Longevity of 2 Piece vs 2+ Piece Stemmed Total Ankle Replacement; Is there an Optimal Length?

Interpreting Long-Term Survivorship of Total Ankle Arthroplasty: Implications of Fixed-Bearing Systems: Commentary on an article by Maxime Sadoun, MD, et al.: "SALTO TALARIS Total Ankle Arthroplasty at a Minimum of 10 Years of Follow-up. Survival and Radiographic and Clinical Outcomes in a Series of 144 Ankles".

Symptomatic ankle osteoarthritis is associated with a substantial disease burden. Although many patients benefit from nonsurgical management, surgical intervention is commonly indicated for endstage osteoarthritis. In recent years, total ankle arthroplasty (TAA) has gained popularity. Patient A: 90 y/o female, severe comorbidities, idiopathic ankle osteoarthritis, orthopedic shoe adaptation. Patient B: 58 y/o female, healthy, arthrodesis for osteoarthritis due to chronic instability, pain-free after one year, full consolidation. Patient C: 66 y/o male, healthy, TAA for posttraumatic osteoarthritis, pain-free one year after surgery with good ankle mobility. The choice of treatment is guided by patient-specific characteristics. Nonoperative management is generally preferred for individuals with mild symptoms, minimal osteoarthritic changes, or those who are non-operable. Arthrodesis is typically indicated for younger, physically active, or heavier patients, whereas total ankle arthroplasty (TAA) is more suitable for relatively older, moderately active patients with a flexible, neutrally-aligned ankle. Overall, management of ankle osteoarthritis is individualized, and TAA can be an effective option for appropriately selected patients.

Total ankle arthroplasty (TAA) is increasingly performed worldwide for the treatment of end-stage tibiotalar osteoarthritis. There are limited data in the literature regarding the long-term survival of third-generation implants. The primary aim of this study was to characterize the long-term survival of the SALTO TALARIS TAA implant. This was a multisurgeon, single-center, retrospective study of 164 consecutive ankles (155 patients) that underwent surgery between 2009 and 2013. The mean age at surgery was 64.4 years, and 60% of patients were women. The mean follow-up was 12 years (range, 10 to 15 years). Implant survival was estimated using the Kaplan-Meier method. Data collected included implant survival, clinical range of motion, American Orthopaedic Foot & Ankle Society (AOFAS) score, and the number of patients with a "forgotten" joint. The same surgical technique and identical pre- and postoperative radiographic assessments were used for all patients. One hundred and fifty-five patients with 164 TAAs were initially included; 17 patients (17 TAAs) died, and 3 patients (3 TAAs, 1.8%) were lost to follow-up before 10 years. Survival free from any surgery involving the tibiotalar joint was 94.1% (95% confidence interval [CI]: 90.5% to 97.9%) at 10 years. Implant survival with the end point of revision of at least 1 metallic component was 96.2% (95% CI: 93.4% to 99.2%) at 10 years. Implant survival with the end point of removal and conversion to arthrodesis was 99% (95% CI: 98% to 100%) at 10 years. At the latest follow-up, the mean dorsiflexion (and standard deviation) was 12° ± 5°, the mean plantar flexion was 23° ± 7°, and the median AOFAS score was 98. Patients considered 62 (43%) of the ankles "forgotten" joints. The SALTO TALARIS TAA is a reliable implant with a low reoperation rate and excellent long-term survival. These findings provide long-term reference survival data for a third-generation fixed-bearing TAA system. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Changes in ankle muscle strength following arthroplasty: A systematic review.

Valgus Ankle Deformity Is Associated with Increased Mechanical Complications and Revision Following Total Ankle Arthroplasty.

Impact of preoperative varus deformity severity on clinical and radiographic outcomes following total ankle arthroplasty.

Little is known regarding the circulating metal levels in patients following total ankle arthroplasty (TAA). Also unknown is the impact of implant modularity. The purpose of this study is to quantify the postoperative serum metal levels in patients who have undergone primary TAA and to evaluate the impact of tibial component design. A cross-sectional study was conducted of patients who had undergone primary TAA during 2010-2023. Ten patients with the Stryker INFINITY System were included in the nonmodular tibia group, 10 patients with the Stryker INBONE System were included in the modular tibia group, and 21 patients without implants were included as a control group. Subjects attended a 1-time visit at minimum 12 months postoperative. Outcome measures included serum cobalt, chromium, and titanium levels measured by inductively coupled plasma mass spectrometry. There were no differences in age, gender, body mass index, or follow-up between the nonmodular tibia, modular tibia, and control groups. Serum titanium levels were greater in the nonmodular tibia group (0.619 µg/L) and modular tibia group (0.993 µg/L) than in the control group (0.150 µg/L) (P < .001 and P < .001, respectively). Serum titanium levels were greater in the modular tibia group than in the nonmodular tibia group (P = .003). Serum cobalt and chromium levels did not differ between groups (P > .05). No associations were found between metal levels and clinical or radiographic outcomes. Results from this study provide the first evidence that TAA is associated with elevated serum metal levels. Serum titanium levels were elevated, whereas chromium and cobalt levels were not. Patients with modular tibial implants had higher titanium levels than patients with nonmodular tibial implants. Possible explanations for these findings may be related to the greater surface area of the modular implants or greater release of metallic debris from tribocorrosion at the numerous modular junctions. These findings regarding implant modularity are hypothesis-generating and require further study.

