e152(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Commentary & Perspective Is Cement Block Arthroplasty the Next Big Thing in Ankles? Commentary on an article by Ho-Seong Lee, MD, et al.: ‘‘Cement Arthroplasty for Ankle Joint Destruction’’
Justin Greisberg, MD Is ankle replacement so primitive compared with other joint arthroplasties that we look at cement block ‘‘arthroplasty’’ as a success? Of course not, but a casual read of the title of this article might lead an orthopaedist to wonder. Cement block arthroplasty seems like a procedure right out of an orthopaedic text from the 1970s, so why should this be an article in JBJS in 2014? A closer inspection of the study by Lee et al. shows that it is really a collection of three different, rarely indicated procedures: 1. Talar body replacement for patients with a tumor without destruction of the ankle and subtalar joints. Several case reports have shown some success with use of custom talar body implants, with the native talar neck and head left intact or the entire talus replaced with metal or ceramic1,2. 2. Ankle/hindfoot arthrodesis with tibiotalocalcaneal screws and cement for structural support, with the intention of achieving a stable pseudarthrosis. 3. Cement block arthroplasty, in which the cement is a rigid spacer, with emphasis on restoration of alignment. The first procedure, talar body replacement, is a unique operation for a younger patient with a tumor. However, the second and third procedures are for patients with loss of the ankle joint and extensive destruction of the talus, possibly with infection. In most cases, this loss and destruction are the result of trauma (talar fracture complications) or a failed total ankle replacement. (Patients with neuropathic arthropathy, or a Charcot ankle, may also have erosive arthritis of the ankle and hindfoot, but salvage with a tibiocalcaneal fusion may be easier because a stable nonunion is usually good enough. This disease entity differs from a failed total ankle replacement and thus should be considered separately.) Options are limited for treating a patient with extensive destruction of the ankle and talus (without neuropathy). A true tibiotalocalcaneal fusion requires structural bone graft and has a longer healing time, a higher nonunion rate, and inferior outcomes compared with routine ankle fusion. Resection of the talar body (talectomy), possibly with a Blair fusion (fusion of the talar neck to the distal part of the tibia), is another option but is similar to tibiotalocalcaneal fusion, with lots of stiffness and mediocre results3. Transtibial (below-the-knee) amputation is another possibility and may offer better outcomes in younger patients, but with obvious long-term financial, emotional, and psychological costs. A cement arthroplasty is yet another method for salvage of a destroyed ankle joint with loss of the talus. Because cement can elute antibiotics, it is particularly tempting for difficult infections. The recovery time is probably faster than that of a true tibiotalocalcaneal fusion or a Blair fusion, so it is more appealing to an older patient who has already been through several operations. However, for most patients with nonunion of an ankle fusion or a failed total ankle replacement, surgical revision to an isolated ankle fusion remains the first choice. Ankle arthrodesis, in the setting of functioning subtalar and hindfoot joints, provides good results. In fact, recent studies suggest that ankle fusion may be almost as good as ankle replacement4-6. The goal of ankle arthrodesis is to restore alignment and obtain a solid osseous fusion, so how can cement arthroplasty, whose goal is fibrous nonunion, be considered successful? To really understand how cement arthroplasty works, one has to study the patients in this article and the problems for which they were treated. Seven of the sixteen patients had diabetes and thus may have had some degree of peripheral neuropathy and, consequently, more tolerance of a painful condition. Furthermore, the problem being treated was so bad in many cases that even a mediocre result can be considered a ‘‘home run.’’ To go from a painful, deformed, infected ankle to one that is less sore, more straight, more stable, and not infected is a big step forward. Finally, are the outcomes of these patients really that good? Three of the sixteen used a walking brace for normal ambulation, three used a cane or crutches, and one used a wheelchair. The importance of this study is that it increases recognition of the problem presented by patients with loss of the ankle joint and destruction of much of the talus. As more ankle arthroplasties are performed, there may be more patients with this problem. Many painful total ankle replacements can be successfully addressed with total ankle revision. However, talar body fracture below an implant and recalcitrant infection are unsolved problems that will become more prevalent in the near future as the rate of ankle replacement increases over time.
