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

Custom Patient-Specific 3D-Printed Titanium Truss Tibiotalocalcaneal Arthrodesis Implants for Failed Total Ankle Replacements: Classification, Technical Tips, and Treatment Algorithm

BACKGROUND

The management of failed total ankle replacements, with significant loss of bone stock, is challenging with high rates of complications and associated morbidity. Recent technological advances have enabled the development of patient-customized 3D-printed titanium truss arthrodesis implants, which offer an alternative salvage option for failed total ankle replacements.

METHODS

A prospective observational study was performed of 6 cases of failed total ankle replacements that were managed using custom patient-specific 3D-printed titanium truss arthrodesis implants. Technical tips, classification, and a treatment algorithm were developed based on our initial experience.

RESULTS

Between November 2018 and March 2022, 6 patients underwent arthrodesis for failed total ankle replacements. Follow-up was available for all cases. The mean follow-up was 3.0 years (range 1-4.5). The mean MOXFQ Index improved from 73.1 to 32.3 (P < .05). The mean EQ-5D-5L Index improved from 0.366 to 0.743 (P < .05) and the EQ-VAS also improved from 53.0 to 63.3 (P = .36). The mean VAS-Pain score at final follow-up was 27.5. There were no cases of nonunion. None of the patients were smokers. The overall complication rate was 50%. Two patients returned to surgery: one for wound washout following TAR explantation and a second for removal of metalwork 2 years following surgery for a prosthetic joint infection secondary to hematogenous spread. No patients underwent revision fixation or amputation.

CONCLUSION

Custom patient-specific 3D-printed titanium truss arthrodesis implants are a viable treatment option for failed total ankle replacements.

Republication of "Total Ankle Replacement Conversion to Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft and Pseudoelastic Intramedullary Nail Providing Sustained Joint Compression"

Tibiotalocalcaneal (TTC) arthrodesis is commonly performed to salvage a failed total ankle replacement. These salvage procedures are complicated by significant bone loss from the ankle replacement and are associated with low patient satisfaction. Here, we describe 2 cases of patients who presented with a failed total ankle replacement and underwent arthrodesis using a bulk femoral head allograft and a novel pseudoelastic intramedullary nail. The intramedullary nail contains an internal pseudoelastic element that adapts to bone resorption and settling allowing for compression to be maintained at the arthrodesis sites throughout healing. In the first case, a 65-year-old woman with a failed total ankle replacement underwent TTC arthrodesis. The second case involved an obese 53-year-old woman who had previously undergone 2 total ankle replacement procedures that resulted in unsuccessful outcomes. In both cases, union was demonstrated on computed tomographic scan by 6 months. At 2 years postsurgery, both patients were satisfied with the procedure. These cases provide preliminary evidence that tibiotalocalcaneal arthrodesis with a pseudoelastic IM nail and structural allograft is an appropriate treatment for failed total ankle replacements. Level of Evidence: Level IV, therapeutic, case series.

Management of Periprosthetic Bone Cysts After Total Ankle Arthroplasty

Modern improvements in total ankle arthroplasty (TAA) have increased the performance of this procedure for treatment of end-stage ankle arthritis. A common finding after TAA is the formation of periprosthetic bone cysts, which can be clinically silent or result in TAA failure. The exact cause of periprosthetic bones cysts has not been established, but major theories are related to osteolysis secondary to implant wear, micromotion, and stress shielding. Treatment can be nonoperative with clinical observation for small, asymptomatic cysts. Large, progressive, and symptomatic cysts often merit surgical treatment with debridement and grafting, revision TAA, or salvage arthrodesis.

Revision Surgery for Failed Total Ankle Replacement

Revision surgery for failed total ankle replacement is a challenge to the revision surgeon. Deformity, presence of infection, segmental bone defects, patient comorbidities, and soft tissue compromise all are significant considerations when determining appropriate procedures. Revision total ankle replacement, explant and fusion with or without lengthening, use of a trabecular metal cage, placement of an antibiotic cement spacer, grafting, and amputation all are viable options to treat patients with failed ankle arthroplasty.