What Circulating Titanium May Be Telling Us After Total Ankle Arthroplasty.

Body mass index (BMI) is associated with increased risk of complications in total hip and knee arthroplasty and is commonly used to screen for surgical eligibility. BMI's role in total ankle arthroplasty (TAA), however, is less defined, with limited evidence connecting obesity to poor outcomes. This study evaluates the potential trade-off between reducing complications and restricting access to care when applying BMI-based eligibility criteria for TAA. We conducted a retrospective cohort study of 3019 patients who underwent primary TAA between January 1, 2007, and December 31, 2023, using the American College of Surgeons National Surgical Quality Improvement Program database, which restricts data collection to 30 days postoperatively. We assessed the number of complications potentially avoided, and the number of complication-free surgeries potentially denied under various BMI eligibility thresholds and random selection. For each cutoff, we calculated the positive predictive value (PPV). Among the 3019 patients analyzed (mean age 65 years; 45.3% female), with a BMI cutoff of ≥30 kg/m2, 1527 patients would have been denied a complication free surgery, and 58 patients would have avoided complications. Using a BMI cutoff of ≥40 kg/m2, 237 patients would have been denied a complication-free surgery, and 9 patients would have avoided complications. Both cutoffs had a PPV of 3.7% (95% CI of 2.7%-4.6% and 1.3%-6.0%, respectively). For each patient with a complication avoided with a BMI cutoff of either ≥30 or ≥40 kg/m2, 27.3 patients would have been denied a complication-free surgery. Random selection performed the same with a PPV of 3.6%, and 26 patients denied complication-free surgery for each patient, with a complication avoided. With a BMI cutoff of ≥30 or ≥40 kg/m2, the number of patients denied a complication-free surgery is approximately 27 times larger than those spared complications, and BMI criteria demonstrated a similar PPV for complications compared to random selection. Based on this analysis of 30-day postoperative complications, BMI-based cutoffs alone may not be sufficient to determine TAA eligibility. Level III, retrospective cohort study.

BackgroundConflicting evidence exists regarding the ability of surgical helmet systems (SHSs) to reduce rates of infection after joint replacement. The purpose of this study was to investigate the use of SHS in total ankle arthroplasty (TAA) and their effect on postoperative infection rates.MethodsA retrospective cohort study was conducted on patients who underwent elective primary TAA between January 2013 and June 2023 in a US private academic setting to compare rates of surgical site infection with and without the use of an SHS. Demographic characteristics, revision rates, superficial and deep infection, and their respective operative or nonoperative treatment, patient-reported outcome measures (12-Item Short Form Health Survey physical component summary [PCS], Foot and Ankle Ability Measure [FAAM], visual analog scale [VAS]), and implant survivorship were collected and compared between groups.ResultsA total of 938 patients who underwent primary TAA at our institution were included in this study, with 496 (52.9%) in the hood group and 442 (47.1%) in the conventional gown group at a mean follow-up of 6.8 (range: 2-12.5) years. There were no significant differences found between the use of a surgical hood vs conventional gowning with regard to overall surgical site infection (5.24% vs 4.98%, P = .972) and deep prosthetic joint infection (2.62% vs 2.71%, P = 1.000). A multivariable logistic regression model controlling for age, body mass index, tobacco use, and diabetes found no association between the use of surgical hoods and surgical site infections after TAA (OR = 1.12, P = .710). Furthermore, no differences in FAAM, VAS, PCS, or implant survivorship were found between groups.ConclusionAlthough SHS may provide additional protection for the surgeon from being contaminated during the surgery, the use of surgical hoods was not associated with a protective effect against surgical site infection. Considering the disadvantages and added costs of SHS, the decision to wear hoods during TAA is therefore left to the individual surgeon's discretion and personal preference.

