Arthrodèse de cheville pour échec d’arthroplastie totale

Complications and results of the arthrodesis after total ankle arthroplasty failure: a retrospective monocentric study of 12 cases

INTRODUCTION

Total ankle arthroplasty (TAA) has the objective to maintain the range of motion of the tibiotarsal joint and to preserve the nearby joints. However, the complication rate and failures remain quite high after TAA. The main objective of the study was to evaluate the improvement in the functional scores of the tibiotarsal arthrodesis after TAA failure. The secondary objective was to assess the specific complications.

MATERIALS AND METHODS

This monocentric retrospective series includes 12 patients (nine men, three women, average age 52.5 years) operated between 2003 and 2018. An iliac graft was used in all cases. The arthrodesis was stabilized either by screws or by retrograde nailing.

RESULTS

The reoperation was due to painful malleolar conflicts or loosening. The AOFAS score increased from 38/100 to 67/100 (51-86) post-operatively. The fusion was acquired at 3.7 months (3-6) except in two cases.

DISCUSSION AND CONCLUSION

The 83% primary fusion rate is in the low average of the literature and 92% fusion rate in the high average after reoperation. All patients were improved even in two non-unions. The results of this study confirm that the arthrodesis after TAA failure is a reliable alternative to the TAA replacement. However, they are lower than those after a first-line arthrodesis.

Staged Treatment of Infected Tibiotalar Fusion Using a Combination Antibiotic Spacer and Antibiotic-Coated Intramedullary Nail

Pilon fractures are notoriously difficult injuries to treat. The current published data on salvage procedures after failed pilon fractures includes both total ankle arthroplasty (TAA) and tibiotalar fusion, each with its own specific indications. However, no acceptable treatment algorithm addressing the complications of these limb salvage procedures is available. We present the case of a 23-year-old patient, who sustained a complex pilon fracture after a motor vehicle accident. The patient was referred to our institution after an initial fixation attempt, followed by subsequent failed TAA, which was complicated by an infected fusion attempt. We describe a staged treatment approach to clearing the infection and obtaining the final fusion goals.

Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis

BACKGROUND

Up to now, there has been no evidence that salvage arthrodesis would perform inferior when compared with primary ankle arthrodesis. The purpose of this study was to compare their clinical and radiographic results.

METHODS

A retrospective analysis was performed using 2 validated scores and assessment of radiographic union by comparing 23 patients who underwent salvage ankle arthrodesis (group SA = salvage arthrodesis) after failed total ankle replacement with 23 matched patients who received primary ankle arthrodesis (group PA = primary arthrodesis). The mean follow-up period was 38 (range 16-92) months in group SA and 56 (23-94) months in group PA.

RESULTS

Complete union was achieved in 17 patients (74%) after a mean time of 50 (13- 114) weeks in group SA and in 16 patients (70%) after a mean time of 23 (10-115) weeks in group PA. The SF-36 score averaged 48 points (7-80) in SA and 66 points (14-94; P = .006) in group PA. In group SA the mean FFI was 57% (22-82) for pain and 71% (44-98) for function. In group PA significantly better results for pain with 34% (0-88; P = .002) and function with 48% (1-92; P = .002) were found.

CONCLUSION

Salvage arthrodesis led to impaired life quality and reduced function combined with significantly higher pain when compared with primary ankle arthrodesis. These findings can be used to counsel our patients preoperatively.

LEVEL OF EVIDENCE

Level III, retrospective case series.

Cement arthroplasty for ankle joint destruction

BACKGROUND

The aim of this study was to investigate the outcomes of cement arthroplasty used as a primary salvage procedure to treat ankle joint destruction.

METHODS

This study included sixteen patients who underwent primary cement arthroplasty from May 2004 to March 2012 because of an ankle disorder, including intractable infection, nonunion, or a large bone defect or tumor. The mean age of the patients was fifty-seven years (range, twenty-three to seventy-four years), and the mean follow-up period was thirty-nine months (range, fourteen to 100 months). The cement spacer position, cement breakage, osteolysis around the inserted cement, and alignment of the joint were evaluated radiographically. American Orthopaedic Foot & Ankle Society (AOFAS) scores and visual analogue scale (VAS) pain scores were recorded preoperatively and at the time of final follow-up. Functional questionnaires were used to assess the duration for which the patient could walk continuously, use of walking aids, sports activity, consumption of pain medication, and the patient's subjective assessment of the percentage of overall improvement compared with before the cement arthroplasty.

