Single stage revision ankle arthroplasty, Is it safe?

Abstract

Background

The number of total ankle replacements (TAR) is increasing each year and with that an associated rise in the burden of revision ankle replacement (rTAR) (Ratnamsey et al.) [3]. When a TAR fails, two options emerge: Arthrodesis or rTAR (Goldberg et al.) [1]; (Egglestone et al.) [2]; (Hinterman et al.) [4]. The preferred option in our centre following network discussion, is to convert the failing TAR to a rTAR. There is uncertainty whether this is best done in a single staged approach or two stages. The aim of this review was to assess the outcomes of single-to-two-staged approaches in rTAR, and to ascertain if there was any increase in complications or impaired outcome in the single-staged approach.

Method

A review was carried out of the prospectively collected data of all rTAR performed in our centre between Nov 2016 and Jan 2023. We reviewed: preoperative micro-sampling, intra-op microbiology and histology results, infection rate, tourniquet time, length of hospital stay, wound complications and PROMS of all patients who had undergone a single-staged rTAR, compared to two stages.

Results

We identified 86 rTAR patients, with a mean age of 71.4 (38−88) with a minimum of 2-year follow-up, range 2–7 years. There were 44 Left and 42 Right failing total ankle replacements. 14 were two staged procedures and 74 were single staged. No preoperative microbiology sampling was performed in the single or in the staged group. Both groups who underwent intraoperative microbiology sampling showed no positive microbiology growth. There was a significant difference in tourniquet times but with no associated significant complication rate in the single staged group versus the staged group. There was one infection in the single-staged group that went on to have a successful DAIR. There was no difference in wound complications post-op. Both groups showed improvement in PROMS, with no difference between the groups or in increase in length of hospital stay.

Conclusion

In our series, which is the largest in the literature, we have found single-staged revision arthroplasty to be safe and effective compared to a two-stage procedure in patients where there is a low index of suspicion of infection.

Level of Evidence

Level III, Retrospective Cohort

1

Introduction

Total Ankle Replacement is an increasingly common procedure (National Joint registry executive summary) in the UK and when it fails, four options may be considered: conversion to fusion (ankle or Tibio Talar Calcaneal Nail with augements). Revision Total Ankle Replacement (rTAR), cement spacer or below knee amputation (Goldberg et al. , Egglestone et al. , Hinterman et al. , Myerson et al. ). The Nottingham Foot and Ankle unit performs between 18–20 rTARs per year, compared to the England average of 3 (National Joint Registry data set) and it has shown good results with conversion of a failing TAR to rTAR (Jamjoom et al.) .

With increase in number of TAR there has been a subseqent increase in the burden of rTAR . There is some debate in the literature with regard to the optimal workup of a failing TAR and, due to low numbers, most of the algorithms are based on evidence from the hip and knee replacement literature (Inform Trial) (Matar et al.) . In revision ankle arthroplasty there is ongoing debate over the need for preoperative sampling, due to concerns of missing potential quiescent infection. There are a plethora of guidelines if there is a concern about infection but that doesn’t always reflect clinical practice (guidelines from the International Disease Society of America / Musculoskeletal Infection Society / European Bone and Joint Infection Society ). The commonest reason for revision ankle arthroplasty is malalignment resulting in aseptic loosening and pain (NJR revision ankle data set 2022: Patient characteristics) , but there is a concern about whether we are missing potential quiescent infections.

There are certain advantages to staged surgery. For example, it can be challenging to remove implants such as stemmed implants (Zenith/ Mobility) or implants that are well integrated into bone and proceed with a rTAR in a single setting. Once the implant has been removed, more accurate deep tissue sampling can be performed and, in cases of severe bone loss or deformity, staging allows more planning and scanning post implant removal. However, single-stage surgery in cases where there is a low suspicion of infection allows definitive treatment, although there are concerns about operating time, missing quiescent infections and potentially a higher complication rate, especially if associated with additional procedures performed at the same time to balance the rTAR.

