Long-term follow-up of mobile-bearing total ankle replacement in patients with inflammatory joint disease

Long-term Outcomes After Total Ankle Arthroplasty: A Systematic Review

Background

Total ankle arthroplasty has emerged as a treatment to successfully treat ankle arthritis. Recent studies have reported more than 40 000 total ankle arthroplasties (TAAs) being performed between 2009 and 2019 in the United States. Although recent studies have reported favorable patient-reported outcomes at short- and midterm follow-up, there is a paucity of aggregate literature reporting on long-term patient-reported outcomes (PROs) after TAA. The purpose of this review is to report an aggregate of literature on minimum 10-year patient-reported outcomes after TAA.

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) were queried in June 2024. Primary research articles were included if they reported minimum 10-year PROs or satisfaction for patients who underwent primary TAA and were written in English. Survivorship was reported based on implant failure, which was determined uniquely by each study.

Results

Eight studies met the inclusion criteria. A total of 595 ankles with a range of average ages from 51 to 73.7 years were included in the study with follow-up ranging from a minimum of 10 years to a minimum of 20 years. Six of the 8 studies reported average follow-up ranging from 11.9 to 15.8 years. Two of the 8 studies reported significant improvement in PROs following surgery. Survivorship at a minimum of 10-year follow-up ranged from 66% to 94.4%. Average time to implant failure ranged from 4.6 to 13.8 years.

Conclusion

Patients undergoing primary TAA were reported to have generally improved PROs at minimum 10- year follow-up. However, they demonstrated variable rates of survivorship ranging from 66% to 94.4%. Of those experiencing implant failure, average time to failure ranged from 4.6 to 13.8 years. Survivorship should be interpreted with caution because of varying definitions between studies. Further studies should seek to standardize the definition of survivorship and reporting of PROs to allow for effective analysis of heterogeneity.

Outcomes after total ankle arthroplasty with an average follow-up of 10 years: A systematic review and meta-analysis

BACKGROUND

The literature demonstrating positive outcomes after total ankle arthroplasty (TAA) is mounting. However, the long-term outcomes of TAA (≥ 10 years) remain minimally reported. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics over multiple TAA studies with greater than 10 years of average follow-up.

METHODS

TAA studies were searched in Medline, Embase, and Scopus from the date of inception to September 12, 2022. Inclusion criteria included 1) studies of patients that underwent uncemented TAA, and 2) studies with an average follow-up time of at least ten years. Manuscripts in non-English languages and isolated abstracts were excluded. We collected American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) scores from the included studies for pooled meta-analysis. Due to the varying definition of survivability between studies, this metric was not assessed in our final evaluation.

RESULTS

Our data included approximately 3651 patients (3782 ankles). Of the 25 studies with an average follow-up of 10 years included in the systematic review, 5 provided pre- and post-operative AOFAS means and 5 provided pre- and post-operative VAS means with associated measures of variability and were included in our meta-analysis. The weighted mean difference between pre-and post-operative AOFAS and VAS scores was -40.36 (95% CI -47.24 to -33.47) and 4.52 (95% CI: 2.26-6.43), respectively. The risk of bias was low to moderate for the included studies.

CONCLUSION

Outcomes following TAA are favorable and indicate patient-reported outcome improvement over long-term follow-up. However, a significant amount of heterogeneity exists between studies. Future, prospective, randomized research should focus on standardizing outcome measures, survivorship, and complication reporting methodologies to allow for pooled meta-analyses of these important outcome metrics.

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.

Outcome Reporting in Total Ankle Arthroplasty: A Systematic Review

Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.

Long-term follow-up of Bologna-Oxford (BOX) total ankle arthroplasty

PURPOSE

The purpose of this retrospective study was to evaluate the long-term results with a minimum of ten years follow-up of primary Bologna-Oxford (BOX) TAA.

METHODS

Between December 2004 and December 2009, 80 patients (82 ankles) underwent a primary BOX TAA performed by a single senior surgeon, expert in foot and ankle surgery. Pain and functional outcomes were analysed using Visual Analogue Scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) scoring system, Foot Functional Index Disability and Pain (FFI-Disability, FFI-Pain) score for comparative analysis.