RESULTS

The cement spacer was retained without breakage for a mean of thirty-nine months (range, fourteen to 100 months). Osteolysis around the cement was observed in one patient at seventy-eight months, and subluxation developed in one patient. The mean AOFAS and VAS pain scores improved from 39 (range, 11 to 71) preoperatively to 70 (range, 47 to 88) postoperatively (p = 0.001) and from 8 (range, 4 to 9) to 3 (range, 1 to 7) (p = 0.001), respectively. At the final follow-up evaluation, nine of the sixteen patients did not require walking aids, ten used no pain medication, and nine were able to walk continuously for more than an hour. One patient complained of persistent pain and was considered to have had a failure of the procedure.

CONCLUSIONS

Primary cement arthroplasty might be a treatment option for advanced ankle destruction in elderly and less active patients.

LEVEL OF EVIDENCE

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

Surgical tip: Titanium foam blocks can simplify fusion of failed total ankle replacements

Ankle arthrodesis following failed ankle replacements is a technically challenging task because of the large defect left behind after the prosthesis is removed. The usual practice is to use bulk grafts which are either autografts or allografts to fill the defect. We report our experience with the use of a titanium foam block specifically designed for fusion of failed ankle replacements. This particular method was chosen to avoid the technical difficulties and morbidities associated with the use of bulk autografts and allografts. We describe the surgical technique and early results in the first two cases performed in our unit. The satisfactory clinical and radiologic results in the two cases demonstrate the ability of the titanium foam block to simplify an otherwise complex procedure without compromising the outcome.

Arthrodesis After Failed Total Ankle Replacement

BACKGROUND

The literature on salvage procedures for failed total ankle replacement (TAR) is sparse. We report a series of 17 patients who had a failed TAR converted to a tibiotalar or a tibiotalocalcaneal arthrodesis.

METHODS

Between 2003 and 2012, a total of 17 patients with a failed TAR underwent an arthrodesis. All patients were followed on a regular basis through chart review, clinical examination and radiological evaluation. The following variables were analyzed: pre- and postoperative Meary angle, cause of failure, method of fixation, type of graft, time to union, complications, and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score. The average follow-up was 30.1 months. The average period from the original arthroplasty to the arthrodesis was 49.8 months.

RESULTS

Thirteen of the 17 ankles were considered radiographically healed after the first attempt in an average time of 3.7 months and 3 after repeat arthrodesis. Bone grafts were used in 16 patients. The median postoperative AOFAS score was 74.5. The mean Meary angle of the hindfoot was 5 degrees of valgus.

CONCLUSION

Tibiotalar and tibiotalocalcaneal arthrodeses were effective salvage procedures for failed TAR. Massive cancellous allografts were a good alternative to compensate for the large bone defect after removal of the prosthesis and to preserve the leg length.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement

BACKGROUND AND PURPOSE

Arthrodesis after failed total ankle replacement is complicated and delayed union, nonunion, and shortening of the leg often occur-especially with large bone defects. We investigated the use of a trabecular metal implant and a retrograde intramedullary nail to obtain fusion.

PATIENTS AND METHODS

13 patients with a migrated or loose total ankle implant underwent arthrodesis with the use of a retrograde intramedullary nail through a trabecular metal Tibial Cone. The mean follow-up time was 1.4 (0.6-3.4) years.

RESULTS

At the last examination, 7 patients were pain-free, while 5 had some residual pain but were satisfied with the procedure. 1 patient was dissatisfied and experienced pain and swelling when walking. The implant-bone interfaces showed no radiographic zones or gaps in any patient, indicating union.

INTERPRETATION

The method is a new way of simplifying and overcoming some of the problems of performing arthrodesis after failed total ankle replacement.

