Complication rates after total ankle arthroplasty in one hundred consecutive prostheses

Contemporary modern total ankle arthroplasty (TAA): A systematic review and meta-analysis of indications, survivorship and complication rates

BACKGROUND

This study evaluates the clinical outcomes of contemporary total ankle arthroplasty (TAAs) to primarily establish the current benefits and risks to facilitate informed decision making to secondarily establish if improvements are seen between subsequent generations of implants, bearing philosophy, and associated surgical technique.

METHODS

A systematic review and meta-analysis of published data from January 2000 to January 2020 was conducted following PRISMA guidelines.

INCLUSION CRITERIA

English language papers, adult population, ≥20 ankles with a minimum follow up ≥24 months, pre- and post-operative functional scores available. Ankle implants were characterised by generations, which were determined from the original studies and confirmed based on literature set definitions.

RESULTS

A total of 4642 TAAs in 4487 patients from 51 studies were included. The mean age was 61.9-years and follow up 57.8-months. Overall, 10-year survivorship rates were 77.63 %, with mobile bearing designs showing a small but significant advantage. Improved survivorship favoured the most modern implants at both two (p < 0.05), and 10-years (p < 0.01). The relative risk of a complication occurring improved with the evolution of implants e.g., nerve injury, and post-operative complications such as fracture, wound complications (e.g., dehiscence or heamatoma) and radiological abnormalities (e.g., radiolucencies, heterotopic bone formation and aseptic loosening). However, surgical site infection, and intra-operative fracture rates remain implant independent.

CONCLUSIONS

Modern TAA offers improved survivorship, even with a trend to lower mean implantation age, similar complexity and ever changing indications. It would appear that implant evolution has reduced risks, especially those associated with revision, without affecting functional outcomes.

STAR® total ankle replacements with BONIT® coating: A prospective 2-17 year follow-up study of 474 ankles from a single center

BACKGROUND

Different coatings of the metal implants of STAR prostheses have been used since 1999. In Europe metal implants with a double calcium-phosphate coating (BONIT) on a titanium sprayed surface have been available since 1999.

METHODS

We present a 2-17 year follow-up of a consecutive series from a single center with 474 STAR ankle replacements where the BONIT type of coating has been used.

RESULTS

55 prostheses (12%) have been revised, the majority of them due to fracture of the mobile bearing. 22 prostheses (5%) have been converted to an arthrodesis. Analysis of survival of the specific components showed an estimated 10-year survival rate of the tibia component, talus component and polyethylene mobile bearing of 99%, 98% and 84%, respectively. The corresponding estimated 15-year survival was 98%, 98% and 74%, respectively.

CONCLUSION

This study showed an extraordinary high survival rate of the metal implants.

LEVEL OF EVIDENCE

Level III, prospective cohort series.

Total Ankle Replacement Infections: A Systematic Review of the Literature

Periprosthetic infection (PJI) after TAR is a serious complication, often requiring further surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. This systematic review aims to summarize the current evidence on the management of TAR PJI and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Seventy-one studies met the inclusion criteria, reporting on cases of TAR PJI. A total of 298 PJIs were retrieved. The mean incidence of PJI was 3.8% (range 0.2-26.1%). Furthermore, 53 (17.8%) were acute PJIs, whereas most of them (156, 52.3%) were late PJIs. Most of the studies were heterogeneous regarding the treatment protocols used, with a two-stage approach performed in most of the cases (107, 35.9%). While the prevalence of ankle PJI remains low, it is potentially one of the most devastating complications of TAR. This review highlights the lack of strong literature regarding TAR infections, thus highlighting a need for multicentric studies with homogeneous data regarding the treatment of ankle PJI to better understand outcomes.

Obesity and Ankle Prosthesis Revision: A Systematic Review and Meta-analysis

BACKGROUND

The increasing number of total ankle arthroplasties (TAAs) has led to growing evidence on the risk factors for complications after surgery. However, the role of obesity in this patient group has been the subject of much debate. Therefore, this systematic review aimed to investigate the evidence for untoward effects of obesity following TAA.

METHODS

We conducted a comprehensive search on April 28, 2023, in MEDLINE (via PubMed), Embase, and CENTRAL. Eligible observational studies reported on the short- and long-term outcomes of primary TAA, comparing patients with and without obesity (defined as body mass index > 30). Using a random effects model, we calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) from 2 by 2 tables (event and nonevent in the obese and nonobese primary TAA groups).

RESULTS

Nine studies with 10 388 patients were eligible for inclusion in the meta-analysis. We found significantly higher odds of revision in the obese group compared to the nonobese group (OR = 1.68, CI: 1.44-1.95). However, the odds of overall perioperative complications (OR = 1.55, CI: 0.50-4.80) and wound complications (OR = 1.34, CI: 0.29-6.20) were nonsignificantly higher in the obese group.

