SLR - April 2023 - Nathan Tirabassi, DPM
Title: Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty Using the INBONE II ProsthesisReference: Jamjoom, Bakur A et al. “Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty Using the INBONE II Prosthesis.” The Journal of bone and joint surgery. American volume vol. 104,17 (2022): 1554-1562. doi:10.2106/JBJS.21.01240
Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Nathan Tirabassi, DPM
Residency Program: Rochester General Hospital - Rochester, NY
Podiatric Relevance: Although the long term survival rate of total ankle arthroplasty (TAA) implants does not match the survival rates of total knee and hip arthroplasty implants, over the last few decades, total ankle arthroplasty has become increasingly popular among foot and ankle surgeons. To date, there is very little data published on the success of revision TAA. Within this study, the INBONE II Prosthesis was utilized in revision TAA surgery where short-term radiographic and clinical success was measured retrospectively to prove viability of its usage.
Methods: Inclusion criteria included symptomatic patients with aseptic loosening of both talar and tibial components, insert wear, talar malalignment, and heterotopic ossification. Exclusion criteria included a minimum of 2 year follow up, patients who underwent ankle debridement, gutter clearance, liner exchange, or current or postoperative infection following primary TAA. Postoperatively, the patients underwent radiographic evaluation measuring sagittal distal tibial component angle, coronal distal tibial component angle, tibiotalar angle, lateral talar station, and talar component flexion angle. Preoperative angles were compared immediately postoperatively and at annual follow ups. Utilizing Manchester-Oxford Foot Questionnaire (MOXFQ) and EuroQol-5 Dimensions (EQ-5D), clinical outcomes were measured based on patient-reported data. Twenty-eight patients and 29 procedures were reviewed (one bilateral case).
Results: The mean age was 68 years. Mean duration from primary TAA to revision was 87.5 months (range 16 - 223 months). Indications for revision included aseptic loosening of both talar and tibial components (24), insert wear (3), talar malalignment (1), and heterotopic ossification (1). The types of prostheses explanted consisted of Mobility (25), BOX (2), STAR (1) and Zenith (1). 35 procedures including deep deltoid release (11), talar bone grafting using allograft (10), lateral ligament reconstruction (4), Achilles tendon lengthening (4), medial gutter release (2), removal of retained hardware (2), calcaneal osteotomy (1), and subtalar arthrodesis (1) were required in addition to the revision for 22 cases. In 2 procedures, patients were found to have infections with 1 needing removal of the revisional TAA components along with antibiotics and surgical debridement. Significant improvement was found in the postoperative coronal distal tibial component angle, tibiotalar angle, and lateral talar station measurement. The mean follow up was reported at 40 months. When comparing preoperative and postoperative MOXFQ scores there was a significant difference in all 3 domains and the index. The EQ-5D scores displayed significant improvement in the mobility, usual activities, and pain/discomfort complaints categories.
Conclusion: Revision TAA is relatively uncommon and the gold standard for revision surgery for failed TAA is ankle arthrodesis which eliminates functionality for the patient. This study delivers encouraging evidence that a revision TAA utilizing the INBONE II prosthesis can result in improved radiographic and clinical outcomes allowing patients to avoid ankle arthrodesis. Although, there are limitations such as selection bias, retrospective nature of the review, and timing of data collection, this study provides optimistic evidence of the success of revision TAAs with the INBONE II. Future multi-center, prospective studies will further provide satisfactory options for surgeons to utilize in the event of TAA failure.