Residual pain due to soft-tissue impingement after uncomplicated total ankle replacement

Younger age correlates with increased gutter impingement rates after total ankle arthroplasty

BACKGROUND

While total ankle arthroplasty (TAA) has evolved over the years with improved designs and enhanced bony fixation methods, it remains a technically demanding procedure with a risk of early postoperative complications. One of the most common complications associated with TAA is medial and lateral gutter ankle impingement, which can lead to issues such as increased pain and decreased range of motion (ROM). However, there is a paucity of information in the literature discussing the impact of certain risk factors on gutter impingement complications.

METHODS

A retrospective analysis was conducted on a cohort of patients who underwent a TAA at a single institution from 2003 to 2019 with a minimum of 2-year follow-up. Patient were identified as having gutter impingement based on diagnostic imaging and/or clinical examination. Data collection included demographics, implant type, follow-up time, and co-morbidities. Multivariate odds ratios (OR) of experiencing gutter impingement were calculated for perioperative variables.

RESULTS

The study included a total of 908 patients who underwent TAA with a minimum of 2 year follow up and 121 patients (13.3 %) who subsequently experienced gutter impingement. The average follow-up time was 5.84 + /- 3.07 years. There were 178 patients under 55 years old, 495 patients aged 55 to 70, and 235 patients over 70 years old. A higher rate of gutter impingement was observed in patients under 55 years of age compared to those aged 55 to 70 and over 70 (20.8 % vs. 13.5 % vs. 7.2 %; p < 0.01). Multivariable logistic regression revealed that patient age was significantly correlated with gutter impingement following TAA, with an OR of 0.94 (CI: 0.91-0.98; p < 0.01).

CONCLUSION

This study demonstrated increased incidence of gutter impingement in younger patients who underwent TAA. Propensity for scar tissue formation may be higher in this population. Scar tissue deposition following TAA can cause narrowing of the medial and lateral clear spaces, potentially leading to gutter impingement. Additionally, younger patients may have increased activity demands, which subsequently may cause higher rates of symptomatic impingement. As increased impingement after TAA may require the need for additional debridement surgeries, it is important to understand the intricate relationship between age and gutter impingement for managing patient expectations following TAA.

LEVEL OF EVIDENCE

Level III.

Postoperative Medial Malleolar Fractures in Total Ankle Replacement Are Associated With Decreased Medial Malleolar Width and Varus Malalignment: A Case-Control Study

BACKGROUND

There are limited data regarding risk factors associated with periprosthetic medial malleolar fractures in total ankle arthroplasty (TAA). This case-control study aimed to identify the risk factors and analyze the effect of prophylactic screw fixation in preventing a medial malleolar fracture after TAA.

METHODS

A case-control study was conducted on 149 patients who underwent primary TAA. Twenty patients with postoperative medial malleolar fractures >4 weeks postoperatively (cases) were identified. An additional 129 patients (controls) were randomly selected from the TAA database. Radiographic evaluation included tibial component coronal alignment and postoperative medial malleolar width. Demographics and radiographic variables were compared between cohorts. Logistic regression was used to investigate the association between medial malleolar fracture and postoperative coronal alignment, medial malleolar width, and prophylactic fixation of the medial malleolus.

RESULTS

Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.52 mm [1.6]) than in the control group (11.78 mm [1.74]) (P < .001). Mean (SD) tibial component coronal alignment was 92.17 degrees (2.77) in the fracture cohort and 90.21 degrees (1.66) in the control group (P = .002). Regression analysis identified a significant negative association between postoperative medial malleolar width and the probability of fracture (OR = 0.06, 95% CI 0.01, 0.26, P < .001). Varus malalignment of the tibial component was positively associated with the probability of fracture (OR = 1.90, 95% CI 1.27, 2.86, P = .002). Prophylactic screw fixation resulted in more than 90% reduction in the odds of a fracture (OR = 0.04, 95% CI 0.01, 0.45, P = .01). ROC curve analysis determined a medial malleolar width of 10.3 mm as a potential threshold for predicting fracture.