Distal tibial distraction osteogenesis-an alternative approach to addressing limb length discrepancy with concurrent hindfoot and ankle reconstruction

Background

Limb length discrepancy (LLD) in the setting of concurrent hindfoot and ankle deformity poses an added level of complexity to the reconstructive surgeon. Regardless of etiology, a clinically significant LLD poses additional challenges without a forthright and validated solution. The purpose of the current study is to determine whether reconstructive hindfoot and ankle surgery with concurrent lengthening through a distal tibial corticotomy is comparable to other treatment alternatives in the literature.

Patients and methods

A retrospective review of hindfoot and ankle deformity correction utilizing Ilizarov circular external fixation with concurrent distal tibial distraction osteogenesis from July 2009 to September 2014 was conducted.

Results

This study included 19 patients with a mean age of 47.47 ± 13.36 years with a mean follow up of 576.13 ± 341.89 days. The mean preoperative LLD was 2.70 ± 1.22 cm and the mean operatively induced LLD was 2.53 ± 0.59 cm. The mean latency period was 9.33 ± 3.47 days and distraction rate was 0.55 ± 0.16 mm/day. The mean distraction length was 2.14 ± 0.83 cm and mean duration of external fixation was 146.42 ± 58.69 days. The time to union of all hindfoot and ankle fusions was 121.00 ± 25.66 days with an overall fusion rate of 85.71%.

Conclusions

The successful treatment of hindfoot and ankle deformity correction in the setting of LLD using the technique of a distal tibial corticotomy and distraction osteogenesis is reported and illustrates an additional treatment technique with comparable measured outcomes to those previously described. We urge that each patient presentation be evaluated with consideration of all described approaches and associated literature to determine the current best reconstructive approach as future studies may validate or replace the accepted options at present.

Tibiotalocalcaneal Arthrodesis for Severe Talar Avascular Necrosis

Severe talar avascular necrosis has many etiologies and can cause bone loss/hindfoot deformity. Tibiotalar calcaneal arthrodesis is a salvage procedure after severe talar avascular necrosis. Large bone voids can present significant challenges. Modest successes have been reported with structural block allograft tibiotalocalcaneal arthrodesis using either plate and screws, intramedullary nail fixation, or a combination. The advent of 3-dimensional printed titanium trusses has given surgeons another option for filling voids and providing structural support to prevent collapse. Although these options expand the armamentarium, treating surgeons must adhere to principles of arthrodesis: stable constructs, thorough joint surface preparation, and correction of deformity.

The Use of Tantalum Metal in Foot and Ankle Surgery

There are several reconstructive procedures in foot and ankle surgery wherein structural grafts are needed to fill defects, restore height, and maintain correction while providing an osteoconductive environment until fusion occurs. Traditionally used autografts and allografts have their disadvantages and limitations. Porous tantalum, with stiffness similar to bone and its biocompatibility, can be a viable option in foot and ankle reconstructive procedures.

Total Ankle Replacement Conversion to Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft and Pseudoelastic Intramedullary Nail Providing Sustained Joint Compression

Tibiotalocalcaneal (TTC) arthrodesis is commonly performed to salvage a failed total ankle replacement. These salvage procedures are complicated by significant bone loss from the ankle replacement and are associated with low patient satisfaction. Here, we describe 2 cases of patients who presented with a failed total ankle replacement and underwent arthrodesis using a bulk femoral head allograft and a novel pseudoelastic intramedullary nail. The intramedullary nail contains an internal pseudoelastic element that adapts to bone resorption and settling allowing for compression to be maintained at the arthrodesis sites throughout healing. In the first case, a 65-year-old woman with a failed total ankle replacement underwent TTC arthrodesis. The second case involved an obese 53-year-old woman who had previously undergone 2 total ankle replacement procedures that resulted in unsuccessful outcomes. In both cases, union was demonstrated on computed tomographic scan by 6 months. At 2 years postsurgery, both patients were satisfied with the procedure. These cases provide preliminary evidence that tibiotalocalcaneal arthrodesis with a pseudoelastic IM nail and structural allograft is an appropriate treatment for failed total ankle replacements.

Level of Evidence:

Level IV, therapeutic, case series.

