The ankle joint is a highly constrained one with a surface area that is one-third of the knee and hip and has thinner cartilage as well.¹ As a result, a total ankle replacement (TAR) carries higher loads, which may explain the shorter survivorship, compared with that of total knee replacement and total hip replacement.

First-generation ankle replacements were cemented, constrained two-piece systems without modularity. During the 1970s, TAR surgery was largely abandoned, with failure rates as high as 72% at 10 years.² However, with the development of second- and third-generation TAR utilizing modern designs, with multiple component sizes, improved fixation options, and instrumentation, there has been a resurgence in TAR. Gougoulias et al.³ performed a systemic review of the available literature regarding outcomes of TARs between 2003 and 2008. Unfortunately, only level IV evidence was available, highlighting the need for improved prospective studies. In their study, posttraumatic arthritis was the leading indication for TAR (34%). The overall failure rate was 10% at 5 years. Complications were common and included superficial wound complications as high as 14.7%, deep infection rates as high as 4.6%, and residual pain as high as 60%. Progression of adjacent arthritis ranged from 15% to 19% in the talonavicular and subtalar joints, respectively. With this resurgence comes the need for proper management of the failed TAR. In their review, 62% of failures were able to undergo revision TAR.

Kotnis et al.⁸ published a helpful review of their experience with revision TAR. They found that patients with a failed TAR frequently present with persistent pain; however, the clinician should press the patient for any symptoms worrisome for infection. Initial evaluation should include anteroposterior, lateral, and oblique radiographic views of the ankle as well as the foot if there is pain in adjacent joints. Radiographs should be examined thoroughly for radiolucent lines around the components and possible subsidence. Diagnostic injections under sterile conditions can be used to elucidate the source of joint pain. All patients should have basic laboratory tests, including cell count and differential, erythrocyte sedimentation rate, and C-reactive protein (CRP). If the results from these are equivocal, a fluoroscopically guided aspiration and tissue biopsy can be performed.

In the early postoperative period, periprosthetic fractures, bone cysts, gutter impingement, and arthrofibrosis may lead to continued pain and disability. Periprosthetic fractures may
pose a challenge as the available surface area for healing and bone quality may be poor. Nonoperative management can be accomplished with casting and prolonged non-weight bearing at the risk of losing motion. Open reduction internal fixation is the treatment of choice, and when performed, it should be according to standard AO techniques. Bone cysts can be related to arthritis and should be addressed at the primary procedure. Delayed presentation of bone cysts is usually related to polyethylene foreign-body reaction and should be addressed with curettage and bone grafting. Gutter impingement and arthrofibrosis can be improved with arthroscopic arthrolysis.