CONCLUSION

Decreased medial malleolar width and postoperative varus malalignment were associated with an increased risk of postoperative medial malleolar fracture. Therefore, surgeons should consider prophylactic screw fixation in patients with a medial malleolar width <10.3 mm or at risk of postoperative varus deformity.

Outcomes of Lateral Transfibular Approach for Total Ankle Replacement

Total ankle replacement through a lateral transfibular approach with trabecular metal implants was introduced in 2012 and originally was advertised as a safer approach in terms of wound healing issues. Further studies showed no significant difference comparing anterior and lateral approach for infections and would healing issues, whereas the main advantage is deformity correction, acting on coronal, sagittal, and rotational deformities and on fibular length issues. It showed a survival rate of 97.7% at 5 years follow-up.

Outcomes of Total Ankle Arthroplasty After Reoperation due to Gutter Impingement

Gutter impingement is one of the most common causes of subsequent surgery after total ankle arthroplasty (TAA). Although gutter debridement has been reported to resolve preoperative symptoms early on, persistent pain after surgery, recurrence, and poor functional outcome scores have been described in patients who have undergone reoperation for gutter debridement. The cause of gutter impingement after TAA is multifactorial, and a better understanding of its causes and optimal surgical techniques for intervention is needed.

The Role of Arthroscopy After Total Ankle Replacement

Alongside advances and trends in foot and ankle surgery, arthroscopy provides a minimally invasive option in exploring and addressing pain after total ankle replacement (TAR). It is not uncommon for patients to develop pain months or even years after TAR implantation for both fixed and mobile-bearing designs. Arthroscopic debridement of gutter pain can provide successful outcomes in the hands of the experienced arthroscopist. Surgeon preference and experience will dictate the threshold for intervention, approach, and tool selection. This article provides a brief look into the background, indications, technique, limitations, and outcomes for arthroscopy after TAR.

Early-Term Results of the Cadence Total Ankle Prosthesis: An European Noninventor Study

BACKGROUND

Although considerable literature can be found on the outcome of total ankle replacement (TAR), only a few studies have reported the results of the fixed-bearing Cadence prosthesis. This noninventor study reports a consecutive series of 60 Cadence TAR systems with a mean of 2.9 years' follow-up, focusing on clinical and radiographic outcomes and early complications. This study is the first to assess true postoperative radiographic ankle prosthesis range of motion (ROM) and to report an unanticipated serious adverse device effect.

METHODS

Sixty patients who underwent primary TAR with the Cadence prosthesis between July 2016 and July 2019 were clinically and radiographically evaluated preoperatively and at last follow-up after the procedure. Revisions, additional procedures, implant failure, and complications were reported according to the classifications of Vander Griend and Glazebrook. Radiographic outcomes included radiographic TAR ROM, bone-implant interface, and alignment parameters.

RESULTS

The survival rate of the prosthesis was 98.3%. The mean radiographic ankle ROM at the last follow-up was 24 degrees (9 degrees of dorsiflexion and 15 degrees of plantarflexion). The coronal and sagittal alignment of TAR was 90.8 degrees and 3.9 degrees, respectively. Bone-implant interface analysis revealed osteolysis in 9 ankles (15%) and radiolucent lines in 33 ankles (55%) occurring at both component interfaces. Intraoperative complications were 3 periprosthetic malleolar fractures (5%). Five talar implant fractures (implant failure of 8.3%) were observed, and 1 unexplained persistent pain that required a conversion from TAR to a tibiotalocalcaneal arthrodesis.

CONCLUSION

Clinical, radiograph ROM, implant position outcomes, and survival rate at an early-term follow-up of 2.9 years were similar to those reported in recent Cadence studies. However, this study reports 5 unanticipated talar implant fractures and a high rate of posterior radiolucent lines.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Intermediate to long-term clinical outcomes and survival analysis of the Salto Mobile Bearing total ankle prothesis

INTRODUCTION

Osteoarthritis of the ankle is a major burden to affected patients. While tibio-talar arthrodesis has been the gold-standard regarding the treatment of osteoarthritis of the ankle joint for many years, at present total ankle arthroplasty (TAA) provides appealing clinical outcomes and is continually gaining popularity. The aim of this study was to evaluate the intermediate- to long-term clinical outcome including the survival rate of Salto Mobile Bearing TAA (Tonier SA, Saint Ismier, France).