Salvage arthrodesis of a failed total ankle replacement using a custom 3D-printed cage implant: A case report and review of the literature

We present a case report of a 66-year-old female who underwent salvage arthrodesis after a failed Scandinavian Total Ankle Replacement secondary to aseptic loosening and talar subsidence. Secondary to the loss of talar integrity the decision was made to proceed with revisional ankle arthrodesis. To maintain limb length the primary surgeon (EH) elected to use a custom cage implant in combination with an intramedullary nail construct in a single stage approach. The custom cage was augmented with autograft & allograft cancellous bone in addition to allograft recombinant human bone morphogenic protein, and allograft adult mesenchymal stem cells. The incision sites healed post-operatively without incident and at post-op week 16 the patient progressed to full unrestricted weight bearing in normal shoe wear with a gauntlet ankle brace. Although an isolated report, this case shows promise for further development of the technique. We believe this revisional arthrodesis technique warrants further research and consideration as a potential addition to the failed total ankle arthroplasty treatment algorithm.

Massive Chondroblastoma of the Talus: Treatment With En Bloc Talectomy and Tibiocalcaneal Arthrodesis: Long-Term Follow-up of a Case

Chondroblastomas are benign bone tumors that are usually located at epiphyseal regions of long bones, and are rarely located at the talus. The usual treatment consists of curettage and filling of the bone defect with bone either bone grafts or some other material, such as cement. The authors present a case of a massive chondroblastma of the talus, extending outside of bone boundaries and with a huge soft tissue mass and invasion of the adjacent calcaneus. Management included an en bloc talectomy through a double medial and lateral approach, and curettage and filling with cement of the calcaneal extension. Reconstruction was done by means of a tibiocalcaneal arthrodesis. At 11 years of follow-up, no tumor recurrence has occurred, and the AOFAS functional score is 83 out of 100 points.

LEVELS OF EVIDENCE

Level IV: Therapeutic.

Revision of Stemmed Agility Implants

Total ankle arthroplasty has advanced rapidly in the last 20 years. Early agility implants enjoyed improved survivability compared with more archaic total ankle implants. When talar subsidence occurs, the revision options include a stemmed component to improve stability by spanning the subtalar joint. Removal and revision of these stemmed components can be difficult because of ingrowth and bone loss.

[Aseptic loosening of total ankle replacement and conversion to ankle arthrodesis]

OBJECTIVE

To remove loosened prosthesis components, to perform augmentation, to address osseous defects, to perform neutrally aligned ankle arthrodesis, and to achieve postoperative pain relief.

INDICATIONS

Symptomatic, aseptic loosening of total ankle replacement (TAR) with/without substantial bone defect of the tibial and/or talar bone stock.

CONTRAINDICATIONS

General surgical or anesthesiological risks, periprosthetic infection, local or systemic infection, nonmanageable soft tissue problems.

SURGICAL TECHNIQUE

Removal of both prosthesis components using the previous incision (mostly using anterior ankle approach). Careful debridement of bone stock at the tibial and talar side. Osseous augmentation of defects using autologous or homologous cancellous bone, if needed, using structural allografts.

POSTOPERATIVE MANAGEMENT

A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6-8 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated gradually after progressive osseous healing has been confirmed.

RESULTS

Between January 2007 and December 2012, ankle arthrodesis was performed in 9 patients with failed TAR (6 men and 3 women, mean age 56.4 ± 7.0 years, range 47.8-66.0 years). The mean time between the initial TAR and revision surgery was 4.5 ± 2.4 years (range 1.2-7.9 years). In one patient irrigation and debridement was performed due to superficial wound infection. Another patient had a delayed osseous healing 11 months after the revision surgery.

Repair of segmental radial defects in dogs using tailor-made titanium mesh cages with plates combined with calcium phosphate granules and basic fibroblast growth factor-binding ion complex gel

Repair of large segmental defects of long bones are a tremendous challenge that calls for a novel approach to supporting immediate weight bearing and bone regeneration. This study investigated the functional and biological characteristics of a combination of a tailor-made titanium mesh cage with a plate (tTMCP) with tetrapod-shaped alpha tricalcium phosphate granules (TB) and basic fibroblast growth factor (bFGF)-binding ion complex gel (f-IC gel) to repair 20-mm segmental radial defects in dogs. The defects were created surgically in 18 adult beagle dogs and treated by implantation of tTMCPs with TB with (TB-gel group) or without (TB group) f-IC gel. Each tTMCP fitted the defect well, and all dogs could bear weight on the affected limb immediately after surgery. Dogs were euthanized 4, 8 and 24 weeks after implantation. Histomorphometry showed greater infiltration of new vessels and higher bone union rate in the TB-gel group than in the TB group. The lamellar bone volume and mineral apposition rate did not differ significantly between the groups, indicating that neovascularization may be the primary effect of f-IC gel on bone regeneration. This combination method which is tTMCP combined with TB and f-IC gel, would be useful for the treatment of segmental long bone defects.

