Takedown of Painful Ankle Arthrodesis to Total Ankle Arthroplasty: A Case Series of 77 Patients.

Treatment of painful or malaligned ankle arthrodesis can present as a challenging issue. Several published studies have demonstrated that takedown of a painful ankle arthrodesis to total ankle arthroplasty can assist in restoring some sagittal plane motion and improving functional scores. The goal of this study was to contribute to the limited body of literature with the largest cohort and longest follow-up to date. A retrospective analysis was performed on patient and surgical characteristics of those who underwent a conversion of a painful ankle arthrodesis to a total ankle arthroplasty by 1 of 3 experienced total ankle arthroplasty surgeons from February 2003 to December 2016 with ≥2 years of follow up. Seventy-seven subjects were included for evaluation, with an implant retention rate of 88% (68 of 77) and mean follow-up of 8.3 years (range 2.6 to 15.8). Of the 11 (14%) failures (defined as retrieval or exchange of metallic components), 8 (10%) were revised to a total ankle replacement, 2 (2%) underwent revision arthrodesis, and 1 (1%) elected for below-the-knee amputation. The mean time since the primary arthrodesis was 8.6 years (range 1 to 44), and the longer time interval between primary arthrodesis to takedown total ankle arthroplasty did not correlate with poorer outcome scores or increased risk of failure. The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot, Buechel-Pappas, and visual analog pain scale scores improved from preoperative values, with less satisfaction noted in those who needed revision surgery. The conversion of a painful ankle arthrodesis to a total ankle implant is a viable option to obtain range of motion and improved patient satisfaction scores similar to primary total ankle replacement.

Takedown of Ankle Arthrodesis With Insufficient Fibula: Surgical Technique and Intermediate-Term Follow-Up.

Conversion of ankle arthrodesis to total ankle arthroplasty has recently gained popularity. However, technical challenges are present when treating patients without a sufficient fibular buttress. We describe a technique for restoration of an adequate fibular buttress using an iliac crest bone graft or malleolar relocation. The results of 10 patients with an average follow-up period of 56 (range 24 to 123) months are presented. Of the 10 patients, 3 underwent tricortical iliac bone augmentation of the fibula, 4 underwent repositioning of the remnant fibula, and in 3, the in situ fibula was used. The average interval from fusion to takedown was 15.1 (range 5 to 35) years, and the average age at takedown was 52.8 (range 33 to 75) years. The average improvement in the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale and Buechel-Pappas scale scores was 35.8 (range 30 to 46) and 34 (range 25 to 42), respectively. Three patients underwent a total of 7 subsequent operations related to the ankle implant. Only 1 of the patients had any residual frontal plane deformity. None of the patients exhibited any component subsidence; however, 2 patients experienced asymptomatic lateral talar component overgrowth. The improvement in the clinical scores in this group of patients suggests that takedown of an ankle arthrodesis with an insufficient fibula is a viable option to improve function. Various techniques to restore the lateral buttress can be used even with complete absence of the distal fibula.

Combined Total Ankle Arthroplasty With Posterior Tibial Tendon Transfer for End-Stage Cavovarus Deformity.

Posterior tibial tendon transfer has been described to reduce and balance the cavovarus deformity in those patients who receive a total ankle replacement for end-stage arthritis. In this article, we discuss the indications and provide a detailed description of the technique for this powerful procedure. Case examples that demonstrate the utility of the procedure are provided.

Talolisthesis in end stage ankle arthrosis.

BACKGROUND: Sagittal displacement in patients with end stage ankle arthritis has been described as the tibiotalar ratio (TTR). Yet the incidence, distribution and predictive factors of talolisthesis are unknown. METHODS: The radiographs of 470 cases of ankle arthritis were compared with a control group of 49 normal ankles. The TTR was measured for both groups. Additional co-variables included the anterior and lateral distal tibial angles, and talar tilt. RESULTS: The mean TTR in the arthritis cohort was 34.8+9.12 compared to the normal group of 34.1+2.62. Twenty-eight percent of the ankles had anterior displacement and twenty-eight percent had posterior talolisthesis, while forty-four percent had normal tibiotalar alignment. Multivariate linear regression revealed significant predictors of anterior distal tibial angle (p<0.0001) and talar tilt (p=0.0007) for abnormal TTR. CONCLUSION: Sagittal displacement is common in end stage ankle arthritis and is affected by ligamentous laxity and joint morphology.