MATERIAL AND METHODS

In this retrospective study intermediate- to long-term outcomes measures [Ankle Range of Motion (ROM), American Orthopaedic Foot and Ankle Score (AOFAS score) and survival rate] of 171 consecutive TAA were analysed and compared before and after surgery. Revision was defined as secondary surgery with prothesis component removal, while reoperation was defined as a non-revisional secondary surgery involving the ankle.

RESULTS

At a mean follow-up (FU) period of 7.2 ± 2.7 years (range 2.0 to 14.1 years) there was a significant improvement in ankle ROM (total ROM improved from 25.0° ± 15.0° to 28.7° ± 11.3°, p = 0.015; plantarflexion improved from 18.4° ± 11.7° to 20.6° ± 8.2°, p = 0.044; dorsiflexion improved from 6.6° ± 5.7° to 8.1° ± 4.9°, p = 0.011). AOFAS score increased significantly by 41 ± 15 points after surgery (43.3 ± 11.1 before and 84.3 ± 12.0 after surgery, p < 0.001). Overall survival rate within the FU was 81.3% (95% CI 75.3% to 87.3%) with any secondary surgery, 89.9% (95% CI 84.1% to 93.6%) with revision and 93.6% (95% CI 89.8% to 97.3%) with reoperation as endpoint.

CONCLUSION

This study endorses the previously reported appealing intermediate- to long-term outcomes of the Salto Mobile Bearing TAA. There was a significant increase in ROM and AOFAS score as well as decent implant survival at final FU.

Posteromedial structure protection during ankle replacement: Surgical technique

Residual pain after ankle replacement may implicate lesions in posteromedial structures, including the posterior tibial pedicle and tendon. The technique described here protects these structures, by positioning a malleable plate via a medial retromalleolar counter-approach. The technique seems not to cause any specific iatrogenicity. We advocate systematic implementation of this kind of protection in ankle replacement surgery. LEVEL OF EVIDENCE: IV, retrospective study.

Long-Term Clinical Outcomes and Implant Survivorship of 151 Total Ankle Arthroplasties Using the HINTEGRA Prosthesis: A Minimum 10-Year Follow-up

BACKGROUND

Few studies have investigated long-term clinical outcomes of a mobile-bearing total ankle arthroplasty (TAA) system. This study analyzed long-term outcomes of TAA using the HINTEGRA prosthesis at a single, non-developer center.

METHODS

Primary TAAs were performed on 213 ankles in 194 patients, and 151 consecutive ankles [71%] in 136 patients with a minimum follow-up of 10 years after the primary TAA were included in this study. Clinical results were assessed using a visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale score, the Ankle Osteoarthritis Scale (AOS) pain and disability subscores, and ankle range of motion. Prosthesis survivorship, reoperations, and risk factors were also evaluated.

RESULTS

The mean follow-up was 135.5 months (range, 120.0 to 204.0 months). All clinical scores and ankle range of motion improved significantly from preoperatively to 2 years, 4 to 6 years, and ≥10 years after TAA (p < 0.001). A total of 43 ankles (28.5%) required revision procedures, with the most common reason being periprosthetic osteolysis (32 ankles [21.2%]). The overall implant survivorship was 93.5% in Kaplan-Meier survival analysis at the mean follow-up of 11.3 years after the TAA.

CONCLUSIONS

TAA using the HINTEGRA prosthesis with careful follow-up observation and appropriate adjunct procedures for the treatment of end-stage ankle arthritis produced satisfactory clinical results, which were maintained at a follow-up of ≥10 years, and resulted in 93.5% of implant survivorship.

