536368
research-article2014
FAIXXX10.1177/1071100714536368Foot & Ankle InternationalDeleu et al
Article
Arthrodesis After Failed Total Ankle Replacement
Foot & Ankle International® 2014, Vol. 35(6) 549–557 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714536368 fai.sagepub.com
Paul-André Deleu, MSc Pod1,2, Bernhard Devos Bevernage, MD1, Pierre Maldague, MD1, Vincent Gombault, MD1, and Thibaut Leemrijse, MD1
Abstract 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. Keywords: total ankle replacement, tibiotalar arthrodesis, tibiotalocalcaneal arthrodesis, bone grafts Although the survivorship of total ankle replacements (TARs) has improved, long-term results of TAR are not as satisfactory as those of total hip and knee replacements.10 While the longevity and the number of primary TAR continue to increase, so does the prevalence of associated complications.10,16 Gougoulias et al10 reported that the overall failure rate was approximately 10% at 5 years, which required revision arthroplasty or conversion to a tibiotalar or tibiotalocalcaneal arthrodesis. Total ankle replacements can fail because of a wide variety of causes such as infection, mechanical failure, aseptic or septic loosening, unexplained persistent pain, periarticular cysts, necrosis, soft tissue imbalance, instability, poor osseous integration, migration with or without osteolysis of the tibial or talar component, spacer failure, wound dehiscence, and mis-sizing and malpositioning of the TAR components.* The choice of the revision technique will mostly depend on the cause of failure, the bone defect, quality of the bone itself, and the experience and expertise of the surgeon.3,16 Based on reviews of the literature, arthrodesis is currently carried out more frequently compared with revision replacement for failed TAR.3,10 *References 1-6, 8, 9, 11, 13-17, 19-23, 26.
Arthrodesis can provide a more predictable outcome compared with revision arthroplasty; however, it has to face additional problems compared with a primary arthrodesis. The major difficulty is the severe bone loss due not only to resection for explantation of the prosthesis but also to wear with secondary periprosthetic osteolysis, which can potentially cause important leg length discrepancy.4,6,23 To overcome these problems, surgeons have used different types of auto- and allografts to bridge and fill the defect and to provide mechanical support.† To date, several arthrodesis techniques associated with auto- or allografts or a combination of both have been described in the literature, but there is still no ideal concept that fits for every patient. †
References 1, 2, 4-6, 8, 9, 11, 13-16, 19, 21, 23.
1
Foot & Ankle Institute, Clinique du Parc Léopold, Bruxelles, Belgium Institut D’Enseignement Supérieur Parnasse Deux-Alice, Division of Podiatry, Bruxelles, Belgium 2
Corresponding Author: Paul-André Deleu, MSc Pod, Foot & Ankle Institute, Clinique du Parc Léopold, 38, Rue Froissart, 1040 Bruxelles, Belgium. Email: [email protected]
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
550
Foot & Ankle International 35(6)
The literature on salvage procedures for failed ankle replacement is sparse. We report a series of 17 patients who had a failed TAR converted to a tibiotalar or a tibiotalocalcaneal arthrodesis and propose an algorithm to guide the treatment of these patients.
Methods Between 2003 and 2012, a total of 17 patients with a failed TAR underwent an arthrodesis by the senior surgeon (T.L.). There were 5 men and 12 women with an average age of 57.3 years (range, 41-77 years) and with an average body mass index (BMI) of 26.7 (range, 22.2-32.7). The initial diagnosis was posttraumatic osteoarthritis (OA) in 7 patients, rheumatoid arthritis (RA) in 4 patients, and idiopathic OA in 6 patients. The type of implants included 8 AES (Biomet France S.A.R.L., Valence, France) prostheses, 6 Hintegra (Newdeal SA, Lyon, France) prostheses, 1 Mobility (DePuy International, Leeds, UK) prosthesis, 1 Salto (Tornier Implants, Grenoble, France) prosthesis, and 1 STAR (Waldemar Link, Hamburg, Germany) prosthesis. The average time from TAR to arthrodesis was 49.8 months (range, 1-144 months). The comorbidities were smoking in 2 patients, high blood pressure in 5 patients, and 1 patient with osteoporosis due to 20 years of corticosteroid therapy for her RA. Pre- and postoperative radiological evaluation was done with conventional radiography in the weightbearing position (anteroposterior and lateral views). Based on postoperative conventional radiography, computed tomography (CT) scans were planned between 2 and 3 months postoperatively to seek further radiological evidence of solid fusion. Union was defined as the presence of bridging trabeculae at the level of the operated joint(s) on the axial and sagittal plane views of the CT scan.4,13,23 Conventional radiographies and CT scans were reviewed by an independent radiologist who was unaware of the clinical results and by the orthopedic surgeon. If no fusion was obtained at that time, new CT scans were performed at a 3-month interval. All patients were regularly followed through chart review, clinical examination, and radiological evaluation every month during the first year and afterward once every year. The average follow up was 29.1 months (range, 12-77 months) after the arthrodesis. All patients were followed up for a minimum of 12 months. The following variables were exported from a clinical database for the purpose of the present study: 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 individual results of the clinical and radiographic evaluation are presented in Tables 1 and 2. The average follow-up was 30.1 months (range, 12-77 months). The average period from the original arthroplasty to the arthrodesis was 49.8 months (range, 1-144 months).
Operative technique for tibiotalar arthrodesis. The ankle was exposed through an antero-medial approach between the tibialis anterior and extensor hallucis longus. Synovectomy was performed and the polyethylene component of the TAR was removed. The hardware components of the TAR were removed with care to avoid further bone loss. Afterward, the joint was debrided of fibrous tissue and necrotic bone until healthy and qualitative subchondral bone was exposed. The lateral malleolus was preserved. The ankle was positioned in neutral position with a valgus angulation of the hindfoot of 0 to 5 degrees to have a plantigrade foot. Proper alignment of the foot was temporarily maintained with 2-mm Kirschner wires, which were used for fixation with cannulated screws. The first wire was positioned from the medial part of the tibia to the talus and the second from the lateral malleolus to the talus. Fluoroscopic control was performed to avoid any damage to the subtalar joint, which must be perfectly preserved. If the alignment was correct, definitive fixation was performed with a minimum of two 4.5-mm or 7.3-mm screws. When the bone stock allowed it, an additional third screw was sometimes added to increase the stability of the arthrodesis. If the bone defect was large, an appropriate bone graft was selected and trimmed during surgery to fill the bone gap. The height was restored with the main axis being in the middle of the joint. The residual bone gaps were filled with a bone auto- or allograft or both (Table 1). When the talus and the graft were well positioned against the tibia with provisional 2-mm Kirschner wires, an anterior neutralization plate (Tibiaxys; Integra, Newdeal, Lyon, France) was applied with the distal end being in the talar neck. Fluoroscopic control was performed to avoid any damage to the subtalar joint, whose preservation was a prerequisite for a successful outcome. To increase the stability of the construct, 2 additional screws crossing each other from both malleoli were positioned to obtain a peritalar fusion through or with the help of native bone. Stability was a major issue to obtain a fusion, but screws were especially used for maintenance of the alignment, length, and rotation rather than for compression. Only a few patients required compressive screws going from the lateral or medial malleolus into the talus, to obtain fusion from native bone on both malleolar sides, while waiting for the full integration of the allograft reconstruction. Operative technique for tibiotalocalcaneal arthrodesis. In cases where the residual bone was found to be of poor quality or when the subtalar joint was noted to be degenerative, the arthrodesis was extended into the subtalar joint. In such a case, a curved centro-medullar nail was used most often. To reach the subtalar joint, an additional approach from underneath the lateral malleolus to the sinus tarsi was performed to remove the cartilage of both facets of the subtalar joint.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
551
Deleu et al Table 1. Demographic Data and Results of the Clinical and Radiographic Assessments.
