comparison of postoperative gait parameters after total ankle arthroplasty and ankle fusion: A systematic review.

Ankle pathology, such as severe arthritis, often necessitates surgical intervention to restore mobility and alleviate pain. Two commonly performed procedures for end-stage ankle disease are ankle fusion (AF) and total ankle arthroplasty (TAA). This review aims to compare the impact of AF and TAA on postoperative gait parameters. An extensive search in PubMed, Scopus, and Web of Science electronic databases was conducted with the use of the keywords ("ankle arthrodesis" OR "ankle fusion") AND ("ankle replacement" OR "ankle arthroplasty") AND "gait." Clinical studies in terms of postoperative gait parameters were included in this review. At least one of the following gait parameters, included in gait analysis, should be researched: spatiotemporal variables and joint kinematics and kinetics. An initial search revealed 221 studies. After the removal of duplicates and screening of titles,10 studies (7 prospective and 3 retrospective case series) were included for qualitative analysis. In the majority of studies, there is no significant difference in spatiotemporal parameters, such as walking speed, cadence, stance duration, step length, and stride length among AF and TAA patients. Postoperative sagittal ankle ROM, mainly maximum ankle dorsiflexion angle is significantly higher in TAA patients, while results concerning hip and knee ROM are variable. The comparison of AF and TAA in terms of postoperative gait parameters has shown variable results. In the majority of studies, there is no significant difference in spatiotemporal and kinetic parameters among AF and TAA patients. Further high-quality prospective studies are needed to fully elucidate the comparison of postoperative gait parameters.

Tibial Axis-to-Talus Distance: A Clinically Reliable Measurement for Sagittal Translation of the Talus in Total Ankle Arthroplasty.

Background: Sagittal talar translation is an important factor influencing the sagittal alignment of total ankle arthroplasty (TAA). Thus, accurate measurement of sagittal talar translation is crucial. This study proposes a simple method (tibiotalar distance [TTD]) that can quantify talar translation without being affected by the ankle and subtalar joint condition or the talar component position in patients with TAA. Methods: We enrolled 280 eligible patients (296 ankles) who underwent primary TAA between 2005 and 2019 and retrospectively reviewed them for sagittal talar translation. The TTD was measured for each patient on weight-bearing lateral ankle radiographs by 3 raters. In addition, we analyzed interrater and intrarater reliability for the TTD method. Results: We found that the TTD method could quantify the talar translation and was not affected by the preoperative condition of the ankle joint surface, subtalar joint pathologies, or the postoperative talar component position. The TTD method showed an excellent intraclass correlation coefficient (> 0.9) in all interrater and intrarater reliability analyses. In the analysis of 157 healthy, unoperated contralateral ankles, we identified that TTD showed a Gaussian distribution (p = 0.284) and a mean of 38.91 mm (normal range, 29.63-48.20 mm). Conclusions: The TTD method is a simple and reliable method that could be applied to patients with TAA to assess the sagittal talar translation regardless of the pre-and postoperative joint condition and implantation status.

Three-Dimensional Printed Total Talus Replacement with a Concurrent Total Ankle Arthroplasty as a Personalized Approach for Advanced Ankle Osteoarthritis A Case Repor.

Ankle arthritis is becoming more common and can be pain-ful and debilitating. As the disease progresses, degenera-tive cystic changes may be found in the distal fibula, distal tibia, and talus. After failure of non-operative modalities, arthrodesis is often considered the surgical intervention of choice, but this leaves the patient with reduced range of motion, altered gait, and can negatively impact adjacent joints of the foot. Total ankle arthroplasty has been found to be an effective surgical option for ankle arthritis but is contraindicated in patients with talar collapse. When this is the case, a more personalized approach for preserving ankle motion is necessary. We present the case of a 65-year-old male with severe right ankle arthritis and talar collapse treated with a custom three-dimensionally printed talus and concurrent total ankle replacement with 2-year follow-up.