Articular congruency of the Salto Talaris total ankle prosthesis.

BACKGROUND: The Salto-Talaris polyethylene articulating surface was designed to allow, but limit accessory motion. This investigation examines surface characteristics between the polyethylene bearing and anatomic talar component in various positions of function. METHODS: A Salto Talaris talar prosthesis and matching polyethylene bearing were scanned to create digital solid body models and manipulated to assess surface contact during simulated gait. With computer micromanipulation of the component positions, the surface intersections were recorded for 15 different alignments. RESULTS: The Salto Talaris has limited contact congruity with four points of contact in dorsiflexion, neutral, and plantarflexion. Lateral and medial translations showed only 2-point contact. The radii of curvatures between the talar component and polyethylene surfaces do not match. There was no sulcus contact yet component separation distance was small, suggesting increased loads. CONCLUSION: Surface incongruency was measured based on computer model analysis which raises a concern of increased contact pressures.

Gutter impingement after total ankle arthroplasty.

BACKGROUND: Symptomatic gutter impingement after ankle arthroplasty has been reported with various designs. However, the incidence and origin of impingement have not been fully elucidated. Furthermore, the outcome of patients following gutter debridement has not been reported. METHODS: A review of 489 total ankle replacements was performed to calculate the incidence of symptomatic gutter impingement in 4 different devices and between the presenting causes of arthritis. The incidence of gutter impingement was determined for patients with and without preemptive gutter resection at the time of implantation. The functional outcome of 30 of the 34 patients who had subsequent gutter debridement was determined with 3 different outcome instruments. RESULTS: Symptomatic gutter disease occurred in 34 of 489 cases (7%) followed for a minimum of 1 year (range, 1-12 years). There was a 2% incidence of gutter disease in the 194 ankles that had prophylactic gutter resection at the time of implantation and a 7% incidence in the 295 ankles that did not have gutter resection at the time of implantation. When the ankle treated with an Agility (DePuy Orthopaedics, Inc, Warsaw, IN) device was excluded, there was a 2% and an 18% incidence of gutter disease in the 2 groups, respectively (P < .05). There was no difference in the incidence of gutter disease between the various implants and origins of ankle arthritis. Postoperative outcomes were favorable in the 27 patients who did not have another procedure after the initial gutter debridement. Seven patients (21%) required reoperation. CONCLUSION: Prophylactic gutter resection should be considered at the time of implantation to reduce the incidence of postoperative symptoms. Although most patients had favorable outcomes following gutter debridement, there was a high reoperation rate. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Relationship of alignment and tibial cortical coverage to hypertrophic bone formation in Salto Talaris® total ankle arthroplasty.

A retrospective analysis of 107 Salto Talaris(®) total ankle replacements was performed to determine the effect of alignment and tibial cortical coverage on the formation of heterotopic bone. The radiographic parameters were studied for at least 18 months to detect any changes over time. The angle of insertion of the implant was most often in varus and with a positive anterior slope. A slight increase was seen in the slope over time (p < .0001) but was not clinically relevant. The mean percentage of cortical coverage of the tibial component was 89%, and only 7 patients had complete coverage of both the anterior and the posterior cortices. The percentage of patients who had hypertrophic bone growth increased over time (p < .0001). As the slope of the implant increased, there was a negative correlation with the degree of tibial coverage (p = .007). There was also an increase in the extent of hypertrophic bone as the tibial coverage decreased. None of the patients had symptoms that required an additional surgical procedure. The results of the present study indicate a high incidence of hypertrophic bone proliferation when the dimensions of the tibial component do not match the anteroposterior depth of the tibia at the plane of resection. Despite the high occurrence rate, the clinical relevance of hypertrophic bone is obscure.

Metal-reinforced cement augmentation for complex talar subsidence in failed total ankle arthroplasty.