Case
Sex
Age, y
Diagnosis
Implant
1 2
M F
53 49
IDIO OA RA
STAR AES
3
M
61
PT OA
4 5
F F
64 53
IDIO OA PT OA
6
F
56
RA
7 8 9 10
M F F F
77 57 37 53
IDIO OA IDIO OA RA PT OA
11
M
49
IDIO OA
12
F
65
PT OA
Hintegra
13 14
M F
61 85
RA IDIO OA
15
F
59
16
F
17
F
Reason for Failure
AL + Lux MPI AL + GR on MPI AES NE TA + Mig TA AES Inf + Lux MPI Mobility Pain
Time to Failure, mo Arthrodesis
Graft
Time to Healed Repeat Deviation, Fusion, at First Attempt Arthrodesis deg Follow-up AOFAS mo
48 144
TTC TTC
AlloS FH AlloS TA
NU 12
No Yes
No NA
5 4
48 77
65 76
51
TTC
AlloS Tib
3
Yes
NA
4
36
78
4 29
TTC TTC
NU NU
No No
Yes Yes
3 7
42 52
73 73
68
TTC
AlloS FH AlloS FH + Mo Allo FH AlloS FH
NU
No
Yes
5
48
76
68 60 72 49
TTC TTC TTC TTC
AlloS Tib + CA IC CA IC + DBM AlloS FH AlloS Tib + BM IC
3 3 3 3
Yes Yes Yes Yes
NA NA NA NA
7 4 3 4
41 12 23 14
73 76 78 78
61
TT
3
Yes
NA
7
16
75
Inf
7
TTC
3
Yes
NA
8
18
73
Hintegra Hintegra
Inf AL
1 24
TT TTC
2 3
Yes Yes
NA NA
3 5
14 15
78 77
PT OA
AES
Os + AL
102
TT
4
Yes
NA
6
14
73
41
PT OA
Hintegra
Pain
21
TT
3
Yes
NA
5
12
75
54
PT OA
Hintegra
Pain
38
TT
AlloS FH Sec + CA IC + DBM AlloS FH Sec + CA IC + DBM No AlloS FH Sec + CA IC + DBM Tricortical IC + Ca IC + Mo Allo FH AlloS FH + BM IC + DBM AlloS FH + BM IC + DBM
3
Yes
NA
5
12
70
AES
NE TA + Mig TA AES Os + Mig TA SALTO Os + Lux MPI AES Os + Inf + CF AES Os + Mig TA + CF Hintegra AL
AES, Ankle Evolutive System prosthesis (Biomet France S.A.R.L., Valence, France); AL, aseptic loosening; AlloS, structural allograft; AOFAS, American Orthopaedic Foot and Ankle Society; BM, bone marrow; CA, cancellous bone; CF, cystic fistula; DBM, demineralized bone matrix; FH, femoral head; GR, granuloma; Hintegra, Hintegra prosthesis (Newdeal SA, Lyon, France); IC, iliac crest; IDIO OA, idiopathic osteoarthritis; Inf, infection; Lux, dislocation; Mig, migration; Mo, morselized; MPI, mobile polyethylene insert; NA, not applicable; NE, necrosis; NU, nonunion; Os, osteolysis; PT OA, posttraumatic osteoarthritis; RA, rheumatoid arthritis; SALTO, Salto prosthesis (Tornier Implants, Grenoble, France); STAR, Scandinavian Total Ankle Replacement prosthesis (Waldemar Link, Hamburg, Germany);TA, talus; Tib, tibia; TT, tibiotalar arthrodesis; TTC, tibiotalocalcaneal arthrodesis.
After the joints were prepared, the ankle and the hindfoot were placed in 5 degrees of valgus, neutral dorsiflexion, and 5 degrees of external rotation. A guide wire was passed through the calcaneus and the talus into the tibia under fluoroscopic control. The medullary canal was reamed 1.5 mm larger than the planned size of the nail. A bone allograft was prepared from a femoral head and shaped according to the dimensions of the bone defect on both the tibial and talar side. It was very important to fill any residual gaps in the bone continuity with bone auto- or allograft or even both (Table 1). Afterward, fluoroscopic control was performed to ensure the position of the foot; a retrograde intramedullary nail (T2 Ankle Arthrodesis Nail; Stryker, Kiel, Germany) was used in a static fashion with 2 screws in the calcaneus, 1 screw in the talus, and 2 proximally in the tibial shaft.
Protocol for Infected TAR When infection was suspected, a 2-stage salvage procedure was performed. The first stage was composed of an extensive debridement with removal of the prosthetic components and all nonviable and infected tissues.25 Multiple tissue samples
from the joint capsule and the component-bone interface were taken and sent for further microbiological and histological analysis. Criteria for infection were based on 3 main components: (1) C-reactive protein (inflammatory parameter), (2) cultures of multiple tissue samples that were collected to seek a clinically important organism, and (3) the presence of plasmocytes as histologic criteria. The resulting bone defect after debridement was filled with an antibiotic impregnated polymethylmetacrylate cement spacer (Palacos gentamycine 40 g) to preserve length and stability. The main advantage of gentamycine was that it statistically has the widest spectrum to treat many types of bacterial infections.16,19,26 External stabilization with a custom brace or external fixator completed the provisional construct. After the histopathological and bacteriological procurement, an intravenous antibiotic regimen was started and further adjusted according to the antibiogram. If an external fixator was used, it was removed in a transitional stage to allow skin healing at the pins holes through the use of a cast. In stage 2, after 6 weeks of antibiotic therapy and once the C-reactive protein levels normalized, the final reconstruction was performed. The cement spacer was removed and a new debridement resected 1 to 2 mm more at both
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
552
Foot & Ankle International 35(6)
Table 2. Review of Previous Studies Concerning “Arthrodesis After Failed Total Ankle Replacement.”
Age, y
Time to Failure, mo
Graft, %
Time to Union, mo
Healed After First Attempt, %
Complications, %
Follow-up, mo
Study
Year
No. of Subjects
Kitaoka and Romness15 Carlsson et al4 Gabrion et al9 Anderson et al1 Zwipp and Grass26 Hopgood et al13 Kotnis et al16
1992
38
57
42
33 TT; 5 TTC
89
NR
87
13
96
1998 2004 2005 2005
21 8 16 4
59 57 55 42
40 36 62 45
20 TT; 1 TTC 6 TT; 2 TTC 16 TTC 3 TT; 1 TTC
100 25 88 100
NR 3.1 43 3.5
62 87 69 75
38 13 31 25
NR 56 34 37.5
2006 2006
23 16
62 64.7
41 33
61 100
4 8
74 94
26 6
29 12
Schill21 Culpan et al6 Moor et al19 Carlsson5 Thomason and Eyres23 Doets and Zürcher8 Henricson and Rydholm11 Berkovitz et al2 Jehan and Hill14 McCoy et al18 Our study
2007 2007 2008 2008 2008
15 16 3 3 3
56 54 NR 49 66
115 41 NR 76 72
16 TT; 7 TTC 10 TTC; 1 KA; 5 RTAR 15 TTC 16 TT 3 TTC 3 TT 3 TTC
100 100 100 100 100
3.9 3 3 / 3
87 94 100 0 100
13 6 0 100 0
23 44 32 37 32
2010
18
55
49
7 TT; 11 TTC
100
6.3
61
39
NR
2010
13
NR
84
13 TTC
100
NR
92
8
17
2011 2012 2012 2013
12; 12 4 7 17
58; 65.3 66.5 52 57.3
41.3; 63.1 20 70.9 49.8
83; 100 100 0 94
NR; NR 3.5 6.3 3.7
92; 59 100 100 76.5
Type of Fusion
12 TT; 12 TTC 4 TT 4 TT; 3 TTC 5 TT; 12 TTC
8; 41 0 0 23.5
57.9; 33.2 NR 58 29.1
KA, knee amputation; NR, not reported; RTAR, revision arthroplasty; TT, tibiotalar arthrodesis; TTC, tibiotalocalcaneal arthrodesis.
bony ends, sending them for new cultures. Residual native bone was prepared to obtain a bleeding bone to increase the chance of incorporation of the bone allograft that was implanted. The construct with or without a bone graft was mechanically stable to obtain healing. Afterward, the same protocol for noninfected TAR was followed.