RESULTS

A total of 52 patients (54 implants) in a cohort of 80 (82 implants) were examined at a minimum ten years follow-up. Twenty implants out of 54 underwent implant failure (37 %) and 34 patients were enrolled in the present study. The mean VAS for pain decreased significantly from 8.5 ± 1.2 to 2.9 ± 2.2 (p<0.01) and the mean AFOAS score changed from 28.6 ± 11.8 pre-operatively to 72.7 ± 16.9 (p<0.01) at last follow-up. Ninety-seven percent was satisfied with a mean FFI-Disability score that improved from 77.6 ± 19.3 to 26.7 ± 25.4 (p<0.01) and FFI-Pain score that decreased from 76.2 ± 14.2 to 31.4 ± 25.6 (p<0.01). We calculated post-operative alignment using alpha, beta and gamma angles with no difference at long-term follow-up. The survival rate of the implant was 66% at ten years of follow-up.

CONCLUSIONS

Our data suggest that BOX TAA is an implant with a good patient satisfaction rate at long-term follow-up; therefore, it is a valid option to increase the quality of life in subjects with end-stage osteoarthritis; however, long-term survivorship is unsatisfactory when compared to modern knee and hip implant.

Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty

Background

Ankle distraction arthroplasty has emerged as an alternative treatment for ankle arthritis. There are few reports on the magnetic resonance imaging (MRI) findings after distraction arthroplasty. This study sought to determine whether there are positive changes on MRI after ankle distraction and improvements on X-ray. Additionally, patient-reported outcomes and joint range of motion (ROM) after ankle distraction are described.

Materials and methods

Thirty-two patients (mean age 49 years) who underwent ankle distraction had pre-operative and one-year postoperative MRIs, which were graded using a modified whole-organ magnetic resonance imaging score (WORMS). Ankle joint space and ROM were measured. A non-validated three-item questionnaire was administered to assess functional outcomes.

Results

Although the anterior quadrant of the ankle showed a trend to improvement in cartilage morphology on the postoperative MRI, the WORMS did not demonstrate a significant difference in any of its subcategories. While reduction in joint osteophytes was observed and maintained short term, this was mainly due to resection intraoperatively. X-rays revealed a significant increase in joint space, and there was a significant increase in ankle dorsiflexion. Eight-seven percent of the patients were satisfied with their functional outcome.

Conclusion

At short-term follow-up, MRI scores after ankle distraction arthroplasty did not demonstrate significant improvement despite positive changes on X-ray and improved clinical outcomes and ankle ROM. Further study on larger patient numbers with longer follow-up is required.

Level of evidence

IV, Case Series

How to cite this article

Haleem AM, Galal S, Nwawka OK, et al. Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty. Strategies Trauma Limb Reconstr 2020;15(3):157–162.

Long-term Follow-up Results of Buechel-Pappas Ankle Arthroplasty

BACKGROUND

Total ankle replacement (TAR) is gaining popularity as a treatment option for ankle osteoarthritis. Long-term implant survival is a critical outcome to determine the success of the TAR implant. The Buechel-Pappas (BP) implant is a second-generation mobile bearing implant. The aim of this study was to analyze the BP implant survivorship at 10-year follow-up, make a subanalysis between patient groups, and evaluate long-term functional outcomes.

METHODS

Data of 86 patients who received 101 BP implants between 1993 and 2010 were obtained from a prospectively documented database. Subanalyses were done for patients diagnosed with inflammatory joint disease and noninflammatory joint disease, and patients with preoperative tibiotalar neutral and nonneutral alignment. A Kaplan-Meier curve was used for survival analysis. Long-term functional outcomes were assessed with the following patient-reported outcome measures: Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), Short Form-36 (SF-36) Stand Version 2.0 Health Survey and 3 anchor questions.

RESULTS

The survival rate of the BP implant at 10 years was 86% (95% confidence interval, 78%-93%). A total of 31 patients (36%) required 55 reoperations, and in 13 patients (15%) a revision procedure was performed. In this series, no significant difference in 10-year survival rate was found between neither the inflammatory joint disease and noninflammatory joint disease group ( P = .47), nor the tibiotalar neutral and nonneutral alignment group ( P = .16). At a mean follow-up of 16.8 years for 21 patients, the mean FAOS activities of daily living (ADL) and FAAM ADL subscale scores were 75/100 and 56/100 points. The mean physical component summary (PCS) and mental component summary (MCS) of the SF-36 were 34/100 and 51/100 points, respectively.