Bone grafting for periprosthetic bone cysts following total ankle arthroplasty.

Aims: The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan. Methods: We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured. Results: Out of 37 ankles, graft incorporation was successful in 30 cases. Among the remaining seven cases, four (10.8%) exhibited cyst re-progression, so secondary bone grafting was needed. After secondary bone grafting, no further progression has been noted, resulting in an overall 91.9% success rate (34 of 37) at a mean follow-up period of 47.5 months (24 to 120). The remaining three cases (8.1%) showed implant loosening, so tibiotalocalcaneal arthrodesis was performed. Functional outcomes were also improved after bone grafting in all variables at the latest follow-up (p < 0.05). The mean incorporation rate of the grafts according to the location of the cysts was 84.8% (55.2% to 96.1%) at the medial malleolus, 65.1% (27.6% to 97.1%) at the tibia, and 81.2% (42.8% to 98.7%) at the talus. Smoking was identified as a significant predisposing factor adversely affecting graft incorporation (p = 0.001). Conclusion: Bone grafting for periprosthetic bone cysts following primary TAA is a reliable procedure with a satisfactory success rate and functional outcomes. Regular follow-up, including CT scan, is important for the detection of cyst re-progression to prevent implant loosening after bone grafting.

Revision Total Ankle Arthroplasty Using the INBONE II System.

BACKGROUND: The utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, leading to a higher occurrence of revision TAA procedures because of failure of primary TAA. This study aims to examine the clinical results associated with revision TAA using the INBONE II system. Given the growing number of TAA revision procedures and a focus on motion-preserving salvage options, we evaluated our early experience with revision TAA. METHODS: A retrospective analysis was conducted on a group of 60 presumed noninfected patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis. RESULTS: The study revealed high complication rates but generally fair clinical outcomes for revision TAA using the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n = 6), nerve injury/impingement (n = 5), infection (n = 3), fracture (n = 3), implant failure (n = 3), impaired wound healing (n = 2), and osteolysis (n = 3). The 3-year survivorship rate from reoperation was 92.0% (82.7%-100.0%) whereas the 3-year survivorship rate from major complications was 90.4% (80.8%-100.0%). CONCLUSION: We report high complication rates but generally fair clinical results for revision TAA utilizing the INBONE II system.

Implant Choice May Reduce the Risk of Early Mechanical Failure in Total Ankle Replacement.

BACKGROUND: Total ankle replacements (TARs) have rapidly advanced in terms of volume, technique, design, and indications. However, TARs are still at risk for early mechanical failure and revision. Prior studies have investigated potential risk factors for failure, but have been limited to smaller series or older implants. This study sought to identify risk factors for early mechanical failure in modern TAR. METHODS: This is a retrospective study of a single-institution registry. Five surgeons contributed cases involving patients who underwent a primary TAR with any implant. Implants were grouped on the basis of the type of fixation. The primary outcome was early mechanical failure (revision with component removal for a non-infectious etiology, that is, subsidence, aseptic loosening, and/or malalignment). Logistic regression determined the effects of age, weight, hindfoot arthrodesis, implant type, and radiographic deformity on failure. RESULTS: The 731 included patients had a mean follow-up of 2.7 years. Ten percent (71 patients) had hindfoot arthrodesis. There were 33 mechanical failures (4.5%) at a mean of 1.7 years after the index surgical procedure. Our model demonstrated that hindfoot arthrodesis was associated with 2.7 times greater odds of failure (p = 0.045), every 10 kg of body weight increased the odds of tibial-sided failure by 1.29 times (p = 0.039), and implants with more extensive tibial fixation (stems or keels) lowered the odds of tibial failure by 95% (p = 0.031). CONCLUSIONS: In patients with uncontrollable risk factors (hindfoot arthrodesis) or risk factors that may or may not be modifiable by the patient (weight), implants with more robust tibial fixation may be able to reduce the risk of early mechanical failure. Further research is warranted to support efforts to decrease early failure in TAR. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A macro-micro FE and ANN framework to assess site-specific bone ingrowth around the porous beaded-coated implant: an example with BOX® tibial implant for total ankle replacement.

