Conversion of Ankle Arthrodesis to Total Ankle Arthoplasty How I - PowerPoint PPT Presentation

Conversion of Ankle Arthrodesis to Total Ankle Arthoplasty How I do it and the results? Michael J. Coughlin, M.D. Boise, Idaho

Conflicts • None for this talk • Consultant with Arthrex, Stryker, Integra • Royalties from Arthrex, Stryker, Integra, Erchonia • Textbook royalties- Elsevier

Outline • Case Examples • Review Literature

Case example • 60 yo F posttraumatic arthritis of the ankle after a fall from a ladder in 1997. Presents with a painful nonunion of the tibiotalar joint arthrodesis. Arthroscopic ankle fusion (s/p removal of hardware) • With severe subtalar and talonavicular arthrosis. • PMH: DM

CT scan

Options? • 1. Tibiotalocalcaneal arthrodesis with talonavicular arthrodesis, +/- calcaneocuboid arthrodesis • 2. Triple arthrodesis and conversion of tibiotalar nonunion to total ankle arthroplasty • 3. Nonoperative options (brace)

Indications for take down TAR • Painful nonunion or malunion of a tibiotalar arthrodesis • Subtalar arthritis following tibiotalar fusion

Contraindications • Infection • Absence of distal fibula • Metal allergy • Concern for soft tissues • Ligamentous injury

Let’s look at the literature!

C.O.-2004 • N=19 Agility ankles, avg follow up 39 months • 15 reoperations, 3 BKAs (16%) • Mean ROM 26 degrees • AOFAS score 42 to 68 (D+) • Patients with a clear diagnosis did best postop • Ankles without a lateral malleolus did poorly

This bridge has been burned! Not sufficient anatomy- absent fibula!

Absent medial and lateral malleolus ! Don’t make things more complicated.

JBJS-2009 • N=30 Hintegra ankles, follow up avg 56 mos • Average ROM 24 degrees • AOFAS score 34 to 71 (C-) • 77% satisfied • 5 intraop fractures, 1 conversion to TTC nail, 1 talar component revision (subsidence) osteopenia • Felt mobile bearing was more forgiving than fixed bearing devices • Be prepared to treat ligamentous instability Deltoid ligament attenuation or rupture –

JBJS-2015 • N=23 ankles, avg follow up 33 mos • VAS score 65.7 to 18.3 • SF-36 score 37.7 to 19.3 • Mean ROM 23 degrees • 20% of tibial components and 70% talar components subsided • 87% implant survival, 1 required TTC nail • 3 talar implants (13%) required revision • Suggest prophylactic malleolar screw fixation

Talar subsidence -this is a problem- Very difficult salvage!

You might watch this! It may sink more!

Initial x-ray look good!

Talar subsidence!

A difficult salvage! TTC rod and allograft

• N=5, avg 21 mo follow-up Charlotte group • 4/5 satisfied • Postop VAS 31.3 • Postop AOFAS 82.6 • Avg ROM 35 degrees • No significant complications

Staged revision surgery • Underwent triple arthrodesis with staged STAR total ankle arthroplasty

• Tibiotalar nonunion takedown and conversion to STAR total ankle arthroplasty • Revision subtalar and talonavicular fusion due to delayed union

• 8 years out from surgery • Pain 0-1/10 • ROM 35 degrees • Climbed Diamond Head on Waikiki and hiked Machu Picchu postop By Martin St-Amant (S23678) - Own work , CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=8450312 By Cristo Vlahos - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=23207465

• Patients must be aware of risk-the downside • Selected patients • Who desire motion • Minimal osteopenia • Intact malleoli

Lateral fusion with absent fibula- Don’t think about it!

Severe ankle DJD, varus and translation (prior ST fusion)

This has the anatomy, and you can consider a takedown But you are trading a solid fusion for a somewhat unknown future!

8/12/2013

Bibliography • Greisberg J, Assal M, Flueckiger G, Hansen ST. Takedown of ankle fusion and conversion to total ankle replacement. Clin Orthop Rel Res 2004;424:80-8 • Hintermann B, Barg A, Knupp M, Valderrabano V. Conversion of painful ankle arthrodesis to total ankle arthroplasty. J Bone Joint Surg Am 2009;91:850-8 • Pellegrini MJ, Schiff AP, Adams SB, Queen RM, DeOrio JK, Nunley JA, Easley ME. Conversion of tibiotalar arthrodesis to total ankle arthroplasty. J Bone Joint Surg Am 2015;97:2004-13 • Huntington WP, Davis WH, Anderson R. Total ankle arthroplasty for the treatment of symptomatic nonunion following tibiotalar fusion. Foot Ankle Spec 2016;xx:1-8