Patient-specific instrumentation (PSI) in total ankle arthroplasty: a systematic review

Standard Total Ankle Arthroplasty vs. Patient-Specific Instrumentation: A Comparative Study

PURPOSE

This retrospective study aims to compare surgical outcomes between two cohorts of patients who underwent total ankle arthroplasty (TAA) using either standard technique or patient-specific instrumentation (PSI).

METHODS

A consecutive series of patients who affected of end-staged ankle osteoarthritis were retrospectively assessed and divided into two groups based on TAA techniques: a TAA standard technique group and a TAA-using PSI group. The two groups were compared in terms of operative time, additional procedures, complications (neurovascular and wound problems, infection, loosening and osteolysis, revision and explantation rates, and perioperative fracture), clinical scores, and range of motion (ROM).

RESULT

Fifty-one patients underwent standard TAA, while 13 patients underwent TAA with PSI. At 1-year follow-up, there were no significant differences in complication rates between the two groups (p > 0.05). AOFAS scores were similar, with the standard TAA group scoring 83.33 ± 7.55 and the PSI group scoring 82.92 ± 9.7 (p = 0.870). Likewise, the postoperative ROM did not differ significantly, with 15.12 ± 7.6 degrees for the standard TAA group and 16.05 ± 6.7 degrees for the PSI group (p = 0.689). However, the standard TAA group experienced significantly longer operative time (107.1 ± 22.1 min) compared to the PSI group (91.92 ± 22.9 min, p = 0.032). Additionally, the standard TAA group required more adjunctive procedures (29.7%) compared to the PSI group (7.7%, p = 0.04). Residual pain was also more frequently reported in the standard TAA group (62.7%) than in the PSI group (30.7%, p = 0.038).

CONCLUSION

While both techniques resulted in comparable complication rates, clinical scores and ROM, the PSI group reported significantly shorter operative time and less residual pain, thus requiring fewer postoperative procedures.

Learning curve of total ankle arthroplasty: a systematic review

INTRODUCTION

Together with ankle arthrodesis, total ankle arthroplasty is now accepted as a first-line intervention in the management of end-stage arthritis of the ankle. The evidence regarding how outcomes are affected by surgeon experience is inconsistent; we performed a systematic review to evaluate the effect of a learning curve in total ankle arthroplasty outcomes.

METHODS

An electronic database search was performed in PubMed, Embase, ISI Web of Science and Cochrane trials. Two reviewers independently conducted a two-stage title/abstract and full text screening. English-language original research studies comparing patient-reported outcome measures (PROMs), complication/revision rates, operative time, length of stay or radiation exposure according to surgeon experience were included. Quality assessment was performed using the methodological index for non-randomised studies.

RESULTS

All but one included study report either improved PROMs, reduced complication/revision rate, reduced hospital stay length/operative time or reduced radiation exposure with increasing surgeon experience. However, the majority of these findings lack statistical significance. Two studies assessing the plateau of the learning curve report a wide range of plateau thresholds between 9 and 39 cases.

CONCLUSION

This review finds a largely non-significant trend towards improvements in PROMs, complication, and revision rates with improved surgeon experience. The lack of statistical significance in a number of studies may be partially explained by methodological flaws, with more suitably designed studies reporting significant improvements. Future research into the effect of advancements in implant design and insertion guides is required to further characterise the magnitude of the learning curve and guide both mitigation and learning strategies.

Two to Five-Year Outcomes of Total Ankle Arthroplasty with the Infinity Fixed-Bearing Implant: A Concise Follow-up of a Previous Report

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Patient Specific Instruments and Patient Individual Implants—A Narrative Review

Joint arthroplasties are one of the most frequently performed standard operations worldwide. Patient individual instruments and patient individual implants represent an innovation that must prove its usefulness in further studies. However, promising results are emerging. Those implants seem to be a benefit especially in revision situations. Most experience is available in the field of knee and hip arthroplasty. Patient-specific instruments for the shoulder and upper ankle are much less common. Patient individual implants combine individual cutting blocks and implants, while patient individual instruments solely use individual cutting blocks in combination with off-the-shelf implants. This review summarizes the current data regarding the implantation of individual implants and the use of individual instruments.