The aim of this study was to review our experience of single-staged rTAR compared to the two-staged approach, with regard to infection, intra-op microbiology results, wound complications, tourniquet time, intra-operative complications, hospital stay and patient-related outcome measures (PROMs) ( Fig. 1 ).

Fig. 1

Standard Case discussed at Network meeting of a painful maligned Zenith TAR converted to an Inbone II.

2

Methods

All rTARs were worked up, discussed at the multidisciplinary meeting and or regional network meeting as per the BOA guidelines on speciality standards , and unless there was concern of infection or significant bone loss, patients were offered single-staged surgery. All revisions were to the Inbone II Stryker Implant. All surgery was performed by the senior authors and, in some cases, both attended the rTAR case. At the time of surgery, microbiology sampling was performed intraoperatively as per the Oxford consensus ; 5 microbiology and 1 histology specimens were collected and sent for laboratory analysis. Patients were given routine microbiology prophylaxis as per unit guidelines.

All the data was recorded in the unit database prospectively and this was retrospectively analysed. Patients were divided into two groups based on whether they underwent single-stage or two-stage rTAR. The primary outcomes measures were infection rates, intraoperative microbiology results, wound complications needing intervention, tourniquet time, hospital stay, and the secondary outcome measure was PROMs, measured using the Manchester-Oxford Foot Questionnaire (MOXFq) . MOXFq was recorded preoperatively, 6 months, 1 year, and then annually for the lifespan of the implant. PROMs were scored independently by the physio-arthroplasty practitioner.

3

Results

From 2016 to 2023, a total of 86 patients were identified, with a mean age of 71.6 years (range: 38–88).

There were 72 patients in the single-stage group and 14 patients in the two-stage group. The total tourniquet time was 170.29 min (±40.9), ranging from 110 to 330 min in the single-stage group, compared to a mean of 152.69 min (±30.6), ranging from 137 to 198 min in the two-stage group.

During both single-stage and two-stage procedures, the tourniquet was deflated and reinflated during surgery. This meant that there were two sets of tourniquet times, and they were added to denote the total time in minutes. No significant difference in total tourniquet times was observed between the two groups (p > 0.05). [ Table 1 ] [ Fig. 2 ].

Table 1

Tourniquet times.

Stage Tourniquet time
Single stage 170.29
Two stage 152.69
Fig. 2

Tourniquet time.

There was no significant intra-op microbiology growth found in either group, supporting the notion that preoperative sampling may not be necessary in single-stage revision where there is a low suspicion of infection.

In the single-stage group 1 patient had a postoperative wound complication that required further intervention due to concern of infection and underwent a DAIR (Debridement, Antibiotics, and Implant Retention). In the two-stage group there were no wound complications. So the infection rate in the single-stage group was 1.33 %, compared to none in the two-stage group. This was not a statistically significant difference [ Table 2 , Fig. 3 ].

Table 2

Wound complications requiring intervention.

Wound Complications needing intervention Cases Wound issues
Single stage 72 1
Two stage 14 0
Fig. 3

Wound issues.

The length of the stay was longer in the single-stage group, with a mean stay of 2.22 days (±1.77), ranging from 1 to 10 days, compared to the two-stage group with a mean stay that was 1.64 days (±0.72), ranging from 1 to 3 days This was statistically different. However, the single-stage group had two outliers that had a stay of 10 days for social reasons and the rTARs performed on Fridays tended to stay in over the weekend period and go home on Monday, which reflected more staffing issues than clinical necessity. Furthermore, this does not take into account the previous hospital stay during the first stage of the surgery (Implant removal + Cement spacer) [ Table 3 , Fig. 4 ].

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Sep 5, 2026 | Posted by in ORTHOPEDIC | Comments Off on Single stage revision ankle arthroplasty, Is it safe?

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