CHAPTER SYNOPSIS:
Total ankle arthroplasty (TAA) has become a viable treatment for end-stage ankle arthrosis. However, complication and failure rates are still higher than those for hip or knee arthroplasty. In this chapter, studies from the past 10 years were reviewed in an attempt to define why TAA fails. This resulted in the identification of complications that were frequently occurring or have consequences in the survival of TAA. This allowed proposal of a classification system that indicates how common and dangerous are the complications of TAA.
IMPORTANT POINTS:
Classification of Total Ankle Arthroplasty Complications
Good (very unlikely to cause TAA failure)
- 1
Intraoperative bone fracture
- 2
Nonunion
- 3
Wound-healing problems
Bad (likely to cause TAA failure)
- 1
Technical error
- 2
Subsidence
- 3
Postoperative bone fracture
Dangerous (very likely to cause TAA failure)
- 1
Deep Infection
- 2
Aseptic loosening
- 3
Implant failure
CLINICAL/SURGICAL PEARLS:
- 1
When performing TAA, one must be aware of the common and dangerous complications that may compromise the clinical outcome of patients receiving TAA.
- 2
Early identification of complications of TAA coupled with knowledge of the severity will allow more effective treatment to minimize morbidity associated with TAA.
HISTORY/INTRODUCTION/SCOPE OF THE PROBLEM
End-stage ankle arthrosis (EAA) is a cause of chronic disability. Recent reports have suggested that the debilitation and reduction in quality of life caused by EAA are severe.
Ankle arthrodesis has been used to successfully treat disabling EAA since the late nineteenth century with good short-term results. In an attempt to improve clinical outcomes for surgical treatment of EAA, the principles of joint replacement for the hip and knee were applied to the ankle. This resulted in the development of more than 23 total ankle arthroplasty (TAA) prostheses in the 1970s. Many of the initial designs were poor, leading to excessive talar bone resection, tibiotalar malalignment, and frictional forces between the fibula articular surface and tibial component. These early two-component, constrained, first-generation designs led to unsatisfactory results with high complication rates and eventual recommendations that ankle arthroplasty with constrained prosthesis should be abandoned. Consequently, ankle arthrodesis persisted as the standard of care for ankle arthritis and the enthusiasm for first-generation TAA was lost.
More recently, several studies have reported poor long-term clinical outcomes after ankle arthrodesis with high incidence of ipsilateral hindfoot arthritis, particularly of the subtalar joint. This has led to a resurgence of second- and third-generation TAA implants with design features that included three components—mobile bearing, nonconstrained, and noncemented (e.g., Agility Ankle, Buechel-Pappas, Hintegra, LCS, Norwegian TPR, and Scandinavian Total Ankle Replacement–STAR).
Currently, second- and third-generation TAA prostheses have shown positive short- and medium-term results in North America and Europe ( Table 21-1 ). This chapter will serve as a review of the most relevant current (as of January 2008) literature available on outcomes of selected second- and third-generation TAA prosthesis. The goal of this chapter is to use the present data available to identify survivorship rates and causes for failure of second- and third-generation TAAs to provide more up-to-date information on survival of TAA.
| Study | Mean Follow-up Time | Implant | No. of Cases | % Survival |
|---|---|---|---|---|
| Spirt et al. | 33 mo | Agility | 306 | 89.2 |
| Knecht et al. | 108 mo | Agility | 132 | 89.4 |
| Hosman et al. | 32 mo | Agility | 117 | 92.3 |
| Hurowitz et al. | 40 mo | Agility | 65 | 67.7 |
| Schuberth et al. | 24 mo | Agility | 50 | 84.0 |
| Ali et al. | 60 mo (3–150) | B-P | 35 | 97.1 |
| Kurup et al. | 34 mo | B-P | 34 | 88.2 |
| San Giovanni et al. | 100 mo | B-P | 31 | 93.5 |
| Beuchel et al. | 60 mo | B-P (deep sulcus) | 75 | 98.7 |
| Buechel et al. | 144 mo | B-P (shallow sulcus) | 40 | 82.5 |
| Su et al. | 77 mo | B-P/HSS | 27 | 92.6 |
| Doets et al. | 91 mo | B-P/LCS | 93 | 83.9 |
| Hinterman et al. | 36 mo | HINTEGRA | 271 | 85.6 |
| Henricson et al. | 25 mo | HINTEGRA | 29 | 86.2 |
| Henricson et al. | 54 mo | STAR | 318 | 77.0 |
| Fevang et al. | 37 mo | STAR | 212 | 90.1 |
| Wood et al. | 46 mo | STAR | 200 | 92.7 |
| Valderrabano et al. | 44 mo | STAR | 68 | 86.8 |
| Anderson et al. | 52 mo | STAR | 51 | 76.5 |
| Hosman et al. | 43 mo | STAR | 45 | 93.3 |
| Lodhi et al. | ≈28–78 mo | STAR | 27 | 96.3 |
| Kofoed et al. | 113 mo | STAR cemented | 33 | 72.7 |
| Kofoed et al. | 113 mo | STAR noncemented | 25 | 96.0 |
| Takakura et al. | 62 mo | TNK new ceramic * | 70 | 95.7 |
| Fevang et al. | 92 mo | TPR cemented | 32 | 81.3 |
| Total cases | 2386.0 | |||
| Overall survival rate | 87.6 | |||
METHODS OF LITERATURE REVIEW
The 20 studies included in this systematic review were identified in a PubMed search for a 10-year period (1997–2007) using the keywords ankle arthroplasty and/or ankle replacement and/or ankle prosthesis. Inclusion criteria consisted of at least 25 implants with a minimum of 2 years of follow-up that includes reports on survival and complications. These studies varied in methodology and thus may include some inaccuracies due the nature and completeness of data reported.
