Revision Total Ankle Research Articles

Lessons from revision total ankle replacement: tibias fail earlier, and taluses fail later (and fail again)

Lessons from revision total ankle replacement: tibias fail earlier, and taluses fail later (and fail again)

Exploring Revision Total Ankle Arthroplasty Failures A Comparison Between Failed and Successful Revision Cases

This study assesses the comorbidities that are associated with failed revision total ankle arthroplasty (TAA) and explores the outcomes following a failed revision TAA. A retrospective analysis was conducted on a cohort of patients who underwent a revision TAA at a single institution from 2008 to 2022. Patients were identified as having revision failure if they required explantation, below-knee amputation (BKA), or a revision of either metal component. Statistical analysis was performed to identify any significant differences and summarize outcomes. The study included a total of 87 patients who underwent revision TAA with 12 patients who subsequently experienced revision failure. The revision TAA failure rate was 13.8%. There were higher rates of former smokers (58.3%; n = 7) and a history of diabetes (33.3%; n = 4) in the failure cohort, although these differences did not reach statistical significance. Limb salvage procedures were achieved in 11 cases (91.7%). Approaches for failed revision TAAs included arthrodesis (n = 5) with 2 isolated ankle arthrodesis (AA) and 3 tibio-talo-calcaneal (TTC) arthrodesis, an additional revision arthroplasty (n = 6), or amputation (n = 1). Ankle arthroplasty retention was successful in 6 cases (50.0%). Our results demonstrate that a second revision approach was chosen in half of the cases, underscoring its viability as a successful intervention according to patient preferences. Level of Evidence: III

The INVISION Talar Component in Revision Total Ankle Arthroplasty: Analysis of Early Outcomes.

Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component. This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus. The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively. In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

A COMPARISON OF FUNCTIONAL OUTCOME SCORES FOR PRIMARY AND REVISION ANKLE ARTHROPLASTIES

BackgroundPatients who undergo either primary or revision total ankle replacement (TAR) expect improvements in pain, function and quality of life. The goal of this study was to measure the functional outcome improvements and the difference in patient-reported outcomes in patients undergoing primary total ankle replacements compared to revision TAR.MethodsA single-center prospective cohort study was undertaken between 2016 and 2022. All patients were followed up for a minimum of 6 months. Patients undertook the Manchester Oxford Foot Questionnaire (MoxFQ) and EQ-5D health quality questionnaires pre-operatively, at 6 months and yearly for life. The Mann Whitney test was undertaken for statistical analysis.ResultsA total of 165 primary and 71 revision ankle replacements were performed between 2016 and 2022. The mean age was 71 years for primary replacements and 69 years for revisions. The INFINITY was utilized in the majority of primary total ankle replacements. Revision replacements were either the INBONE II or INVISION and they were most often revising the MOBILITY implant. The main indication for revision was aseptic loosening (83%). Other causes included infection, malalignment and insert wear. The overall MoxFQ improved by a mean of 46.5 for primaries and 40.2 for revisions. The EQ-5D score also showed overall improvements with the mean difference in mobility increasing by 1.6.ConclusionBoth primary and revision ankle replacements result in improved functional scores at 6 months, 1 year and 2 years. In this cohort with the implants used, both primary and revision ankle replacements demonstrate similar improvements in functional scores.

CLINICAL AND RADIOLOGICAL OUTCOMES OF REVISION TOTAL ANKLE ARTHROPLASTY USING THE INBONE II PROSTHESIS

BackgroundThe literature on the outcome of revision total ankle arthroplasty (TAA) remains limited. We aim to report the clinical and radiological outcomes of revision TAA at a high-volume centre in the UK.MethodsRetrospective review of 28 patients that underwent 29 revision TAA procedures using INBONE II prosthesis. Demographic, radiological, and patient reported outcome measures data were analysed.ResultsThe mean (range) duration from primary TAA to revision was 87.5 (16–223) months. The main indication for the revision was aseptic loosening of the primary TAA (82.8%). Additional procedures were required in 75.9% of patients. At mean (range) follow-up of 40 (24- 60) months, the infection, re-operation, and implant survival rates were 6.9%, 6.9% and 96.5% respectively. A significant postoperative improvement in the component alignment radiographic measures was observed. Osteolysis, subsidence, loosening and heterotopic ossification rates were comparable to other reports and did not influence the clinical outcome. A significant improvement was observed in the MOXFQ (all domains) and the EQ-5D (three domains) at 24 months postoperatively.ConclusionsRevision TAA using INBONE II was associated with good short-term survival and improvement in the postoperative scores at 2 years. Maintenance of the postoperatively improved alignment was documented at follow up. The relatively high survival rate in this series supports the notion that revision TAA is a satisfactory option for failed primary TAA.