CONCLUSION

Based on our results, obesity may have affected long-term outcomes following TAA and may have negatively affected the prosthesis's survival.

Body Mass Index (BMI) Cutoffs and Racial, Ethnic, Sex, or Age Disparities in Patients Treated With Total Ankle Arthroplasty

Background

The rising prevalence of obesity among American adults has disproportionately affected Black adults and women. Furthermore, body mass index (BMI) has historically been used as a relative contraindication to many total joint arthroplasty (TJA) procedures, including total ankle arthroplasty. The purpose of this study was to investigate potential disparities in patient eligibility for total ankle arthroplasty based on race, ethnicity, sex, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods

Patients in the ACS-NSQIP database who underwent TAA from 2011 to 2020 were retrospectively reviewed in a cross-sectional analysis. BMI cutoffs of <50, <45, <40, and <35 were then applied. The eligibility rate for TAA was examined for each BMI cutoff, and findings were stratified by race, ethnicity, sex, and age. Independent t tests, chi-squared tests, and Fisher exact tests were performed to compare differences at an α = 0.05.

Results

A total of 1215 of 1865 TAA patients (65.1%) were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cutoff of <35 (P = .004). Hispanic patients had generally lower rates of eligibility across all BMI cutoffs. In contrast, Asian American and Pacific Islander patients had higher rates of eligibility at the BMI cutoffs of <35 (P = .033) and <40 (P = .039), and White non-Hispanic patients had higher rates of eligibility across all BMI cutoffs. Females had lower eligibility rates across all BMI cutoffs. Ineligible patients were also younger compared to eligible patients across all BMI cutoffs.

Conclusion

Stringent BMI cutoffs may disproportionately disqualify Black, female, and younger patients from receiving total ankle arthroplasty.

Level of Evidence

Level III, retrospective cross-sectional study.

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is a popular modality to treat end-stage arthritis or internal ankle derangement. Unfortunately, failure rates remain undesirably high, with severe complications, including prosthesis failure, ankle fusion, and amputation. The importance of a stable soft-tissue envelope for coverage of implant compromise has been previously described, but the predictive factors for successful salvage of complicated TAA remain poorly understood.

METHODS

A retrospective review was conducted of patients requiring soft-tissue reconstruction following TAA wound complications. Patient demographics, history, microbiological data, reconstructive approach, and outcomes data were collected. Statistical analysis was used to abstract factors associated with unsuccessful prosthetic salvage.

RESULTS

In all, 13 patients met inclusion criteria: 8 (61.5%) achieved prosthetic salvage, and 5 (38.5%) failed. The majority (90.9%) of patients presented with infected joints. Reconstructive techniques included skin grafts, dermal substitutes, locoregional flaps, and free tissue transfer. Successful prosthetic salvage was associated with shorter time intervals between wound diagnosis and index reconstructive surgical intervention (median: 20 days for salvage vs 804 days for failure; P = .014). Additionally, salvage was associated with reduced time from the index orthopaedic/podiatric surgical intervention to the index reconstructive surgery procedure (12 vs 727 days; P = .027).

CONCLUSION

The prognosis of complicated TAA requiring soft-tissue reconstruction remains poor, especially in patients who present with infected joints. Several reconstructive techniques, ranging from simple skin grafts to complex free tissue transfers, can be used successfully. Early intervention to achieve soft-tissue coverage is crucial in maximizing salvage rates in the setting of complicated and infected TAA.

LEVEL OF EVIDENCE

Level IV.

The Effect of Tranexamic Acid on the Outcome of Total Ankle Replacement

Background: Infection rates after total ankle replacement (TAR) are known to be greater than those after hip or knee arthroplasty. Swelling after TAR can make wound healing more difficult, which can lead to infection. Tranexamic acid (TXA) has been shown to minimize blood loss after surgery, improving healing outcomes. We aim to assess the effect of TXA on blood loss and wound complications in TAR.

Methods: The research looked retrospectively at patients who had TAR procedures between September 2014 and December 2019. The procedures were done using the anterior approach at a single hospital by two, foot and ankle surgeons. Tranexamic acid was given intraoperatively before the tourniquet was inflated. The surgeons did not use surgical drains. Pre and postoperative hemoglobin levels, outcome scores as well as post-operative complications were all documented.

Results: A total of 69 patients were included in the study with 33 of them receiving TXA. With a mean age of 67.2, we had 31 females and 38 males. Tranexamic acid was given in doses ranging from 1 gm to 2 gm. None of the patients required blood transfusions after surgery, and there was no statistically significant difference in pre and postoperative hemoglobin levels between the two groups. In the TXA group, there were fewer wound complications. The TXA group achieved better results compared to the non-TXA group (p=0.0130).