Survivorship of Total Ankle Arthroplasty Failure
The follow-up periods reported in the 20 studies reviewed ranged from 24 to 144 months (see Table 21-1 ), which could be considered to be of short or intermediate duration compared with those reported for other arthroplasty procedures such as hip or knee, which commonly report follow-up periods greater than 15 years.
Survivorship of TAA reported for the short- and intermediate-term follow-up in this review ranges from 67.7% to 98.7% with an overall mean of 87.6% survival at 64 months for 2386 TAAs reviewed (see Table 21-1 ). These are significantly improved over survivorships that were reported in the past for first-generation TAAs but still fall short of the generally more successful survivorships reported for total knee and hip arthroplasty. Thus, as the incidence of TAA increases, especially in younger patients, an increased burden of revision TAA can be anticipated.
These concerns are best addressed by identifying the most likely causes for failure of TAA to serve as baseline information that will assist with tailoring an approach to dealing with failed TAAs. In this review, identification of significant reported complications and complication leading to TAA implant failure will be necessary steps to identify the etiology of failed TAA.
Significant Reported Complications in Total Ankle Arthroplasty
In a review of the 20 current studies significant reported complications for TAA were identified ( Table 21-2 ), which include intraoperative bone fracture, postoperative bone fracture, wound-healing problems, deep infection, aseptic loosening, nonunion, implant failure, subsidence, and technical error. These complications were considered as significant due to their consequences or rate of occurrence.
| Study | Implant | Mean Follow-up (Months) | # Cases | Intra-op Bone Fracture (%) | Post-op Bone Fracture | Wound-Healing Problem (including superficial infections) | Deep Infection | Aseptic 1 Loosening | Non-union | Implant 2 Failure | Subsidence 3 | Technical Error 4 | # Complications (% Rate per study) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Spirt | Agility | 33 | 306 | 9 (2.9) | 3 (1.0) | N/A | 5 (1.6) | 22 (7.2) | 14 (4.6) | N/A | N/A | 40 (13.1) | 91 (29.7) |
| Knecht | Agility | 108 | 132 | N/A | N/A | 3 (2.3) | 3 (2.3) | 4 (3.0) | 9 (6.8) | 4 (3.0) | 16 (12.1) | 1 (0.8) | 40 (30.3) |
| Hosman | Agility | 32 | 117 | N/A | N/A | N/A | 1 (0.9) | 7 (6.0) | N/A | N/A | N/A | 1 (0.9) | 9 (7.7) |
| Hurowitz | Agility | 40 | 65 | N/A | N/A | 9 (13.8) | 3 (4.6) | 8 (12.3) | N/A | N/A | 5 (7.7) | 4 (6.2) | 29 (44.6) |
| Schuberth | Agility | 24 | 50 | 19 (38) | N/A | 10 (20) | 1 (2) | N/A | 6 (12) | N/A | 5 (10) | 8 (16.0) | 49 (98.0) |
| Ali | B-P | 60 | 35 | 2 (5.7) | N/A | 2 (5.7) | 0 | N/A | 1 (2.9) | N/A | 0 | 1 (2.9) | 6 (17.1) |
| Kurup | B-P | 34 | 34 | 5 (14.7) | N/A | 3 (8.8) | 0 | N/A | N/A | N/A | N/A | 8 (23.5) | 16 (47.1) |
