SLR - November 2022 - Akshitha Sreeram, DPM
Title: Periprosthetic Osteolysis as a Risk Factor for Revision After Total Ankle Arthroplasty: A Single-Center Experience of 250 Consecutive CasesReference: Lee GW, Lee KB. Periprosthetic Osteolysis as a Risk Factor for Revision After Total Ankle Arthroplasty: A Single-Center Experience of 250 Consecutive Cases. J Bone Joint Surg Am. 2022 Aug 3;104(15):1334-1340. doi: 10.2106/JBJS.21.01093. Epub 2022 May 23. PMID: 35930380.
Level of Evidence: Level 4
Reviewed by: Akshitha Sreeram, DPM
Residency program: Ascension SE Wisconsin Milwaukee
Podiatric Prevalence: Due to the advancements made in modern biotechnology, total ankle arthroplasty (TAA) is quickly becoming more commonly used in the treatment of chronic ankle arthritis. However, this procedure is not without its difficult complications. One of these complications is periprosthetic osteolysis which if left untreated, can lead to loss of fixation and mechanical instability. The purpose of this study is to assess the incidence of occurrence, risk factors associated with periprosthetic osteolysis and its effect on clinical outcomes.
Methods: A level 4 retrospective study was conducted on all patients who received a TAA performed by a single surgeon between Jan 2005 and Dec 2017 with a minimum follow up of 36 months. Radiographic assessment was performed at 1, 3, 6, 12 months after surgery and if there were any signs of osteolysis, a CT was performed. The primary assessment tool used for clinical evaluation was the Ankle Osteoarthritis Scale (AOS). The other outcome measurements were American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) pain assessments. Predisposing factors were evaluated in all the patients for a comparative assessment.
Results: A total of 236 patients (250 TAAs) were included using cementless mobile bearing HINTEGRA prosthesis. The mean follow up was 83.5 months. 79/250 (31.6%) ankles developed periprosthetic osteolysis of >2 mm, detected at a mean of 28.8 months. Of these 79 ankles, 30.4% were detected by 1 year, 54.4% by 2 years and 74.7% by 3 years post op. Revision was performed if osteolysis progressed to >5 mm and/or was symptomatic. 39/250 required revision. 29 ankles underwent bone grafting with poly exchange, 5 were treated with TAA revision and 5 underwent arthrodesis. Of the 29 treated with bone grafting, 3 needed repeat bone grafting, 1 underwent revision TAA and 2 required a tibiotalocalcaneal arthrodesis. The osteolysis group showed significantly lower clinical outcomes for all variables than compared to the non-osteolysis group at final follow up. Of the predisposing variables evaluated between both groups, the only one found to be significant was rheumatoid arthritis. There was also no difference between the tibiotalar coronal plane deformity between the osteolysis and non-osteolysis group.
Conclusions: Periprosthetic osteolysis is a common challenging problem that affects clinical outcomes and the long term success of TAAs. This study found that this most commonly occurs within 3 years post op and can be associated with rheumatoid arthritis. This study also demonstrates that patients with osteolysis without implant loosening can be reasonably treated with curettage and bone grafting. Limitations of this study include a relatively short follow up time and CT scans were not performed on every patient. Also, revision was performed if osteolysis was greater than 5 mm or symptomatic, however this standard was not set by specific evidence based guidelines. Further understanding of this phenomenon is key in improving long term survivorship of TAAs