J Bone Joint Surg Am. 2014;96:e152(1-2)
d
http://dx.doi.org/10.2106/JBJS.N.00630
e152(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 17 S E P T E M B E R 3, 2 014 d
d
C O M M E N TA RY & P E R S P E C T I V E
d
We need to develop techniques to deal with catastrophic failure of total ankle replacements. The biggest problem is talar bone loss, but other problems include soft-tissue stiffness/fibrosis and loss of limb length. Cement ankle arthroplasty is one tool in our ‘‘bag of tricks’’ that we can use to salvage a difficult situation. Congratulations to the authors for bringing this problem and procedure into the light. Justin Greisberg, MD* Columbia University, New York, NY *The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
References 1. Magnan B, Facci E, Bartolozzi P. Traumatic loss of the talus treated with a talar body prosthesis and total ankle arthroplasty. A case report. J Bone Joint Surg Am. 2004 Aug;86(8):1778-82. 2. Tsukamoto S, Tanaka Y, Maegawa N, Shinohara Y, Taniguchi A, Kumai T, Takakura Y. Total talar replacement following collapse of the talar body as a complication of total ankle arthroplasty: a case report. J Bone Joint Surg Am. 2010 Sep 1;92(11):2115-20. 3. Van Bergeyk A, Stotler W, Beals T, Manoli A 2nd. Functional outcome after modified Blair tibiotalar arthrodesis for talar osteonecrosis. Foot Ankle Int. 2003 Oct;24(10): 765-70. 4. Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. 5. Saltzman CL, Kadoko RG, Suh JS. Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop Surg. 2010 Mar;2(1):1-7. Epub 2010 Feb 4. 6. Schuh R, Hofstaetter J, Krismer M, Bevoni R, Windhager R, Trnka HJ. Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome. Int Orthop. 2012 Jun;36(6):1207-14. Epub 2011 Dec 16.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Commentary & Perspective Is Cement Block Arthroplasty the Next Big Thing in Ankles? Commentary on an article by Ho-Seong Lee, MD, et al.: ‘‘Cement Arthroplasty for Ankle Joint Destruction’’
Justin Greisberg, MD Is ankle replacement so primitive compared with other joint arthroplasties that we look at cement block ‘‘arthroplasty’’ as a success? Of course not, but a casual read of the title of this article might lead an orthopaedist to wonder. Cement block arthroplasty seems like a procedure right out of an orthopaedic text from the 1970s, so why should this be an article in JBJS in 2014? A closer inspection of the study by Lee et al. shows that it is really a collection of three different, rarely indicated procedures: 1. Talar body replacement for patients with a tumor without destruction of the ankle and subtalar joints. Several case reports have shown some success with use of custom talar body implants, with the native talar neck and head left intact or the entire talus replaced with metal or ceramic1,2. 2. Ankle/hindfoot arthrodesis with tibiotalocalcaneal screws and cement for structural support, with the intention of achieving a stable pseudarthrosis. 3. Cement block arthroplasty, in which the cement is a rigid spacer, with emphasis on restoration of alignment. The first procedure, talar body replacement, is a unique operation for a younger patient with a tumor. However, the second and third procedures are for patients with loss of the ankle joint and extensive destruction of the talus, possibly with infection. In most cases, this loss and destruction are the result of trauma (talar fracture complications) or a failed total ankle replacement. (Patients with neuropathic arthropathy, or a Charcot ankle, may also have erosive arthritis of the ankle and hindfoot, but salvage with a tibiocalcaneal fusion may be easier because a stable nonunion is usually good enough. This disease entity differs from a failed total ankle replacement and thus should be considered separately.) Options are limited for treating a patient with extensive destruction of the ankle and talus (without neuropathy). A true tibiotalocalcaneal fusion requires structural bone graft and has a longer healing time, a higher nonunion rate, and inferior outcomes compared with routine ankle fusion. Resection of the talar body (talectomy), possibly with a Blair fusion (fusion of the talar neck to the distal part of the tibia), is another option but is similar