salvage arthrodesis after failed ankle replacement

Salvage Arthrodesis After FailedAnkle ReplacementSurgical Decision Making

Mark J. Berkowitz, MDa,*, Roy W. Sanders, MDb,Arthur K. Walling, MDb

KEYWORDS

� Ankle fusion � Tibiotalocalcaneal fusion � Failed ankle replacement � Allograft� Arthroplasty

KEY POINTS

� Despite improvement in design and instrumentation, failure of total ankle replacementsremains a common problem.

� Loss of bone stock frequently prevents successful revision of the failed total ankle leavingfusion as the treatment of choice.

� Quality of talar bone stock and condition of the subtalar joint determine whether an iso-lated ankle fusion is viable or whether the fusion must be extended to include the subtalarjoint as well.

� Addressing the large bone defect after implant removal and achieving stable internal fixa-tion remain the primary technical challenges.

� Successful results are possible using structural allogenic bone graft and aggressiveinternal fixation.

INTRODUCTION

The first generation of total ankle replacements experienced an unacceptably highrate of complication and overall failure, with reoperation rates as high as 41%.1–9

Improvements in the design of total ankle arthroplasty (TAA) components and refine-ments of surgical technique have built on this disappointing initial experience andmade TAA a legitimate treatment alternative to fusion in the management of theseverely arthritic ankle.10

a Orthopaedic and Rheumatologic Institute, Cleveland Clinic, A40, 9500 Euclid Avenue, Cleveland,OH 44195, USA; b Florida Othopaedic Institute, 13020 Telecom Parkway North, Temple Terrace,FL 33637, USA* Corresponding author.E-mail address: [email protected]

Foot Ankle Clin N Am 17 (2012) 725–740http://dx.doi.org/10.1016/j.fcl.2012.08.009 foot.theclinics.com1083-7515/12/$ – see front matter � 2012 Elsevier Inc. All rights reserved.

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Yet, despite early evidence of decreased complications and improved outcomeswith the newer TAA designs, the current state of total ankle replacement has not yetachieved a commensurate level of success compared with total knee and total hiparthroplasty.8,11–24 Whereas long-term survival rates greater than 95% have beenachieved in both total knee and total hip arthroplasty, the rate of failure and reopera-tion remains substantially higher after total ankle replacement.25,26

Numerous factors contribute to the high rate of failure of ankle replacement,including component loosening and subsidence, malalignment, mis-sizing of compo-nents, ligamentous instability, dislocation of the polyethylene component, syndes-motic nonunion, impingement with either medial or lateral malleolus, persistent pain,compromise of the soft tissue envelope, and deep infection.9,27

In certain situations, complications associated with total ankle replacement can beaddressed such that the prosthesis can be retained or successfully revised. Spirt andcolleagues10 reviewed 306 consecutive Agility total ankle arthroplasties and reportedtheir experience managing complications associated with ankle replacement. Despitea 28% rate of reoperation and a 5-year survival rate of 54% with reoperation as theend point, only 2.9% of the prostheses could not be salvaged. The most commonprocedures performed included debridement of osseous impingement, correction ofaxial malalignment, and replacement of loose components. Only 1 patient requiredankle fusion and 8 patients underwent transtibial amputation.Despite the success of the authors of this study in achieving retention of the pros-

thesis, in many instances this is not possible, particularly when the components aregrossly loose, the soft tissue envelope is tenuous, and bone stock is compromised.24

In these difficult situations, salvage of the lower extremity with conversion to fusionhas been and remains the standard treatment.3,6,7 Ideally, the fusion is limited tothe tibiotalar joint to preserve subtalar and hindfoot motion. But in some instances,the fusion cannot be limited to the tibiotalar joint. This situation occurs when talarbone stock is so limited that adequate fixation cannot be achieved across the anklealone or when the subtalar joint has developed arthrosis or become violated by subsi-dence of the talar component. In these situations, tibiotalocalcaneal fusion isindicated.In both of these situations, the conversion of the failed ankle replacement to fusion

presents a technically difficult undertaking primarily because of 2 fundamental chal-lenges: how to manage the large resultant bone defect and how to achieve optimalfixation. Each of these challenges is more complex when the fusion involves boththe ankle and hindfoot. The bone defect is invariably larger when tibiotalocalcanealfusion is indicated, and fixation must adequately stabilize both motion segments ifsuccessful fusion is to occur. This article focuses on the indications for isolated anklefusion versus tibiotalocalcaneal fusion and presents a variety of bone grafting andinternal fixation strategies designed to achieve successful salvage of these difficultcases.

