Ankle Fusion Takedown to Total Joint Arthroplasty

Kaitie Ward R2 WSPMA Annual Conference 04/30/2017

No Disclosures

Literature Review Ankle Arthrodesis= Gold standard for end stage ankle arthritis [1-3]

Poor outcomes persist: [1,2,4,5] Infection Nonunion Malalignment Adjacent joint destruction

Literature Review

Possible secondary interventions: [1,2,4-7] Revision arthrodesis

Extension of the fusion mass

Talar allograft

Amputation

Total ankle arthroplasty (TAA)

Literature Review

Sequelae of ankle arthrodesis Adjacent joint arthritis Subtalar joint

Negatively influence functionality and quality of life [4-6] Decreased rate of successful fusion when compared to non-ankle arthrodesis

[8].

Pantalar joint arthrodesis is frequently poorly tolerated Oxygen consumption equivalent to BKA [3,9,10]

Takedown Fusion to TAA= Additional treatment modality with high patient satisfaction [1-3,5,6].

May be considered in: Absence of infection Appropriate bone quality [1,3]

More favorable outcomes: Definable source of pain Lower metabolic demand Advanced age Shorter duration of primary

fusion Lack of fibular resection

[2,5,6]

Literature Review

Case Series

To present ankle fusion takedown and conversion to arthroplasty as an additional alternative treatment option for unfavorable outcomes of ankle arthrodesis.

Methodology

Retrospective chart review 2009-2015 Mean follow-up=147 months Single surgeon 4 patients Demographics, comorbidities, procedure details, and complications were

evaluated Assessment of ankle ROM, subjective pain levels, weight bearing radiographs

and patient’s activity level

Procedures Ankle arthrodesis takedown and conversion to TAA performed by primary

surgeon in 4 pts Indications:

Ankle nonunion Increasing hindfoot pain Subtalar joint arthritis Decreased function Malunion

Traditional anterior approach Pre-operative imaging Previous joint location Osteotomy placement Sufficient medial and lateral malleoli for stability Implantation of a two-component constrained implant

Results

Age/Sex/ Laterality

Comorbidities Indications Time from Arthrodesis

(Months)

Subtalar Joint

Arthrodesis

Complications Final Follow-Up (Months)

Subjective Results

Objective Results

75/F/L Diabetes mellitus II Rheumatoid

arthritis

Ankle nonunion 11.3 No Superficial wound dehiscence

66.8 No pain Very pleased

Mild swelling Incision healed Ankle ROM- DF

+10°, PF +25°

73/M/R Peptic ulcer disease Hypertension Hyperlipidemia

STJ DJD 144.7 Yes, concurrent Superficial wound dehiscence with

infection

3.9 Mild pain Moderate swelling

Incision healed Ankle ROM- DF

+10°, PF + 25°

53/F/L Gastric ulcers Seizure disorder Osteopenia Chronic Pain Smoker

Ankle nonunion 32.4 Yes, subsequent Hardware irritation 57.4 Not tender over ankle

Mild swelling Incision healed Light touch

sensation decreased

Ankle ROM- DF +0°, PF +20°

60/F/R Fibromyalgia Ankle nonunion 20.2 No STJ arthritis 18.6 Not tender over ankle

Pain and stiffness at STJ

Mild swelling Incision healed STJ ROM-

Limited Ankle ROM- DF

+5°, PF +20°

Average- 65 Average- 52.2 Average- 36.7

Case Example 73 yo M

12 years s/p right ankle arthrodesis

Pre-Operative Ankle Views

Post-Operative Ankle Views

Analysis & Discussion

Complex patient factors for poorly tolerated ankle fusions Lack of consensus for treatment of STJ arthritis STJ pathology at some point in treatment course Salvage vs. fusion Fibular resection

Conclusion

TAA may be utilized as a salvage procedure 4 patients with favorable outcomes

Average final follow-up of 36.7 months

More studies needed Staging vs unstaged?

References

1. Barg A, Hintermann B. Takedown of Painful Ankle Fusion and Total Ankle Replacement Using a 3-Component Ankle Prosthesis. Tech Foot Ankle Surg. 9(4):190-198,2010.

2. Greisberg J, Assal M, Flueckiger G, Hansen ST. Takedown of Ankle Fusion and Conversion to Total Ankle Replacement. Clin Orthop Relat Res. 424:80-88,2004.

3. Raikin, SM, Rampuri V. An Approach to the Failed Ankle Arthrodesis. Foot Ankle Clin. 13(3):401-416,2008. 4. Coester L, Saltzman CL, Leupold J, Pontarelli W. Long-Term Results Following Ankle Arthrodesis for Post-Traumatic

Arthritis. J Bone Joint Surg. 83(2):219-228,2001. 5. Hintermann B, Barg A, Knupp M, Valderrabano V. Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty. J

Bone Joint Surg. 91:850-858,2009.

6. Hintermann B, Barg A, Knupp M, Valderrabano V. Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty-Surgical Technique. J Bone Joint Surg. 92 Suppl 1:55-66,2010.

7. Giannini S, Buda R, Cavallo M, Ruffilli A, Fornasari PM, Vannini F. Conversion of Painful Ankle Arthrodesis to Bipolar Fresh Osteochondral Allograft: Case Report. FAI. 33(8):678-681,2012.

8. Zanolli, DH, Nunley JA, Easley ME. Subtalar Fusion Rate in Patients with Previous Ipsilateral Ankle Arthrodesis. FAI. 36(9):1025-1028,2015.

9. Acosta R, Ushiba J, Cracchiolo A. The Results of a Primary and Staged Pantalar Arthrodesis and Tibiotalocalcaneal Arthrodesis in Adult Patients. FAI. 21(3):82-194, 2000.

10.Pappa JA, Myerson MS. Pantalar and Tibiotalocalcaneal Arthrodesis for Post-Traumatic Osteoarthrosis of the Ankle and Hindfoot. J Bone Joint Surg. 74:1042-1049,1992.

Thank You