LEVEL OF EVIDENCE

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

Mid-Term Functional and Radiological Outcomes of Total Ankle Replacement in an Asian Cohort

There are limited studies looking at longer-term outcomes of the total ankle replacement (TAR) in the Asian cohort. Asian ankles are smaller in size and are more varus compared to Western cohorts. Cultural differences also require increased ankle range of motion demands. Therefore, assessment of longer-term functional and radiological outcomes in the Asian cohort is warranted. Between 2007 and 2015, 43 consecutive patients received a 3-component, cementless, unconstrained, fully congruent TAR. Patients were followed up over a mean 8 (range 5-14 years). Preoperative and postoperative AOFAS ankle-hindfoot score (AOFAS-AHS), visual analogue score (VAS), physical and mental component scores of the SF-36 (PCS and MCS respectively) were calculated. European Foot and Ankle Score was also recorded at 8 years. Radiographs were reviewed postoperatively to assess implant position and study evidence of implant loosening and impingement. At 8 years, survivorship was 83.5%. Reasons for implant removal included infection (n = 2) and aseptic loosening (n = 5). AOFAS-AHS, VAS MCS at 8 years postoperatively were comparable to outcomes at 2 years postoperatively (p > .05). PCS at 8 years demonstrated improvement compared to 2 years postoperatively (49 ± 7 vs 42 ± 11, p = .048). Radiographic impingement was noted in 9 cases (20.9%). Radiological loosening was noted in 8 cases with 5 cases requiring revision surgery. At 8 years postoperatively, clinical outcomes, radiological outcomes and survivorship following TAR in an Asian cohort are satisfactory and comparable to that found in existing literature. Long-term studies are required to ascertain survivorship of TAR. Implant design with the Asian cohort in mind may yield improved outcomes.

Outcomes and Complications of the INFINITY Total Ankle: A Systematic Review

IV.

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 Salto total ankle arthroplasty - Clinical and radiological outcomes at five years

BACKGROUND

Modern designs of total ankle arthroplasty (TAA) have the potential to treat symptomatic ankle OA without adversely affecting ankle biomechanics. We present the mid-term results of a modern, mobile-bearing TAA design.

METHODS

TAA was performed in 50 consecutive patients (55 ankles) in an independent, prospective, single-centre series. Implant survival, patient-reported outcome measures (PROMs) and radiographic outcomes are presented at a mean of five years (range 2-10.5years).

RESULTS

A total of three patients (four ankles) died and two (two ankles) were lost to follow-up. Three TAAs were revised for aseptic loosening (in two cases) or infection. Two further patients underwent reoperations, one for arthroscopic debridement of anterolateral synovitis and one for grafting of an asymptomatic tibial cyst. With all-cause revision as an endpoint, implant survival was 93.3% at five to ten years (95% CI 80.5%-97.8%). If reoperations are included this falls to 90.2% (95% CI 75.6%-96.3%) at five years. No other patient demonstrated radiographic evidence of loosening or subsidence. PROMs and satisfaction were excellent at latest follow-up.

CONCLUSION

At five years, the outcomes for this design of TAA in this series were excellent, and were similar to those of previously published series from the designer centre.

Total ankle arthroplasty: what are the risks?: a guide to surgical consent and a review of the literature

AIMS

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

PATIENTS AND METHODS

A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants.

RESULTS

There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature.

CONCLUSION

Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent. Cite this article: Bone Joint J 2018;100-B:1352-8.

Results at a minimum follow-up of 5 years of a ligaments-compatible total ankle replacement design

BACKGROUND

A new design of 3-part ankle replacement was developed to achieve compatibility with the natural ligaments by allowing certain fibers to remain isometric during passive motion.

METHODS

We evaluate 75 ankle prostheses implanted from July 2003 to December 2008, at a mean follow-up 6.5±1.1years (range 5-9 years). The mean age at surgery was 62±13years (range 29-82).