Lessons From Revision Total Ankle Replacement: Tibias Fail Earlier, and Taluses Fail Later (and Fail Again).

The literature on survivorship and outcomes after revision total ankle replacement (TAR) in the modern era is limited. This study aimed to describe the timing to revision and survivorship after revision TAR. We hypothesized that tibial-sided failures would occur earlier after the primary TAR, and secondary revisions after failure of revision TAR would occur more due to talar-sided failures than tibial-sided failures. This is a single-institution retrospective study of TAR patients with minimum 2-year follow-up. Revision TARs (defined as exchange of tibial and/or talar components) for aseptic causes with any implant were included. Etiology of failure necessitating revision and ultimate outcomes after revision (survival of TAR revision, additional revision, conversion to fusion, and below-knee amputation [BKA]) were recorded. There were 46 revision TARs, with mean age of 60.6 (range: 31-77) years and mean 3.5 years' follow-up postrevision. Revisions for tibial failure occurred significantly earlier (n = 22, 1.3 ± 0.5 years after index procedure) than those for talar failure (n = 19, 2.3 ± 1.7 years after index procedure) or combined tibial-talar failure (n = 5, 3.4 ± 3.4 years after index procedure) (P = .015). Revisions for tibial-only failure had better survival (95.5%) than revisions for talar or combined tibial-talar failures: 26% of talar failures and 20% of combined tibial-talar failures underwent ≥1 revisions. Of the 6 additional revisions after failure of the talar component, 1 ultimately underwent BKA, 2 were converted to total talus replacement, 2 were revised to modular augmented talar components, and 1 was treated with explant and cement spacer for PJI after the revision. TAR tibial failures occurred earlier than talar failures or combined tibial-talar failures. Revisions for talar failures and combined tibial-talar failures were more likely to require additional revision or ultimately fail revision treatment. This is important given the consequences of talar implant subsidence, bone necrosis, loss of bone stock, and limited salvage options.

ALL-COMPONENT REVISION FOR FAILED TOTAL ANKLE ARTHROPLASTY: EARLY RESULTS AND COMPLICATIONS

AimSurgical options for management of a failed ankle arthroplasty are currently limited; typically conversion to fusion is recommended with only a few patients being considered for revision replacement surgery. This paper presents our experience of revision ankle replacements in a cohort of patients with failed primary replacements.MethodA total of 18 revision TAR in 17 patients were performed in patients with aseptic loosening. The technique was performed by a single surgeon (CSK) over a 4 year period between July 2014 and August 2018 using the Inbone total ankle replacement system. Patient demographics and clinical outcomes were collected retrospectively using - MOXFQ, EQ5D, VAS pain score and patient satisfaction questionnaires.Results12 right and 6 left ankle replacements were revised in 17 patients (11 male/ 6 female). The mean age at revision was 69.1 years (range 56–81 years) with a mean BMI of 31. The mean surgical time was 171 minutes with 22% of cases requiring bone grafting. 6 patients had early wound complications, all superficial and settled with dressings. There were no deep infections, 2 patients had further surgery for exploration for possible nerve injuries. At a mean follow up of 20.6 months, 4 patients had mild/moderate ongoing pain with the majority of patients being satisfied with the outcome of their surgery.ConclusionThis study represents one of the largest group of patients reported to have undergone revision total ankle arthroplasty. Our experience shows that this results in acceptable level of complications and provides satisfactory function in most patients. We feel revision TAR is a viable option in patients with failed primary arthroplasty who wish to continue to maintain mobility at the ankle joint.

OUTCOMES OF REVISION TOTAL ANKLE ARTHROPLASTY: A MINIMUM OF TWO-YEAR FOLLOW-UP

IntroductionTotal ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up.MethodsAll patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up.Results33 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 31 patients were included in the study. 4 patients declined participation for completing questionnaires. We received 15/27 (55.5%) completed questionnaires. The mean MOX-FQ average domain score for pain was (50.6 ± 26.9), walking/standing (62.4 ± 36.5) and social function was (43.7± 31.0). The mean FAOS scores were (52.5 ± 30.6; pain), (54.5 ± 29.2; symptoms), (62.1 ± 30.5; ADL) and (35.5 ± 28.2; for quality of life). The mean overall health score today for EQ-5D was 73.9/100. 50% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 57% were satisfied with the improved in daily activities. 78.5% were overall satisfied with the results from surgery.ConclusionRevision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery.