| San Giovanni | B-P | 100 | 31 | 10 (32.3) | 4 (12.9) | 4 (12.9) | 1 (3.2) | 2 (6.5) | 1 (3.2) | N/A | 5 (16.1) | 1 (3.2) | 28 (90.3) |
| Buechel | B-P (Deep Sulcus) | 60 | 75 | 6 (8.0) | N/A | 11 (14.7) | 2 (2.7) | N/A | N/A | 3 (4.0) | 3 (4.0) | 1 (1.3) | 26 (34.7) |
| Buechel | B-P (Shallow Sulcus) | 144 | 40 | 3 (7.5) | N/A | 9 (22.5) | 2 (5.0) | N/A | N/A | 7 (17.5) | 6 (15.0) | N/A | 27 (67.5) |
| Su | B-P/HSS | 77 | 27 | N/A | N/A | 1 (3.7) | 1 (3.7) | N/A | N/A | 1 (3.7) | 3 (11.1) | N/A | 6 (22.2) |
| Doets | B-P/LCS | 91 | 93 | 27 (29.0) | 4 (4.3) | 8 (8.6) | 3 (3.2) | 6 (6.5) | 2 (2.2) | 0 | 7 (7.5) | N/A | 57 (61.3) |
| Hinterman | HINTEGRA 5 | 36 | 271 | 4 (1.5) | 6 (2.1) | 9 (3.3) | 0 | 17 (6.3) | 1 (0.4) | 3 (1.1) | N/A | 5 (1.8) | 45 (16.6) |
| Henricson | HINTEGRA | 25 | 29 | N/A | 0 | N/A | 0 | 3 (10.3) | N/A | 0 | N/A | 1 (3.4) | 4 (13.8) |
| Henricson | STAR | 54 | 318 | N/A | 2 (0.6) | N/A | 10 (3.1) | 31 (9.7) | N/A | 6 (1.9) | N/A | 14 (4.4) | 63 (19.8) |
| Fevang | STAR | 37 | 212 | N/A | 1 (0.5) | N/A | 2 (0.9) | 10 (4.7) | N/A | 2 (0.9) | N/A | 7 (3.3) | 22 (10.4) |
| Wood | STAR | 46 | 200 | 9 (4.5) | 10 (5.0) | 5 (2.5) | 1 (0.5) | 14 (7.0) | N/A | N/A | N/A | 9 (4.5) | 48 (24.0) |
| Valderrabano | STAR | 44 | 68 | N/A | N/A | 1 (1.5) | 0 | 5 (7.4) | N/A | N/A | N/A | 9 (13.2) | 15 (22.1) |
| Anderson | STAR | 52 | 51 | N/A | N/A | 5 (9.8) | N/A | 15 (29.4) | N/A | 2 (3.9) | N/A | 13 (25.5) | 35 (68.6) |
| Hosman | STAR | 43 | 45 | N/A | N/A | N/A | N/A | 2 (4.44) | N/A | N/A | N/A | N/A | 2 (4.4) |
| Lodhi | STAR | 53 a | 27 | 2 (7.4) | 0 | N/A | N/A | N/A | N/A | N/A | 1 (3.7) | 2 (7.4) | 5 (18.5) |
| Kofoed | STAR | 113 | 25 | N/A | N/A | N/A | N/A | 1 (25.0) | N/A | 0 | 0 | 1 (4.0) | 2 (8.0) |
| Kofoed | STAR (Cemented) | 113 | 33 | N/A | N/A | N/A | N/A | 6 (18.2) | N/A | 1 (3.0) | 1 (3.0) | 1 (3.0) | 9 (27.3) |
| Takakura | TNK * | 62 | 70 | 4 (5.7) | N/A | 2 (2.9) | 1 (1.4) | 23 (32.9) | N/A | 6 (8.6) | 23 (32.9) | 2 (2.9) | 61 (87.1) |
| Fevang | TPR | 92 | 32 | N/A | N/A | N/A | N/A | 6 (18.8) | N/A | N/A | N/A | N/A | 6 (18.8) |
| Sum | 1520 | 2386 | 100 | 30 | 82 | 36 | 182 | 34 | 35 | 75 | 129 | 703 (35.6) | |
| Total | |||||||||||||
| Unadjusted reported complication rate | 63.3 | 2386 | 4.2 | 1.3 | 3.4 | 1.5 | 7.6 | 1.4 | 1.5 | 3.1 | 5.4 | 29.5 | |
| Adjusted b reported complication rate | Varies | Varies | 8.1 | 2.0 | 6.6 | 1.7 | 8.7 | 4.4 | 5.0 | 10.7 | 6.0 | ||
Related posts:
Allograft Resurfacing of the Tibiotalar Joint
Recognition and Salvage of the Failed Ankle Replacement Arthroplasty
Conversion of a Failed Total Ankle Replacement to an Ankle Fusion: Indications and Technique
Diagnosis and Classification of Bone Defects: The Effect on Total Ankle Arthroplasty
Tendon Transfers for Acquired Posterior Tibial Tendon Deficiency
Midfoot Arthritis: Nonoperative Treatment and Arthrodesis
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