Total Ankle Replacement with Use of a New Three-Component Implant

Authors: Pascal F. Rippstein, MD; Martin Huber, MD; J. Chris Coetzee, MD; Florian D. Naal, MD

Journal:  JBJS TAR 3 Component System

Abstract: 

Background: Total ankle arthroplasty has evolved over the past decade, and newer three-component implants have demonstrated favorable clinical results and improved survivorship. The present study analyzed the clinical and radiographic results of the first 240 total ankle arthroplasties performed by the authors with one of these new three-component prostheses. Methods: Two hundred and forty consecutive primary total ankle arthroplasties were performed in 233 patients (115 women and 118 men; mean age, 61.6 years) between November 2003 and October 2007 with the Mobility prosthesis. Intraoperative and postoperative complications, reoperations, and failures were recorded. The American Orthopaedic Foot & Ankle Society hindfoot score and a visual analog scale score assessment of pain were determined at each follow-up visit. Range of ankle motion was measured on functional radiographs, and the radiographs were studied to assess component positioning, radiolucencies, new bone formation, and periprosthetic bone cysts.  Results: Two hundred and thirty-three of the arthroplasties were available for follow-up at least one year after surgery. The mean duration of follow-up was 32.8 ± 15.3 months. There were ten intraoperative complications (4.2%) and twenty postoperative complications (8.6%). A reoperation was necessary in eighteen ankles (7.7%). Five arthroplasties (2.1%) failed at a mean of twenty-seven months after surgery. The mean American Orthopaedic Foot & Ankle Society hindfoot score improved from 48.2 to 84.1 points (p < 0.001). The mean pain level decreased from 7.7 to 1.7 points (p < 0.001). The mean total range of ankle motion improved from 19.8° to 21.9° (p < 0.001). The tibial component had a mean of 2.1° of varus and a mean posterior slope of 6.0° relative to the tibial axis. The prevalence of nonprogressive radiolucency ranged from 1.8% to 37.3% in the ten zones surrounding the tibial component, and from 0 to 2.2% in the three zones surrounding the talar component. Conclusions: The short-term clinical and radiographic results after Mobility total ankle arthroplasty are encouraging and are at least comparable with those associated with other modern three-component implants. The minimum duration of follow-up of one year is short, and studies with longer follow-up are needed to confirm our findings.

Keywords: 
ankle, ankle replacement arthroplasty, osteoarthritis of ankle, tibia, prosthesis implantation

Functional Outcomes after Fibula Locking Nail for Fragility Fractures of the Ankle

Authors: Aysha Rajeev, Shanaka Senevirathna, Sarkhell Radha, and N.S. Kashayap

Journal: JFAS Functional Outcomes after Fibula Locking Nail

Abstract:  The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of 

complications. It also helps to restore function and results in patient satisfaction.

Keywords: Functional outcome, internal fixation, surgery, trauma

The Taylor Spatial Frame for Correction of Neglected Fracture Dislocation of the Ankle

Authors: Ravikiran Shenoy, George Kubicek, Michael Pearse

Journal:  JFAS Taylor Spatial Frame

Treatment of neglected fracture dislocations of the ankle poses a surgical challenge. Extensive open reduction can frequently be contraindicated because of local skin conditions and contractures. The Taylor Spatial Frame™ (TSF) has been used to reduce and maintain reduction of complex fractures. Its use in fracture dislocation of the ankle joint has not been described. We describe a case where a TSF was used to reduce and treat a 6-week-old fracture dislocation of the ankle. The TSF is a versatile device, which has a role in the management of both acute and neglected fractures.

Keywords: Ankle fracture, dislocation, neglected fracture dislocation, Taylor Spatial Frame

Medial Malleolar Fractures: A Biomechanical Study of Fixation Techniques

Authors: T. Ty Fowler, MD; Kevin J. Pugh, MD; Alan S. Litsky, MD, ScD; Benjamin C. Taylor, MD; Bruce G. French, MD

Journal: ORTHOPEDICS August 2011;34(8):349

Fracture fixation of the medial malleolus in rotationally unstable ankle fractures typically results in healing with current fixation methods. However, when failure occurs, pullout of the screws from tension, compression, and rotational forces is predictable. We sought to biomechanically test a relatively new technique of bicortical screw fixation for medial malleoli fractures. Also, the AO group recommends tension-band fixation of small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation. A well-documented complication of this technique is prominent symptomatic implants and secondary surgery for implant removal. Replacing stainless steel 18-gauge wire with FiberWire suture could theoretically decrease symptomatic implants. Therefore, a second goal was to biomechanically compare these 2 tension-band constructs.