Bone Graft The type of bone graft used for each patient is detailed in Table 1. Both types of allograft were prepared by the same bone bank (certified by the Belgian Health Authorities) and could be used alone or in association with a cancellous bone autograft procured at the patient’s pelvis.
Postoperative Care All patients were immobilized nonweightbearing in a below-knee cast for 2 months and then allowed to weightbear in a removal rigid orthopaedic walker boot for a further month. Thromboembolic prophylaxis was used until the patient was mobile. Patients were screened for signs of local infection; C-reactive protein level was monitored and conventional x-rays were made every month. At 3 months, a CT scan was performed.
Results Thirteen of the 17 ankles were considered radiographically healed at the first attempt after an average time of 3.7 months, whereas 3 healed after repeated attempts of fusion. Bone grafts were used in 16 patients. Massive bone allograft was used exclusively in 7 ankles and in association with a bone autograft in 9 ankles. Two-stage surgery was performed in 4 patients. The median value of the total AOFAS score was 74.5 (range, 65-78). The mean Meary angle of the hindfoot was 5 degrees of valgus (range, 3-7). Tibiotalar arthrodesis was performed with stabilization screws in 1 patient (case 11) and with contoured plates in 4 patients (cases 13, 15, 16, and 17). All patients achieved satisfactory union. Tibiotalocalcaneal arthrodesis was performed in 12 patients with an intramedullary nail. We reported 1 perioperative tibial fracture, which occurred when the nail was introduced in the tibia (case 14). However, the fragments were not displaced and a longer casting period was required. No revision surgery was needed. There were 4 nonunions (cases 1, 4, 5, and 6), 1 asymptomatic and 3 that united after a second operative attempt (Table 1). At the latest review, all patients were free of symptoms.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
553
Deleu et al
Discussion Arthrodesis is a salvage procedure after failed TAR and generally has union rates between 61% and 100%,‡ except the case series of Carlsson,5 in which none of his patients fused. The union rate of our series at the first attempt was 76.5%. The results of the present series compare favorably with other series. Successful union was achieved in 76.5% of the cases at first attempt. The mean time to fusion was 3.7 months. In our series of patients, the mean age at the time of fusion was 58 years with a TAR failure at a mean of 50 months. Two large series reported similar findings (Table 2).4,15 An algorithm for the treatment of the failed ankle replacement has been developed and implemented at our institute (Figure 1). The possibility of revision arthroplasty and the presence of infection are the main factors that will influence the allocation of the patients in one of those groups. Tibiotalar and tibiotalocalcaneal arthrodeses are reliable operative procedures and provide a definitive solution to the problem of the patient.11,22 However, the mobility of those joints is not preserved. Revision implants have been developed but are expensive since most have to be custom made and could potentially lead to a higher degree of bone loss. This could make it difficult to revise.12 Literature has shown that the effectiveness of a total ankle replacement is quite surgeon dependent.3 Revising an ankle prosthesis with another implant depends on variables such as infection, bone loss, osteoarthritis in the subtalar joint, or the presence or absence of infection (Figure 1). To achieve fusion in tibiotalar or tibiotalocalcaneal arthrodesis after failed TAR, good debridement of bony surfaces and extensive bone grafting are essential (Figures 2 and 3).4,11,14 Depending on the volume of graft needed to fill the defect, an auto- or allograft or combinations of both were selected. More than 90% of the arthrodeses performed as a salvage procedure for failed TAR used an auto- or allograft or a combination of both to fill the bone defect (Table 2).§ The mechanical resistance of the allograft was beyond the influence of the surgeon and was related to donor data and tissue bank processing. But the incorporation of the graft or the union is partially surgeon dependent since bone bed preparation during surgery is critical for union between the graft and the residual bone to occur. In our series, we used processed cancellous bone allografts from femoral head, tibia, and talus to preserve the leg length. The advantages of these allografts are good osteoconductive properties, no harvesting morbidity, and possibility to fill up large bone defects. However, these allografts are not osteogenic or osteoinductive. ‡
References 1, 2, 4, 6, 8, 9, 11, 13-17, 19, 21, 23. References 1, 2, 4-6, 8, 9, 11, 13-16, 19, 21, 23.
§
Literature has shown that fracture of large allografts occurred in about 16% of the cases and is usually seen 2 or more years after implantation.7 The risk of fracture has been linked to the size of the allograft, and some reports have recommended shortening of the leg to reduce the size of the allograft needed. However, it is generally believed that these fractures are occurring through areas where revascularization and ingrowth of host tissue are absent and not due to the size of the allograft.7 The present authors strongly agree with the fact that a bone allograft should be used in association with an osteoinductor such as demineralized bone matrix (DBM) or bone autograft. Adding an osteoinductive environment to the bone allograft is of primary importance to improve mechanical stability of the operated site by the growth of host tissue within the allograft. This can be further underpinned with the results of the present series, where it seems that a better fusion rate was obtained in patients with a bone allograft associated with an iliac bone autograft and/or DBM from the bone bank compared with the subgroup of patients with the exclusive use of a bone allograft (Table 1). All these patients were satisfactorily healed at the first attempt in a mean time of 3.1 months. This could be explained by the fact that autologous bone graft harvested from the iliac crest supplies not only a 3-dimensional bony lattice but also osteogenic cells that will form new bone.6,7 Despite the encouraging results reported in the literature and in the present series, the harvest of autograft can be associated with pain at the donor site, the potential for local complications such as hematoma or fracture, and limited supply.7 To avoid these potential complications, one can observe from the last 2 cases of the present series that similar fusion time was achieved when bone marrow instead of cancellous bone autograft was used in association with DBM and cancellous allograft (Table 1, Figure 3). The extraction of the iliac bone marrow with a trocar is also less aggressive than the extraction of tricortical bone or cancellous bone from the iliac crest. The time to union was 3 months and is comparable with the results reported by Culpan et al,6 who used tricortical autologous graft from the iliac crest. However, further studies are needed to confirm these observations. Demineralized bone matrix is an osteoinductive material extracted from an allograft.7 It can be used alone or associated with bone marrow to favor union between host bone and the allograft. Every patient who received DBM healed at first attempt after 3 months (Table 1). This compares favorably with other series (Table 2). Two studies used a hollow cone or a titanium cage filled with morselized autologous or allograft bone in an attempt to fill in the bone defect and to preserve the leg length.5,11 Despite the successful use of titanium cages (DePuy Spine, Raynham, MA) with autologous bone in
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
554
Foot & Ankle International 35(6)
Figure 1. Algorithm for the treatment of the failed ankle replacement. OA, osteoarthritis; STJ, subtalar joint; TAR, total ankle replacement.