There are limited options for failed total ankle arthroplasty (TAA) with major talar bone loss and component subsidence. Surgical options for this condition include revision arthroplasty, salvage arthrodesis, or amputation. Revision arthroplasty generally has been considered in situations of loose components with minimal bone loss or use of expensive custom-fabricated prosthetic components with elongated stems. Historically, failure that involves major talar bone loss has been considered resistant to reconstruction, and responsive only to complex arthrodesis or amputation. In this report, we describe a unique method of restoring talar support and preserving ankle function after failed TAA with major talar bone loss and component subsidence. Talar reconstruction using metal-reinforced bone cement augmentation is combined with the Inbone (Wright Medical Technology, Inc., Arlington, TN) total ankle system to restore talar height and ligamentous support. This technique has been used successfully in the last 4 years for various patterns of talar bone loss and obviates the need for custom components. When successfully performed, the revision technique results in restoration of mechanical alignment, anatomic height, and component support, in addition to providing substantial symptomatic relief.

Interval changes in postoperative range of motion of Salto-Talaris total ankle replacement.

The purpose of the present study was to identify changes in the range of motion during the first year after placement of the Salto-Talaris total ankle implant. The first 97 cases were assessed throughout the year at 6 weeks and 3, 6, and 12 months. Data were extracted through retrospective chart review, operative reports, and electronic goniometry of the implant in maximal dorsiflexion and plantarflexion. The range of motion incrementally improved through the treatment course, with the greatest increases occurring between 6 weeks and 6 months. The mean range of motion at 6 weeks was 11.85° ± 0.824° standard error, which had increased by 3.07° ± 0.862° to 14.92° (p < .0001) at 3 months postoperatively. From 3 to 6 months, it increased 3.96° ± 0.981° to 18.88° (p < .0001) at 6 months postoperatively. From 6 to 12 months, the mean range of motion increased to 20.11° ± 1.243° (p = .3765). The overall mean increase in the range of motion from 6 weeks to 12 months was 8.25° (p < .0001). These results have demonstrated a predictable incremental increase in motion over time, with the largest percentage of improvement occurring from 6 weeks to 6 months. This information will aid surgeons in guiding patient expectations after implant arthroplasty of the ankle.

Total ankle replacement in the varus ankle.

Treatment of ankle varus with total ankle replacement (TAR) lacks consensus regarding the limits of deformity that can be managed successfully without recurrence. With newer anatomic prosthetic designs and a comprehensive surgical approach, treatment of frontal plane deformities with implant arthroplasty has gained acceptance. The purpose of this retrospective study was to determine the outcome and compare correction of large frontal plane varus deformities with TAR using 2 different replacement systems. Also, a stepwise surgical approach for consistent correction was determined. TAR was performed on 26 patients with varus ankle deformity and a mean age of 63.85 ± 9.33 (range 48-86) years. Duration of follow-up was 16.69 ± 7.26 (range 7-37) months. The difference between the immediate postoperative frontal plane radiographic alignments was compared with the preoperative deformity, and reevaluated after at least 1 year of weight-bearing function. The preoperative mortise view varus deformity was 16.8° ± 6.79° (range 6°-28°), whereas at final follow-up the degree of varus was 0° ± 2.64° (P < .0001) on the anteroposterior view and 0.5° ± 2.7° (P < .0001) on the mortise view. All but one patient was corrected to within 4° of frontal plane neutral. Overall, correction was maintained throughout the study period. In conclusion, surgical treatment of the varus ankle arthrosis with TAR can be successful.

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010.

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Medial Column Biomechanics: Nonsurgical and Surgical Implications.

Understanding of medial column biomechanics is paramount to a successful outcome in both conservative and surgical treatment. Dysfunctions of the dynamic stabilizers as well as the static stabilizers of the medial column play a role in pathomechanics. Conservative options for addressing the medial column include custom foot orthotics and bracing. Options for addressing the medial column surgically with the goal to restore a stable tripod configuration, include first tarsometatarsal joint arthrodesis, opening plantarflexory medial cuneiform osteotomy, and naviculocuneiform arthrodesis.

Joint curettage arthrodesis technique in the foot: a histological analysis.

