Revision Total Ankle Replacement

1. Revision Total Ankle Replacement
Journal of Bone and Joint Surgery
Essential Surgical Techniques
January 2016,vol 4
Mayerson and Aiyer et al
Institute of Foot and Ankle Reconst
Baltimore
Presenter : Dr Saumya Agarwal
Junior resident Dept of Orthopaedics J.N. Medical College
and Dr. Prabhakar Kore Hospital and MRC, Belgaum

2. INTRODUCTION
• Failure rates of Total Ankle Replacement – 10% to
30% - over 10 yrs
• A recent meta-analysis – 317 TAR – failure rate of
12% @ 6 yrs
• Another meta-analysis - 852 patients – 24% had
poor result

3. • 5year survivorship rate – 78%
• 10 year survivorship rate – 77%
• Study describes approach – failed total ankle
replacement – goal of best salvaging the joint
with a revision arthroplasty

4. INDICATIONS
• Loosening and subsidence of talar component -
main
• Gross dissolution of talus – previously considered
a contra-indication
• Technique described here can manage

5. • Talar component subsides posteriorly – leads
to angulation and deformation
• Patient must have good range of motion
(radiographs in flexion and extension)

8. CONTRA-INDICATIONS
• Chronic pain
• Recent/ongoing infection
• Anterior soft tissue envelope is severely scarred
• Prior wound healing difficulty in anterior aspect
of ankle

9. INCISION AND EXPOSURE
• Supine position
• Employ prior anterior midline incision
• Protect branch of superficial peroneal nerve
• Incise extensor retinaculum completely upto
proximal aspect of talonavicular joint

10. • Enter between tibialis anterior and extensor
hallucis longus tendon
• Expose tibia
• Incise ankle joint capsule
• Remove the heterotopic bone till prosthesis is
visible

13. Removal of Talar Component
• Place curved osteotome under interface
between talus and talar component
• Lift the talar component off
• Not to gouge the talus b’coz it may be helpful
to insert threaded insertion guide into talus to
facilitate removal
• Extract the polyethylene

14. Removal of Tibial Component
• Place osteotome at interface between tibial
component and tibial osseous cortex
• Disengage the tibial component from osseous
interface
• Technique preserves majority of anterior tibial
cortical rim for support of revision prosthesis

15. Make Tibial Bone Cut
• Tibial cuts can be made proximal or distal to
tibial osseous defects
• Distal tibial cuts limits joint elevation -
facilitate bone preservation
• proximal tibial cuts leads to joint line elevation

16. • Insert 3.5mm guide pin into proximal tibial
tubercle
• Attach tibial alignment guide
• Attach cutting guide to tibial alignment jig
• Cut should be perpendicular to mechanical
axis

18. • Drill the proximal 2 holes on either side of
tibial cutting jig
• Place pins in proximal 2 holes to protect
malleoli from excursion of saw blade
• Make the tibial cut and remove the cutting
guide

20. Make Talar Bone Cut
• Attach the talar cutting block to tibial alignment
guide

21. Limited amount of bone should be resected from
talus
Slide cutting block
until it is flush with
talar surface

22. • Place pins to lock talar cutting block into
desired position
• Place a saw through distal
slot of guide to perform
talar cut

23. • Freehand technique to make the talar cut

24. • Place a lamina spreader into wound to distract
the joint
• This aids with fluoroscopic visualization of
joint to ensure that bone cuts and joint
preparation are adequate

25. • Evaluate status of osseous
surfaces to ascertain
whether grafting or cementing
is necessary to support
the revision components

26. Managing Loosening & Cavitary Defects
If there is substantial bone loss around tibia
after component removal, consider impaction
bone grafting, as better bone quality makes it
easier to obtain a press fit and allow
immediate weight bearing.

27. Place Trial Components
• Insert tibial and talar trials and appropriately
sized polyethlene at the same time
• Lock the talar trial with pins placed medially
and laterally on anterior edge

29. • Check the fluoroscopic position of trial
components and check complete range of
motion to ascertain stability

30. • Drill holes for tibial component keel and then
remove tibial trial
• Drill holes for talar component keel and then
remove talar trial
• Thoroughly irrigate the wound

31. Cementing Technique
• In revision settings, manual cement insertion
is important because there is no medullary
canal to work around

32. Results
• 41 patients
• Mean time b/w TAR & revision TAR – 51 months
• Talar subsidence – most common (63%)
• Subtalar arthrodesis – 54%

33. • Arc of motion improved 5°, i.e., to 23° post-op
• 41
34 retained TAR
5 revision arthrodesis
2 amputation
Mean follow up time - 49 months

34. • AOFAS score 65 points
• VAS 4.4 points
• Revised foot function index score – 68%
excellent results
• 73% return to their prior job
• only 44% able to return to previous activity
level

35. Pitfalls & Challenges

36. • Many patients with previous TAR, have
implants from syndesmotic arthrodesis or in
the medial malleolus
• These screws should be left in place, to
prevent #

37. • Implants that cross tibia should be removed to
facilitate correct placement of tibial
component

38. Take Home Message
Revision Total Ankle Replacement is better
than Arthrodesis in failed Primary Total Ankle
Replacement