Lessons from Revision Total Ankle Replacement: Tibias Fail Early, and Taluses Fail Late (And Fail Again)

Introduction/Purpose: With the last decade’s surge in total ankle replacement (TAR), there is an anticipated commensurate increase in the number of revisions that orthopaedic foot and ankle surgeons will encounter. The salvage and implant options to deal with a failed primary TAR are expanding. However, the literature on survivorship and outcomes after revision TAR in the modern era is relatively limited. What’s more, little is known about the risk factors for further revision or failure of revision TAR. This study aimed to describe the timing to and survivorship after revision TAR. We hypothesized that tibial-sided failures would occur earlier after the index surgery, and secondary revisions after failure of revision TAR would occur more due to talar-sided failures than tibial-sided failures. Methods: This is a single-institution retrospective cohort study of TAR patients (2012-2022) with minimum 2-year follow-up. Revision TARs (defined as exchange of tibial and/or talar components) with any implant (Cadence, Inbone, Invision, Infinity, Salto, STAR, Vantage, Zimmer; or custom total talus replacement [TTR]) were included. Five surgeons contributed patients. Demographics, primary and revision surgical data, and postoperative complications were recorded. Etiology of failure necessitating revision (tibial failure, talus failure, combined failure) and ultimate outcomes after revision (revision TAR survived, additional revisions, conversion to fusion, below-knee-amputation [BKA]) were recorded. Revisions for periprosthetic joint infection (PJI) and conversions to fusion were excluded. There were 59 ankles that underwent revision for any cause. Excluding 9 2-stage revisions for PJI and 3 conversions to ankle or tibiotalocalcaneal fusion, there were 47 ankles that underwent revision TAR that were included for analysis. Chi-square and ANOVA tests were used to compare risk factors and timing for failure. Results: There were 47 revision TARs, with mean age 60.6 (range: 31-77) years, mean BMI 29.5 kg/m2, 19 (40.4%) females, and mean 3.5 years follow-up. Revisions for tibial failure (n=22) occurred significantly earlier (1.3 ± 0.5 years) than those for talus failure (n=19, 2.3 ± 1.7 years) or combined tibial/talus failure (n=6, 2.9 ± 3.3 years) (P=0.048). Revisions for tibial-only failure had significantly better survivorship (95.5%) than revisions for talus or combined tibia/talus failures: 26% of talus failures and 33% of combined tibia/talus failures underwent at least one more revision (P=0.033). Of the 7 failures after revision talus, 2 ultimately underwent BKA, 2 were converted to TTR, 2 were revised to modular stemmed talus implants, and 1 was treated with explant and cement spacer for PJI. Conclusion: This study demonstrates that TAR tibial failures occur earlier than talus failures or combined tibial/talus failures. When patients with isolated tibial failure undergo revision of both tibial and talar components, they usually do well with good survivorship post-revision. However, revisions for talar failures and combined tibial/talar failures occur later but are more devastating: nearly 1/3 go on to a second revision. This is important given the consequences of talar implant subsidence, bone necrosis, loss of bone stock, and limited salvage options. As TAR utilization expands, it is imperative to develop implants and surgical strategies to maximize success for revision surgery. Flowchart of failures after revision TAR. PJI = periprosthetic joint infection. TTC = tibiotalocalcaneal. BKA = below-knee amputation. Tibial implant geometry included: Low-pro = lowprofile tibial implant. Stem = stemmed tibial implant. Keel = keeled tibial implant. Talus implant geometry included: chamfer/round and flat-cuttalus.

Association of Radiographic Soft Tissue Thickness With Revision Total Ankle Arthroplasty Following Primary Total Ankle Arthroplasty: A Minimum of 5-year Follow-up.

The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA. A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA. The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P < .01) and the talus tissue thickness (odds ratio: 1.10 [1.05-1.15]; P < .01) measurements were significant predictors of revision TAA in multivariable logistic regression models. However, BMI was not a significant predictor of revision TAA. The two metrics demonstrated excellent interrater reliability. Greater soft tissue thickness was a better predictor of revision TAA compared with BMI. These findings suggest that radiographic soft tissue thickness may be a valuable tool for assessing the risk of the need for revision TAA following primary TAA. Further research is needed to validate and explore the potential impact on clinical practice. Level III, comparative study.

