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Total Ankle Arthroplasty in Inflammatory Joint Disease with Use of Two Mobile-Bearing Designs
H. Cornelis Doets, MD1; Ronald Brand, PhD2; Rob G.H.H. Nelissen, MD, PhD3
1 Department of Orthopaedic Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC Amsterdam, The Netherlands. E-mail address: orkdo@slz.nl
2 Department of Medical Statistics, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
3 Department of Orthopaedic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
View Disclosures and Other Information
A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
Note: The authors thank Dr. Mick C. Van Joost, MD, formerly of the Department of Orthopaedics, Academic Medical Center, Amsterdam, The Netherlands, for his assistance in the radiographic evaluation of the patients.
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Slotervaart Hospital, Amsterdam, and the Departments of Orthopaedic Surgery and Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Jun 01;88(6):1272-1284. doi: 10.2106/JBJS.E.00414
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Background: Interest in mobile-bearing total ankle arthroplasty has increased in recent years. However, to our knowledge, no study has focused exclusively on patients with the diagnosis of inflammatory joint disease or has provided a detailed analysis of the risk factors for failure.

Methods: A prospective observational study of the results of cementless mobile-bearing total ankle arthroplasty in patients with inflammatory joint disease (mainly rheumatoid arthritis) was conducted at two centers. Ninety-three total ankle arthroplasties were performed. The LCS (low contact stress) prosthesis was used initially, in nineteen ankles, between 1988 and 1992, and a modification of the LCS prosthesis, the Buechel-Pappas design, was used in seventy-four ankles between 1993 and 1999. Clinical and radiographic follow-up was performed at yearly intervals. Three clinical scoring systems were used, and any complication was recorded throughout follow-up. Actuarial survival (with revision as the end point), multivariate analysis, and a competing risk approach were used to describe the long-term outcome.

Results: The clinical result at one year after surgery showed a significant improvement in the scores on all three scoring systems (p < 0.05). Ankle dorsiflexion (mean, 7°) also improved significantly (p < 0.05) compared with the preoperative state. The most frequent complication was a malleolar fracture, which occurred in twenty ankles. Only when it occurred in combination with a deformity in the frontal plane did this complication have an adverse effect on the end result. At a mean follow-up of eight years, seventeen patients (twenty-one ankles) had died and fifteen ankles had been revised because of aseptic loosening (six ankles), primary or secondary axial deformity with edge-loading (six ankles), deep infection (two ankles), and a severe wound-healing problem (one ankle), leaving fifty-seven ankles (61%) that were evaluated. The mean overall survival rate at eight years was 84%. An increased failure rate was encountered in ankles with a preoperative deformity in the frontal plane of >10° (p = 0.03) and in ankles in which an undersized tibial component had been implanted (p = 0.02).

Conclusions: Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used. Aseptic loosening and persistent deformity are the most important modes of failure.

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

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    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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