Conclusion: Tranexamic acid is safe and effective in lowering postoperative bleeding and preserving hemostasis after deflating the tourniquet, reducing edema and postoperative wound problems such as breakdown and dehiscence.

Ten-year revision rates of contemporary total ankle arthroplasties equal 22%. A meta-analysis

BACKGROUND

The National Institute for Health and Care Excellence criterion for hip replacements is a (projected) revision rate of less than 5% after 10 years. No such criterion is available for ankle prostheses. The objective of the current study is to compare survival rates of contemporary primary ankle prostheses to the hip-benchmark.

METHODS

The PRISMA methodology was used. Eligible for inclusion were clinical studies reporting revision rates of currently available primary total ankle prostheses. Data was extracted using preconstructed forms. The total and prosthesis-specific annual revision rate was calculated.

RESULTS

Fifty-seven articles of eight different ankle prostheses were included (n = 5371), totaling 513 revisions at an average 4.6 years of follow-up. An annual revision rate of 2.2 was found (i.e. an expected revision rate of 22% at 10 years).

CONCLUSIONS

The expected 10-year revision rate of contemporary ankle prostheses is lower than the current benchmark for hip prostheses.

Patient reported outcome measures in ankle replacement versus ankle arthrodesis - A systematic review

OBJECTIVES

Compare the functional outcomes of comparative studies of ankle arthrodesis (AA) and total ankle replacements (TAR).

DESIGN

Systematic review using PRISMA guidelines.

DATA SOURCES

Medline, Cochrane and EMBASE databases in July 2020.

ELIGIBILITY CRITERIA

Studies that directly compared TAR and AA which reported patient reported outcomes measures (PROMs) of pain, function and quality of life.

DATA EXTRACTION AND SYNTHESIS

Two authors independently reviewed all papers. PROMs were allocated into pain, function or quality of life domains. Two summary statistics were created to allow for analysis of the PROMs. These statistics were the mean difference in post-operative score and the mean difference in the change of score.

RESULTS

1323 papers were assessed of which 20 papers were included. 898 ankle arthrodesis and 1638 ankle replacements were evaluated. The mean follow up was 3.3 years (range 0.5-13.0 years). AA patients had a mean age of 55.7 (range 20-82) and TAR 62.5 (range 21-89). There was major heterogeneity in outcomes used. We were unable to find a significant difference between the reported change in PROMs following TAR and AA. 29.3% of PROMs and their subscores showed TAR had better outcomes, 68.7% showed no significant difference and only 2.0% showed AA to have better outcomes.

CONCLUSIONS

The majority of published studies found equality in patient reported outcomes following TAR and AA although the quality of the studies was of low-level evidence. There is an urgent need for randomised controlled studies to definitively answer this important clinical question.

Modern total ankle arthroplasty versus ankle arthrodesis: A systematic review and meta-analysis

The controversy in surgical management of end-stage tibiotalar arthritis with Total Ankle Arthroplasty (TAA) versus Ankle Arthrodesis (AA) has grown in parallel with the evolution of both procedures. No randomized controlled trials exist due to the vast differences in surgical goals, patient expectations, and complication profiles between the two procedures. This makes high quality systematic reviews necessary to compare outcomes between these two treatment options. The aim of this study was to provide a systematic review with meta-analysis of publications reporting outcomes, complications, and revision data following third-generation TAA and/or modern AA published in the past decade. Thirtyfive articles met eligibility criteria, which included 4312 TAA and 1091 AA procedures. This review reports data from a mean follow-up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort. There was no significant difference in overall complication rate following TAA compared to AA (23.6% and 25.7% respectively, P-value 0.31). Similarly, there was no significant difference in revision rate following TAA compared to AA (7.2% and 6.3% respectively, P-value 0.65). Successful treatment of end-stage tibiotalar arthritis requires an understanding of a patients’ goals and expectations, coupled with appropriate patient selection for the chosen procedure. The decision to proceed with TAA or AA should be made on a case-by-case basis following an informed discussion with the patient regarding the different goals and complication profiles for each procedure.

Effect of Tranexamic Acid on Wound Complications and Blood Loss in Total Ankle Arthroplasty

BACKGROUND

Tranexamic acid (TXA) is a medication that has been shown to decrease blood loss and risk of blood transfusion in total knee and total hip arthroplasty. The purpose of this study was to evaluate the use of TXA in patients undergoing total ankle arthroplasty (TAA). We hypothesized there would be less blood loss and wound complications in patients receiving TXA.