spine surgery, the results of using this technique as a salvage procedure for failed total replacement were disappointing since none of the reported cases healed at the first attempt (Table 2).5 Henricson and Rydholm11 used a trabecular metal Tibial Cone (Zimmer, Warsaw, IN) filled with morselized autologous or allograft bone. They reported satisfactory results in 12 of their 13 operated patients (Table 2). The better results obtained with the trabecular metal Tibial Cone than with the titanium cage are mainly to be attributed to the fact that stability of the arthrodesis was further increased with an intramedullary nail in the study by Henricson and Rydholm.11 The method of fixation has also been pointed out as one of the key factors to achieve a successful arthrodesis. Different methods of fixation have been used in the literature: combination of screws,4,6,8,13-15,26 blade plate,2,4,6,8,9,20,26
nail,|| external fixation,15-17 and Kirschner wires.8 The use of a retrograde intramedullary nail has been suggested by several authors to be the method of choice in fusion after failed total ankle replacements, especially in cases with large bone defects.1,13,16 However, other studies have reported that a uniform contact between host and allograft bone with a stable interface could be better obtained with plating than with nailing.7,24 It is of primary importance to preserve the lateral and medial malleoli to reinforce laterally the stability of either type of arthrodesis by creating a large contact area between the host and the bone graft and by adding screws from the medial and lateral malleoli to the talus and bone graft (Figure 3). ||
References 1, 2, 6, 8, 9, 11, 13, 16, 19, 21, 23.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
555
Deleu et al
Figure 2. (a) Tibiotalocalcaneal arthrodesis after failed total ankle replacement: (A) preoperative anteroposterior (AP) view of Ankle Evolutive System prosthesis (Biomet France S.A.R.L., Valence, France); (B, C) preoperative computed tomography (CT) scan representing the frontal and sagittal view of the ankle and the hindfoot. One can observe the massive osteolysis around the tibial component, the migration of the talar component and the cystic fistula above the malleolus. (b) Postoperative AP (A) and lateral views (C) of the tibiotalocalcaneal arthrodesis (follow-up at 12 months) and the postoperative CT scan (B, D) at 12 months: *integration of the cancellous tibial allograft + **mixture of cancellous graft with demineralized bone matrix was placed posteriorly to the cancellous allograft.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
556
Foot & Ankle International 35(6)
Figure 3. (a) Example of a tibiotalar arthrodesis after failed total ankle replacement (TAR; case 17). The bone grafts included bone marrow from the iliac crest in association with demineralized bone matrix (DBM) and a cancellous allograft: (A, B) preoperative conventional anteroposterior and lateral weightbearing x-rays (follow-up at 3 months); (C, D) postoperative conventional anteroposterior and lateral weightbearing x-rays (follow-up at 3 months): one can observe the bone graft with the host and the additional stability procured by the screws from the medial and lateral malleoli to the talus and bone graft. (b) Example of a tibiotalar arthrodesis after failed TAR (case 17). The bone grafts were from the iliac crest in association with DBM and a cancellous allograft: (A-C) postoperative computed tomography scan: frontal and sagittal views: the bone formation made from bone marrow from the iliac crest association with DBM (B) and the cancellous femoral head allograft (C).
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
557
Deleu et al
Conclusions From our series and a review of the literature (Table 2), it appears that a successful fusion and a good clinical outcome can be expected in patients who benefit from a tibiotalar or a tibiotalocalcaneal arthrodesis as a salvage procedure for failed TAR. An isolated tibiotalar arthrodesis as a salvage procedure for failed total ankle replacement can be considered only in patients with good bone stock and a normal subtalar joint. In the case of subtalar joint arthritis or severe bone loss, tibiotalocalcaneal arthrodesis fusion is the preferable technique. Massive cancellous allografts are a good alternative to compensate the large bone defect after the removal of the prosthetic components and allow us to preserve the leg length. However, from our experience, cancellous allografts should always be used in combination with a bone autograft or bone marrow and, if not available, DBM. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Anderson T, Rydholm U, Besjakov J, Montgomery F, Carlsson AS. Tibiotalocalcaneal fusion using retrograde intramedullary nails as a salvage procedure for failed total ankle prostheses in rheumatoid arthritis: a report on sixteen cases. Foot Ankle Surg. 2005;11(3):143-147. 2. Berkovitz MJ, Clare MP, Walling AK, Sanders R. Salvage of failed total ankle arthroplasty with fusion using cancellous allograft and internal fixation. Foot Ankle Int. 2011;32(5): 493-501. 3. Besse JL, Colombier JA, Asencio J, et al. Total ankle arthroplasty in France. Orthop Traumatol Surg Res. 2010;96(3):291-303. 4. Carlsson AS, Montgomery F, Besjakov J. Arthrodesis of the ankle secondary to replacement. Foot Ankle Int. 1998;19(4):240-245. 5. Carlsson AS. Unsuccessful use of a titanium mesh cage in ankle arthrodesis: a report on three cases operated on due to a failed ankle replacement. J Foot Ankle Surg. 2008;47(4):337-342. 6. Culpan P, Le Strat V, Piriou P, Judet T. Arthrodesis after failed ankle replacement. J Bone Joint Surg Br. 2007;89(9): 1178-1183. 7. Delloye C, Cornu O, Druez V, Barbier O. Bone allografts: what they can offer and what they cannot. J Bone J Surg Br. 2007;89(5):574-580. 8. Doets HC, Zürcher AW. Salvage arthrodesis for failed total ankle arthroplasty. Acta Orthop. 2010;81(1):142-147.
9. Gabrion A, Jardé O, Havet E, et al. Ankle arthrodesis after failure of a total ankle prosthesis: 8 cases. Rev Chir Orthop. 2004;90(4):353-359. 10. Gougoulias N, Khanna A, Maffuli N. How successful are current ankle replacements? A systematic review of the literature. Clin Orthop Relat Res. 2010;468(1):199-208. 11. Henricson A, Rydholm U. Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement. Acta Orthop. 2010;81(6):745-747. 12. Hintermann B, Barg A, Knupp M. Revisionsarthroplastik des oberen Sprunggelenks. Orthopäde. 2011;40(11):10001007. 13. Hopgood P, Kumar R, Wood PL. Ankle arthrodesis for failed total ankle replacement. J Bone J Surg Br. 2006;88(8):10321038. 14. Jehan S, Hill SO. Operative technique of two parallel compression screws and autologous bone graft for ankle arthrodesis after failed total ankle replacement. Foot Ankle Int. 2012;33(9):767-771. 15. Kitaoka HB, Romness DW. Arthrodesis for failed ankle arthroplasty. J Arthroplasty. 1992;7(3):277-284. 16. Kotnis R, Pasapula C, Anwar F, Cooke P, Sharp RJ. The management of failed ankle replacement. J Bone Joint Surg Br. 2006;88(8):1039-1047. 17. Michelson JD, Curl LA. Use of demineralized bone matrix in hindfoot arthrodesis. Clin Orthop Relat Res. 1996;325(4):203208. 18. McCoy TH, Goldman V, Fragomen AT, Rozbruch SR. Circular external fixator-assisted ankle arthrodesis following failed total ankle arthroplasty. Foot Ankle Int. 2012;33(11):947-955. 19. Moor BK, Klammer G, Maquiera GJ, Espinosa N. Salvage arthrodesis after failed total ankle replacement: reconstruction with structural allograft and intramedullary nail. Techn Foot Ankle Surg. 2008;7(4):271-278. 20. Ritter M, Nickisch F, DiGiovanni C. Technical tip: posterior blade plate for salvage of failed total ankle arthroplasty. Foot Ankle Int. 2006;27(4):303-304. 21. Schill S. Ankle arthrodesis with interposition graft as a salvage procedure after failed total ankle replacement [in German]. Oper Orthop Traum. 2007;19(5-6):547-560. 22. Spirt AA, Assal M, Hansen ST. Complications and fail ure after total ankle arthroplasty. J Bone Joint Surg Am. 2004;86(6):1172-1178. 23. Thomason K, Eyres KS. A technique of fusion for failed total replacement of the ankle: tibio-allograft-calcaneal fusion with a locked retrograde intramedullary nail. J Bone Joint Surg Br. 2008;90(7):885-888. 24. Vander Griend R. The effect of internal fixation on the healing of large allografts. J Bone Joint Surg Am. 1994;76(5):657663. 25. Zalavras CG, Patzakis MJ, Thordarson DB, et al. Infected fractures of the distal tibial metaphysis and plafond: achievement of limb salvage with free muscle flaps, bone grafting, ankle fusion. Clin Orthop Relat Res. 2004;427:57-62. 26. Zwipp H, Grass R. Ankle arthrodesis after failed joint replacement. Oper Orthop Traum. 2005;17(4-5):518-533.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
research-article2014
FAIXXX10.1177/1071100714536368Foot & Ankle InternationalDeleu et al
Article
Arthrodesis After Failed Total Ankle Replacement
Foot & Ankle International® 2014, Vol. 35(6) 549–557 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714536368 fai.sagepub.com
Paul-André Deleu, MSc Pod1,2, Bernhard Devos Bevernage, MD1, Pierre Maldague, MD1, Vincent Gombault, MD1, and Thibaut Leemrijse, MD1
Abstract 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. Keywords: total ankle replacement, tibiotalar arthrodesis, tibiotalocalcaneal arthrodesis, bone grafts Although the survivorship of total ankle replacements (TARs) has improved, long-term results of TAR are not as satisfactory as those of total hip and knee replacements.10 While the longevity and the number of primary TAR continue to increase, so does the prevalence of associated complications.10,16 Gougoulias et al10 reported that the overall failure rate was approximately 10% at 5 years, which required revision arthroplasty or conversion to a tibiotalar or tibiotalocalcaneal arthrodesis. Total ankle replacements can fail because of a wide variety of causes such as infection, mechanical failure, aseptic or septic loosening, unexplained persistent pain, periarticular cysts, necrosis, soft tissue imbalance, instability, poor osseous integration, migration with or without osteolysis of the tibial or talar component, spacer failure, wound dehiscence, and mis-sizing and malpositioning of the TAR components.* The choice of the revision technique will mostly depend on the cause of failure, the bone defect, quality of the bone itself, and the experience and expertise of the surgeon.3,16 Based on reviews of the literature, arthrodesis is currently carried out more frequently compared with revision replacement for failed TAR.3,10 *References 1-6, 8, 9, 11, 13-17, 19-23, 26.
