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The Scandinavian Total Ankle ReplacementLong-Term, Eleven to Fifteen-Year, Survivorship Analysis of the Prosthesis in Seventy-two Consecutive Patients
Samuel Brunner, MD1; Alexej Barg, MD1; Markus Knupp, MD1; Lukas Zwicky, MSc1; Ashley L. Kapron, BS2; Victor Valderrabano, MD, PhD3; Beat Hintermann, MD1
1 Clinic of Orthopaedic Surgery, Kantonsspital Liestal, Rheinstrasse 26, CH-4410 Liestal, Switzerland. E-mail address for A. Barg: alexejbarg@mail.ru
2 Department of Orthopaedics, Harold K. Dunn Orthopaedic Research Laboratory, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108
3 University Hospital of Basel, University of Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland
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Investigation performed at the Clinic of Orthopaedic Surgery, Kantonsspital Liestal, Liestal, Switzerland

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Apr 17;95(8):711-718. doi: 10.2106/JBJS.K.01580
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The objective of this study was to determine the long-term survivorship and clinical and radiographic results of the Scandinavian Total Ankle Replacement (STAR).


From February 1996 to March 2000, seventy-seven ankles in seventy-two patients (thirty-seven female and thirty-five male patients, with an average age of fifty-six years) underwent total ankle replacement using the STAR prosthesis with a single coating of hydroxyapatite. Two patients were lost to follow-up, and twelve patients with thirteen ankle replacements died. The average duration of follow-up for the patients without revision was 12.4 years (range, 10.8 to 14.9 years). Sixty-two of the seventy-seven ankles were available for final follow-up.


Twenty-nine (38%) of the seventy-seven ankles had a revision of at least one of the metallic components. The probability of implant survival was 70.7% at ten years and 45.6% at fourteen years. The main reasons for revision were aseptic loosening, subsidence of the talar component, and progressive cyst formation. Polyethylene insert fractures were observed in eleven ankles.


While the midterm to short-term results for patients managed with the STAR prosthesis have been encouraging at 3.7 years, the long-term survivorship of the same cohort was considerably inferior. The subjective and clinical results of the patients with retained prostheses are generally good and comparable with results reported in the current literature.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Roger A. Mann, MD and Michael Coughlin, MD
    Posted on July 31, 2013
    Failure of hydroxyapatite coating in total ankles
    Principal Investigators for the STAR PMA Study for the United States

    Brunner et al. reported on a detailed study regarding the STAR total ankle performed at their institution between February, 1996 and March, 2000. In the article, they stated that the STAR prosthesis they chose to implant was manufactured with a single coating of hydroxyapatite. They neglected to point out that Link, Inc., the manufacturer of this particular product (a chrome/cobalt prosthesis with a grit-blasted surface coated with a single layer of hydroxyapatite) stopped manufacturing this particular prosthesis in January of 1998 and stopped shipping it for implantation in February of 1999. Of particular importance is that this specific version of the STAR was never released for general use or study in the United States, yet the product name remains the same, potentially confusing the reader.

    Brunner et al. reported that 25 (86%) of 29 of patients requiring revisions developed problems at the bone-prosthesis interface; this was indeed the reason why Link, Inc. discontinued the use of this particular implant in favor of the titanium spray implant design. While the article is indeed factual regarding the authors' results, it is mainly of historic value, as manufacture of the prosthesis was discontinued in 1998 and it was never released to our knowledge in the U.S. market.

    Although the authors have stated no conflict of interest, we wish to point out the senior author, Dr. Hintermann, who performed all of these operations, has designed and is involved in the marketing of a total ankle prosthesis that directly competes in Europe with the current 3-part STAR prosthesis.

    We appreciate the opportunity to comment on this publication.

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