Nationally Representative Trends in Incidence of Procedures Done Concomitantly With Primary and Revision Total Ankle From 2012 to 2020

Background As new literature emerges and practice patterns fluctuate, there is a significant potential for variation with regard to adjunctive procedures performed with primary total ankle arthroplasty (pTAA) and revision total ankle arthroplasty (rTAA). Our study aims to evaluate yearly trends in the incidence of concomitant procedures and compare the incidence of adjunctive procedures between pTAA and rTAA. Methods The 2012-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all pTAA and rTAA. The number of concurrent procedures was compared between pTAA and rTAA and compared across years available in the most current version of the NSQIP database (2012-2020). Results Patients undergoing pTAA had a higher mean age than patients undergoing rTAA (64 vs 61 years; P &lt; .001), and patients undergoing rTAA had higher wound class (P &lt; .001), indicating higher levels of contamination. Concurrent procedures were performed significantly less frequently with pTAA than rTAA (mean procedures 0.82 vs 1.30; P &lt; .001). Removal of deep implants was more commonly coded with rTAA than pTAA (9.0% vs 17.7%; P &lt; .001). Gastrocnemius recession was more frequently performed with pTAA than rTAA (10.4% vs 3.0%; P = .001). Conclusion As pTAA and rTAA increase in incidence throughout the United States, there is increased importance on furthering our understanding of these procedures. This study provides a nationally representative analysis of adjunctive procedures with pTAA and rTAA from 2012 to 2020. Generally, more adjunctive procedures are performed with rTAA versus pTAA, confirming the high complexity of rTAA. Levels of Evidence: Level III

Early Survivorship, Clinical and Radiographic Outcomes of a Modular Augmented Revision Total Ankle Arthroplasty System.

As the number of total ankle arthroplasties (TAAs) performed annually increases, there is increased demand for modular revision implants. There is limited early survivorship and clinical outcome data for the INVISION Total Ankle Arthroplasty System (Wright Medical Technology/Stryker). This study aims to determine early implant survivorship, complications, and radiographic and patient-reported outcomes (PROs) of the INVISION implant in the revision setting. This is a single-institution retrospective review of adult patients who underwent revision TAA with the INVISION implant with minimum 2-year follow-up. Demographics, complications, radiographic data, and PROs (PROMIS) were collected. The primary outcome was implant survivorship. Secondary outcomes were reoperation, radiographic complications, and PROs. Nineteen patients underwent revision INVISION TAA with mean follow-up of 3.5 years. INVISION revision TAA was used for tibial (n = 6) or talar (n = 7) component subsidence, recurrent tibiotalar malalignment (valgus = 1, varus = 3), and postinfection bone loss (n = 2). Two-year implant survivorship was 100%. There were no reoperations. One patient had lucency of the talar component at 6 months post TAA revision with INVISION. One patient had talar subsidence at final follow-up. Two-year postoperative follow-up PROMIS domains improved significantly (P < .05). There was excellent short-term survivorship of the INVISION TAA implant, with no failures. There were significant improvements in PROs and low rates of subsidence and lucencies. The results of this study support using the INVISION implant in the revision TAA setting. Level III, retrospective cohort.

Survival of revision ankle arthroplasty.

The number of revision total ankle arthroplasties (TAAs) which are undertaken is increasing. Few studies have reported the survival after this procedure. The primary aim of this study was to analyze the survival of revision ankle arthroplasties using large datasets. Secondary aims were to summarize the demographics of the patients, the indications for revision TAA, further operations, and predictors of survival. The study combined data from the National Joint Registry and NHS Digital to report the survival of revision TAA. We have previously reported the failure rates and risk factors for failure after TAA, and the outcome of fusion after a failed TAA, using the same methodology. Survival was assessed using life tables and Kaplan Meier graphs. Cox proportional hazards regression models were fitted to compare failure rates. A total of 228 patients underwent revision TAA. The mean follow-up was 2.6 years (SD 2.0). The mean time between the initial procedure and revision was 2.3 years (SD 1.8). The most commonly used implant was the Inbone which was used in 81 patients. A total of 29 (12.7%) failed; nine (3.9%) patients underwent a further revision, 19 (8.3%) underwent a fusion, and one (0.4%) had an amputation. The rate of survival was 95.4% (95% confidence interval (CI) 91.6 to 97.5) at one year, 87.7% (95% CI 81.9 to 91.7; n = 124) at three years and 77.5% (95% CI 66.9 to 85.0; n = 57) at five years. Revision-specific implants had a better survival than when primary implants were used at revision. A total of 50 patients (21.9%) had further surgery; 19 (8.3%) underwent reoperation in the first 12 months. Cox regression models were prepared. In crude analysis the only significant risk factors for failure were the use of cement (hazard ratio (HR) 3.02 (95% CI 1.13 to 8.09)) and the time since the primary procedure (HR 0.67 (95% CI 0.47 to 0.97)). No risk factors for failure were identified in multivariable Cox regression modelling. Revision TAAs have good medium term survival and low rates of further surgery. New modular revision implants appear to have improved the survival compared with the use of traditional primary implants at revision.