Arthrodesis can provide a more predictable outcome compared with revision arthroplasty; however, it has to face additional problems compared with a primary arthrodesis. The major difficulty is the severe bone loss due not only to resection for explantation of the prosthesis but also to wear with secondary periprosthetic osteolysis, which can potentially cause important leg length discrepancy.4,6,23 To overcome these problems, surgeons have used different types of auto- and allografts to bridge and fill the defect and to provide mechanical support.† To date, several arthrodesis techniques associated with auto- or allografts or a combination of both have been described in the literature, but there is still no ideal concept that fits for every patient. †
References 1, 2, 4-6, 8, 9, 11, 13-16, 19, 21, 23.
1
Foot & Ankle Institute, Clinique du Parc Léopold, Bruxelles, Belgium Institut D’Enseignement Supérieur Parnasse Deux-Alice, Division of Podiatry, Bruxelles, Belgium 2
Corresponding Author: Paul-André Deleu, MSc Pod, Foot & Ankle Institute, Clinique du Parc Léopold, 38, Rue Froissart, 1040 Bruxelles, Belgium. Email: [email protected]
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
550
Foot & Ankle International 35(6)
The literature on salvage procedures for failed ankle replacement is sparse. We report a series of 17 patients who had a failed TAR converted to a tibiotalar or a tibiotalocalcaneal arthrodesis and propose an algorithm to guide the treatment of these patients.
Methods Between 2003 and 2012, a total of 17 patients with a failed TAR underwent an arthrodesis by the senior surgeon (T.L.). There were 5 men and 12 women with an average age of 57.3 years (range, 41-77 years) and with an average body mass index (BMI) of 26.7 (range, 22.2-32.7). The initial diagnosis was posttraumatic osteoarthritis (OA) in 7 patients, rheumatoid arthritis (RA) in 4 patients, and idiopathic OA in 6 patients. The type of implants included 8 AES (Biomet France S.A.R.L., Valence, France) prostheses, 6 Hintegra (Newdeal SA, Lyon, France) prostheses, 1 Mobility (DePuy International, Leeds, UK) prosthesis, 1 Salto (Tornier Implants, Grenoble, France) prosthesis, and 1 STAR (Waldemar Link, Hamburg, Germany) prosthesis. The average time from TAR to arthrodesis was 49.8 months (range, 1-144 months). The comorbidities were smoking in 2 patients, high blood pressure in 5 patients, and 1 patient with osteoporosis due to 20 years of corticosteroid therapy for her RA. Pre- and postoperative radiological evaluation was done with conventional radiography in the weightbearing position (anteroposterior and lateral views). Based on postoperative conventional radiography, computed tomography (CT) scans were planned between 2 and 3 months postoperatively to seek further radiological evidence of solid fusion. Union was defined as the presence of bridging trabeculae at the level of the operated joint(s) on the axial and sagittal plane views of the CT scan.4,13,23 Conventional radiographies and CT scans were reviewed by an independent radiologist who was unaware of the clinical results and by the orthopedic surgeon. If no fusion was obtained at that time, new CT scans were performed at a 3-month interval. All patients were regularly followed through chart review, clinical examination, and radiological evaluation every month during the first year and afterward once every year. The average follow up was 29.1 months (range, 12-77 months) after the arthrodesis. All patients were followed up for a minimum of 12 months. The following variables were exported from a clinical database for the purpose of the present study: 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 individual results of the clinical and radiographic evaluation are presented in Tables 1 and 2. The average follow-up was 30.1 months (range, 12-77 months). The average period from the original arthroplasty to the arthrodesis was 49.8 months (range, 1-144 months).
Operative technique for tibiotalar arthrodesis. The ankle was exposed through an antero-medial approach between the tibialis anterior and extensor hallucis longus. Synovectomy was performed and the polyethylene component of the TAR was removed. The hardware components of the TAR were removed with care to avoid further bone loss. Afterward, the joint was debrided of fibrous tissue and necrotic bone until healthy and qualitative subchondral bone was exposed. The lateral malleolus was preserved. The ankle was positioned in neutral position with a valgus angulation of the hindfoot of 0 to 5 degrees to have a plantigrade foot. Proper alignment of the foot was temporarily maintained with 2-mm Kirschner wires, which were used for fixation with cannulated screws. The first wire was positioned from the medial part of the tibia to the talus and the second from the lateral malleolus to the talus. Fluoroscopic control was performed to avoid any damage to the subtalar joint, which must be perfectly preserved. If the alignment was correct, definitive fixation was performed with a minimum of two 4.5-mm or 7.3-mm screws. When the bone stock allowed it, an additional third screw was sometimes added to increase the stability of the arthrodesis. If the bone defect was large, an appropriate bone graft was selected and trimmed during surgery to fill the bone gap. The height was restored with the main axis being in the middle of the joint. The residual bone gaps were filled with a bone auto- or allograft or both (Table 1). When the talus and the graft were well positioned against the tibia with provisional 2-mm Kirschner wires, an anterior neutralization plate (Tibiaxys; Integra, Newdeal, Lyon, France) was applied with the distal end being in the talar neck. Fluoroscopic control was performed to avoid any damage to the subtalar joint, whose preservation was a prerequisite for a successful outcome. To increase the stability of the construct, 2 additional screws crossing each other from both malleoli were positioned to obtain a peritalar fusion through or with the help of native bone. Stability was a major issue to obtain a fusion, but screws were especially used for maintenance of the alignment, length, and rotation rather than for compression. Only a few patients required compressive screws going from the lateral or medial malleolus into the talus, to obtain fusion from native bone on both malleolar sides, while waiting for the full integration of the allograft reconstruction. Operative technique for tibiotalocalcaneal arthrodesis. In cases where the residual bone was found to be of poor quality or when the subtalar joint was noted to be degenerative, the arthrodesis was extended into the subtalar joint. In such a case, a curved centro-medullar nail was used most often. To reach the subtalar joint, an additional approach from underneath the lateral malleolus to the sinus tarsi was performed to remove the cartilage of both facets of the subtalar joint.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
551
Deleu et al Table 1. Demographic Data and Results of the Clinical and Radiographic Assessments.
