Conversion of Ankle Arthrodesis to Total Ankle Arthoplasty How I - - PowerPoint PPT Presentation

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Conversion of Ankle Arthrodesis to Total Ankle Arthoplasty How I - - PowerPoint PPT Presentation

Jun 30, 2023 296 likes •613 views

Conversion of Ankle Arthrodesis to Total Ankle Arthoplasty How I do it and the results? Michael J. Coughlin, M.D. Boise, Idaho Conflicts None for this talk Consultant with Arthrex, Stryker, Integra Royalties from Arthrex, Stryker,

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Conversion of Ankle Arthrodesis to Total Ankle Arthoplasty How I do it and the results?

Michael J. Coughlin, M.D. Boise, Idaho

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Conflicts

  • None for this talk
  • Consultant with Arthrex, Stryker, Integra
  • Royalties from Arthrex, Stryker, Integra,

Erchonia

  • Textbook royalties- Elsevier
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Outline

  • Case Examples
  • Review Literature
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Case example

  • 60 yo F posttraumatic arthritis of the ankle after a fall

from a ladder in 1997. Presents with a painful nonunion of the tibiotalar joint arthrodesis. Arthroscopic ankle fusion (s/p removal of hardware)

  • With severe subtalar and talonavicular arthrosis.
  • PMH: DM
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CT scan

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Options?

  • 1. Tibiotalocalcaneal arthrodesis

with talonavicular arthrodesis, +/- calcaneocuboid arthrodesis

  • 2. Triple arthrodesis and conversion
  • f tibiotalar nonunion to total ankle

arthroplasty

  • 3. Nonoperative options (brace)
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Indications for take down TAR

  • Painful nonunion or

malunion of a tibiotalar arthrodesis

  • Subtalar arthritis following

tibiotalar fusion

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Contraindications

  • Infection
  • Absence of distal fibula
  • Metal allergy
  • Concern for soft tissues
  • Ligamentous injury
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Let’s look at the literature!

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  • N=19 Agility ankles, avg follow up 39 months
  • 15 reoperations, 3 BKAs (16%)
  • Mean ROM 26 degrees
  • AOFAS score 42 to 68 (D+)
  • Patients with a clear diagnosis did best postop
  • Ankles without a lateral malleolus did poorly

C.O.-2004

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Not sufficient anatomy- absent fibula!

This bridge has been burned!

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Absent medial and lateral malleolus!

Don’t make things more complicated.

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  • N=30 Hintegra ankles, follow up avg 56 mos
  • Average ROM 24 degrees
  • AOFAS score 34 to 71 (C-)
  • 77% satisfied
  • 5 intraop fractures, 1 conversion to TTC nail, 1 talar

component revision (subsidence) osteopenia

  • Felt mobile bearing was more forgiving than fixed

bearing devices

  • Be prepared to treat ligamentous instability

– Deltoid ligament attenuation or rupture

JBJS-2009

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  • N=23 ankles, avg follow up 33 mos
  • VAS score 65.7 to 18.3
  • SF-36 score 37.7 to 19.3
  • Mean ROM 23 degrees
  • 20% of tibial components and 70% talar components

subsided

  • 87% implant survival, 1 required TTC nail
  • 3 talar implants (13%) required revision
  • Suggest prophylactic malleolar screw fixation

JBJS-2015

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Talar subsidence

  • this is a problem-

Very difficult salvage!

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You might watch this! It may sink more!

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Initial x-ray look good!

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Talar subsidence!

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A difficult salvage!

TTC rod and allograft

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  • N=5, avg 21 mo

follow-up

  • 4/5 satisfied
  • Postop VAS 31.3
  • Postop AOFAS

82.6

  • Avg ROM 35

degrees

  • No significant

complications

Charlotte group

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Staged revision surgery

  • Underwent triple arthrodesis with staged STAR total

ankle arthroplasty

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  • Tibiotalar nonunion takedown and conversion to

STAR total ankle arthroplasty

  • Revision subtalar and talonavicular fusion due to

delayed union

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  • 8 years out from

surgery

  • Pain 0-1/10
  • ROM 35 degrees
  • Climbed Diamond

Head on Waikiki and hiked Machu Picchu postop

By Martin St-Amant (S23678) - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=8450312 By Cristo Vlahos - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=23207465
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  • Patients must be aware of

risk-the downside

  • Selected patients
  • Who desire motion
  • Minimal osteopenia
  • Intact malleoli
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Lateral fusion with absent fibula- Don’t think about it!

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Severe ankle DJD, varus and translation (prior ST fusion)

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This has the anatomy, and you can consider a takedown But you are trading a solid fusion for a somewhat unknown future!

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8/12/2013

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Bibliography

  • Greisberg J, Assal M, Flueckiger G, Hansen ST.

Takedown of ankle fusion and conversion to total ankle

  • replacement. Clin Orthop Rel Res 2004;424:80-8
  • Hintermann B, Barg A, Knupp M, Valderrabano V.

Conversion of painful ankle arthrodesis to total ankle

  • arthroplasty. J Bone Joint Surg Am 2009;91:850-8
  • Pellegrini MJ, Schiff AP, Adams SB, Queen RM, DeOrio

JK, Nunley JA, Easley ME. Conversion of tibiotalar arthrodesis to total ankle arthroplasty. J Bone Joint Surg Am 2015;97:2004-13

  • Huntington WP, Davis WH, Anderson R. Total ankle

arthroplasty for the treatment of symptomatic nonunion following tibiotalar fusion. Foot Ankle Spec 2016;xx:1-8