Total Ankle Arthroplasty for the Treatment of Symptomatic Nonunion following Tibiotalar Fusion

Transcription

1 Total Ankle Arthroplasty for the Treatment of Symptomatic Nonunion following Tibiotalar Fusion W I L L I A M P. H U N T I N G T O N, M. D. W. H O D G E S D A V I S, M. D. R O B E R T B. A N D E R S O N, M. D. A O F A S A N N U A L M E E T I N G J U L Y , H O L L Y W O O D, F L O R I D A

2 Disclosures William P. Huntington, M.D. My final disclosure is in the final AOFAS program book I have no potential conflicts of interest with this presentation W. Hodges Davis, M.D. My final disclosure is in the final AOFAS program book I have a potential conflict of interest with this presentation due to: Wright Medical: Consultant and royalties Robert B. Anderson, M.D. My final disclosure is in the final AOFAS program book I have a potential conflict of interest with this presentation due to: Wright Medical: Consultant and royalties

3 Rationale/Background Ankle Arthrodesis Mainstay of treatment for end stage ankle arthritis Non-union rates: as high as 40% in some series Revision arthrodesis is no piece of cake Complication rates 23-60% Revision non-union rates of up to 23% Significant long term sequelae after ankle arthrodesis Abnormal gait patterns/difficulty with uneven surfaces Development of adjacent joint arthritis and need for further surgeries

4 Rationale/Background Total ankle arthroplasty has been proposed as a treatment option for the failed ankle arthrodesis Hinterman et al JBJS Am 2009 Greisberg et al Clin Orthop Rel Res 2004 Advantages Restore pain-free ankle range of motion Negate the long term sequelae seen with ankle arthrodesis Purpose of present study: Evaluate the short-term outcomes associated with the take down of symptomatic nonunions of ankle arthrodeses and conversion to a fixed bearing, intramedullary total ankle arthroplasty Propose that total ankle arthroplasty is a viable salvage option for the treatment of symptomatic nonunions following tibiotalar fusion.

5 Methods 5 patients retrospectively identified who underwent takedown of an aseptic, symptomatic nonunion of an ankle fusion and converted to a total ankle arthroplasty Indications for arthrodesis: 2 post-traumatic OA, 2 RA, 1 1 OA Average age at conversion: 62.2 years old Average time between fusion and conversion: 1.7 years Prospectively evaluated at a minimum of 12 months from conversion (average follow-up: 21.3 months) INBONE total ankle replacement (Wright Medical Technologies, Inc. Arlington, TN ) Fixed bearing implant Intramedullary implant

6 Methods Evaluation Clinical evaluation AOFAS ankle-hindfoot score Foot Function Index Patient satisfaction and VAS pain levels Radiographic evaluation Assessed for tibio-talar loosening and talar subsidence according to criteria proposed by Hintermann et al Clin Orthop Rel Res 2004 Complications

7 Results Complications: No intraoperative complications requiring additional procedures 1 post-op complication: wound excoriation that resolved with local wound care AOFAS ankle-hindfoot score Average: 82.6 Range: Foot Function Index Average: 28.2% Range: 7-49% VAS pain levels Average: 31.1/100 Range:

8 Results 4/5 very satisfied or satisfied with surgery 1 dissatisfied patient has rheumatoid arthritis and takes daily narcotics because of her disease 5/5 would have the operation again No evidence of tibial/talar loosening or talar subsidence in any case at final follow-up No additional procedures have been required

9 Conclusions Total ankle arthroplasty with a fixed bearing, intramedullary implant for a symptomatic nonunion of an ankle arthrodesis is a viable treatment option that provides reliable short-term results

10 References Katsenis D, Bhave A, Paley D, Herzenberg JE. Treatment of malunion and nonunion at the site of ankle fusions with the Ilizarov apparatus. J Bone Joint Surg Am. 2004;87: Easley ME, Montijo HE, Wilson JB, Fitch RD, Nunley JA. Revision tibiotalar arthrodesis. J Bone Joint Surg Am. 2008;90: Kitaoka HB, Anderson PJ, Morrey BG. Revision of ankle arthrodesis with external fixation for nonunion. J Bone Joint Surg Am. 1992;74: Zarutsky E, Rush SM, Schuberth JM. The use of circular wire external fixation in the treatment of salvage ankle arthrodesis. J Foot Ankle Surg. 2005;44: Anderson JG, Coetzee JC, Hansen ST. Revision ankle fusion using internal compression arthrodesis with screw fixation. Foot Ankle Int. 1997;18: Kirkpatrick JS, Goldner JL, Goldner RD. Revision arthrodesis for tibiotalar pseudarthrosis with fibular onlay-inlay graft and internal screw fixation. Clin Orthop Relat Res. 1991;268: Hintermann B, Barg A, Knupp M, Valderrabano V. Conversion of painful ankle arthrodesis to total ankle arthroplasty. J Bone Joint Surg Am. 2009;91: Greisberg J, Assal M, Flueckiger G, Hansen ST. Takedown of ankle fusion and conversion to total ankle replacement. Clin Orthop Relat Res. 2004;424:80-87 Atkinson HDE, Daniels TR, Klejman S, Pinsker E, Houck J, Singer S. Pre- and postoperative gait analysis following conversion of tibiotalocalcaneal fusion to total ankle arthroplasty. Foot Ankle Int. 2010;31: Kitaoka HB, Alexander IJ, Adelaar R, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15: Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function index: A measure of foot pain and disability. J Clin Epidemiol. 1991;44: Hintermann B, Valderrabano V, Dereymaeker G, Dick W. The HINTEGRA ankle: rationale and shortterm results of 122 consecutive ankles. Clin Orthop Relat Res. 2004;424:57-68.