RESULTS

The mean AOFAS scores achieved at pre-op and at last follow-up were respectively 37±5 (23-45) and 78±8 (64-98). (p<0.001). Clinical range of motion of the ankle measured by goniometer pre op was 1°±2 of dorsiflexion and 12°±4° of plantarflexion; at last follow-up range of motion increased to 6°±5° in dorsiflexion (p<0.01) and 18°±7° in plantarflexion (p<0.05). Radiographs showed no loosening and little signs of radiolucency. Two revisions necessitated component removal, neither for implant loosening. The overall survival rate was 97.3%.

CONCLUSIONS

Function and Range-of-motion showed significant improvements. These results demonstrate that ligaments-compatible shaped talar and tibial components, with a fully conforming interposed meniscal bearing, can provide satisfactory survival rates and clinical outcomes in the middle term.

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.

The painful total ankle arthroplasty: a diagnostic and treatment algorithm

The last decade has seen a considerable increase in the use of in total ankle arthroplasty (TAA) to treat patients with end-stage arthritis of the knee. However, the longevity of the implants is still far from that of total knee and hip arthroplasties. The aim of this review is to outline a diagnostic and treatment algorithm for the painful TAA to be used when considering revision surgery. Cite this article: Bone Joint J 2017;99-B:5-11.

Etiology and Treatment of Delayed-Onset Medial Malleolar Pain Following Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) has become a successful treatment for end-stage ankle arthritis. Some patients may still have pain or may present with new pain. Suggested sources of medial pain include tibialis posterior tendonitis, impingement, or medial malleolar stress fracture. Etiology and treatment remain unclear. The objective of our study was to evaluate patients with delayed-onset medial malleolar pain following TAA who underwent treatment with percutaneous medial malleolar screw placement and propose an etiology.

MATERIALS AND METHODS

Patients who had undergone TAA at our institution were reviewed and those with medial malleolar pain were identified. Clinical and radiographic examinations were performed pre- and postoperatively. Radiographs were compared with those from a cohort of controls without a history of medial pain. All affected patients failed conservative therapy and were treated with percutaneous placement of medial malleolar screws positioned from the malleolar tip and extending proximally beyond the tibial component. Postoperatively, patients were placed in an ace wrap and allowed to be weightbearing to tolerance, except for 1 patient initially restricted to partial weightbearing. Visual analog scale (VAS) scores were recorded. Seventy-four (74) patients underwent TAA by the corresponding author. All (100%) were female with an average age of 66 (range, 57-73) years. Average follow-up since screw placement was 21.4 (range, 10-41) months.

RESULTS

Six (8.1%) underwent placement of 2 percutaneous medial malleolar screws. Patients presented with pain an average of 12 (range, 4-24) months postoperatively and underwent screw placement an average of 2.8 (range, 1-6) months after presentation. At the time of TAA, none had a coronal plane deformity and none underwent a deltoid ligament release as part of balancing. All (100%) patients had pain and swelling directly over the medial malleolus prior to screw placement. Postoperatively, 1 (17%) had mild pain clinically at this site and 2 (33%) had occasional pain medially with activity. Average VAS scores improved from 5.7 (range, 4-6) preoperatively to 1.3 (range, 0-3) postoperatively (P < .05). Three (50%) patients had a bone density test and all were normal. Prior to screw placement, radiographs demonstrated no signs of stress fracture or misalignment. Average minimum width of the medial malleolus at the level of the tibial component was 10.2 mm (range, 9.2-11.0), which was significantly less (P < .05) than the control group of 19 patients whose distance measured 12.2 mm (range, 8.5-14.8).

DISCUSSION

Patients who present with new-onset medial malleolar pain with normal radiographs following TAA may have medial malleolar insufficiency fracture. These patients can be treated successfully with minimal morbidity by placement of percutaneous medial malleolar screws. Etiology may be related to deltoid traction, subacute stress fracture, and/or impingement of the talus component on the medial malleolus. Medial malleolar pain may be misdiagnosed as tibialis posterior tendonitis, impingement, or implant failure. This diagnosis should be considered in patients who have pain at the medial malleolus, particularly if they are female or have medial malleolus thickness less than 11 mm at the level of the tibial implant. Placement of prophylactic medial malleolar screws may be considered at the time of TAA when these conditions exist.

