Total Ankle Arthroplasty: Epidemiology and Causes

Author

Year

Design

Rate

Comments

Prissel and Roukis [1]

2013

STAR

10.7%

No comments

Labek et al. [4]

2013

Multiple designs

10% (40% for aseptic loosening)

Registry data from Sweden, Finland, Norway, New Zealand, and Australia were included in this analysis

Noelle et al. [5]

2013

STAR

14.9%

No comments

Roukis and Elliott [3]

2015

Salto mobile and Salto-Talaris

From 2.6% to 5.2% (Salto mobile); from 2% to 2.8% (Salto-Talaris)

Restricting the data to the inventor, design team, or disclosed consultants, the incidence of revision was 5.2% for the Salto mobile version and 2.6% for the Salto-Talaris TAAs. In contrast, data that excluded these individuals had an incidence of revision of 2.8% for the Salto mobile version and 2% for the Salto-Talaris TAAs. The incidences of revision for the Salto mobile version and Salto-Talaris TAAs were lower than those reported through systematic review for the Agility and STAR systems without obvious selection (inventor) or publication (conflict of interest) bias

Lai et al. [6]

2015

9.6%

No comments

Law et al. [7]

2018

7.74%

Medicare database

STAR Swedish Total Ankle Replacement, NA nonavailable

13.3 Causes and Risk Factors

In a series of 114 TAAs (STAR prostheses) reported in 2013 by Noelle et al., 27 (27/114, 23.6%) ankles had complications following primary surgery, and 21 prostheses (21/114, 18.4%) needed revision surgery (14.9% revision TAA), including 4 (3.5%) patients who required tibiotalar fusion. Patients with BMI > 30 showed a higher rate of complications [5].

In 2014, Sadoghi et al. studied the modes of failure after TAA (Table 13.2) (Figs. 13.1, 13.2 and 13.3). They emphasized the importance of comprehending the most frequent failure modes of TAA to suitably designate the resources, healthcare costs, improve surgical treatment methods, and improve the design and longevity of the prostheses [8]. They did not find significant differences between any of the failure modes. However, they found that the number of TAAs was increasing with time.

Table 13.2

Main modes of failure of total ankle arthroplasty (TAA)

Loose talar components

Loose tibial component

Dislocation

Instability

Malalignment (Fig. 13.1)

Deep infection

Fracture (near implant) (Fig. 13.2)

Pain

Defective polyethylene

../images/479782_1_En_13_Chapter/479782_1_En_13_Fig1_HTML.jpg — Fig. 13.1

Intraoperative fluoroscopic image in which an incorrect implantation of the tibial stem can be observed in an Inbone II total ankle prosthesis. The stem provides diaphyseal support to the prosthesis but can increase the risk of sagging of the tibial plate due to the lack of coverage of the anterior cortex of the tibia

../images/479782_1_En_13_Chapter/479782_1_En_13_Fig2_HTML.jpg — Fig. 13.2

Intraoperative fluoroscopy image. A fracture of the tibial malleolus has occurred during prosthetic implantation, and an osteosynthesis with percutaneous K wires has been performed

../images/479782_1_En_13_Chapter/479782_1_En_13_Fig3_HTML.png — Fig. 13.3

A 70-year-old patient with joint pain and stiffness after Ramses ankle prosthesis. (a) On the lateral ankle radiograph, loosening can be observed with sinking of the talar and tibial components with the presence of anterior and posterior heterotopic ossification. (b) Intraoperative image after debridement and resection of the heterotopic ossification in which the subsidence of both components (talar and tibial) can be observed

In 2015, Horisberger et al. reported that bone augmentation was required for RTAA with large osseous defects. In a 5-year period, 10 patients with aseptic loosening of TAA associated with great bone loss at the tibia, the talus, or both, were treated. Autologous structural iliac crest bone augmentation, as a one- or two-stage approach, was used [9]. Adequate bone stock was successfully reestablished. At an average follow-up of 4 years, 2 of 10 cases had to be converted to tibiotalocalcaneal fusion due to persistent pain with considerable arthrofibrosis (joint stiffness) but not loosening.

Patton et al. analyzed the risk factors for infected TAA in a retrospective comparative study (level III of evidence). A group of 966 patients with TAA were reviewed, and 29 cases of infected TAA (3.2%) were identified. The rate of infection in primary TAA was 2.4%, and in RTAA it was 4%. Risk factors for infection in this study included diabetes, previous ankle surgery, and wound healing problems more than 14 days postoperatively. No significant difference was found between groups with respect to risk factors such as smoking, BMI, and operative time [10]. These authors concluded that given the morbidity of infected TAA, meticulous consideration should be made about performing TAA in patients with multiple previous surgeries and comorbidities that predispose to wound-healing difficulties.

In a prospective comparative study (level II of evidence) reported in 2015, Demetracopoulos et al. found that the outcomes of TAA in younger patients were similar to the outcomes in older patients at early follow-up. Some 395 patients were reviewed with a mean follow-up of 3.5 years (range, 2–5.4 years). Patients were divided into three groups based on age at the time of surgery (<55, 55–70, and > 70 years). The rate of wound complications, need for reoperation, and revision were comparable between groups [11].

Roukis and Elliot could not identify any obvious difference in the reasons for revision between the Salto mobile and the Salto-Talaris (fixed-bearing) prostheses. However, the incidence of revision for the Salto mobile version and Salto-Talaris TAAs was lower than that reported for the Agility and STAR systems without obvious selection (inventor) or publication (conflict of interest) bias [3].

Steck et al. reported in 2017 that factors such as patient selection, surgeon experience, implant features, and prosthetic device selection could affect functional results as well as the rate of complications after RTAA (Fig. 13.4). Thus, even with faultless surgical technique and optimal patient selection, complications that require revision can still arise [12].