Salvage of Failed Total Ankle Replacement Using a Custom Titanium Truss

Subsidence of the talar component results in significant morbidity after total ankle replacement. When recognized, prompt revision could be needed to preserve the function of the implant; however, this is not always the case. In situations in which the implant cannot be revised, tibiotalocalcaneal arthrodesis might be necessary to salvage the extremity. The purpose of the present report is to describe the use of a custom titanium alloy truss to fill a bony void created by explantation of the implant components. Total ankle replacement was performed as the initial surgery to address end-stage osteoarthritis. Two years after the index procedure, the patient underwent revision of the polyethylene and talar components with subtalar arthrodesis secondary to progressive subtalar osteoarthritis and talar subsidence. The implant subsequently became infected and was removed. The patient underwent re-implantation after the infection had resolved, but significant talar subsidence required conversion to a tibiotalocalcaneal arthrodesis with a custom titanium alloy truss and retrograde intramedullary nail. At the most recent follow-up appointment, the patient was weightbearing on a stable extremity and pain free. Radiographic examination confirmed appropriate implant alignment and evidence of bone formation throughout the titanium truss. Although our results are restricted to a single case with initial, limited follow-up data, combining sound structural mechanics with an open architecture and unique texture, the custom titanium truss appears to maintain the limb length and promote healing across a large void.

Ankle arthrodesis after failed total ankle replacement: a systematic review of the literature

PURPOSE

As the number of total ankle replacements (TARs) performed has risen, so has the need for revision. The purpose of this investigation was to perform a systematic review of clinical outcomes following a salvage ankle arthrodesis from a failed TAR to identify patient- and technique-specific prognostic factors and to determine the clinical outcomes and complications following an ankle arthrodesis for a failed TAR.

METHODS

We searched PubMed, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials for studies that analyzed ankle fusion after failed TAR with a minimum follow-up of 1 year.

RESULTS

We included 16 studies (193 patients). The majority of patients (41%) underwent the index TAR for rheumatoid arthritis. The majority of these revision surgeries were secondary to component loosening, frequently of the talar component (38%). In the cases that were revised to an ankle arthrodesis, 81% fused after their first arthrodesis procedure. The intercalary bone graft group and the blade plate group had the highest rate of fusion after the first attempt at fusion at 100%, whereas the tibiotalocalcaneal fusion with cage group had the lowest fusion rate at 50%. The overall complication rate was 18.2%, whereas the overall nonunion rate was 10.6%.

CONCLUSION

A salvage ankle arthrodesis for a failed TAR results in favorable clinical end points and overall satisfaction at short-term follow-up if the patients achieve fusion. The bone graft fusion and blade plate group resulted in the highest first-attempt fusion rate, with a low complication rate. Future studies should include prospective, comparative control or surgical groups and use standardized outcome measurements that will make direct comparisons easier.

LEVELS

Level IV: Systematic Review of Level IV Studies.

Salvage of failed total ankle replacement using tantalum trabecular metal: case series

BACKGROUND

Although newer generations of total ankle arthroplasty designs have better clinical outcomes, failure due to aseptic loosening remains a frequent major complication. Arthrodesis is the most common salvage procedure for a failed total ankle replacement. There are several arthrodesis techniques each with its advantages and disadvantages. We present a technique of ankle arthrodesis for failed total ankle replacements using tantalum Trabecular Metal™ (Zimmer, Warsaw, IN) with internal fixation, thus sparing the subtalar joint.