A Systematic Review of Outcomes of Total Ankle Arthroplasty with INBONE II

Category: Ankle Arthritis; Ankle Introduction/Purpose: The INBONE II is a fixed-bearing implant with a stemmed tibial component commonly used for total ankle arthroplasty (TAA). Despite its frequent use and previously reported outcomes within individual clinical studies, no study has systematically reviewed outcomes of TAA with this implant. The purpose of this study was to perform a systematic review of the literature and report on outcomes of TAA with the INBONE II. Methods: A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Databases searched included PubMed, Google Scholar, SCOPUS and CINAHL from database date of inception through February 28th, 2023. Clinical studies of INBONE II outcomes in peer reviewed journals were included. Outcomes included were survivorship, patient reported outcome measures (PROMs), and complications. Outcome results were compiled using weighted averages when possible. This review of 26 articles included 808 patients with 667 primary TAA and 141 revision TAA. Results: Survivorship, with failure defined as metal component revision, was 97.8% at an average follow-up of 49 months (range, 14-85.4 months) and 94.2% at an average follow-up of 25.7 months (range, 9.1-47.5) months for primary and revision TAA respectively. Complication rates for primary TAA included: 3.8% intra-operative fractures, 2.5% post-operative fractures, 1.8% deep infection, 8.0% wound complications, 1.6% rate of poly exchange, and 1.6% nerve injuries. Revision TAA complication rates included: 12.3% intra-operative fractures, 6.9% wound complications, 3.3% deep infections, and a 5.5% incidence of nerve injury. Average PROMs for primary TAA included: AOFAS American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score improved 41 points, visual analog scale (VAS) scores decreased 5.9, and patient satisfaction of 92.6%. Revision TAA PROMs were not consistently reported. Conclusion: This study is the largest compilation of INBONE II outcomes and survivorship. Primary and revision TAA with the INBONE II results in satisfactory improvement in PROMs and low complication rates. The overall survivorship is 97.8% and 94.2% at an average follow-up of 49 months (range, 14-85.4 months) and 25.7 months (range, 9.1-47.5) for primary and revision total ankle arthroplasty respectively. These findings support continued use of this implant in primary and revision TAA.

Patient Reported Outcomes Before and After Revision Total Ankle Arthroplasty Done In the First Two Years of a Single Surgeons Practice

Category: Ankle Arthritis; Ankle Introduction/Purpose: As Total Ankle Arthroplasty (TAA) volume continues to grow nationally, so is the need for revision TAA surgery. A foot and ankle surgeon fresh out of fellowship is likely to encounter these challenging cases soon after beginning practice. The learning curve for ankle replacement has been demonstrated in multiple studies but no such study exists for revision TAA due to the relative infrequency of this procedure. The experience of one high volume revision TAA surgeon in the first two years after fellowship is reviewed in this study. Radiographic, clinical, and patient reported outcomes are analyzed in this study. Methods: In this IRB approved study, we retrospectively reviewed prospectively collected data on 18 patients who underwent Revision Total Ankle Arthroplasty Surgery from January 1, 2018, to January 1, 2021. Patient-reported outcome (PRO) measures including PROMIS depression, physical function and pain interference CATs taken preoperatively and then at specific post- operative intervals were collected on all patients. Radiographic and clinical results were also reviewed. Patients being revised, whether single stage or two-stage, for infection were excluded. Patients converted from ankle arthrodesis to ankle replacement were omitted. Student t tests, chi-square test, and nonparametric alternatives (p &lt;.05) we used. Results: Eighteen patients ( Average age 65.5, 50% male) underwent revision TAA average follow up 25 months. Aseptic loosening (50%) was the most common cause for revision followed by component malpositioning (28.8%). The Scandanavian Total Ankle Replacement was the most commonly revised implant in this study 83.3%. Radiographic parameters (Tibiotalar angle Tibial component positioning) improved after revision TAA. Average Promis physical function improved from 41.18 pre-op to 47.77 (p.078), depression improved from 57.64 pre-op to 49.67(p .025*), and pain interference improved from 61.3 preop to 50.55 (p .045*) after revision TAA. No differences were seen in any outcome measure with regards to time from fellowship, when assessing for a learning curve. See attached table for complete list of results. Conclusion: Revision TAA is a technically challenging procedure. One which will continue to be more and more common as ankle replacement continues to replace arthrodesis as the preferred treatment for ankle arthritis. This study did not identify a learning curve for revision total ankle arthroplasty. Outcomes were similar independent of time after fellowship the cases occurred. Patient reported outcomes, clinical outcomes, and radiographic outcomes all improved in this cohort after revision TAA.

