlled disruption of the bone–implant interface, facilitating safe extraction while minimizing tibial bone loss and reducing the risk of iatrogenic fracture.
Introduction
TAA has become an increasingly utilized treatment for end-stage ankle arthritis, with modern implant designs demonstrating improved survivorship and functional outcomes. ,, Registry and cohort studies have reported mid-term survivorship exceeding 85–90% at 5 to 10 years following implantation. Despite these improvements, revision surgery remains necessary in a subset of patients due to loosening, malalignment, subsidence, or implant failure. ,,
The INBONE total ankle system utilizes a modular intramedullary tibial stem designed to achieve strong metaphyseal and diaphyseal fixation through canal engagement. This design provides excellent implant stability and has demonstrated favorable clinical outcomes in several series. However, the same fixation characteristics that improve implant stability may complicate removal during revision procedures when substantial osseous integration develops along the tibial stem.
Removal of well-fixed tibial components represents one of the most technically challenging aspects of revision TAA. Standard extraction techniques typically rely on implant disassembly followed by axial traction using specialized instrumentation or slap hammer devices. When significant bone–implant integration exists, however, these methods may fail and can risk tibial fracture, cortical violation, or excessive metaphyseal bone loss. Several authors have emphasized the importance of controlled disruption of the bone–implant interface when removing well-fixed arthroplasty components in order to preserve bone stock for subsequent reconstruction. ,,
The purpose of this report is to describe a stepwise surgical technique utilizing fluoroscopically guided flexible osteotomes combined with distal and proximal anterior tibial corticotomies to facilitate safe removal of a well-fixed INBONE tibial stem during revision TAA.
Surgical technique
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Step 1: Implant Disassembly and Initial Disimpaction Attempt
The ankle is exposed through the prior anterior incision. Here we present a case of subsequent periprosthetic dislocation warranting explantation and conversion to tibiotalocalcaneal arthrodesis ( Fig. 1 ). Modular components of the INBONE prosthesis are disassembled according to manufacturer instrumentation. The 18‑mm wrench is attached to the strike rod and axial disimpaction is attempted to mobilize the tibial stem.
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Step 2: Distal Anterior Tibial Corticotomy
Pre operative radiographs.
If standard extraction fails, a distal anterior tibial corticotomy is performed to access the bone–implant interface ( Fig. 2 ). A small cortical window is created over the distal portion of the stem utilizing a 0.062-inch Kirschner wire and completion with a ¼ inch straight osteotome. This anterior cortical window is saved in saline until needed for fixation. Flexible osteotomes are introduced along the bone–implant interface under fluoroscopic guidance. Fluoroscopy is utilized in both anteroposterior and lateral projections to confirm osteotome position along the implant interface. ( Fig. 3 )
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Step 3: Proximal Medial Tibial Corticotomy
Proximal and distal corticotomies shown.
Flexible osteotome is introduced from distal to proximal under lateral fluoroscopic guidance.
If the stem remains fixed, a proximal medial anterior rectangular tibial corticotomy is created to improve access to the proximal stem interface. Flexible osteotomes are advanced proximally and circumferentially around the stem.
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Step 4: Distal Disimpaction Using the Strike Rod
Following partial mobilization, controlled distal-directed disimpaction forces are applied through the strike rod to further disrupt residual fixation.
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Step 5: Circumferential and Posterior Osteotome Release
Flexible osteotomes are advanced circumferentially around the proximal and posterior aspects of the tibial stem to fully disrupt the bone–implant interface. ( Fig. 4 )
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Step 6: Final Stem Extraction
Flexible osteotome is advanced in an anterograde fashion from proximal corticotomy.
Once circumferential mobilization has been achieved; axial extraction is repeated using the strike rod instrumentation and the stem is removed. ( Fig. 5 , Fig. 6 )
Explanted modular stem demonstrating medial bony ongrowth.