CONCLUSION

A survival rate of 86% was found at 10-year follow-up for the Buechel-Pappas implant. Our series demonstrated no significant difference in 10-year survival rates between the 2 patient subgroups. Long-term results of the various functional outcomes varied between poor and moderate.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Outcome after 52 Salto Ankle Prostheses Implanted by a Single Surgeon

While ankle arthrodesis was traditionally the gold standard method of treatment for disabling end-stage ankle arthritis, total ankle replacement (TAR) has been an acceptable alternative. The satisfaction rate of patients with TAR however differs. The purpose of our study is to investigate whether implant survival and results with special emphasis on the satisfaction rate of patients treated with a TAR implanted by a single surgeon were comparable to the literature. This was a retrospective cohort study in a teaching hospital. Data was collected from 52 patients who received a total ankle replacement (TAR) between 05/2002 and 06/2014. The mean follow-up time was 4.2 years (95% CI 3.3 - 5.0). Results showed a high satisfaction rate of 94% and 94% survival of the TAR after 5 years. We conclude that TAR with the Salto prosthesis is, in our hands, a reliable solution for end-stage ankle arthritis, with results comparable to the literature.

The AES total ankle arthroplasty analysis of failures and survivorship at ten years

BACKGROUND

AES mobile-bearing total ankle replacement was developed from the Buechel Pappas model. It was withdrawn in 2009, after identification of a higher than expected complication rate. The purpose of the current study was to analyse clinical outcomes, failures and survival of the initial series of 50 AES published in 2009.

METHODS

In this single-centre continuous prospective study (2003-2006), 50 AES prostheses were included. Pre-operative osteoarthritis was mainly post-traumatic (50%) and secondary to instability (36%). All patients were assessed with clinical and radiographic follow-up at six months, one year, two years and every two to three years thereafter. A CT-scan was systematically performed before procedure, and at two years, five years and ten years. At last follow-up, all patients with TAR had a functional (SF 36, AOFAS) and clinical assessment. All complications or surgical events were analysed.

RESULTS

The mean follow-up was ten ± two years (range, 9-13). The mean AOFAS score was 75 points (range, 26-100). The mean SF 36 score was 69 points (range, 35-97). There was a significant deterioration in AOFAS score at five years and at last follow-up (p < 0.05). Fifteen TARs underwent reoperation for cyst curettage-graft because of development of periprosthetic lesions. Six of them ended up with prosthesis removal-arthrodesis. At the last follow-up, 14 TARs were removed for arthrodesis. Of the 30 prostheses seen at last follow-up, four are awaiting prosthesis removal-arthrodesis and one for cyst curettage-graft. The ten year survivorships free of any prosthesis removal or arthrodesis and free of any reoperation were 68% (95% CI, 55-85) and 57% (95% CI, 44-74), respectively.

CONCLUSION

Our data suggested a high rate of reoperation. Overall ten year survival was lower than with other designs, particularly due to cyst lesions.

LEVEL OF EVIDENCE

Level IV, prospective case series.

In-Patient Trends and Complications After Total Ankle Arthroplasty in the United States

The number of total ankle arthroplasties (TAAs) performed annually in the United States has increased. The purpose of this study was to evaluate the in-patient demographics, complications, and readmission rates of patients after TAA at academic medical centers in the United States. The University HealthSystems Consortium administrative database was searched for patients who underwent TAA in 2007 to 2011. A descriptive analysis of demographics was performed, followed by a similar analysis of clinical benchmarks, including hospital length of stay, hospital direct cost, in-hospital mortality, and 30-day readmission rates. The study included 2340 adult patients with a mean age of 62 years (47% men and 53% women) who underwent TAA. The majority of patients were Caucasian (2073; 88.5%). Average hospital length of stay was 2.2±1.26 days. Average total direct cost for the hospital was $16,212±7000 per case, with 49.7% of patients having private insurance. In-hospital mortality was less than 1%, and overall complications were 1.4%. Complications after discharge included deep venous thrombosis (2.3%), reoperation (0.7%), and infection (3.2%). A readmission rate of 2.7% within the first 30 days from the time of discharge occurred. Total ankle arthroplasty in the United States is a relatively safe procedure with low overall complication rates. Patients who are male, have a history of community-acquired pneumonia, and have a larger number of preoperative comorbidities had a significant increased risk of developing 1 complication within 30 days of surgery.

Total ankle replacement

BACKGROUND

About 1% of adults suffer from painful osteoarthritis of the ankle. The current literature contains no information on the percentage of such patients who derive long-term relief of symptoms from conservative treatment. Advanced ankle osteoarthritis can be treated with non-joint-preserving measures, such as total ankle replacement and ankle fusion.