The Invision Talar Component as a Revision Total Ankle Arthroplasty Option: Analysis of Early Outcomes

Category: Ankle; Other Introduction/Purpose: The Invision talar component was launched in 2018 as a revision total ankle arthroplasty (TAA) specific option geared towards avoiding further subsidence when poor talar bone stock is present. Due to the recency of the market- availability of the Invision, studies evaluating the efficacy of the implant, even in the short-term, are lacking. Thus, the purpose of this study was to present the early-term outcomes of a series of patients undergoing revision TAA with the use of the Invision talar component. Methods: This was a single-center, retrospective review of 28 patients undergoing revision TAA with the Invision talar component and Inbone II tibial component (Wright Medical; Memphis, Tennessee) performed between 2007 and 2022. Mean follow-up was 1.3 ± 0.93 years. Data on patient preoperative characteristics, postoperative complications, and survivorship were collected. The primary outcome measures were time to major complication, reoperation, and infection. Results: The most common concurrent procedures performed with revision TAA with the Invision talar component were gastrocnemius recession (n=14, 50%), subtalar arthrodesis (n=3, 10.7%) and cotton osteotomy (n = 1, 3.6%). The mean preoperative coronal deformity off the tibia was 4.07 ± 3.06 degrees for varus and 3.67 ± 4.36 degrees for valgus deformities, respectively, and postoperatively, was 1.67 ± 2.16 degrees for varus and 2.00 ± 3.48 degrees for valgus. The mean preoperative coronal plane deformity off the talus was 4.83 ± 6.68 degrees for varus and 4.22 ± 4.21 degrees for valgus, respectively, and postoperatively, was 1.23 ± 2.45 degrees for varus and 2.32 ± 3.93 degrees for valgus. The survivorship from any complication, major complication, reoperation, and infection is shown in Table 2. Conclusion: In a series of 28 patients undergoing revision TAA with the Invision talar component and Inbone II tibial component, we demonstrate a survivorship of 92.7% at 1-year follow up. The Invision appears to have a reasonable safety profile in this non- designer series. The implant compares favorably with others utilized in the revision TAA setting at the early-term, but further studies evaluating mid-and long-term outcomes are required to fully assess the efficacy of the Invision.

Early Survivorship, Clinical and Radiographic Outcomes Following Primary and Revision Total Ankle Arthroplasty using a Modular Augmented Revision (INVISION) Implant