HISTORICAL PERSPECTIVE

Initial reports of fusion for the failed total ankle replacement primarily used autogenicbone graft and a combination of external fixation and casting. Stauffer7,28 treated17 patients with a modified Chuinard technique in which horizontally oriented blocksof autologous tricortical iliac crest as well as cancellous autograft were used to fill thebone defect. Stabilization was achieved with compression external fixation for2 months followed by casting for 2 additional months. Groth and Fitch3 also usedstructural iliac crest blocks but oriented them vertically similar to the technique

Salvage Arthrodesis After Failed Ankle Replacement 727

described by Campbell and colleagues29 to better preserve the height of the ankle.These investigators relied on 6 to 9 months of cast immobilization to achieve fusion.Newton6 avoided the use of bone graft altogether by resecting the malleoli and short-ening the limb. Fixation was achieved with a transfixion pin placed through the heeland compression external fixation.The largest of the early reports was published by Kitaoka and Romness.4 Their

series of 38 failed Mayo total ankles remains the most extensive in the literature.They used 4 different techniques in their patients: malleolar resection with primarybone apposition (13 patients); modified Chuinard technique (18 patients); a modifiedCampbell procedure (2 patients); and posterior tibiotalocalcaneal fusion (5 patients).Compression arthrodesis was performed using external fixation in 36 cases andscrews in 2 cases. Thirty patients underwent isolated ankle fusion and 8 underwenttibiotalocalcaneal fusion. The investigators reported overall favorable outcomeswith this approach. They achieved an 89% union rate (4 nonunions) and a 13%perioperative complication rate, excluding the nonunions. Eight patients requiredreoperation. Clinically, 80% were satisfied with their outcome, 67% reported nopain postoperatively, and 57% had no activity restrictions. The investigators clearlyhad concerns about using bone graft to maintain limb length. Two of their4 nonunions occurred in patients with larger bone defects in whom the modifiedCampbell technique was performed. This experience led the investigators torecommend accepting some degree of limb shortening and using Chuinard bonegrafting rather than more aggressive bone grafting techniques aimed at preservinglimb length.

CURRENT LITERATURE

A review of more recent reports shows a definite shift toward use of internal fixationdevices with continued variability in the choice of bone graft. Carlsson andcolleagues30 reported on a series of 21 patients with failed ankle replacements,most of whom had inflammatory arthritis. Most (16/21) were stabilized using anexternal fixator, and 8 patients developed nonunion, including all patients in whomstructural allograft was used (2 of 21). Four of these nonunions were successfullyrevised but 4 nonunions persisted, 1 of which was treated with transtibial amputa-tion. Based on their results, Carlsson and colleagues recommended against use ofstructural allografts. However, several years later the same investigators31 reportedon a series of 16 additional patients who underwent tibiotalocalcaneal fusion withan intramedullary nail rather than external fixation. Using this technique, the investi-gators achieved an 81% fusion rate, and concluded that intramedullary nail fixationwas superior to external fixation. Kotnis and colleagues32 reported on 9 patients withfailed ankle replacements who underwent tibiotalocalcaneal arthrodesis using anintramedullary nail and distal fibular autograft and achieved a 100% union rate. Cul-pan and colleagues33 converted 16 failed ankle replacements to isolated ankle fusionusing a modified Campbell technique and 4.5-mm lag screws. These investigatorsemphasized the principles of maintenance of limb length and tendon function andpreservation of the malleoli and subtalar joint and experienced only a singlenonunion. Hopgood and colleagues34 in England recently presented their experienceconverting 23 failed TAAs to fusion using 3 different techniques: isolated ankle fusionwith screws (8 patients), ankle-hindfoot fusion with an intramedullary nail(10 patients), and ankle-hindfoot fusion with screws (5 patients). These investigatorsdid not use structural bone graft in any cases out of a concern for nonunion. Instead,shortening was accepted in most cases to achieve native bone apposition and