METHODS

This review is based on selected relevant publications, guidelines from Germany and abroad, and the authors' personal experience.

RESULTS

Before surgery is considered, conservative measures such as physiotherapy and orthopedic aids should be used to the fullest possible extent. No randomized trials have yet been published comparing total ankle replacement with ankle fusion. Total ankle replacement with newer types of prosthesis yields good to very good intermediate-term and long-term results, with mean success rates of up to 90% at 10 years (range, 68-100%). Independent risk factors for the failure of ankle replacement are age over 70 years (odds ratio [OR] 3.84), primary osteoarthritis (OR 7.19), post-traumatic osteoarthritis (OR 6.2), and type of prosthesis (e.g., single hydroxyapatite coating: OR 15.04). The average range of motion of the replaced ankle joint is 25° to 30°, with values as high as 60°.

CONCLUSION

Total ankle replacement is a good treatment option for complete, end-stage ankle arthritis. It can restore joint function and make the patient mobile with little or no pain. There are, however, many contraindications to be taken into account. There is a need for further studies of the biomechanics of arthritic and replaced ankle joints and for long-term follow-up studies of total ankle replacement.

Total ankle replacement for posttraumatic arthritis. Similar outcome in postfracture and instability arthritis: a comparison of 90 ankles

BACKGROUND AND PURPOSE

Most studies on total ankle replacement (TAR) have used a case mix of patients. We evaluated the outcome of TAR performed for end-stage arthritis either because of fracture or ligamentous injury.

PATIENTS AND METHODS

We prospectively followed 88 consecutive patients (50 postfracture ankles and 40 ankles with instability arthritis (2 bilateral)) who underwent TAR between 2001 and 2009. Mean follow-up for both groups was 5 years.

RESULTS

Preoperative varus deformity of 10° or more was present in 23 ankles in the instability group. At 6 years, survival with revision or salvage fusion as an endpoint was 87% (95% CI: 74-99) in the postfracture group and 79% (95% CI: 63-94) in the instability group. Progressive periprosthetic osteolysis was seen in 23 ankles, and required salvage fusion in 6. The number of reoperations was similar in both groups. Clinical outcome, as assessed with 2 ankle scores and 2 questionnaires, showed good results and was similar at the latest follow-up.

INTERPRETATION

The outcome was similar in the postfracture and instability groups and also similar to that reported in series including a case mix of patients. In contrast to earlier reports, preoperative frontal plane deformity in this series was not identified as a risk factor for failure.

Incidence of revision after primary implantation of the Salto ® mobile version and Salto Talaris ™ total ankle prostheses: a systematic review

The incidence of revision of total ankle replacement prostheses remains unclear. We undertook a systematic review to identify the material relating to the incidence of revision after implantation of the Salto(®) mobile version and Salto Talaris™ total ankle prostheses. Studies were eligible for inclusion only if they had involved primary total ankle replacement with these prostheses and had included the incidence of revision. Eight studies involving 1,209 Salto(®) mobile version prostheses, with a weighted mean follow-up period of 55.2 months, and 5 studies involving 212 Salto Talaris™ total ankle prostheses, with a weighted mean follow-up period of 34.9 months, were included. Forty-eight patients with Salto(®) mobile version prostheses (4%) underwent revision, of whom 24 (70.5%) underwent ankle arthrodesis, 9 (26.5%) metallic component replacement, and 1 (3%) below-the-knee amputation. Five (2.4%) Salto Talaris™ total ankle prostheses underwent revision (3 metallic component replacement and 2 ankle arthrodeses). Restricting the data to the inventor, design team, or disclosed consultants, the incidence of revision was 5.2% for the Salto(®) mobile version and 2.6% for the Salto Talaris™ total ankle prostheses. In contrast, data that excluded these individuals had an incidence of revision of 2.8% for the Salto(®) mobile version and 2.0% for the Salto Talaris™ total ankle prostheses. We could not identify any obvious difference in the etiology responsible for the incidence of revision between these mobile- and fixed-bearing prostheses. The incidence of revision for the Salto(®) mobile version and Salto Talaris™ total ankle prostheses was lower than those reported through systematic review for the Agility™ and Scandinavian Total Ankle Replacement™ systems without obvious selection (inventor) or publication (conflict of interest) bias.