Using a tibial Sawbones model, 2 bicortical screws were compared with 2 unicortical cancellous screws on a servohydraulic test frame in offset axial, transverse, and tension loading. Second, tension-band fixation using stainless steel wire was compared with FiberWire under tensile loads. Bicortical screw fixation was statistically the stiffest construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques with FiberWire or stainless steel wire. In fact, unicortical screw fixation had only 10% of the stiffness as demonstrated in the bicortical technique. In a direct comparison, tension-band fixation using stainless steel wire was statistically stiffer than the FiberWire construct.

Key words: Medial Malleolar Fractures, Ankle Fracture Fixation Techniques

Distal Femoral Locking Plates for Tibiotalocalcaneal Fusions in the Charcot Ankle: A retrospective study

Authors: Sarah Shogren, DPM , Sara Zelinskas, DPM , Byron Hutchinson, DPM , Vineet Kamboj, DPM

Journal: The Foot and Ankle Online Journal 4 (8): 3

This paper presents a retrospective case series with chart and radiographic review of four patients with Charcot neuroarthropathy and associated ankle valgus. All four patients underwent tibiotalocalcaneal (TTC) arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. A 12 month follow-up was obtained. All four TTC arthrodeses were performed by the same surgeon (BH) including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation. Three patients had satisfactory outcomes with only minor complications. One patient had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. Although this was a small review, on average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. Larger retrospective or even prospective studies are needed to confirm the use of tibiotalocalcaneal arthrodesis using a distal femoral locking plate and external ring fixation in Charcot arthropathy. This small case series shows promise to the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.

Key words: Tibiotalocalcaneal fusions, Charcot Ankle, distal femoral locking plates, ankle valgus

Current Concepts Review: Results of Total Ankle Arthroplasty

Authors: Mark E. Easley, MD; Samuel B. Adams, MD; W. Chad Hembree, MD; James K. DeOrio, MD

Journal: J Bone Joint Surg Am. 2011; 93: 1455-1468

Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence.

Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis.

On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years.

Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or soft-tissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange.

A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.

Key words: N/A

Locked Versus Nonlocked Plate Fixation For Hallux MTP Arthrodesis

Authors: Kenneth J. Hunt, MD; J. Kent Ellington, MD, MS; Robert B. Anderson, MD; Bruce E. Cohen, MD.

Foot & Ankle International: July 2011 (Vol.32 #7)

Dorsal plate fixation is used commonly for arthrodesis of the hallux

first metatarsophalangeal (MTP) joint. Custom dorsal plates

incorporating locking technology have been developed recently for

applications in the foot to provide relative ease of application and

theoretically superior mechanical properties. The purpose of this study

is to compare the radiographic and clinical outcomes of patients

undergoing hallux MTP joint arthrodesis using a locked plate, or a

nonlocked plate. Materials and Methods: We compared consecutive

patients who underwent hallux MTP arthrodesis for a variety of

diagnoses with either a precontoured locked titanium dorsal plate

(Group 1) or a precontoured, nonlocked stainless steel plate (Group 2).

All patients were evaluated with radiographs, visual analog pain scale,

American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a

detailed patient satisfaction survey. Results: There were 73 feet in

Group 1 and 107 feet in Group 2. There was a trend toward a higher

nonunion rate in Group 1 compared to Group 2. When considering

only patients without rheumatoid arthritis (RA), the union rate was

significantly higher in Group 2 compared to Group 1. Hardware failure

and the overall complication rate was equivalent between the two

Groups. Conclusion: As locked plate technology continues to gain

popularity for procedures in the foot, it is important that clinical

outcomes are reported. Locked titanium plates were associated with

higher nonunion rates. Improved plate design, patient selection, and an

understanding of plate biomechanics in this unique loading environment

may optimize future outcomes for hallux MTP arthrodesis.

Level of Evidence: III, Retrospective Comparative Study

Key Words: Hallux Arthrodesis; Hallux Valgus; Hallux Rigidus; Locked

Plate; Arthritis