UNLABELLED: Arthrodesis via joint contour preservation using the curettage method has become popular in foot and ankle surgery to avoid segmental shortening and the need to bone graft. Despite its popularity, the effect of joint curettage has never been histologically evaluated. Knowledge of the histological appearance after joint curettage would be helpful to the foot and ankle surgeon to better understand the function of joint surface preparation for arthrodesis. Five cadaver specimens were used to harvest the first metatarsocuneiform and subtalar joints for routine histological analysis after performing joint curettage technique. One specimen was used as a reference, whereas the remaining specimens were processed after joint surface preparation. Results show a residual layer of calcified cartilage overlying the subchondral plate interface on all osteochondral specimens after joint curettage. This suggests there is a natural histological barrier that may interfere with arthrodesis consolidation. LEVEL OF CLINICAL EVIDENCE: 5.

The effect of frontal plane position on first ray motion: forefoot locking mechanism.

BACKGROUND: Several joints in the foot have a locking mechanism that allows the foot to function as a rigid lever. The transverse tarsal joint (talonavicular and calcaneocuboid joints) has a locking mechanism that is well understood. The purpose of the study is to determine if the first ray also has such a locking mechanism. METHOD: Five cadaver limbs were loaded onto a custom frame. The first metatarsal was attached to a jig that placed a force of 50 N in plantarflexion and dorsiflexion. The motion of the jig was measured with the first ray in three positions: maximally everted, neutral, and maximally inverted. No tendons were loaded to ensure that any change in motion was solely due to osseous position. RESULTS: The average motion of the first ray for the three testing position was as follows: 7 mm in the everted position, 14 mm in the neutral position, and 18 mm in the inverted position. There was a statistically significant increase in range of motion from an everted position to a neutral position (p=0.003). This increase in range of motion continued when the first ray was inverted compared to neutral, but not statistically significance (p=0.07). CONCLUSION: This study demonstrates that the frontal plane position of the first ray affects the sagittal plane motion. An everted position has the least mobility, and we hypothesize that this represents a closed-packed or locked position.

The role of passive plantar flexion in floating toes following Weil osteotomy.

Floating toes are a common complication following Weil osteotomy. The toes are passively plantarflexed via the windlass mechanism, which may play a role in floating toe. Five cadaver lower limb specimens were loaded on a custom frame and 3 different interventions were tested, including control group, Weil osteotomy group, and Weil osteotomy plus plantar plate-shortening group. The extensor tendon to the second toe was loaded with 20 Newtons of tension during the trials, and non-weight-bearing and simulated weight-bearing radiographs were taken to measure the metatarsophalangeal joint extension angle. The extension angle passively plantarflexed 11.20 degrees +/- 3.43 degrees in the control group, 0.40 degrees +/- 0.89 degrees in the Weil osteotomy group, and 8.00 degrees +/- 1.41 degrees in the Weil osteotomy plus plantar plate-shortening group. Comparison of the amount of passive plantarflexion between the groups revealed statistically significant changes between the control and Weil osteotomy groups (P = .0001), and the Weil osteotomy compared with the Weil osteotomy plus plantar plate-shortening (P < .0001); whereas no statistically significant difference was observed between the control and Weil osteotomy plus plantar plate-shortening groups (P = .0893). These results support the idea that the toes undergo passive plantar flexion due to the windlass mechanism, which is dampened by the Weil osteotomy. Dampening of the windlass mechanism may be responsible for floating toe following a Weil osteotomy.

Revision Total Ankle Arthroplasty.

With total ankle arthroplasty, documented complications can be categorized chronologically into intraoperative, postoperative, and late complications. Factors such as patient selection, surgeon experience, implant features, and prosthetic device selection can influence functional outcomes as well as incidence of complications. Even with impeccable surgical technique and optimal patient selection, complications that require revision may still arise and the most common complications with revision solutions are discussed in this article.

Gutter Impingement in Total Ankle Arthroplasty.

UNLABELLED: Gutter pain and impingement are recognized entities following total ankle arthroplasty (TAA). However, little concrete information is available in the existing literature regarding the etiology, potentiating factors, treatment and prevention of gutter disease. This comprehensive monograph discusses this problem in expansive detail and provides insight to surgeons who perform TAA, such that these complications can be minimized in the future. LEVELS OF EVIDENCE: Level V: Expert opinion.