METHODS

A retrospective review of 2 patient cohorts operated on by 2 surgeons was performed from 2010 to 2018. We compared a group of TAA patients that did not receive TXA vs a subsequent group that received TXA. Patients received 1g intravenous TXA before the tourniquet was inflated followed by another 1 g after release of the tourniquet. Intraoperative blood loss was recorded and preoperative hemoglobin and hematocrit levels were compared to postoperative levels. Intraoperative and postoperative complications were compared between the 2 groups. A total of 119 patients were included in the study, of whom 55 received TXA. No significant difference existed between the 2 groups in gender, age, body mass index, or Charlson comorbidity index.

RESULTS

There was no difference in estimated blood loss, postoperative hemoglobin/hematocrit values or preoperative to postoperative change in hemoglobin/hematocrit values. Additionally, there was no difference in wound complications or overall complication rate between the groups.

CONCLUSION

TXA has been shown to be effective in total knee and total hip arthroplasty in decreasing blood loss and transfusion risk. We did not find it to be effective in reducing intraoperative blood loss, perioperative blood loss, or wound complications in TAA.

LEVEL OF EVIDENCE

Level III, comparative study.

The Use of Closed Incision Negative Pressure Therapy Immediately After Total Ankle Arthroplasty Surgeries

Introduction Total ankle arthroplasty (TAA) has become a common procedure in the treatment of end-stage ankle arthritis. Most prostheses utilize an anterior ankle approach, which has been shown to have incisional complication rates of up to 28%, including dehiscence and infection. Wounds in this area can be catastrophic to patient outcomes. Preventing incisional wounds would significantly benefit the patient. The purpose of this study was to evaluate the effect of closed incision negative pressure therapy (ciNPT) in reducing incisional dehiscence and surgical site infection (SSI) after TAA. Materials and methods A retrospective chart review that was approved by the Institutional Review Board (IRB) was performed on patients undergoing TAA. Inclusion criteria were patients undergoing TAA with an anterior incision and ciNPT placed immediately in the operating room. Comorbidities associated with increased wound complications were recorded. Identification of any incisional dehiscence, infections, or deviations from normal postoperative recovery attributed to the former was also recorded. Results Twenty-eight patients met the inclusion criteria. The average age of the patients at the time of surgery was 68 years. Comorbidities associated with compromised healing were obesity (45%), current or former smoking (45%), diabetes (3.5%), and rheumatoid arthritis (7%). There were no postoperative wound complications (100% incisional healing). No patient required any wound-care intervention or had an SSI. None of the patients had any delay in the normal postoperative course. Conclusion Avoiding wound complications in TAA patients is critical to the success of the procedure. This retrospective case series demonstrated 100% healing with the utilization of the ciNPT in both normal and high-risk patients with decreased healing potential. Our results showed a substantial decrease in wound complications and SSIs compared to historical reports. We recommend ciNPT for all TAA procedures utilizing an anterior incision to decrease the risk for wound complications and SSIs.

Results of Trabecular-Metal Total Ankle Arthroplasties With Transfibular Approach

BACKGROUND

Total ankle arthroplasty is an alternative for arthrodesis. The objective of this study was to investigate the safety of trabecular-metal ankle prosthetic system with transfibular approach and external frame and its association with changes in clinical and functional scores.

METHODS

Between May 2013 and June 2017, a total of 104 consecutive patients underwent primary total ankle arthroplasty with a trabecular metal implant. The prospective clinical and radiographic data were collected. The mean follow-up time was 43.6 (14.6) months.

RESULTS

Of 104 patients, 88 (89%) reported improved functioning and 65 (66%) were very satisfied with the surgery. Of the patients, 51 (50%) did not report any pain at the end of follow-up at all. The average Kofoed score was 37.6 (SD 17.4) points at baseline and 74.8 (SD 20.6) points at the end of follow-up. There were 37 additional procedures, and the complication rate was nearly 20%.

CONCLUSION

Trabecular-metal total ankle prosthesis showed promising clinical results concerning pain and function. At 5-year follow-up, osteolysis and component loosening were rare.

LEVEL OF EVIDENCE

Level IV, case series.

The CT gap sign, a case of failure to seat the polythene component in total ankle replacement (infinity)

We present a case of incorrect seating of the polyethylene liner in an INFINITY total ankle replacement causing discomfort and eventually leading to a revision ankle replacement. This malposition of the implant was observed on a computed tomography (CT) scan as a ‘gap’ between the liner and the body of the replacement. The patient complained of discomfort on walking postoperatively, which limited activity. All investigations were normal including X-Ray, inflammatory markers, ultrasound, and it was only the subtle CT changes along with history that confirmed the diagnosis. This case demonstrates a complication of the design of the INFINITY prosthesis and the approach taken to the ankle when inserting. The patient fortunately made a full recovery after revision surgery, returning to normal activities with minimal pain.