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supplemented with either cancellous autograft or an osteoconductive substitute suchas calcium sulfate or calcium triphosphate. Fusion was achieved in 17 of the 23ankles treated. Based on their results, the investigators recommended an intrame-dullary nail as the preferred implant when bone loss is severe but did find a screwconstruct successful for isolated ankle fusion in patients who did not have rheuma-toid arthritis. Poor results and a high nonunion rate led the investigators to abandonthe screw construct for tibiotalocalcaneal fusion. Eight patients required the use ofa shoe lift either built into the shoe or incorporated into a shoe insert to accommo-date limb shortening.We reported on our experience treating 24 failed ankle replacements including

12 ankle fusions and 12 tibiotalocalcaneal fusions.35 Structural allograft and internalfixation were used exclusively. The most common complication was nonunion ofthe subtalar joint in 4 patients who underwent tibiotalocalcaneal fusion. Each wassuccessfully revised when a separate sinus tarsi incision was used to formally preparethe subtalar joint. Based largely on this experience, we have developed an approachto the conversion of failed total ankles to fusion that is tailored to the particular char-acteristics of each individual patient but is based on the principles of maintaining skel-etal length with aggressive use of structural allograft bone and exclusive use of internalfixation devices. The surgical decision making involved in this approach is presentedin the following sections.

PREOPERATIVE EVALUATION

A diligent history and physical examination is performed in all patients with persistentpain associated with an ankle replacement.27 Location and character of the patient’spain is recorded and any provocative maneuvers noted. It is important to assess if thesubtalar joint is serving as a pain generator. Passive range of motion of both the ankleand subtalar joint is assessed and it is noted whether these maneuvers reproduce thepatient’s pain. Subtalar motion on the affected side should be compared with thenormal side to determine any relative loss of motion. Selective injection of the subtalarjoint under fluoroscopy with lidocaine can further assess the degree to which the sub-talar joint is contributing to the patient’s pain symptoms. Alignment is evaluated byviewing the patient both from the front and back while the patient is standing. Gaitis also observed with particular attention to the presence of varus or valgusmalalignment.Particular attention is paid to signs and symptoms of potential deep infection. It

is important to elicit whether the patient has any history of infection, antibiotic use,or difficulty healing the surgical incision. The condition of the skin is closely eval-uated for signs such as warmth, erythema, or drainage. The location of previousincisions should be recorded as well. Signs of vascular disease such as absentpulses or venous stasis changes should be noted and warrant formal vascularevaluation.All patients are evaluated with weight-bearing anteroposterior (AP), mortise, and

lateral ankle radiographs in addition to AP, lateral, and oblique weight-bearing viewsof the foot. Radiographs are closely scrutinized for areas of lysis around the implant,with particular attention paid to the talar component. Obvious subluxation of totalankle components is readily detected, but it may be necessary to perform a carefulcomparison with previous radiographs to detect more subtle changes in implantposition. The presence and severity of subsidence of the talar component shouldbe recorded, with particular attention paid to the remaining talar bone stock(Fig. 1). If there has been subsidence of the talar component, the integrity of the

Fig. 1. (A) Lateral radiograph of STAR (Scandinavian Total Ankle Replacement) prosthesis2 years after implantation. Note substantial talar bone stock and absence of any subsidenceof the talar component. (B) Lateral radiograph of the same patient 6 years after implanta-tion, showing mild talar subsidence. (C) Lateral radiograph 11 years after implantation, withsubsidence into the subtalar joint and severe degradation of talar bone stock. The patientrequired tibiotalocalcaneal fusion with femoral head allograft.


subtalar joint must be assessed. It is also important to look for any signs of subtalararthrosis.Routine laboratory evaluation includes white blood cells, erythrocyte sedimentation

rate (ESR), and C-reactive protein (CRP). Increases of both ESR and CRP togethermay suggest the presence of deep infection.36 If infection is highly suspected, consid-eration can be given to aspiration of the joint.

SURGICAL DECISION MAKING

Based on the results of the preoperative evaluation, the patient can be counseledregarding the expected nature of the surgery. It is also important to include some flex-ibility in the surgical plan, because intraoperative findings may not be consistent withthe preoperative workup. Four critical surgical decisions need to be made during thecourse of this procedure: (1) Is infection present? (2) Can the fusion be limited to theankle joint or must the subtalar joint be included? (3) Which bone graft is most appro-priate? (4) Which internal fixation is most appropriate? Each of these topics is dis-cussed in the next sections (see flowchart).