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the number of total ankle replacements (TAR) performed annually increases, there is an increased demand for implants that can be used in revision scenarios when primary TARs fail. As indications for TAR expand, there is increased reliance on modular systems to treat challenging conditions including bone loss, avascular necrosis, and instability. The INVISION Total Ankle Arthroplasty System (Wright Medical Technology/Stryker, Memphis, TN), released in 2018, includes modular augmented tibial trays and talar plates of varied heights to compensate for bone loss. There is limited data on early survivorship and clinical outcomes of the INVISION. This novel study aims to determine the early implant survivorship, complications, patient-reported outcomes (PROMIS), and radiographic outcomes of the INVISION implant used in both the primary and revision arthroplasty setting. Methods: This study is a single-institution retrospective review of adult patients who underwent primary or revision TAR with the INVISION implant with minimum 2-year follow-up. Demographics, reason for use of INVISION, surgical data, complications, pre- operative and 2 year post-operative radiographic data, and pre-operative and 2-year post-operative patient-reported outcome scores were collected. The primary outcome was survivorship (retention of both tibial/talar components at final follow-up). Secondary outcomes were reoperation (return to OR with retention of both tibial and talar components), radiographic complications (peri-implant lucency, cysts, or subsidence), and patient-reported outcomes (PROMIS pre-operative and 2-year post-operative). PROMIS scores were collected across the following domains: physical function, pain interference, pain intensity, global mental health, and depression score. Results: Twenty-six patients (primary=7; revision=19) underwent INVISION TAR (mean age 62 years, weight 81.kg, BMI 29.3 kg/m2, 15/26 male) with mean follow-up 3.5 years. Reason for INVISION primary TAR included tibial (n=1) or talar (n=5) bone loss, and take-down fusion (n=1); INVISION revision TAR was used for tibial (n=6) or talar (n=7) component subsidence, recurrent tibiotalar malalignment (valgus=1, varus=3), and post-infection bone loss (n=2). Two-year implant survivorship was 100%. There were 2 reoperations (7.7%): 1 gutter debridement and 1 irrigation, debridement and polyethylene exchange for infection. Two-year follow-up PROMIS domains improved significantly (p &lt; 0.05) from pre-operative in both the primary (pain interference, pain intensity) and revision cohorts (pain interference, pain intensity, global physical function). Two-year radiographic follow-up yielded 1 tibial peri-implant lucency and 1 tibial cyst. Conclusion: In this single-institution series, there was excellent short-term survivorship of the INVISION TAR implant with no failures in primary or revision cases. There were significant improvements in patient-reported outcomes scores. There were low rates of peri-implant lucencies and cysts. The results of this study support the use of the INVISION implant in both the complex primary and revision TAR setting. INVISION may offer an alternate surgical solution to fusion, custom printed cage implants, and total talus replacement in this complex patient population. Further research and follow-up data are warranted to report the longer-term outcomes and survivorship of this implant.

Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty using a Revision Ankle System

Category: Ankle Arthritis; Ankle Introduction/Purpose: With the growing popularity of total ankle arthroplasty (TAA), revision surgeries are inevitable and expected to significantly increase over the next decade. Revision TAA remains a significant challenge with high complication rates. No previous study has reported on outcomes following revision TAA using an implant designed specifically for revisions. Theoretical benefits of a revision-specific ankle system include tibial and talar fixation/stability, restoration of joint height, coverage of bone loss/defects, and maximal talar coverage. The purpose of this study was to investigate radiographic and clinical outcomes at a minimum of 2 years following revision TAA using a revision-specific ankle system. Methods: Patients who underwent a revision TAA using a revision-specific ankle system (Invision, Stryker, Kalamazoo, MI) between January 2016 and December 2020 were eligible to be included in this study. Patients with less than 2-year follow-up and unwilling to return to clinic were excluded. Overall, 25 patients met inclusion criteria. Indications for revision TAA (Table 1) included talar loosening (n = 6), tibial loosening (n = 7), talar subsidence (n = 6), re-implant after infection (n = 4), instability (n = 3), periprosthetic fracture (n = 2), and severe osteolysis (n = 2). Medians and interquartile ranges (IQRs) were reported since the data was not normally distributed. Clinical and radiographic outcomes, complications, reoperations, and implant survival was recorded. Results: Implant survival was noted in 80% of patients (20/25) at a median of 3.8 years following revision TAA. Index revision was most commonly performed for implant loosening (tibia 28%, talus 24%), talar subsidence (24%), or re-implant after infection (16%). Foot and Ankle Ability Measure (FAAM) Activities of Daily Living and Sports scores were 53.9 (IQR 46.4, 71.4) and 37.5 (IQR 21.9, 46.9), respectively at final follow-up. There was evidence of talar loosening in 3 patients (12%) and talar subsidence in 5 patients (20%) on final radiographs. Reoperation rate at final follow-up was 48%, most commonly for talar loosening/subsidence (n= 2), tibial loosening (n = 3), septic TAA (n = 1), medial/lateral gutter impingement (n = 2), and instability (n = 2). Conclusion: At a minimum follow-up of 2 years, 80% of patients retained their metal revision TAA, but reoperation rates were high with 48% of patients requiring an additional procedure most commonly for implant loosening, talar subsidence, gutter impingement, or instability. Revision TAA using a revision-specific ankle system is a viable option for patients with a failed TAA. Physicians and patients should be aware that revision TAA remains a significant challenge with a high risk of complication and reoperation rates.