Case
Sex
Age, y
Diagnosis
Implant
1 2
M F
53 49
IDIO OA RA
STAR AES
3
M
61
PT OA
4 5
F F
64 53
IDIO OA PT OA
6
F
56
RA
7 8 9 10
M F F F
77 57 37 53
IDIO OA IDIO OA RA PT OA
11
M
49
IDIO OA
12
F
65
PT OA
Hintegra
13 14
M F
61 85
RA IDIO OA
15
F
59
16
F
17
F
Reason for Failure
AL + Lux MPI AL + GR on MPI AES NE TA + Mig TA AES Inf + Lux MPI Mobility Pain
Time to Failure, mo Arthrodesis
Graft
Time to Healed Repeat Deviation, Fusion, at First Attempt Arthrodesis deg Follow-up AOFAS mo
48 144
TTC TTC
AlloS FH AlloS TA
NU 12
No Yes
No NA
5 4
48 77
65 76
51
TTC
AlloS Tib
3
Yes
NA
4
36
78
4 29
TTC TTC
NU NU
No No
Yes Yes
3 7
42 52
73 73
68
TTC
AlloS FH AlloS FH + Mo Allo FH AlloS FH
NU
No
Yes
5
48
76
68 60 72 49
TTC TTC TTC TTC
AlloS Tib + CA IC CA IC + DBM AlloS FH AlloS Tib + BM IC
3 3 3 3
Yes Yes Yes Yes
NA NA NA NA
7 4 3 4
41 12 23 14
73 76 78 78
61
TT
3
Yes
NA
7
16
75
Inf
7
TTC
3
Yes
NA
8
18
73
Hintegra Hintegra
Inf AL
1 24
TT TTC
2 3
Yes Yes
NA NA
3 5
14 15
78 77
PT OA
AES
Os + AL
102
TT
4
Yes
NA
6
14
73
41
PT OA
Hintegra
Pain
21
TT
3
Yes
NA
5
12
75
54
PT OA
Hintegra
Pain
38
TT
AlloS FH Sec + CA IC + DBM AlloS FH Sec + CA IC + DBM No AlloS FH Sec + CA IC + DBM Tricortical IC + Ca IC + Mo Allo FH AlloS FH + BM IC + DBM AlloS FH + BM IC + DBM
3
Yes
NA
5
12
70
AES
NE TA + Mig TA AES Os + Mig TA SALTO Os + Lux MPI AES Os + Inf + CF AES Os + Mig TA + CF Hintegra AL
AES, Ankle Evolutive System prosthesis (Biomet France S.A.R.L., Valence, France); AL, aseptic loosening; AlloS, structural allograft; AOFAS, American Orthopaedic Foot and Ankle Society; BM, bone marrow; CA, cancellous bone; CF, cystic fistula; DBM, demineralized bone matrix; FH, femoral head; GR, granuloma; Hintegra, Hintegra prosthesis (Newdeal SA, Lyon, France); IC, iliac crest; IDIO OA, idiopathic osteoarthritis; Inf, infection; Lux, dislocation; Mig, migration; Mo, morselized; MPI, mobile polyethylene insert; NA, not applicable; NE, necrosis; NU, nonunion; Os, osteolysis; PT OA, posttraumatic osteoarthritis; RA, rheumatoid arthritis; SALTO, Salto prosthesis (Tornier Implants, Grenoble, France); STAR, Scandinavian Total Ankle Replacement prosthesis (Waldemar Link, Hamburg, Germany);TA, talus; Tib, tibia; TT, tibiotalar arthrodesis; TTC, tibiotalocalcaneal arthrodesis.
After the joints were prepared, the ankle and the hindfoot were placed in 5 degrees of valgus, neutral dorsiflexion, and 5 degrees of external rotation. A guide wire was passed through the calcaneus and the talus into the tibia under fluoroscopic control. The medullary canal was reamed 1.5 mm larger than the planned size of the nail. A bone allograft was prepared from a femoral head and shaped according to the dimensions of the bone defect on both the tibial and talar side. It was very important to fill any residual gaps in the bone continuity with bone auto- or allograft or even both (Table 1). Afterward, fluoroscopic control was performed to ensure the position of the foot; a retrograde intramedullary nail (T2 Ankle Arthrodesis Nail; Stryker, Kiel, Germany) was used in a static fashion with 2 screws in the calcaneus, 1 screw in the talus, and 2 proximally in the tibial shaft.
Protocol for Infected TAR When infection was suspected, a 2-stage salvage procedure was performed. The first stage was composed of an extensive debridement with removal of the prosthetic components and all nonviable and infected tissues.25 Multiple tissue samples
from the joint capsule and the component-bone interface were taken and sent for further microbiological and histological analysis. Criteria for infection were based on 3 main components: (1) C-reactive protein (inflammatory parameter), (2) cultures of multiple tissue samples that were collected to seek a clinically important organism, and (3) the presence of plasmocytes as histologic criteria. The resulting bone defect after debridement was filled with an antibiotic impregnated polymethylmetacrylate cement spacer (Palacos gentamycine 40 g) to preserve length and stability. The main advantage of gentamycine was that it statistically has the widest spectrum to treat many types of bacterial infections.16,19,26 External stabilization with a custom brace or external fixator completed the provisional construct. After the histopathological and bacteriological procurement, an intravenous antibiotic regimen was started and further adjusted according to the antibiogram. If an external fixator was used, it was removed in a transitional stage to allow skin healing at the pins holes through the use of a cast. In stage 2, after 6 weeks of antibiotic therapy and once the C-reactive protein levels normalized, the final reconstruction was performed. The cement spacer was removed and a new debridement resected 1 to 2 mm more at both
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
552
Foot & Ankle International 35(6)
Table 2. Review of Previous Studies Concerning “Arthrodesis After Failed Total Ankle Replacement.”
Age, y
Time to Failure, mo
Graft, %
Time to Union, mo
Healed After First Attempt, %
Complications, %
Follow-up, mo
Study
Year
No. of Subjects
Kitaoka and Romness15 Carlsson et al4 Gabrion et al9 Anderson et al1 Zwipp and Grass26 Hopgood et al13 Kotnis et al16
1992
38
57
42
33 TT; 5 TTC
89
NR
87
13
96
1998 2004 2005 2005
21 8 16 4
59 57 55 42
40 36 62 45
20 TT; 1 TTC 6 TT; 2 TTC 16 TTC 3 TT; 1 TTC
100 25 88 100
NR 3.1 43 3.5
62 87 69 75
38 13 31 25
NR 56 34 37.5
2006 2006
23 16
62 64.7
41 33
61 100
4 8
74 94
26 6
29 12
Schill21 Culpan et al6 Moor et al19 Carlsson5 Thomason and Eyres23 Doets and Zürcher8 Henricson and Rydholm11 Berkovitz et al2 Jehan and Hill14 McCoy et al18 Our study
2007 2007 2008 2008 2008
15 16 3 3 3
56 54 NR 49 66
115 41 NR 76 72
16 TT; 7 TTC 10 TTC; 1 KA; 5 RTAR 15 TTC 16 TT 3 TTC 3 TT 3 TTC
100 100 100 100 100
3.9 3 3 / 3
87 94 100 0 100
13 6 0 100 0
23 44 32 37 32
2010
18
55
49
7 TT; 11 TTC
100
6.3
61
39
NR
2010
13
NR
84
13 TTC
100
NR
92
8
17
2011 2012 2012 2013
12; 12 4 7 17
58; 65.3 66.5 52 57.3
41.3; 63.1 20 70.9 49.8
83; 100 100 0 94
NR; NR 3.5 6.3 3.7
92; 59 100 100 76.5
Type of Fusion
12 TT; 12 TTC 4 TT 4 TT; 3 TTC 5 TT; 12 TTC
8; 41 0 0 23.5
57.9; 33.2 NR 58 29.1
KA, knee amputation; NR, not reported; RTAR, revision arthroplasty; TT, tibiotalar arthrodesis; TTC, tibiotalocalcaneal arthrodesis.
bony ends, sending them for new cultures. Residual native bone was prepared to obtain a bleeding bone to increase the chance of incorporation of the bone allograft that was implanted. The construct with or without a bone graft was mechanically stable to obtain healing. Afterward, the same protocol for noninfected TAR was followed.