Blood Transfusion During Total Ankle Arthroplasty Is Associated With Increased In-Hospital Complications and Costs

INTRODUCTION

Total ankle arthroplasty (TAA) is an increasingly used, effective treatment for end-stage ankle arthritis. Although numerous studies have associated blood transfusion with complications following hip and knee arthroplasty, its effects following TAA are largely unknown. This study uses data from a large, nationally representative database to estimate the association between blood transfusion and inpatient complications and hospital costs following TAA.

METHODS

Using the Nationwide Inpatient Sample (NIS) database from 2004 to 2014, 25 412 patients who underwent TAA were identified, with 286 (1.1%) receiving a blood transfusion. Univariate analysis assessed patient and hospital factors associated with blood transfusion following TAA.

RESULTS

Patients requiring blood transfusion were more likely to be female, African American, Medicare recipients, and treated in nonteaching hospitals. Average length of stay for patients following transfusion was 3.0 days longer, while average inpatient cost was increased by approximately 50%. Patients who received blood transfusion were significantly more likely to suffer from congestive heart failure, peripheral vascular disease, hypothyroidism, coagulation disorder, or anemia. Acute renal failure was significantly more common among patients receiving blood transfusion ( P < .001).

CONCLUSION

Blood transfusions following TAA are infrequent and are associated with multiple medical comorbidities, increased complications, longer hospital stays, and increased overall cost.

LEVELS OF EVIDENCE

Level III: Retrospective, comparative study.

Total ankle arthroplasty incorporating a total talar prosthesis

Aims

Total ankle arthroplasty (TAA) has become the most reliable surgical solution for patients with end-stage arthritis of the ankle. Aseptic loosening of the talar component is the most common complication. A custom-made artificial talus can be used as the talar component in a combined TAA for patients with poor bone stock of the talus. The purpose of this study was to investigate the functional and clinical outcomes of combined TAA.

Patients and Methods

Ten patients (two men, eight women; ten ankles) treated using a combined TAA between 2009 and 2013 were matched for age, gender, and length of follow-up with 12 patients (one man, 11 women; 12 ankles) who underwent a standard TAA. All had end-stage arthritis of the ankle. The combined TAA features a tibial component of the TNK ankle (Kyocera, Kyoto, Japan) and an alumina ceramic artificial talus (Kyocera), designed using individualized CT data. The mean age at the time of surgery in the combined TAA and standard TAA groups was 71 years (61 to 82) and 75 years (62 to 82), respectively. The mean follow-up was 58 months (43 to 81) and 64 months (48 to 88), respectively. The outcome was assessed using the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale, the Ankle Osteoarthritis Scale (AOS), and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q).

Results

The mean preoperative JSSF score of the combined TAA and standard TAA groups was 44 (sd 11) and 49 (sd 10), respectively. The mean postoperative JSSF scores were 89 (sd 6.1) and 72 (sd 15), respectively. The mean postoperative JSSF score of the combined TAA group was significantly higher (p = 0.0034). The mean preoperative AOS scores for pain and function in the combined TAA and standard TAA groups were 5.8 (sd 3.3) and 5.5 (sd 3.1), and 8.6 (sd 1.3), and 7.1 (sd 2.9), respectively. The mean postoperative AOS scores of pain and function were 2.5 (sd 2.5) and 2.2 (sd 1.9), and 2.5 (sd 3.3) and 3.4 (sd 2.9), respectively. There were no significant differences between the two groups in terms of postoperative AOS scores. The mean postoperative SAFE-Q scores were: for pain, 76 (sd 23) and 70 (sd 23); for physical function, 66 (sd 25) and 55 (sd 27); for social function, 73 (sd 35) and 62 (sd 34); for shoe-related, 73 (sd 19) and 65 (sd 26); and for general health, 78 (sd 28) and 67 (sd 29), respectively. There were no significant differences between the two groups in terms of postoperative SAFE-Q scores.

Conclusion

Combined TAA resulted in better clinical results than standard TAA. Cite this article: Bone Joint J 2019;101-B:443–446.

Infections in primary total ankle replacement: Anterior approach versus lateral transfibular approach

BACKGROUND

Total ankle replacement (TAR) represents an alternative to fusion for the treatment of end-stage ankle osteoarthritis. The aim of the present study was to retrospectively assess the frequency of infections between TARs with anterior and lateral transfibular approach at 12-months follow-up.

METHODS

81 TARs through an anterior approach and 69 TARs through a lateral approach were performed between May 2011 and July 2015. We compared surgical time and tourniquet time, as well as superficial and deep infections frequency during the first 12 postoperative months.

