Abstract
Introduction
Total ankle arthroplasty (TAA) is a recognized alternative to arthrodesis for end-stage ankle arthritis. However, failed TAA complicated by severe talar subsidence and bone loss often renders revision arthroplasty not feasible. Conventional salvage arthrodesis techniques using structural grafts or metal blocks are associated with heterogeneous outcomes and high complication rates. In recent years, patient-specific three-dimensional (3D) printed implants have emerged as a promising option for addressing large bone defects.
Case Presentation
A 48-year-old female presented with failed TAA complicated by advanced talar collapse and bone loss. She underwent tibiotalar arthrodesis using a patient-specific 3D-printed porous titanium talus implant with an intramedullary canal designed to accommodate retrograde nail fixation. This design provided immediate structural stability and simplified the procedure by eliminating the need for intraoperative canal preparation. At the 11-month follow-up, radiographs demonstrated progressive osteointegration, and the patient reported significant pain reduction and functional improvement, with no complications observed.
Discussion
Compared with conventional salvage methods, patient-specific 3D-printed implants offer optimal anatomical conformity, reliable structural stability, and the potential to promote osteointegration. This case highlights the practical benefits of an implant intentionally designed to facilitate intramedullary fixation in the setting of severe talar collapse after failed TAA.
Conclusion
Patient-specific 3D-printed porous talus implants with intramedullary canal design may represent a valuable salvage option for failed TAA with severe talar collapse. Despite promising early results, larger cohorts and long-term follow-up are needed to validate this approach. This report adds to the growing body of evidence supporting custom 3D-printed implants for complex ankle salvage.
Introduction
End-stage ankle arthritis is a condition that leads to severe pain, loss of function, and a significant decline in quality of life for patients. Total ankle arthroplasty (TAA) is an increasingly common treatment option used as an alternative to arthrodesis in these patients. ,,
However, various complications can occur following TAA. Component loosening, infection, malposition, wear, and particularly severe talar subsidence and bone loss can necessitate revision surgery. ,,, However, revision TAA attempts are associated with high complication rates and the need for further surgery. ,
Salvage procedures come into consideration for cases that are not suitable for revision arthroplasty or that involve significant bone loss. Arthrodesis is the most frequently preferred method in these patients. ,, However, when large bone defects are present, achieving satisfactory results is difficult due to issues such as anatomical mismatch, graft resorption, donor site morbidity, and a high risk of non-union. ,, The literature highlights a lack of alternatives that provide both structural stability and promise reliable long-term results, especially in cases of severe talar defects.
The aim of this case report is to share the technique and early results of tibiotalar arthrodesis performed using a patient-specific, three-dimensionally (3D) printed titanium talus implant for the revision of a failed TAA due to severe talar collapse. To the best of our knowledge, there are very few case reports regarding the use of a custom, porous titanium implant with a pre-designed canal allowing for intramedullary fixation in such an extensive talar defect. This technique provides immediate structural support in cases of major bone loss, while its porous structure also carries the potential to promote osteointegration.
Case presentation
A 48-year-old female patient presented to our clinic with complaints that developed following a previous total ankle arthroplasty. At the time of presentation, she was experiencing severe ankle pain, loss of function, and difficulty walking. Clinical examination revealed significant limitation of movement and an inability to bear weight. Radiological evaluation with direct radiographs and computed tomography (CT) showed advanced bone loss and a defect around the talar component. Due to prosthesis failure and severe structural deterioration of the talus bone, the option of revision arthroplasty was deemed unsuitable.
Preoperative planning and patient-specific implant design. Three-dimensional renderings show the custom porous titanium talus implant with a preformed intramedullary canal and the planned trajectory for retrograde intramedullary nail fixation.
Surgical plan
Given the extensive talar bone loss, revision arthroplasty was not considered a viable option. Furthermore, the magnitude of the defect and the resulting anatomical incongruity precluded the use of standard bone grafting and plate/screw arthrodesis techniques. Therefore, a custom tibiotalar arthrodesis was planned as a salvage procedure.
Custom implant design
A patient-specific, three-dimensional (3D) printed talus implant was designed based on the patient’s CT data and manufactured from titanium alloy (Ti-6Al-4 V). The implant was tailored to precisely fit the bone defect. Its porous structure was intended to promote osseointegration (bone ingrowth) ( Fig. 1 ).
Surgical technique
The existing, loosened prosthesis components were explanted, and the surrounding fibrous tissue was meticulously debrided ( Fig. 2 Pre-operative loosened ankle prosthesis). The custom-manufactured porous talus implant was then positioned into the defect ( Fig. 3 Intraoperative 3D implant). Crucially, the implant had been pre-designed with an intramedullary canal to accommodate a retrograde nail. Stabilization was achieved via an intramedullary nail, effectively performing the tibiotalar arthrodesis. Final implant position and stability were confirmed intraoperatively with radiography.
Preoperative imaging of the failed total ankle arthroplasty. Plain radiographs, computed tomography images, and three-dimensional CT reconstructions demonstrate talar component subsidence/collapse with severe talar bone loss.
Intraoperative photographs and fluoroscopic images. (a) Exposure of the failed ankle arthroplasty, (b) bone defect after component removal and debridement, (c) explanted prosthetic components and the custom implant, (d) placement of the patient-specific porous talus implant into the defect, and (e–h) fluoroscopic confirmation of implant position and retrograde intramedullary nail fixation.
Follow-up
Wound healing in the early postoperative period was uneventful. Follow-up radiographs demonstrated preserved implant stability ( Fig. 4 . Postoperative 3rd-month X-ray). Clinically, the patient reported a marked reduction in pain, accompanied by an improvement in functional mobility.
Postoperative 3-month follow-up radiographs demonstrating maintained implant alignment and stability after tibiotalar arthrodesis with the patient-specific porous talus implant and retrograde intramedullary nail fixation.
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