LEVEL OF EVIDENCE

Level IV, case series.

Gutter Impingement in Total Ankle Arthroplasty

Gutter pain and impingement are recognized entities following total ankle arthroplasty (TAA). However, little concrete information is available in the existing literature regarding the etiology, potentiating factors, treatment and prevention of gutter disease. This comprehensive monograph discusses this problem in expansive detail and provides insight to surgeons who perform TAA, such that these complications can be minimized in the future.

LEVELS OF EVIDENCE

Level V: Expert opinion.

Arthroscopic Debridement After Total Ankle Arthroplasty

BACKGROUND

Residual pain due to impingement after ankle arthroplasty can be addressed with arthroscopic debridement. Literature focusing on the effectiveness of arthroscopic debridement after total ankle arthroplasty (TAA) is scarce. The authors report a case series of 12 patients complaining of anterior or posterior impingement pain, 11 of which were in the absence of malalignment which were treated by arthroscopy.

METHODS

Of the 106 TAAs performed between 2003 and 2012, a total of 12 subjects reported postoperative pain resulting from anterior or anteromedial impingement, medial and/or lateral gutter impingement, posterior impingement, and/or ankylosis. All patients were reviewed on a regular basis through chart review, clinical examination, and radiologic evaluation. The average time to final follow-up was 58.8 months. The average period from the original TAA to the arthroscopic debridement was 38.2 months.

RESULTS

The median AOFAS hindfoot score was significantly (P < .05) improved from 64.6 preoperatively to 73.5 postoperatively. Eight subjects reported good pain relief after the arthroscopic debridement, and partial pain relief was reported by 4 subjects. Three patients with painful ankylosis had no improvement in the total range of motion of the TAA implant after the arthroscopic debridement.

CONCLUSION

The results suggest that arthroscopic debridement in patients with residual pain due to impingement syndromes after TAA was effective in 8 of the 12 cases at 2 years' follow-up. However, the results suggest that arthroscopic debridement in the presence of painful ankylosis associated with or without impingement syndromes results only in partial pain relief and does not improve the range of motion.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Comparison of the outcomes between two 3-component total ankle implants

BACKGROUND

Total ankle arthroplasty (TAA) with the use of third generation implants has demonstrated favorable clinical results and improved survival. However, few studies have compared the different types of implants. The purpose of this study was to perform a retrospective evaluation of patient outcomes and complications by comparing TAA procedures performed with HINTEGRA versus MOBILITY systems.

METHODS

Fifty-two consecutively enrolled patients (28 men and 24 women; mean age 64.8 years) underwent TAA using HINTEGRA (21 ankles) or MOBILITY (33 ankles) between September 2004 and July 2012. Visual analog scale (VAS) pain scores and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores were determined at each follow-up visit. The radiographs were reviewed to assess component positioning, radiolucency, heterotopic ossification, and other factors. The mean follow-up period was 28.3 months in the HINTEGRA group and 32.5 months in the MOBILITY group.

RESULTS

VAS decreased from 8.3 to 2.0 for the HINTEGRA group and from 7.9 to 2.7 for the MOBILITY group. The AOFAS score increased from 43.8 to 87.3 for the HINTEGRA group and from 46.6 to 83.7 for the MOBILITY group. Intra- and postoperative malleolar fractures were not noted in the HINTEGRA group, whereas 5 ankles (15.2%) in the MOBILITY group sustained this injury (P = .144). Ankle impingement syndrome was noted in 8 ankles (38.1%) in the HINTEGRA group and 3 (9.1%) in the MOBILITY group (P = .015). However, no significant differences in postoperative osteolysis and neuralgia were noted between the groups.

CONCLUSIONS

Both implants exhibited favorable clinical outcome without significant differences. However, in terms of complications, ankle impingement syndrome was significantly more common in the HINTEGRA group, while intraoperative malleolar fracture was observed only in the MOBILITY group.

LEVEL OF EVIDENCE

Level III, comparative series.