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Failed Total Ankle

Replacement

Preop. eval -Erythema, drainage, elevated ESR and CRP

Evaluate subtalar joint and talar bone stock

Intraoperative signs of sepsis -Purulence, >5 PMN’s phpf

Staged fusion Antibiotic cement spacer, IV antibiotics

Severe talar bone loss Arthritic STJ Subsidence into STJ

Significant residual talusHealthy subtalar joint

Isolated ankle fusion

TCC fusion

Small bone defect

Shortening Cancellous allograft

Anterior plate and screws

Large bone defect (>2 cm)

Structural bone graft -IlC allograft -Distal tibial allograft

AO spoon plate AO fusion plate AO locking

Large bone defect

Femoral head allograft

Nail Plate Nail:plate

Is Infection Present?

If infection is suspected based on the preoperative evaluation, the patient should becounseled regarding the potential for a staged procedure. Intraoperatively, synovialbiopsy specimens are sent for pathologic evaluation and culture. If the gross appear-ance is consistent with infection or if specimens reveal greater than 5 polymorphonu-clear leukocytes per high power field and suspicion for infection is high, a stagedprocedure is initiated, consisting of implant removal, aggressive bone debridement,and placement of a monoblock antibiotic cement spacer (Fig. 2). The cement is

Fig. 2. AP radiograph of monoblock antibiotic cement spacer in place after initiation ofstaged conversion to fusion.


impregnated with a high concentration of antibiotics, usually 3 g of vancomycin and3.6 g of tobramycin per package of cement. Eventually, culture-specific intravenousantibiotic therapy is initiated for usually 6 weeks. Conversion to fusion proceedsonly when all clinical and laboratory signs of infection have resolved.

Can the Fusion be Limited to the Ankle?

If the subtalar joint is radiographically healthy and not believed to be a source of pain,and if talar bone stock is well preserved and deemed capable of supporting stableinternal fixation, every attempt should be made to limit the fusion to the ankle. Notonly does this preserve hindfoot motion but it is a simpler, more straightforwardsurgical procedure that achieves higher functional scores and fewer complica-tions.33,35,37–41 This decision can be made only after the implants have been removedand nonviable talus has been debrided back to healthy, bleeding bone, becausepreoperative radiographs may underestimate the loss of talar bone stock that ispresent.Conversely, if the subtalar joint is determined to be contributing significantly to the

patient’s pain or is severely arthritic or violated by talar subsidence, the decision ismade to perform a tibiotalocalcaneal fusion. Tibiotalocalcaneal fusion is also indicatedif the remaining talar bone stock is found to be severely compromised. If tibiotalocal-caneal fusion is chosen, it is important to achieve adequate exposure so that the jointcan be appropriately denuded of cartilage. The subtalar joint can be exposed throughthe anterior incision if the talus has been severely eroded. However, if for instance, thesubtalar joint is arthritic but the residual talus is substantial, then a separate sinus tarsiincision is required to properly prepare the subtalar joint. Failure to achieve this

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preparation increases the risk of subtalar nonunion.35 Some patients may have alreadyundergone subtalar fusion in a previous procedure. In these instances, only the tibio-talar joint requires formal preparation and fusion, but internal fixation implants canreadily cross the fused subtalar joint to improve fixation.

Which Bone Graft is Most Appropriate?

Both tibial and talar bone stock is lost at several stages in the treatment of thesepatients, including the primary arthroplasty, any revision arthroplasty procedures,in vivo osteolysis, the removal of implants, and the bone preparation required afterimplant removal.9 A rational approach to assessing the severity of the bone defectand choosing an appropriate bone grafting strategy is required. This decision canbe made only after the components have been removed and a thorough and aggres-sive bone debridement performed. This strategy allows an accurate assessment of thedimensions of the resultant bone defect and guides the most appropriate choice forbone grafting.The simplest scenario is when a significant portion of the residual talus remains

intact and viable such that the bone defect remains small (2 cm). In this situation,the ankle alone can be fused and the subtalar joint spared. Nonstructural cancellousbone grafting in addition to judicious shortening of the limb are all that is needed toeliminate the defect (Fig. 3). This technique is the fastest andmost technically straight-forward, but should be reserved for small bone defects (<2 cm), when some degree oflimb shortening is acceptable to the patient. Even if the loss of limb length is deemedto be acceptable, attention must be paid to ensure that malleolar impingement doesnot occur when the bone surfaces are impacted, which may be a source of pain orimpede correction of varus or varus deformity.More frequently, the resultant bone defect is greater than 2 cm and requires struc-

tural bone grafting (Fig. 4). The benefits of structural grafting include the ability toreconstitute and maintain limb length with preservation of normal musculotendinousfunction as well as the ability to create a stable, compression arthrodesis.27,29