Non-tobacco nicotine (NTN) products including e-cigarettes, nicotine pouches, and synthetic nicotine devices have become increasingly popular. Although the adverse effects of tobacco-derived nicotine on other surgical outcomes are well established, the impact of NTN use on orthopaedic procedures such as total ankle arthroplasty (TAA) remains unclear. Given nicotine's known effects on vascularity and wound repair, understanding NTN-related perioperative risks is clinically important. A retrospective cohort study was conducted using the TriNetX Research Network. Adults (≥18 years) who underwent primary TAA between January 1, 2004, and December 31, 2024, were identified. Two matched cohorts were constructed: NTN-dependent users and non-nicotine-dependent controls. Outcomes were assessed at 6 months and 1 year included surgical site complications, implant/prosthesis complications, health care use, and nicotine-specific healing outcomes. Implant/prosthesis complications and health care use were also examined at 3 years and 5 years. After matching, 401 patients were included in each cohort (mean age 58.2 years; 34.7% female). At 6 months and 1 year, surgical site complications were significantly higher among NTN users (6 months: P = .017, OR 1.909, 95% CI 1.113-3.275; 1 year: P = .039, OR 1.662, 95% CI 1.021-2.705). With the numbers available, no significant differences were observed for implant/prosthesis complications, health care use, or nicotine-specific healing outcomes at any time point. At 3 years and 5 years, implant and health care-related outcomes were not significantly different between groups. NTN use is primarily associated with early wound-healing complications, specifically surgical site issues, whereas no significant difference was detected for implant-related outcomes. Consequently, including NTN products in routine preoperative screening could facilitate risk stratification and inform patient counseling.

Clinical comparison of two mobile bearing total ankle arthroplasties.

Persistent postoperative radiographic edema as a prognostic marker associated with wound complications and revision risk following anterior approach total ankle arthroplasty: A retrospective review.

Multimodal diagnosis of periprosthetic joint infection after total ankle arthroplasty.

Ankle arthrodesis (AA) has historically been the gold standard surgical treatment for end-stage ankle arthritis, providing reliable pain relief at the expense of motion. Total ankle arthroplasty (TAA) has emerged as a motion-preserving alternative with improving survivorship and functional outcomes. However, large-scale comparative data evaluating complications, reoperation rates, opioid utilization, and health care costs remain limited. This study compared outcomes following AA and TAA using a national administrative database. A retrospective cohort study was performed using a national claims database. Adult patients undergoing primary TAA or AA were identified, excluding cases involving trauma, infection, or malignancy. Propensity score matching (1:1) was performed based on age, sex, year of surgery, insurance type, and comorbidities. Thirty-day complications, 2-year outcomes, postoperative opioid utilization, and cumulative health care costs were assessed. Categorical variables were compared using χ2 testing and continuous variables using independent-samples t-tests. A total of 15 898 patients met inclusion criteria (9271 AA; 6627 TAA). After matching, 6627 patients remained in each cohort. At 2 years, TAA demonstrated lower rates of any reoperation compared with AA (3.1% vs 7.7%, P < .001), driven by lower rates of revision (1.1% vs 3.3%), hardware removal (1.3% vs 5.5%), and infection-related reoperations (1.3% vs 1.9%) (all P < .05). Diagnosis-based endpoints, reported separately, similarly favored TAA. Within 30 days, TAA was associated with fewer complications (1.0% vs 2.3%, P < .001). Although index costs were modestly higher for TAA, cumulative costs at 2 years were lower ($7225 vs $8043, P < .001). Early opioid use was slightly higher following TAA but converged by 1 year. In a propensity-matched national cohort, TAA demonstrated lower reoperation rates, fewer early complications, and lower cumulative costs at 2 years compared with AA, supporting TAA as a durable treatment option.

This study aimed to demonstrate long term clinical follow-up and implant survivorship of Salto Talaris-type primary total ankle arthroplasty (TAA) by 1 foot and ankle-trained surgeon at a single institution. Patients treated with primary Salto Talaris TAA were identified via Current Procedural Terminology (CPT) codes and included if they underwent primary TAA without history of arthrodesis and had complete imaging, clinical evaluation, and patient-reported outcomes preoperatively. Implant survivorship was calculated considering revision as requiring metal component explantation. Patient outcomes at final follow-up were compared to available preoperative values via paired t tests. P <.05 was considered significant. A total of 154 patients met inclusion (55.8% female, mean age at surgery 63.3 ± 8.9 years). Mean follow-up was 9.7 years (range, 0.6-17.6 years). Estimated implant survival probability was 100% at 1 year, 97.2% at 3 years (95% CI 94.6-99.9), 94.9% at 5 years (95% CI 91.3-98.7), 91.6% at 10 years (95% CI 86.7-96.9), and 86.9% at both 12 and 15 years (95% CI 79.3-95.3); no component explantation events occurred between 12 and 15 years, with the final explantation recorded at 15.28 years postoperatively. Thirteen patients underwent revision. There was no significant change in dorsiflexion but a reduction in plantarflexion (Δ = -4.3°, 95% CI -6.0 to -2.6; P < .001) at final follow-up. No significant changes were observed comparing radiographs at 6-week and final follow-up, including tibial component coronal alignment, posterior tibial slope, and talar component position. Among 87 patients (91 TAA) with complete long-term data, VAS pain decreased (Δ = -26.5, 95% CI -33.0 to -20.0; P < .001), mean FCS 12 increased (Δ = +20.9, 95% CI 18.7-23.2; P < .001), and MCS increased (Δ = +5.2, 95% CI 2.9-7.5; P < .001). All FAOS subscales improved significantly (P < .001). This cohort suggests that Salto Talaris-type TAA is associated with durable survivorship and patient outcomes at long-term follow-up in this single-surgeon series.