Application of 3D printed patient-specific instruments in the treatment of large tibial bone defects by the Ilizarov technique of distraction osteogenesis

Background

The Ilizarov technique of distraction osteogenesis is an effective treatment for tibia defect. However, repeated attempts to reduce due to the complexity of the bone defect during the operation will increase the operation time and iatrogenic injury, and excessive radiation exposure. Three-dimensional (3D)-printed patient-specific instrument (PSI) for preoperative 3D planning and intraoperative navigation have the advantages of accuracy and visualization. The purpose of this study is to investigate whether 3D-printed PSI is helpful to correct tibial bone defects accurately and effectively.

Method

From May 2019 to September 2022, 19 patients with tibial bone defects were treated, including 9 males and 10 females, aged 37 to 64 years. There were 4 cases in proximal tibia, 9 in midshaft tibia and 6 in distal tibia. All were treated with Ilizarov technique of distraction osteogenesis. 3D-printed PSI was used in 9 cases, while traditional surgery was used in 10 cases. All patients underwent computed tomography before surgery. Computer software was used to analyze the measurement results, design and print PSI. During the operation, PSI was used to assist in reduction of tibia. Operation times were recorded in all cases, the number of fluoroscopy during the operation, and the varus/valgus, anteversion/reversion angle after the operation were measured. All measurement data were expressed by means ± SD, and Student's t test was used to examine differences between groups. The chi square test or Fisher's precise test was used to compare the counting data of the two groups.

Result

All PSI matched well with the corresponding tibia bone defect, and were consistent with the preoperative plan and intraoperative operation. The affected limb had a good reduction effect. The operation time from the beginning of PSI installation to the completion of Ilizarov ring fixator installation was 31.33 ± 3.20 min, while that in the traditional operation group was 64.10 ± 6.14 min (p < 0.001). The times of fluoroscopy in the PSI group during operation was 10.11 ± 1.83, and that in the traditional operation group was 27.60 ± 5.82. The reduction effect of tibia in PSI group was better than that in traditional operation group, with the average angle of PSI group is 1.21 ± 0.24°, and that of traditional operation group is 2.36 ± 0.33° (p < 0.001).

Conclusion

The PSI simplifies procedures, reduces the difficulty of the operation, improves the accuracy of the operation, and provides a good initial position when used in distraction osteogenesis to treat the tibial defects.

Long-term Follow-up of 254 Ceramic Coated Implant (CCI) Evolution Total Ankle Replacements

BACKGROUND

The ceramic coated implant (CCI) Evolution was a third-generation implant design used in approximately 2000 total ankle replacements (TARs) between 2003 and 2016. Because this implant was abandoned, long-term follow-up studies are lacking.

METHODS

All patients undergoing TAR using a CCI prosthesis between 2004 and 2012 were included for analysis. Preoperatively the tibiotalar alignment was measured, and postoperatively the patients were followed up clinically, with radiographs and by questionnaire. The primary outcome was implant survival at 10 years of follow-up. Implant survival was also compared for (1) inflammatory joint disease vs noninflammatory joint disease and (2) preoperative tibiotalar neutral vs varus or valgus alignment. The secondary outcomes were complications, reoperations, and function (assessed by patient-reported outcome measures).

RESULTS

Two hundred fifty-four TARs were performed in 237 patients. Two hundred twelve additional procedures were performed to achieve stable ankles. At 10-year follow-up, the survival was 67.5%, with an average time to revision of 4.5 years. The 10-year survival of the inflammatory joint disease group was 76.8% and of the noninflammatory joint group 63.1% (P = .44). In 248 TARs, the preoperative tibiotalar alignment was measured; (62% neutral, 25% varus, and 13% valgus), these showed 10-year survival rates of 74.7%, 48.2%, and 68.9% respectively (P = .07). The complication rate was 54%; 37% of patients underwent reoperation. At a mean of 8.5 years, postoperative satisfaction scored an average of 7.0 (SD 2.26) on a 0- to 10-point numeric rating scale. The mean Foot and Ankle Ability Measure sports subscore was 24.7, the mean Foot and Ankle Outcome Score (FAOS) sports subscore was 42.8, and the mean 36-Item Short Form Health Survey score was 40.0. Regarding daily activities, the mean FAOS was 81.0.

CONCLUSION

This is currently the sole study reporting the long-term results of the CCI prosthesis. The survival and functional outcomes were inferior to other third-generation mobile-bearing ankle implants.