Bone Graft The type of bone graft used for each patient is detailed in Table 1. Both types of allograft were prepared by the same bone bank (certified by the Belgian Health Authorities) and could be used alone or in association with a cancellous bone autograft procured at the patient’s pelvis.
Postoperative Care All patients were immobilized nonweightbearing in a below-knee cast for 2 months and then allowed to weightbear in a removal rigid orthopaedic walker boot for a further month. Thromboembolic prophylaxis was used until the patient was mobile. Patients were screened for signs of local infection; C-reactive protein level was monitored and conventional x-rays were made every month. At 3 months, a CT scan was performed.
Results Thirteen of the 17 ankles were considered radiographically healed at the first attempt after an average time of 3.7 months, whereas 3 healed after repeated attempts of fusion. Bone grafts were used in 16 patients. Massive bone allograft was used exclusively in 7 ankles and in association with a bone autograft in 9 ankles. Two-stage surgery was performed in 4 patients. The median value of the total AOFAS score was 74.5 (range, 65-78). The mean Meary angle of the hindfoot was 5 degrees of valgus (range, 3-7). Tibiotalar arthrodesis was performed with stabilization screws in 1 patient (case 11) and with contoured plates in 4 patients (cases 13, 15, 16, and 17). All patients achieved satisfactory union. Tibiotalocalcaneal arthrodesis was performed in 12 patients with an intramedullary nail. We reported 1 perioperative tibial fracture, which occurred when the nail was introduced in the tibia (case 14). However, the fragments were not displaced and a longer casting period was required. No revision surgery was needed. There were 4 nonunions (cases 1, 4, 5, and 6), 1 asymptomatic and 3 that united after a second operative attempt (Table 1). At the latest review, all patients were free of symptoms.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
553
Deleu et al
Discussion Arthrodesis is a salvage procedure after failed TAR and generally has union rates between 61% and 100%,‡ except the case series of Carlsson,5 in which none of his patients fused. The union rate of our series at the first attempt was 76.5%. The results of the present series compare favorably with other series. Successful union was achieved in 76.5% of the cases at first attempt. The mean time to fusion was 3.7 months. In our series of patients, the mean age at the time of fusion was 58 years with a TAR failure at a mean of 50 months. Two large series reported similar findings (Table 2).4,15 An algorithm for the treatment of the failed ankle replacement has been developed and implemented at our institute (Figure 1). The possibility of revision arthroplasty and the presence of infection are the main factors that will influence the allocation of the patients in one of those groups. Tibiotalar and tibiotalocalcaneal arthrodeses are reliable operative procedures and provide a definitive solution to the problem of the patient.11,22 However, the mobility of those joints is not preserved. Revision implants have been developed but are expensive since most have to be custom made and could potentially lead to a higher degree of bone loss. This could make it difficult to revise.12 Literature has shown that the effectiveness of a total ankle replacement is quite surgeon dependent.3 Revising an ankle prosthesis with another implant depends on variables such as infection, bone loss, osteoarthritis in the subtalar joint, or the presence or absence of infection (Figure 1). To achieve fusion in tibiotalar or tibiotalocalcaneal arthrodesis after failed TAR, good debridement of bony surfaces and extensive bone grafting are essential (Figures 2 and 3).4,11,14 Depending on the volume of graft needed to fill the defect, an auto- or allograft or combinations of both were selected. More than 90% of the arthrodeses performed as a salvage procedure for failed TAR used an auto- or allograft or a combination of both to fill the bone defect (Table 2).§ The mechanical resistance of the allograft was beyond the influence of the surgeon and was related to donor data and tissue bank processing. But the incorporation of the graft or the union is partially surgeon dependent since bone bed preparation during surgery is critical for union between the graft and the residual bone to occur. In our series, we used processed cancellous bone allografts from femoral head, tibia, and talus to preserve the leg length. The advantages of these allografts are good osteoconductive properties, no harvesting morbidity, and possibility to fill up large bone defects. However, these allografts are not osteogenic or osteoinductive. ‡
References 1, 2, 4, 6, 8, 9, 11, 13-17, 19, 21, 23. References 1, 2, 4-6, 8, 9, 11, 13-16, 19, 21, 23.
§
Literature has shown that fracture of large allografts occurred in about 16% of the cases and is usually seen 2 or more years after implantation.7 The risk of fracture has been linked to the size of the allograft, and some reports have recommended shortening of the leg to reduce the size of the allograft needed. However, it is generally believed that these fractures are occurring through areas where revascularization and ingrowth of host tissue are absent and not due to the size of the allograft.7 The present authors strongly agree with the fact that a bone allograft should be used in association with an osteoinductor such as demineralized bone matrix (DBM) or bone autograft. Adding an osteoinductive environment to the bone allograft is of primary importance to improve mechanical stability of the operated site by the growth of host tissue within the allograft. This can be further underpinned with the results of the present series, where it seems that a better fusion rate was obtained in patients with a bone allograft associated with an iliac bone autograft and/or DBM from the bone bank compared with the subgroup of patients with the exclusive use of a bone allograft (Table 1). All these patients were satisfactorily healed at the first attempt in a mean time of 3.1 months. This could be explained by the fact that autologous bone graft harvested from the iliac crest supplies not only a 3-dimensional bony lattice but also osteogenic cells that will form new bone.6,7 Despite the encouraging results reported in the literature and in the present series, the harvest of autograft can be associated with pain at the donor site, the potential for local complications such as hematoma or fracture, and limited supply.7 To avoid these potential complications, one can observe from the last 2 cases of the present series that similar fusion time was achieved when bone marrow instead of cancellous bone autograft was used in association with DBM and cancellous allograft (Table 1, Figure 3). The extraction of the iliac bone marrow with a trocar is also less aggressive than the extraction of tricortical bone or cancellous bone from the iliac crest. The time to union was 3 months and is comparable with the results reported by Culpan et al,6 who used tricortical autologous graft from the iliac crest. However, further studies are needed to confirm these observations. Demineralized bone matrix is an osteoinductive material extracted from an allograft.7 It can be used alone or associated with bone marrow to favor union between host bone and the allograft. Every patient who received DBM healed at first attempt after 3 months (Table 1). This compares favorably with other series (Table 2). Two studies used a hollow cone or a titanium cage filled with morselized autologous or allograft bone in an attempt to fill in the bone defect and to preserve the leg length.5,11 Despite the successful use of titanium cages (DePuy Spine, Raynham, MA) with autologous bone in
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
554
Foot & Ankle International 35(6)
Figure 1. Algorithm for the treatment of the failed ankle replacement. OA, osteoarthritis; STJ, subtalar joint; TAR, total ankle replacement.