Although iliac crest autograft can be considered in this situation, such as in the

Fig. 3. (A) AP radiograph of loose, painful STAR total ankle in low-demand 82-year-old man.(B) Lateral radiograph after conversion to ankle fusion with primary shortening and use ofnonstructural cancellous bone graft. Note the lag screws aimed into the healthy anteriortalar bone stock.

Fig. 4. Typical bone defect after component removal.


modified Campbell technique, the morbidity of autologous iliac crest bone harvest isnot insignificant. Donor site pain, meralgia paresthetica, herniation, hematoma, infec-tion, and fracture have led us to move almost categorically away from structural auto-graft to allograft.42–45

Several options exist for structural allograft, each showing specific qualities withrespect to its preparation and handling that should be kept in mind when choosing.The modified Campbell technique can be performed with tricortical blocks cut from

either iliac crest or femoral head allograft. This form of allograft is readily available inmost hospitals, and provides a simple technique for filling the gap. A sagittal saw isused to cut multiple rectangular wedges of bone that are then impacted to fill thedefect remaining after TAA implant removal (Fig. 5). Residual gaps between thehost bone and the wedges of allograft are filled with cancellous bone.Another option is fresh-frozen distal tibial allograft. Distal tibial allograft is attractive

in that it can be cut to almost exactly fill the defect left after removal of the tibial and

Fig. 5. Intraoperative photograph depicting modified Campbell technique using iliac crestallograft wedges to fill the bone defect after implant removal.

Berkowitz et al734

talar components (Fig. 6). This potential for intimate fit and bony contact maydecrease the need for additional bone grafting and minimize the risk of nonunion.However, significant time and attention are necessary to achieve this intimate fit.Numerous trials are usually required, and it is not uncommon to spend 25 to 30minutes contouring this graft before an acceptable fit is achieved. This graft mayalso require special procurement, because it is not routinely available in mosthospitals.When talar bone stock is severely compromised and tibiotalocalcaneal fusion is

indicated, large bulk allografts are required to fill the significant defect. Themost usefulgraft choice in this situation is fresh-frozen femoral head allograft.46–49 We use a tech-nique using acetabular reamers to prepare the bone bed and create concentricsurfaces for fusion through the anterior approach routinely used for ankle arthroplasty(Fig. 7). After implant removal and initial debridement of the bone surfaces, an acetab-ular reamer, usually size 40 to 44 but chosen based on the patient’s size, is used tocreate a concave bleeding bone surface out of the distal tibia. To achieve the appro-priate exposure, Homan retractors are used to retract the soft tissue medially andlaterally, the foot is allowed to plantarflex and fall posteriorly, and the distal tibia artic-ular surface is delivered into the surgical wound. If the talus is severely eroded, theacetabular reamer can also be used to create another concave surface out of theposterior facet of the calcaneus. Alternatively, if residual talus is substantial, a flatcut of the talus can be used. The femoral head allograft is then placed into the defect.Concave reamers from a hip resurfacing instrumentation set can be used to improvethe fit of the allograft into the recipient bed if needed. The hindfoot and ankle are thenpositioned appropriately for fusion. The concentric nature of the graft-bone interfacefacilitates final adjustment of the position of fusion and is more forgiving than flat cuts.Internal fixation can then be placed.Femoral head allograft has proved useful in addressing even massive bone defects

after failed ankle replacement. However, nonunion, fracture, and disease transmissionremain concerns. In our series of 24 failed ankle replacements, 4 patients developedsubtalar nonunion, 1 patient developed a nonunion at the interface with the talar head,and 1 patient experienced fracture of the femoral head allograft.35 As mentionedearlier, it is important to ensure that the subtalar joint is adequately prepared throughthe anterior incision. A separate Ollier incision should be used liberally if the adequacyof subtalar preparation is in doubt Fig. 8. In addition, all large structural allografts areaugmented with osteoinductive materials such as iliac crest bone marrow aspirate,

Fig. 6. (A) Lateral radiograph of persistently painful Buechel-Pappas prosthesis. Note pres-ervation of substantial talar bone stock. (B) Patient underwent successful conversion to iso-lated ankle fusion using distal tibial allograft and an AO fusion plate with lag screws.