RESULTS

In the anterior approach group, there were 3 (3.7%) deep infections and 4 (4.9%) superficial wound infections. In the lateral approach group, there were 1 (1.4%) deep infection and 2 superficial wound infections (2.9%). There were not statistically significant differences between the groups. There was a significant difference between anterior approach (115minutes) and lateral approach group (179minutes) in terms of surgical time (P<0.001).

CONCLUSIONS

The frequency of superficial and deep periprosthetic infections during the first postoperative year was not significantly different in the lateral approach group compared to the anterior approach group, despite the significantly longer surgical time in the lateral transfibular approach group.

Effects of Cryopreserved Amniotic Membrane-Umbilical Cord Allograft on Total Ankle Arthroplasty Wound Healing

Relatively high rates of wound healing complications continue to be reported with a total ankle arthroplasty (TAA) anterior incision. The amniotic membrane-umbilical cord (AM-UC) allograft is a regenerative orthobiologic adjunct that modulates wound healing by down-regulating inflammation, enhancing local healing and antimicrobial factors, and reducing scar formation. The purpose of this study was to determine whether local application of a cryopreserved AM-UC allograft enhances soft tissue healing after TAA. A total of 104 patients with symptomatic ankle arthritis who failed conservative management underwent standard TAA. At skin closure, patients were allocated to either the treatment (local application of AM-UC) or control (no allograft) group. Demographic data, patient comorbidities, and radiographic findings were collected. The primary outcome was a major complication necessitating reoperation. Secondary outcomes were time to healing, minor complications (i.e., skin dehiscence, local wound care, use of antibiotics), and patient scar assessment. Local application of an AM-UC allograft significantly decreased the overall time to skin healing (28.5 days vs 40 days; p = .03). Two patients required a reoperation for soft tissue wound complications, with no difference (p = 1.00) between the groups. No statistically significant difference was detected in terms of skin dehiscence, local wound care, or antibiotic prescriptions in the 2 groups. Regenerative technology using local application of a cryopreserved AM-UC allograft may enhance TAA outcomes by decreasing the time to healing. Larger randomized controlled trials are needed to determine whether an AM-UC allograft enhances soft tissue wound healing and ultimately reduces the incidence of devastating soft tissue complications.

Effect of Obesity on Total Ankle Arthroplasty: A Systematic Review of Postoperative Complications Requiring Surgical Revision

Total ankle arthroplasty has become an increasingly used alternative to ankle arthrodesis for the treatment of end-stage ankle arthritis. However, despite progressive technological advances and the advent of multiple commercial implant systems, some concern remains for the relatively high complication and failure rates. The objective of the present investigation was to perform a systematic review of the incidence of complications in obese patients undergoing total ankle arthroplasty. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with ≥15 total participants, a mean follow-up period of ≥12 months, ≥1 defined cohort with a body mass index of ≥30 kg/m², and a reported incidence rate of complications requiring revisional surgery at the final follow-up point. Four studies met our inclusion criteria, with a total of 400 implants analyzed. Of these, ≥71 (17.8%) developed a complication requiring a revisional surgical procedure. The most commonly reported surgeries were revision of the metallic components and ankle gutter debridement. It is our hope that our investigation will allow foot and ankle surgeons to more effectively communicate the perioperative risk to their patients during the education and consent process.

Soft Tissue Reconstruction After Total Ankle Arthroplasty

Wound complications following total ankle replacement are common. A team approach, including plastic surgeons, should be utilized to manage these wound issues. The handling of the wound, from the index procedure, to a variety of flaps, can be utilized to provide a successful outcome following an ankle replacement.

Dealing with the Stiff Ankle: Preoperative and Late Occurrence

In patients with a stiff ankle replacement, appropriate resection of scarred capsular structures, hypertrophic bone debridement, and careful release of tendons should be performed to achieve good outcomes. Appropriately sized and correctly implanted components are required to restore ankle function to as normal as possible. Although not proven, the better a total ankle replacement is balanced, the less likely scar and heterotopic bone formation will occur. In patients with a stiff and painful ankle replacement, a preoperative diagnostic workup is mandatory to understand the underlying pathologic process and plan appropriate treatment. All underlying causes should be addressed.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Iatrogenic Arteriovenous Fistula With Associated Pseudoaneurysm of Posterior Tibial Artery After Revision Total Ankle Arthroplasty: A Case Report

Iatrogenic vascular injuries in elective orthopedic surgery are rare. However, these are important complications to recognize early and treat appropriately because the potential sequelae can be devastating. Arteriovenous fistula of the lower extremity after total ankle arthroplasty has not been previously described in published studies. The proper diagnosis of arteriovenous fistulas can be difficult without a high index of suspicion, and treatment often involves surgical intervention. We present the case of a 62-year-old male who developed an iatrogenic arteriovenous fistula with associated pseudoaneurysm of the posterior tibial artery after revision total ankle arthroplasty that was treated with surgical ligation and excision, followed by reverse saphenous vein grafting.