spine surgery, the results of using this technique as a salvage procedure for failed total replacement were disappointing since none of the reported cases healed at the first attempt (Table 2).5 Henricson and Rydholm11 used a trabecular metal Tibial Cone (Zimmer, Warsaw, IN) filled with morselized autologous or allograft bone. They reported satisfactory results in 12 of their 13 operated patients (Table 2). The better results obtained with the trabecular metal Tibial Cone than with the titanium cage are mainly to be attributed to the fact that stability of the arthrodesis was further increased with an intramedullary nail in the study by Henricson and Rydholm.11 The method of fixation has also been pointed out as one of the key factors to achieve a successful arthrodesis. Different methods of fixation have been used in the literature: combination of screws,4,6,8,13-15,26 blade plate,2,4,6,8,9,20,26
nail,|| external fixation,15-17 and Kirschner wires.8 The use of a retrograde intramedullary nail has been suggested by several authors to be the method of choice in fusion after failed total ankle replacements, especially in cases with large bone defects.1,13,16 However, other studies have reported that a uniform contact between host and allograft bone with a stable interface could be better obtained with plating than with nailing.7,24 It is of primary importance to preserve the lateral and medial malleoli to reinforce laterally the stability of either type of arthrodesis by creating a large contact area between the host and the bone graft and by adding screws from the medial and lateral malleoli to the talus and bone graft (Figure 3). ||
References 1, 2, 6, 8, 9, 11, 13, 16, 19, 21, 23.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
555
Deleu et al
Figure 2. (a) Tibiotalocalcaneal arthrodesis after failed total ankle replacement: (A) preoperative anteroposterior (AP) view of Ankle Evolutive System prosthesis (Biomet France S.A.R.L., Valence, France); (B, C) preoperative computed tomography (CT) scan representing the frontal and sagittal view of the ankle and the hindfoot. One can observe the massive osteolysis around the tibial component, the migration of the talar component and the cystic fistula above the malleolus. (b) Postoperative AP (A) and lateral views (C) of the tibiotalocalcaneal arthrodesis (follow-up at 12 months) and the postoperative CT scan (B, D) at 12 months: *integration of the cancellous tibial allograft + **mixture of cancellous graft with demineralized bone matrix was placed posteriorly to the cancellous allograft.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
556
Foot & Ankle International 35(6)
Figure 3. (a) Example of a tibiotalar arthrodesis after failed total ankle replacement (TAR; case 17). The bone grafts included bone marrow from the iliac crest in association with demineralized bone matrix (DBM) and a cancellous allograft: (A, B) preoperative conventional anteroposterior and lateral weightbearing x-rays (follow-up at 3 months); (C, D) postoperative conventional anteroposterior and lateral weightbearing x-rays (follow-up at 3 months): one can observe the bone graft with the host and the additional stability procured by the screws from the medial and lateral malleoli to the talus and bone graft. (b) Example of a tibiotalar arthrodesis after failed TAR (case 17). The bone grafts were from the iliac crest in association with DBM and a cancellous allograft: (A-C) postoperative computed tomography scan: frontal and sagittal views: the bone formation made from bone marrow from the iliac crest association with DBM (B) and the cancellous femoral head allograft (C).
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
557
Deleu et al
Conclusions From our series and a review of the literature (Table 2), it appears that a successful fusion and a good clinical outcome can be expected in patients who benefit from a tibiotalar or a tibiotalocalcaneal arthrodesis as a salvage procedure for failed TAR. An isolated tibiotalar arthrodesis as a salvage procedure for failed total ankle replacement can be considered only in patients with good bone stock and a normal subtalar joint. In the case of subtalar joint arthritis or severe bone loss, tibiotalocalcaneal arthrodesis fusion is the preferable technique. Massive cancellous allografts are a good alternative to compensate the large bone defect after the removal of the prosthetic components and allow us to preserve the leg length. However, from our experience, cancellous allografts should always be used in combination with a bone autograft or bone marrow and, if not available, DBM. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Anderson T, Rydholm U, Besjakov J, Montgomery F, Carlsson AS. Tibiotalocalcaneal fusion using retrograde intramedullary nails as a salvage procedure for failed total ankle prostheses in rheumatoid arthritis: a report on sixteen cases. Foot Ankle Surg. 2005;11(3):143-147. 2. Berkovitz MJ, Clare MP, Walling AK, Sanders R. Salvage of failed total ankle arthroplasty with fusion using cancellous allograft and internal fixation. Foot Ankle Int. 2011;32(5): 493-501. 3. Besse JL, Colombier JA, Asencio J, et al. Total ankle arthroplasty in France. Orthop Traumatol Surg Res. 2010;96(3):291-303. 4. Carlsson AS, Montgomery F, Besjakov J. Arthrodesis of the ankle secondary to replacement. Foot Ankle Int. 1998;19(4):240-245. 5. Carlsson AS. Unsuccessful use of a titanium mesh cage in ankle arthrodesis: a report on three cases operated on due to a failed ankle replacement. J Foot Ankle Surg. 2008;47(4):337-342. 6. Culpan P, Le Strat V, Piriou P, Judet T. Arthrodesis after failed ankle replacement. J Bone Joint Surg Br. 2007;89(9): 1178-1183. 7. Delloye C, Cornu O, Druez V, Barbier O. Bone allografts: what they can offer and what they cannot. J Bone J Surg Br. 2007;89(5):574-580. 8. Doets HC, Zürcher AW. Salvage arthrodesis for failed total ankle arthroplasty. Acta Orthop. 2010;81(1):142-147.
9. Gabrion A, Jardé O, Havet E, et al. Ankle arthrodesis after failure of a total ankle prosthesis: 8 cases. Rev Chir Orthop. 2004;90(4):353-359. 10. Gougoulias N, Khanna A, Maffuli N. How successful are current ankle replacements? A systematic review of the literature. Clin Orthop Relat Res. 2010;468(1):199-208. 11. Henricson A, Rydholm U. Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement. Acta Orthop. 2010;81(6):745-747. 12. Hintermann B, Barg A, Knupp M. Revisionsarthroplastik des oberen Sprunggelenks. Orthopäde. 2011;40(11):10001007. 13. Hopgood P, Kumar R, Wood PL. Ankle arthrodesis for failed total ankle replacement. J Bone J Surg Br. 2006;88(8):10321038. 14. Jehan S, Hill SO. Operative technique of two parallel compression screws and autologous bone graft for ankle arthrodesis after failed total ankle replacement. Foot Ankle Int. 2012;33(9):767-771. 15. Kitaoka HB, Romness DW. Arthrodesis for failed ankle arthroplasty. J Arthroplasty. 1992;7(3):277-284. 16. Kotnis R, Pasapula C, Anwar F, Cooke P, Sharp RJ. The management of failed ankle replacement. J Bone Joint Surg Br. 2006;88(8):1039-1047. 17. Michelson JD, Curl LA. Use of demineralized bone matrix in hindfoot arthrodesis. Clin Orthop Relat Res. 1996;325(4):203208. 18. McCoy TH, Goldman V, Fragomen AT, Rozbruch SR. Circular external fixator-assisted ankle arthrodesis following failed total ankle arthroplasty. Foot Ankle Int. 2012;33(11):947-955. 19. Moor BK, Klammer G, Maquiera GJ, Espinosa N. Salvage arthrodesis after failed total ankle replacement: reconstruction with structural allograft and intramedullary nail. Techn Foot Ankle Surg. 2008;7(4):271-278. 20. Ritter M, Nickisch F, DiGiovanni C. Technical tip: posterior blade plate for salvage of failed total ankle arthroplasty. Foot Ankle Int. 2006;27(4):303-304. 21. Schill S. Ankle arthrodesis with interposition graft as a salvage procedure after failed total ankle replacement [in German]. Oper Orthop Traum. 2007;19(5-6):547-560. 22. Spirt AA, Assal M, Hansen ST. Complications and fail ure after total ankle arthroplasty. J Bone Joint Surg Am. 2004;86(6):1172-1178. 23. Thomason K, Eyres KS. A technique of fusion for failed total replacement of the ankle: tibio-allograft-calcaneal fusion with a locked retrograde intramedullary nail. J Bone Joint Surg Br. 2008;90(7):885-888. 24. Vander Griend R. The effect of internal fixation on the healing of large allografts. J Bone Joint Surg Am. 1994;76(5):657663. 25. Zalavras CG, Patzakis MJ, Thordarson DB, et al. Infected fractures of the distal tibial metaphysis and plafond: achievement of limb salvage with free muscle flaps, bone grafting, ankle fusion. Clin Orthop Relat Res. 2004;427:57-62. 26. Zwipp H, Grass R. Ankle arthrodesis after failed joint replacement. Oper Orthop Traum. 2005;17(4-5):518-533.
Downloaded from fai.sagepub.com at Universidad de Sevilla. Biblioteca on June 1, 2015