to tibiotalocalcaneal fusion, with lots of stiffness and mediocre results3. Transtibial (below-the-knee) amputation is another possibility and may offer better outcomes in younger patients, but with obvious long-term financial, emotional, and psychological costs. A cement arthroplasty is yet another method for salvage of a destroyed ankle joint with loss of the talus. Because cement can elute antibiotics, it is particularly tempting for difficult infections. The recovery time is probably faster than that of a true tibiotalocalcaneal fusion or a Blair fusion, so it is more appealing to an older patient who has already been through several operations. However, for most patients with nonunion of an ankle fusion or a failed total ankle replacement, surgical revision to an isolated ankle fusion remains the first choice. Ankle arthrodesis, in the setting of functioning subtalar and hindfoot joints, provides good results. In fact, recent studies suggest that ankle fusion may be almost as good as ankle replacement4-6. The goal of ankle arthrodesis is to restore alignment and obtain a solid osseous fusion, so how can cement arthroplasty, whose goal is fibrous nonunion, be considered successful? To really understand how cement arthroplasty works, one has to study the patients in this article and the problems for which they were treated. Seven of the sixteen patients had diabetes and thus may have had some degree of peripheral neuropathy and, consequently, more tolerance of a painful condition. Furthermore, the problem being treated was so bad in many cases that even a mediocre result can be considered a ‘‘home run.’’ To go from a painful, deformed, infected ankle to one that is less sore, more straight, more stable, and not infected is a big step forward. Finally, are the outcomes of these patients really that good? Three of the sixteen used a walking brace for normal ambulation, three used a cane or crutches, and one used a wheelchair. The importance of this study is that it increases recognition of the problem presented by patients with loss of the ankle joint and destruction of much of the talus. As more ankle arthroplasties are performed, there may be more patients with this problem. Many painful total ankle replacements can be successfully addressed with total ankle revision. However, talar body fracture below an implant and recalcitrant infection are unsolved problems that will become more prevalent in the near future as the rate of ankle replacement increases over time.
J Bone Joint Surg Am. 2014;96:e152(1-2)
d
http://dx.doi.org/10.2106/JBJS.N.00630
e152(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 17 S E P T E M B E R 3, 2 014 d
d
C O M M E N TA RY & P E R S P E C T I V E
d
We need to develop techniques to deal with catastrophic failure of total ankle replacements. The biggest problem is talar bone loss, but other problems include soft-tissue stiffness/fibrosis and loss of limb length. Cement ankle arthroplasty is one tool in our ‘‘bag of tricks’’ that we can use to salvage a difficult situation. Congratulations to the authors for bringing this problem and procedure into the light. Justin Greisberg, MD* Columbia University, New York, NY *The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
References 1. Magnan B, Facci E, Bartolozzi P. Traumatic loss of the talus treated with a talar body prosthesis and total ankle arthroplasty. A case report. J Bone Joint Surg Am. 2004 Aug;86(8):1778-82. 2. Tsukamoto S, Tanaka Y, Maegawa N, Shinohara Y, Taniguchi A, Kumai T, Takakura Y. Total talar replacement following collapse of the talar body as a complication of total ankle arthroplasty: a case report. J Bone Joint Surg Am. 2010 Sep 1;92(11):2115-20. 3. Van Bergeyk A, Stotler W, Beals T, Manoli A 2nd. Functional outcome after modified Blair tibiotalar arthrodesis for talar osteonecrosis. Foot Ankle Int. 2003 Oct;24(10): 765-70. 4. Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. 5. Saltzman CL, Kadoko RG, Suh JS. Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop Surg. 2010 Mar;2(1):1-7. Epub 2010 Feb 4. 6. Schuh R, Hofstaetter J, Krismer M, Bevoni R, Windhager R, Trnka HJ. Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome. Int Orthop. 2012 Jun;36(6):1207-14. Epub 2011 Dec 16.