ABSTRACTObjectiveThere is no consensus on the age restriction for total ankle arthroplasty (TAA) patients. The aim of our study was to analyze the clinical function, radiographic outcomes, patient satisfaction, and complications between patients under 50 years old and those over 65 years old who underwent TAA with the INBONE II prosthesis for end‐stage ankle arthritis.MethodsPatients who received TAA with the INBONE II prosthesis between September 2016 and August 2021 were included in the study. A total of 68 patients were enrolled and divided into two groups based on age: the younger group (28 patients age ≤ 50 years) and the elderly group (40 patients age ≥ 65 years). Demographic data and patient‐reported outcomes, including 36‐Item Short‐Form Health Survey (SF‐36), American Orthopedic Foot & Ankle Society (AOFAS), Foot Function Index (FFI), and Visual Analogue Scale (VAS) scores, were collected preoperatively and at the latest follow‐up. Radiographic measurements, including tibial articular surface angle (TAS), talar tilt angle (TT), and tibial lateral surface angle (TLS), were evaluated on weight‐bearing images preoperatively and at the latest follow‐up. Range of motion (ROM) and complications were documented. Patient satisfaction was assessed using a five‐point Likert scale.ResultsWith a median follow‐up of 4 years, there were no statistically significant differences in AOFAS and SF‐36 scores between the two groups at the latest follow‐up. However, the elderly group showed slightly lower VAS and FFI scores compared to the younger group, while the younger group demonstrated slightly greater dorsiflexion angles. There were no statistically significant differences in radiographic evaluations, patient satisfaction, and complications between the two groups.ConclusionThe 4‐year postoperative outcomes of TAA using the INBONE II prosthesis were comparable between patients younger than 50 years and those older than 65 years, indicating that age alone may not serve as a definitive criterion for patient selection in TAA with this implant.Trial RegistrationRetrospectively registered.Level of Evidence4.

BackgroundThe influence of preoperative coronal alignment on outcomes after total ankle arthroplasty (TAA) remains controversial, particularly in the presence of varus or valgus deformity. This study aimed to evaluate midterm clinical and radiographic outcomes of Salto mobile-bearing TAA according to preoperative varus, neutral, and valgus alignment.MethodsThis retrospective single-center study reviewed 124 ankles that underwent primary TAA between 2014 and 2021 and were followed up for a minimum of 2 years. Ankles were classified into varus, neutral, and valgus groups based on predefined radiographic criteria. Clinical and radiographic outcomes, as well as implant survivorship, were evaluated. Adjunctive corrective procedures were performed as indicated to address associated deformities.ResultsFinal clinical outcomes, including American Orthopaedic Foot and Ankle Society scores, visual analog scale pain scores, and ankle range of motion, did not differ significantly among alignment groups. Most radiographic parameters improved postoperatively; however, ankles with preoperative varus alignment demonstrated greater residual hindfoot varus. Kaplan-Meier analysis demonstrated favorable midterm revision-free and reoperation-free survivorship.ConclusionsTAA can achieve favorable midterm clinical outcomes across a spectrum of preoperative coronal alignment patterns when combined with appropriate adjunctive corrective procedures. Varus deformity, including more severe forms, often requires additional correction; however, when appropriately addressed, clinical outcomes are likely to be maintained. Given the limited number of valgus ankles and the midterm follow-up duration, cautious interpretation is warranted, and further studies are needed to clarify long-term outcomes.

CORR Insights®: Is Preoperative Moderate to Severe Varus Alignment Associated With Survivorship and Outcome Scores at a Minimum of 5 Years After Mobile-bearing Total Ankle Arthroplasty With the Hintegra Device?