The use of mechanoregulatory schemes based on finite element (FE) analysis for the evaluation of bone ingrowth around porous surfaces is a viable approach but requires significant computational time and effort. The aim of this study is to develop a combined macro-micro FE and artificial neural network (ANN) framework for rapid and accurate prediction of the site-specific bone ingrowth around the porous beaded-coated tibial implant for total ankle replacement (TAR). A macroscale FE model of the implanted tibia was developed based on CT data. Subsequently, a microscale FE model of the implant-bone interface was created for performing bone ingrowth simulations using mechanoregulatory algorithms. An ANN was trained for rapid and accurate prediction of bone ingrowth. The results predicted by ANN are well comparable to FE-predicted results. Predicted site-specific bone ingrowth using ANN around the implant ranges from 43.04 to 98.24%, with a mean bone ingrowth of around 74.24%. Results suggested that the central region exhibited the highest bone ingrowth, which is also well corroborated with the recent explanted study on BOX®. The proposed methodology has the potential to simulate bone ingrowth rapidly and effectively at any given site over any implant surface.

Outcomes of Total Ankle Arthroplasty After Reoperation due to Gutter Impingement.

Gutter impingement is one of the most common causes of subsequent surgery after total ankle arthroplasty (TAA). Although gutter debridement has been reported to resolve preoperative symptoms early on, persistent pain after surgery, recurrence, and poor functional outcome scores have been described in patients who have undergone reoperation for gutter debridement. The cause of gutter impingement after TAA is multifactorial, and a better understanding of its causes and optimal surgical techniques for intervention is needed.

Results of Total Ankle Arthroplasty Versus Ankle Arthrodesis.

No differences have been found between total ankle arthroplasty (TAA) and ankle arthrodesis (AA) with respect to patient-reported outcome measures (PROMs), although both interventions were shown to improve PROMs with respect to the preoperative situation. That is, both interventions (AA and TAA) were effective in improving preoperative symptoms. On the other hand, 2-year complication rates were higher after AA (27%) than after TAA (16%); however, infection rates were similar (4%). The published revision rate after AA is 16% versus 11% after TAA. In short, TAA and AA appear to offer the same PROMs, but TAA has a lower rate of complications (except for infection) and revisions.

Total Ankle Arthroplasty in Young Patients.

With continuing advancements in total ankle arthroplasty (TAA), it is quickly becoming the procedure of choice for older patients with end-stage ankle arthritis. Multiple studies have been conducted on younger patients who have undergone TAA with promising results, but is it the procedure of choice? Considerations of TAA versus ankle arthrodesis, TAA implant longevity, outcomes of revision TAA, and whether patients should be offered an arthrodesis with plans for conversion to arthroplasty may help elucidate whether pursuing ankle arthroplasty in a younger, more active population is the correct approach for surgeons.

Complications in Total Ankle Replacement.

The debate between ankle arthrodesis and total ankle replacement for patients with end-stage arthritis of the ankle joint is an ongoing topic in orthopedic surgery. Ankle arthrodesis, or fusion, has been the traditional treatment for ankle arthritis. It involves fusing the bones of the ankle joint together, eliminating the joint and creating a solid bony union. Arthrodesis is effective in reducing pain in the ankle, but it results in a loss of ankle motion. This can increase the load on adjacent joints, such as the subtalar joint, which may lead to accelerated degeneration and arthritis in those joints over time.

Outcomes of Total Ankle Replacement with Preoperative Varus Deformity.