Periprosthetic fracture after total ankle replacement: surgical technique

Level of Evidence: V, Expert Opinion

Ankle arthrodesis

Numerous techniques for ankle arthrodesis have been reported since the original description of compression arthrodesis. From the early 1950s to the mid 1970s, external fixation was the dominant technique utilized. In the late 1970s and 1980s, internal fixation techniques for ankle arthrodesis were developed. In the 1990s, arthroscopic ankle arthrodesis was developed for ankle arthrosis with minimal or no deformity. The open technique is still widely used for ankle arthrosis with major deformity. For complex cases that involve nonunion, extensive bone loss, Charcot arthropathy, or infection, multiplanar external fixation with an Ilizarov device, with or without a bone graft, may achieve successful union. The fusion rate in most of the recently published studies is 85% or greater, and may depend on the presence of infection, deformity, avascular necrosis, and nonunion.

Tricortical bone grafts for treatment of malaligned tibias and fibulas

Malunions and malaligned nonunions of the tibia and fibula after fracture alter limb function and can be corrected only with surgical intervention. We sought to determine whether using tricortical portions of the iliac crest in conjunction with osteotomy and internal fixation could successfully treat malunions and malaligned nonunions of the tibia and fibula. Seventeen patients with either a malunion or a malaligned nonunion of the tibia or fibula were treated with an osteotomy, deformity correction, and placement of an autogenous iliac crest tricortical bone graft with open reduction and internal fixation (ORIF). The minimum followup was 3 months (average, 32 months; range, 3-118 months). Sixteen patients (94%) had clinical and radiographic evidence of healing at an average of 99 days (range, 43-229 days). Major complications occurred in four patients; one had a persistent nonunion, two had wound infections, and one underwent resection of the distal fibula for subsequent development of fibulotalar arthrosis after ankle arthrodesis. Minor complications occurred in two patients, one tendinitis and one persistent malunion. There were no complications at the iliac crest bone graft site. Autogenous iliac crest tricortical bone grafts, when used in conjunction with correction of alignment and stable internal fixation, are a reasonable option for treatment of nonunions and malaligned nonunions of the tibia and fibula.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

[Short-term results after STAR total ankle replacement]

BACKGROUND

This retrospective study was performed to investigate the clinical and radiological results after STAR total ankle replacement.

MATERIAL AND METHODS

Between January 2000 and September 2004, 49 patients with an average age of 62.5 years underwent total ankle replacement with the STAR prosthesis. At an average follow-up of 30.4 months, 48 patients were examined clinically and radiologically. The Kofoed ankle score and the patients' subjective satisfaction were evaluated.

RESULTS

The operation improved the Kofoed ankle score significantly, from 28 to 86 points, 90% of the patients were satisfied with the results. The revision rate was 10%.

CONCLUSION

The early results after implantation of the STAR ankle prosthesis are encouraging. With correct indication, a high rate of pain reduction and patient satisfaction can be achieved. The long-term benefit of this procedure has yet to be determined.

Ankle arthrodesis: the simple and the complex

Ankle arthrodesis is by no means a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of ankle positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to recognize important patient factors and to determine which type of ankle arthrodesis is most appropriate for that specific patient.

A technique of fusion for failed total replacement of the ankle

Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb.

We describe a technique for restoring talar height using an allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).

Unsuccessful use of a titanium mesh cage in ankle arthrodesis: a report on three cases operated on due to a failed ankle replacement

Three patients with a failed total ankle arthroplasty underwent tibiocalcaneal arthrodesis. In an attempt to preserve leg length, a titanium cage filled with autologous bone was placed in the defect. None of the ankles healed primarily. After 9 to 29 months, the cages, which only contained necrotic material, were removed and repeat arthrodesis was performed using a retrograde intramedullary nail. After this procedure, 1 ankle had healed after 14 months whereas 2 did not heal. However, after a third attempt, using external fixation, 1 of the latter 2 healed. The method used in this report cannot be recommended. Although titanium mesh cages filled with autograft have been successfully used to substitute for vertebral defects, the author does not feel that the method can be recommended for ankle arthrodesis.

Arthrodesis after failed total ankle replacement

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.

Ankle arthrodesis for failed total ankle replacement

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.