Ankle Arthroplasty

 

OATARTAR

 

Design

 

Cemented TARAnkle OA Arthroplasty APAnkle Arthroplasty post ORIF lateral

 

Historical - poor outcomes with cemented implants

 

3rd generation implants

- minimal bony resection with uncemented implants

- talus resurfacing with smooth surface

- +/- stems or pegs

- highly crosslinked polyethelene implant - mobile bearing versus fixed bearing

 

Stryker InfinityStyker STARInbone

Infinity implant                                                                 STAR implant                                  Inbone

 

Depuy AgilitySalto TalarisTrabecular Metal

Agility                                                                                  Salto Tolaris                               Trabecular metal

 

Results

 

10 year revision rate

 

Australian Joint Registry 2023 Supplementary Report

- 4000 primary TAR

- mean age 65

- 10 year revision rate 15%

 

3rd and 4th generation implants

 

Australian Joint Registry 2023 Supplementary Report

- improving outcomes with implants over last 5 years

- prior to 2015: 5 year revision rate: 11%

- since 2015: 5 year revision rate: 6%

 

Revision rate by prosthesis Australian Joint Registry 2023 Supplementary Report

Prosthesis Number implanted 1 year 3 year 5 year 7 year 10 year 14 year
STAR 49 4 13 15 22    
Hintermann 538 4 9 12 16 20  
Mobility 568 2 7 10 11 15 17
Salto 421 2 6 9 12 15  
Salto Tolaris 526 1 4 5 5    
Infinity 744 1 3        
Trabecular Metal 339 1 2        

 

Contraindications

 

Absolute Relative

Infection

Charcot

Poor soft tissue envelope

Severe malalignment or instability

Talus AVN > 1/3

Malalignment

Poor bone stock

Obesity

Diabetes

Smoking

 

CT

 

Evaluate bone stock to determine if TAR is appropriate

 

TAR CTTAR CTTAR CT

 

CTCTCT



Technique

 

A. Anterior approach

 

TARTAR

 

Smith & Nephew Salto Tolaris Technique PDF

 

Vumedi total ankle arthroplasty via anterior approach

 

Vumedi total ankle arthroplasty with patient specific jigs

 

Protect SPN and divide extensor retinaculum

- between Tibialis anterior and EHL

- retract neurovascular bundle laterally

- remove anterior osteophytes

 

Tibial cut

- distal alignment jig / extramedullar jig +/- image intensifier +/- patient specific jigs

- resect few mm above eroded bone

- preserve medial and lateral malleolus

 

Talar dome resurfacing

- jig to make chamfer cuts

 

Insert mobile / fixed bearing

 

B. Lateral approach and fibular osteotomy

 

TAATAA

 

Zimmer Biomet Trabecular Metal PDF

 

Vumedi fibula osteotomy approach for total ankle arthroplasty

 

Complications

 

Australian Joint Registry 2023 Supplementary Report

- 4000 primary TAR

- mean age 65

 

Indication for revision Percentage
Loosening 30%
Infection 13%
Lysis 10%
Instability 9%
Implant breakage 9%
Pain 6%
Impingement 5%
Fracture 5%

 

Medial malleolar intra-operative / postoperative fracture

 

Loose TAR APTAR Loose

 

Gutter impingement

 

Schuberth et al Foot Ankle Int 2013

- incidence of 7% symptomatic gutter impingement

- reduced to 2% if patients underwent prophylactic gutter clearance at time of TAR

- subsequent gutter debridement successful in 80% of patients

 

Loosening

 

Options

 

Athrodesis

Revision TAR

 

Infection

 

Acute postoperative

 

Lachman et al Foot Ankle Int 2018

- 14 acute hematogenous infected TAR

- treated with DAIR and poly exchange

- long term failure rate 54%

 

Chronic

 

Conti et al Foot Ankle Int 2022

- 11 patients with chronic TAR infection

- treated with 2 stage revision

- 90% survival at 3 years

 

TAR infectTAR infect

 

TAR infectTAR infect2 stageTAR

2 stage revision chronic infection

 

Arthrodesis

 

TAR looseTAR looseFusionTAR loose

 

Revision

 

Revision TAR APRevision TAR Lateral

 

Results

 

Gross et al Foot Ankle Spec 2015

- systematic review of arthrodesis for failed TAR

- 80% union rate

 

Conversion arthrodesis to arthroplasty

 

Chu et al J Foot Ankle Surg 2021

- systematic review of conversion arthrodesis to arthroplasty

- 6 studies and 172 ankles

- salvage pantalar fusion 2.3%

- amputation 2.3%