The Burden of Revision Total Ankle Replacement Has Markedly Increased from 2010 to 2020

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) surgery has steadily increased in recent decades. The aim of the current study was to investigate the evolving burden of revision surgery and risk factors and timing of revision or implant removal. We hypothesized that there has been an increase in revision TAR and explant surgeries in the past decade and that younger age and higher comorbidity burden are risk factors for revision and explant. Methods: Using the 2010-2020 PearlDiver M151Ortho dataset, this retrospective cohort study identified primary TAR, TAR revision, and TAR explant patients. This is a large national database containing billing claims information on over 151 million patients in the United States across all payer types and sites of care. Patient factors investigated included age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated using ICD-9 and ICD-10 diagnosis codes). Annual incidence for primary and revision TAR, and explant were recorded. Multivariate logistic regression analyses were performed to determine independent risk factors for revision TAR or explant relative to primary TAR. For explants, the eventual intervention by two years was analyzed. Ten-year timing and survival to revision or explant surgery following patient-matched unilateral TAR were characterized. Results: Over the study period, there were 10,531 primary, 1,218 revision, and 1,735 explant TARs (increasing by 310%, 398%, and 9.6%, respectively). Independent predictors of revision TAR included: younger age (odds ratio [OR] 1.29 per decade decrease) and higher ECI (OR 1.23 per 2-point increase) (p &lt; 0.0001 for both). Independent predictors of explant surgery included: younger age (OR 1.80 per decade decrease, p&lt; 0.0001), female sex (OR 1.17, p=0.0011), and higher ECI (OR 1.35 per 2-point increase, p&lt; 0.0001). Explanted patients went on to arthrodesis (37.7%), amputation (26.1%), revision TAR (14.7%), or no identified procedure/other procedures (21.5%) within the subsequent two years. The 10-year implant survival rate following primary TAR was 91.8%. 73% and 83% of revisions and explants occurred in the first three years following index TAR, respectively. Conclusion: The burden of TAR revision has grown substantially over the past decade. Younger age, female sex, and higher patient comorbidity burden were associated with increased risk of revision or explant surgery. If explant is pursued, most went on to arthrodesis or amputation. These results suggest that care should be taken in patient selection for TAR to minimize the occurrence of revision and explant surgery. Treatment algorithms should be modified to optimize outcomes among patients who undergo explant or revision surgery.

Revision Total Ankle Arthroplasty Outcomes in a Large Single-Center Series: Evaluation of Coronal Plane Deformity Correction and Patient Reported Measures

Category: Ankle Arthritis Introduction/Purpose: As total ankle arthroplasty (TAA) rises in popularity nationwide, the incidence of major complications and need for revision TAA will continue to increase. A better understanding of the ability to durably correct deformity and improve patient reported outcomes (PROs) in the TAA revision setting is paramount for surgeons facing the impending wave of failed TAA. Thus, the purpose of this study was to present the largest single-center case series of revision TAA to date and to evaluate improvement in PROs and maintenance of correction of coronal plane deformity in patients undergoing this procedure. Methods: This was a single-center, retrospective review of 87 revision TAAs performed between 2007 and 2022. Reoperations for cyst formations only or without metallic component exchange were excluded. The two most common implants used for revision TAA were Inbone II (n=65) and Inbone I (n=14). Mean follow-up was 2.8 ± 2.9 years. Data on patient preoperative characteristics, concurrent procedures, and postoperative complications were collected. The primary outcome measures were time to major complication, reoperation, and infection. Secondary outcomes included PROs and correction of coronal plane deformity measured from both the tibial plafond and talar articulating surface from pre- to post-operatively. Cox regression analyses were performed to compute survivorship. Results: The most common concurrent procedures performed concomitantly with revision TAA were gastrocnemius recession (n=31, 35.6%), subtalar arthrodesis (n=18, 20.7%), and talonavicular arthrodesis (n=5, 5.7%). Mean preoperative coronal plane deformity measured off both the tibial plafond and talar articular surface improved after revision TAA. 1- and 5-year survivorship from major complication, reoperation, and infection is shown in Table 2. Fourteen patients underwent subsequent revision, including TAA (n= 6, 6.9%), arthrodesis (n= 4, 4.6%), below-the-knee amputation (n= 2, 2.3%), or implantation of an antibiotic spacer (n= 2, 2.3%). At one-year postoperatively, mean VAS pain score, SF36, and AOFAS Hindfoot score was 18.2 ± 16.0, 73.0 ± 13.3, and 68.8 ±:9.3, respectively, representing an improvement in PROs after revision TAA. Conclusion: In the largest single-center series of patients undergoing single or double component exchange revision TAA, we demonstrate durable improvements in coronal plane deformity measured off both the tibial plafond and talar articular surface. We also noted 63.0% survivorship with regards to reoperation and improvements in average PROs across the cohort. Overall, revision TAA is a successful procedure, but is associated with higher failure rates at 5 years than primary TAA.