Fig. 7. (A) Fresh-frozen femoral head allograft before preparation. (B) Acetabular reamercreating concentric concave surface of bleeding bone in distal tibial articular surface.(C) Femoral head after inferior flat cut has been performed. (D) Femoral head allograft afterinsertion filling bone defect. (E, F) AP and lateral radiographs showing incorporation offemoral head allograft at both talar and tibial interfaces.


Fig. 8. Lateral radiograph showing subtalar nonunion in talocalcaneal fusion using femoralhead allograft and nail-plate construct.

Berkowitz et al736

demineralized bone matrix, and bone morphogenetic protein to minimize the risk ofnonunion.

Which Internal Fixation is Most Appropriate?

An anterior plate and lag screw construct is effective at achieving successful isolatedtibiotalar fusion after failed ankle replacement. However, the choice of plate and theorientation of the lag screws are important. A 3.5-mm pelvic reconstruction plateand lag screws has proved successful in standard ankle fusions without a bonedefect,50 but it should be used after failed ankle replacement only when shorteningis performed and structural bone graft is not used. A stronger plate is needed whena bone defect is present. Structural grafts, particularly allografts, require longerperiods for incorporation and require a more stable plate construct to allow forcreeping substitution.44,51 In this situation, an Arbeitsgemeinschaft fur Osteosynthe-sefragen (AO) spoon plate, AO ankle fusion plate, or AO large fragment locking T-platesupplemented with cannulated lag screws provides a stable and low profile construct.It is also recommended to use the home run screw, placed from posterolateral to ante-romedial. Not only has a screw placed in the sagittal plane been shown to increaseoverall rigidity and resist shear with plantarflexion-dorsiflexion, but this screw obtainspurchase in the intact anterior half of the talus, which is not usually affected by lysisand erosion.52 Screws placed in the coronal plane should also be aimed slightlymore anterior into the healthier residual talus (Fig. 9).For tibiotalocalcaneal fusions, even greater stability is required in light of the allo-

graft being larger and the fact that fixation is required across both the ankle and thesubtalar joints. Three constructs can be considered in this situation: intramedullaryhindfoot nail, anterior plate, combined nail-plate. Each of these options has been

Fig. 9. Lateral radiograph of isolated ankle fusion with distal tibial allograft using posteriorto anterior home run screw to engage healthy anterior talar bone. Note anterior AO spoonplate also included in construct.


shown capable of achieving successful fusion.35 Whether a nail, plate, or combinedconstruct is used, it is important to pay particular attention to subtalar fixation,because this is the joint most prone to nonunion. Multiple lag screws should be placedacross the talocalcaneal joint, whether a plate or nail is being used (Figs. 10 and 11).Although axial compression can be applied using modern intramedullary hindfootnails, this compression is not applied perpendicular to the posterior facet of the sub-talar joint. The interlocking bolts used in these hindfoot nails do not provide a lag effectacross the joint. Adding additional subtalar compression screws can make up for thisinherent limitation with the nail.

Fig. 10. Lateral radiograph showing multiple lag screws placed across the subtalar joint intibiotalocalcaneal fusion with femoral head allograft.

Fig. 11. Lateral radiograph reveals successful tibiotalocalcaneal fusion with nail: plateconstruct. Note additional lag screws outside the nail to stabilize the subtalar joint.

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SUMMARY

As total ankle designs improve, ankle arthroplasty will continue to evolve asa competing alternative with ankle fusion for the treatment of end-stage ankle arthritis.This situation ensures that the failed ankle replacement will continue to presenta complex array of surgical challenges. Ruling out infection must always be theprimary consideration, followed by determining whether the extent of fusion can belimited to the ankle. The surgeon must then have multiple weapons in the armamen-tarium to address the bone defect and achieve stable internal fixation. Addressingthese 4 critical considerations allows fusion to remain a viable means of salvagingthe failed ankle replacement.

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salvage arthrodesis after failed ankle replacement

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