Historically, coronal plane deformities of greater than 10° to 15° have been deemed contraindications for total ankle replacement (TAR). However, recent studies show satisfactory results in TAR with severe preoperative varus deformity. When correctly applying ancillary procedures, preoperative varus deformity can be structurally corrected, resulting in similar clinical scores to those obtained with "regular TAR." However, complications and revisions appear to increase with increasing deformity. Unfortunately, results of TAR in varus ankles consist of heterogeneous data (eg, with regards to prosthetic brands, bearing-types, duration of follow-up, and ancillary procedures) precluding strict conclusions. This could be solved by an international consensus group.

Outcomes of Conversion of Ankle Fusion to Total Ankle Arthroplasty.

With ankle replacements gaining popularity and documented good functional outcomes, there is an increasing number of patients inquiring about the possibility of converting an ankle fusion to a replacement. This could be due to pain, limited function, or increasing adjacent joint arthritis. There is an increasing body of evidence in the literature that a conversion to a replacement is possible and that the outcomes are positive. There are also absolute contradictions for a conversion. An absent fibula, pain of unknown origin, and recent infection fall in this category. Long-term follow-up is needed to see if conversions of ankle fusions to replacements have the same functional results and longevity as primary replacements.

Outcomes of Revision Total Ankle Replacement.

The objective of this study is to provide an up-to-date review of the outcomes of revision total ankle arthroplasty (TAA). Relevant studies published over the last decade were reviewed. Twelve studies were included. At a median follow-up of 4 years, the median survival and reoperation rates were 86% and 16%, respectively. Significant postoperative improvements in patient-reported outcome measures were recorded in 6 studies. Significant improvement in alignment was documented in 1 study only. Revision TAA is a safe procedure that can produce good outcomes. Nevertheless, data relating to long-term outcome are still limited in quantity and duration.

Diagnosis and Management of Infected Total Ankle Replacements.

As the number of primary total ankle replacements increases for treatment of end-stage ankle arthritis, failures are also expected to rise. Periprosthetic joint infection is among the causes of failures and has been reported to be as high as 5%. Diagnosis is usually made by a combination of clinical examination findings, imaging, laboratory, and microbiological workup. Management is generally separated into limb salvage or amputation. Limb salvage can be challenging and may involve a single versus staged approach. Options include revision arthroplasty or arthrodesis procedures (ankle versus tibiotalocalcaneal), and a multidisciplinary approach is sought to eradicate infection before definitive management.

Outcomes following total ankle total talus replacement: A systematic review.

BACKGROUND: Prosthetic substitution of the talus presents a significant challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis and eventual talar collapse. The purpose of this systematic review is to evaluate whether total ankle total talus replacement (TATTR) leads to improved clinical and radiographic outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. METHODS: We searched the concepts of talus, prosthesis, and arthroplasty in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through March 9, 2023. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 6) inflammatory arthropathy to tibiotalar joint. Patients less than 18 years of age and manuscripts in non-English languages were excluded. RESULTS: Of the 7625 references, 16 studies met the inclusion criteria, yielding data from 136 patients (139 ankles). The studies varied in design, with case reports and retrospective case series being predominant. The overall weighted average modified Coleman Methodology Score (mCMS) was 70.4 out of 100, indicating moderate flaws in study design that may be subject to various forms of bias and possible confounders. Demographics showed a diverse range of etiologies, with alumina ceramic being the primary prosthesis material. Functional scores demonstrated improvements in dorsiflexion and plantarflexion, although patient-reported outcome measures (PROs) were inconsistently reported. Complications included fractures, heterotopic ossification, prolonged wound healing, and infections. Revision details were sparsely reported. CONCLUSION: TATTR is a promising treatment modality for improving short-term functional outcomes for patients with avascular necrosis or trauma-related issues. However, this systematic review underscores the need for standardized reporting, longer-term follow-ups, and further research to establish the procedure's efficacy and safety, particularly in comparison to other treatment modalities. LEVEL OF EVIDENCE: III, Systematic Review of Level IV Studies.