Time trends and risk factors for perioperative complications in total ankle arthroplasty: retrospective analysis using a national database in Japan

Background

Total ankle arthroplasty (TAA) has become increasingly popular worldwide as an alternative to ankle arthrodesis for surgical treatment of end-stage ankle arthritis. The aim of this epidemiological study, using a national inpatient database in Japan, was to describe the volume, utilization, patient characteristics, and temporal trends regarding these procedures in Japan, and to identify the risk factors associated with perioperative adverse events in TAA.

Methods

This was a population-based, retrospective cohort study. We retrospectively identified 2775 patients in the Diagnosis Procedure Combination database who underwent ankle arthrodesis or TAA for ankle arthritis at 559 hospitals in Japan from 2007 to 2013. Information on sex, age, main diagnosis, use of blood transfusion, duration of anesthesia, length of hospital stay, in-hospital mortality, hospitalization costs, additional procedures after primary surgery, and use of negative pressure wound therapy was extracted. Multivariable logistic regression analysis was performed to analyze the effect of various factors on the incidence of perioperative adverse events in TAA, including additional procedure during hospitalization, negative pressure wound therapy, blood transfusion, and in-hospital death.

Results

We identified 465 patients who underwent TAA and 2310 patients who underwent ankle arthrodesis. There was no apparent increase in the proportion of TAAs performed during the survey period. Patients undergoing TAA tended to be older, female, and have rheumatoid arthritis compared with those undergoing ankle arthrodesis. Patients undergoing TAA had shorter length of stay, higher hospitalization costs, and more blood transfusions compared with those undergoing ankle arthrodesis. Lower hospital volume and shorter anesthesia time were associated with higher rates of adverse events after TAA.

Conclusions

Despite an increase in the popularity of TAA internationally, the number of TAAs performed remains low in Japan. Lower hospital volume and anesthesia time were associated with higher rates of perioperative adverse events after TAA.

Level of evidence

IV, Cross-sectional study

Posterior Ankle Structure Injury During Total Ankle Replacement

Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence, infection, bone fractures, and heterotopic ossification. However, patients can still experience unresolved pain even when these problems have been ruled out. We initiated a study to more clearly define the relative risk of injury to the anatomic structures in the posterior ankle during total ankle replacement using a third-generation implant system. Ten fresh-frozen adult cadaveric below-the-knee specimens were positioned in the intraoperative positioning frame of an approved total ankle replacement system and adjusted to achieve proper foot alignment using fluoroscopic imaging. The relationship between the tibial cutting guide pins and the posterior neurovascular and tendon structures was measured using digital calipers. High rates of posterior structural injury were found. Nearly all proximal-medial pins encountered a posteromedial neurovascular structure, most commonly the tibial nerve. The distal-medial pins mainly encountered posteromedial tendinous structures, in particular, the flexor digitorum longus tendon. The proximal lateral pins were highly likely to encounter the Achilles tendon and the sural nerve. Our results support our hypothesis that the tibial neurovascular structures are at the greatest risk when preparing for and completing the bony resection, particularly with the medial and proximal cuts. Posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. Further study of posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.

Incidence of Complications During Initial Experience with Revision of the Agility and Agility LP Total Ankle Replacement Systems: A Single Surgeon's Learning Curve Experience

As the frequency in which foot and ankle surgeons are performing primary total ankle replacement (TAR) continues to build, revision TAR will likely become more commonplace, creating a need for an established benchmark by which to evaluate the safety of revision TAR as determined by the incidence of complications. Currently, no published data exist on the incidence of intraoperative and early postoperative complications during revision of the Agility or Agility LP Total Ankle Replacement Systems during the surgeon learning curve period; therefore, the authors sought to determine this incidence during the senior author's learning curve period.

Arthroscopic Management of Complications Following Total Ankle Replacement

There is great potential of managing the complications of total ankle replacement arthroscopically and endoscopically, and these procedures can be summarized into 3 groups. Group 1 includes procedures of the ankle joint proper with close proximity to the articular components of the total ankle replacement. Group 2 includes procedures of the tibia and talus with close proximity to the nonarticular parts of the total ankle replacement. Group 3 includes procedures that are away from the total ankle replacement. However, these remain master arthroscopist procedures and should be performed by foot and ankle surgeons who perform them with regularity.