AKILE™ total ankle arthroplasty: Clinical and CT scan analysis of periprosthetic cysts

INTRODUCTION

Despite good clinical results following total ankle replacement (TAR), the development of large periprosthetic cysts (>400 mm(2)) in the medium-term is a source of concern.

OBJECTIVE

The primary objective of this study was to detect any large periprosthetic cysts in a cohort of AKILE™ patients using radiographs and CT scans, and then to compare these findings to published ones.

MATERIAL AND METHODS

A total of 127 TAR procedures were performed between June 1995 and January 2012. We retrospectively reviewed 68 cases with the newest AKILE™ implant design that had a minimum follow-up of 36 months. The average follow-up was 81 ± 33 months; eight patients were lost to follow-up. The outcomes consisted of analyzing radiographs (A/P and lateral weight bearing views, Meary view and lateral views of flexion/extension) and helical CT scans, performing clinical evaluations (range of motion, AOFAS score, Foot Function Index, pain levels) and determining the survivorship of TAR implants.

RESULTS

TAR survival at 5 years was 79% for in situ implants and 62% for revision-free implants. The AOFAS score improved from 33.7 ± 14.7 to 77.1 ± 15.1 (out of 100) and the pain sub-score was 30.2 ± 9.7 (out of 40) at the last follow-up. The average ankle range of motion was 32.3° ± 12.7° on the radiographs. CT scan revealed Type A cysts (<200 mm(2)) under the talar implant in 52% of cases and in the tibia in 50% of cases; these cysts were smaller than 100 mm(2) in 80% of cases and had no effect on the implants. No periprosthetic cysts larger than 400 mm(2) in size were identified.

DISCUSSION

The medium-term functional results and survivorship are comparable to those reported for other TAR designs. The incidence of cysts was low overall and there were no large-diameter cysts, which should improve long-term survival. The implant's design and materials likely played a role in preserving the periprosthetic bone stock. The AKILE™ TAR has distinctive features related to the low rate of large periprosthetic cysts in the medium-term.

LEVEL OF EVIDENCE

IV (retrospective case series).

Skin, fascias, and scars: symptoms and systemic connections

Every element or cell in the human body produces substances that communicate and respond in an autocrine or paracrine mode, consequently affecting organs and structures that are seemingly far from each other. The same also applies to the skin. In fact, when the integrity of the skin has been altered, or when its healing process is disturbed, it becomes a source of symptoms that are not merely cutaneous. The skin is an organ, and similar to any other structure, it has different functions in addition to connections with the central and peripheral nervous system. This article examines pathological responses produced by scars, analyzing definitions and differences. At the same time, it considers the subcutaneous fascias, as this connective structure is altered when there is a discontinuous cutaneous surface. The consequence is an ample symptomatology, which is not limited to the body area where the scar is located, such as a postural or trigeminal disorder.

The outcome of the Mobility total ankle replacement at a mean of four years

We performed a retrospective review of a consecutive series of 178 Mobility total ankle replacements (TARs) performed by three surgeons between January 2004 and June 2009, and analysed radiological parameters and clinical outcomes in a subgroup of 129 patients. The mean follow-up was 4 years (2 to 6.3). A total of ten revision procedures (5.6%) were undertaken. The mean Ankle Osteoarthritis Scale (AOS) pain score was 17 (0 to 88) and 86% of patients were clinically improved at follow-up. However, 18 patients (18 TARs, 14%) had a poor outcome with an AOS pain score of > 30. A worse outcome was associated with a pre-operative diagnosis of post-traumatic degenerative arthritis. However, no pre- or post-operative radiological parameters were significantly associated with a poor outcome. Of the patients with persistent pain, eight had predominantly medial-sided pain. Thirty TARs (29%) had a radiolucency in at least one zone.

The outcome of the Mobility TAR at a mean of four years is satisfactory in > 85% of patients. However, there is a significant incidence of persistent pain, particularly on the medial side, for which we were unable to establish a cause.

Cite this article: Bone Joint J 2013;95-B:1366–71.