Ankle arthrodesis or total ankle arthroplasty surgery for end stage ankle arthritis, which is best? A review of the best available evidence.

BACKGROUND: End Stage Ankle Arthritis (ESAA) causes pain and dysfunction. It is treated effectively with Total Ankle Arthroplasty (TAA) or Ankle Arthrodesis (AA). Currently there is no consensus on which surgical procedure is superior. This paper will provide a systematic review of all published high-quality studies directly comparing TAA and AA for the surgical treatment of ESAA to determine superiority. METHODS: A comprehensive literature review of the highest quality studies published that directly compare clinical outcomes of TAA and AA for surgical treatment of ESAA was conducted. Each study was assigned a Level of Evidence (LOE) rating (I-III) and then summarized to assign a grade of recommendation (A-C, I). Superiority was determined for the clinical outcomes of pain, activity, Health Related Quality of Life (HRQL), readmission to hospital, revision surgery and general complications. RESULTS: There is fair evidence (GOR B) that supports both TAA and AA for the surgical treatment of ESAA. However, TAA trended to be superior for pain relief (GOR B), activity (GOR B), health related quality of life (GOR B) and readmission rate (GOR B) while AA trended to be superior for revision rates (GOR B). Conflicting evidence was presented for general complications (GOR C) CONCLUSION: Due to the lack of level I papers and the findings from the papers reviewed not being consistent, no definitive conclusion on which procedure is better can be made. However, there is enough evidence to provide a basis for which procedure is more effective in each of the outcomes reviewed. This should be considered when deciding on which procedure is best suited for a patient on a case-by-case basis. To allow for a stronger recommendation, further studies-ideally, high-quality level I randomized control trials directly comparing Ankle Arthrodesis and Total Ankle Arthroplasty are needed. LEVEL OF EVIDENCE: Level III, systematic review.

Patient-Reported Outcomes in Total Ankle Arthroplasty: Patient Specific Versus Standard Instrumentation.

BACKGROUND: Total ankle arthroplasty (TAA) can now be performed using patient-specific instrumentation (PSI). Advantages include the ability to preoperatively plan and reduce the number of intraoperative surgical steps. The aim of this study was to compare PSI with standard instrumentation (SI) in a nonrandomized retrospective cohort study with respect to patient-reported outcome measures (PROMs). Secondary aims were to compare complications, reoperations, tourniquet time, fluoroscopy time, and postoperative alignment. METHODS: In all, 159 patients (111 men, 48 women) undergoing a total of 168 Infinity TAA (Stryker, Memphis, TN) using PSI (Prophecy, Stryker, Memphis, TN) or SI between 2014 and 2021 were included with a minimum follow-up of 12 months. The PROMs were obtained preoperatively and at 1 year, and included the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS), and European Quality of Life 5 Dimension 3 Level (EQ-5D-3L). Coronal plane deformity correction was assessed using the midline tibiotalar angle (MTTA). Demographics, tourniquet time, and intraoperative fluoroscopy times were obtained from the hospital records. RESULTS: There were 61 TAAs in the PSI group and 107 TAAs in the SI group. There was no significant difference in total MOXFQ, AOS, or EQ-5D. There was a significantly reduced tourniquet time (PSI mean: 95.39 minutes, SI mean: 116.87 minutes, P < .001) and radiation exposure (PSI mean: 31 seconds, SI mean: 53 seconds, P < .001). Angular correction was more accurate in the PSI group (PSI mean: 1.29°, SI mean: 2.26°, P = .005). CONCLUSION: This study supports the use of PSI to decrease operative time, reduce intraoperative fluoroscopy, improve accuracy of implantation, and improve postoperative alignment in TAA. There was a significant difference (P = .032) in favor of PSI in the walking/standing domain of the MOXFQ at 12 months but no significant difference in overall PROMs. LEVELS OF EVIDENCE: Level III, Retrospective.