Incidence of Complications During the Surgeon Learning Curve Period for Primary Total Ankle Replacement: A Systematic Review

Surgeons performing primary total ankle replacement have achieved outcomes comparable to ankle arthrodesis. However, while many reports exist suggesting the presence of a surgeon learning curve period during initial performance of primary total ankle replacement, no published analysis of the actual incidence of complications encountered during this period exists. Therefore, we sought to provide such an analysis through systematic review. A total of 2453 primary total ankle replacements with 1085 complications (44.2%) were identified. Our results revealed conflicting data whether an acceptably low incidence of high-grade complications leading to total ankle replacement failure exists during the surgeon learning curve period.

Obesity Is Associated With Increased Complications After Operative Management of End-Stage Ankle Arthritis

BACKGROUND

Total ankle arthroplasty (TAA) and ankle arthrodesis (AA) are two operative options for the management of end-stage ankle arthritis that has failed conservative interventions. Obesity is associated with a greater incidence of musculoskeletal disease, particularly osteoarthritis of the weight-bearing joints, including the ankle. The objective of the present study was to use a national database to examine the association between obesity and postoperative complications after TAA and AA.

METHODS

The PearlDiver database was queried for patients undergoing AA and TAA using International Classification of Diseases, 9th Revision (ICD-9) procedure codes. Patients were divided into obese (body mass index ≥30 kg/m(2)) and nonobese (body mass index <30 kg/m(2)) cohorts using ICD-9 codes for body mass index and obesity. Complications within 90 days postoperatively were assessed using ICD-9 and Current Procedural Terminology (CPT) codes.

RESULTS

23,029 patients were identified from 2005 to 2011, including 5361 with TAA and 17,668 with AA. Obese TAA patients had a significantly increased risk of 90-day major, minor, local, systemic, venous thromboembolic, infectious, and medical complications compared with nonobese patients. The incidence of revision TAA was also significantly higher in obese patients compared with nonobese patients. Findings were similar for AA, as all types of complications were significantly higher in obese patients compared with nonobese patients.

CONCLUSION

Obesity was associated with significantly increased rates of all complications after both TAA and AA. The cause of this association was likely multifactorial, including increased rates of medical comorbidities, intraoperative factors, and larger soft tissue envelopes.

LEVEL OF EVIDENCE

Level III, comparative series.

Use of Negative Pressure Wound Therapy on Closed Surgical Incision After Total Ankle Arthroplasty

BACKGROUND

Wound healing problems of the anterior ankle incision are among the most common complications after total ankle arthroplasty, possibly resulting in exposure of the prostheses and infection. The aim of this study was to investigate the role of negative pressure wound therapy (NPWT) in decreasing the rate of wound healing problems after total ankle arthroplasty.

METHODS

This is a retrospective cohort study including consecutive patients who underwent total ankle arthroplasty by a single surgeon at a single institution between 2009 and 2013. The incisional negative pressure dressing was applied to all patients who underwent total ankle arthroplasty between 2012 and 2013 with a continuous application of -80 mm Hg negative pressure for 6 days postoperatively. The control group consisted of patients who underwent total ankle arthroplasty between 2009 and 2012 with a conventional nonadherent gauze dressing. Seventy-four patients were involved in this study: 37 in the control group and 37 in the incisional NPWT group.

RESULTS

All patients tolerated the incisional NPWT to completion without any dressing failures or skin problems. Both groups showed similar distributions in demographics and perioperative risk factors for wound healing. There were 9 (24%) wound healing problems in the control group and 1 (3%) in the incisional NPWT group. Incisional NPWT was found to reduce wound healing problems with an odds ratio of 0.10 (95% CI, 0.01-0.50; P = .004).

CONCLUSIONS

Our study demonstrated that there was a decreased incidence of wound healing problems following total ankle arthroplasty with incisional NPWT dressings. This is the first study evaluating the efficacy of incisional NPWT as an adjunct treatment for wound healing after total ankle arthroplasty.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Are our expectations bigger than the results we achieve? a comparative study analysing potential advantages of ankle arthroplasty over arthrodesis

PURPOSE

Prior studies have reported improved gait performance and kinematics after total ankle arthroplasty (TAR) compared to ankle arthrodesis (AAD). Given these findings, AAD has been primarily considered as a salvage procedure that may lead to adjacent joint degeneration.

METHODS

A total of 101 TAR and 40 screw arthrodeses were enrolled in a retrospective study with a prospectively designed follow-up examination that included gait analysis and outcome assessment with the AOFAS hindfoot score and FAOS questionnaire.

RESULTS

Significant asymmetry in gait and reduced range of motion compared to normal remained after both procedures. Subjective outcome improved after both procedures, and pain was significantly better after TAR. Limited functional gains after TAR and joint degeneration to the same degree after both procedures was seen in the mid-term. Hindfoot fusion seemed to have a greater impact on postoperative function than ankle arthrodesis.

CONCLUSION

Considering only minor functional gains of TAR compared to AAD the implantation of current TAR designs in large patient series may be questioned.