METHODS

Three patients who had undergone arthrodesis for a failed total ankle replacement using tantalum Trabecular Metal were retrospectively reviewed. The mean follow-up period was 57 (range, 31-86) months. The mean age at ankle arthroplasty was 57 (range, 33-72) years and at ankle arthrodesis was 63 (range, 44-74) years. The mean time from arthroplasty to arthrodesis was 7 (range, 2-11) years.

RESULTS

The American Orthopaedic Foot and Ankle Society (AOFAS) score improved from 30.7 (range, 20-39) preoperatively to 72.7 (range, 65-77) postoperatively at the time of last follow-up. Arthrodesis was achieved at a mean of 3 months, and there were no complications.

CONCLUSION

The technique described has several advantages when compared to other methods of salvage ankle arthrodesis. The subtalar joint is not included in the fusion unless it is degenerative and symptomatic. Height of the ankle is maintained throughout the fusion process. Furthermore, Trabecular Metal is abundantly available; it avoids donor site morbidity and eliminates the risk of transmissible diseases.

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.

[Tibiocalcaneal arthrodesis with retrograde nails. Description of a hindfoot procedure after massive talus destruction]

Following loss of the talus, tibiocalcaneal fusion is often the only available means of obtaining weight-bearing ability in the lower limb. Length discrepancy may be managed with an allograft. This casuistic describes 6 patients with tibiocalcaneal fusion (mean age 64 years) who had received a structural femoral head allograft fusion for failed total ankle arthroplasty (3 cases), Charcot arthropathy (2 cases) and osteomyelitis (1 case). The mean follow-up was 33 months and all limbs could be salvaged. There were two cases of non-union (one with infection). The mean AOFAS score was 51 and the mean Mazur score was 37. In the SF-36 the mean PCS was 34.4 and the mean MCS was 48.4. It was shown that in the hindfoot, as at other sites, allografts may be used for the filling of major bone defects; however, the patient function will still be massively impaired. Therefore, the procedure should be confined to cases where less complex and less invasive techniques are unlikely to be of benefit.

Fusion following failed total ankle replacement

Although mid- to long-term results after total ankle replacement have improved because of available second- and third-generation devices, failure of total ankle replacement is still more common compared with total hip replacement and total knee replacement. The portfolio of available total ankle replacement revision component options is small. Furthermore, the bone stock of the tibiotalar region is scarce making it difficult and in some situations impossible to perform revision total ankle replacement. In these cases tibiotalar and tibiotalocalcaneal fusions are valuable options. This article describes which surgical procedures should be performed depending on the initial situation and gives detailed advice on surgical technique, postoperative care, and clinical results.

Revision of failed ankle implants

Total ankle joint replacement (TAR) has been offered as an alternative to ankle joint arthrodesis since the 1970s. TAR offers the benefit of perseveration of joint motion, with potential decreased occurrence of adjacent joint degeneration, and a more expedient path to weight bearing. Since their introduction, TAR devices have undergone a variety of modifications, specifically in regards to the number and type of components used.

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.

Can porous tantalum be used to achieve ankle and subtalar arthrodesis?: a pilot study

A structural graft often is needed to fill gaps during reconstructive procedures of the ankle and hindfoot. Autograft, the current gold standard, is limited in availability and configuration and is associated with donor-site morbidity in as much as 48%, whereas the alternative allograft carries risks of disease transmission and collapse. Trabecular metal (tantalum), with a healing rate similar to that of autograft, high stability, and no donor-site morbidity, has been used in surgery of the hip, knee, and spine. However, its use has not been documented in foot and ankle surgery. We retrospectively reviewed nine patients with complex foot and ankle arthrodeses using a tantalum spacer. Minimum followup was 1.9 years (average, 2 years; range, 1.9-2.4 years). Bone ingrowth into the tantalum was analyzed with micro-CT in three of the nine patients. All arthrodeses were fused clinically and radiographically at the 1- and 2 year followups and no complications occurred. The American Orthopaedic Foot and Ankle Society score increased from 32 to 74. The micro-CT showed bony trabeculae growing onto the tantalum. Our data suggest tantalum may be used as a structural graft option for ankle and subtalar arthrodesis. All nine of our patients achieved fusion and had no complications. Using tantalum obviated the need for harvesting of the iliac spine.

LEVEL OF EVIDENCE

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