The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 92, Issue Supplement 1 Part 1

Surgical Techniques | March 01, 2010

Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty: Surgical Technique

Beat Hintermann, MD¹; Alexej Barg, MD¹; Markus Knupp, MD¹; Victor Valderrabano, MD, PhD²

¹ Clinic of Orthopaedic Surgery, Kantonsspital, Rheinstrasse 26, CH-4410 Liestal, Switzerland. E-mail address for B. Hintermann: beat.hintermann@ksli.ch
² Clinic of Orthopaedic Surgery, University of Basel, University Hospital, Spitalstrasse 21, CH-4031 Basel, Switzerland

View Disclosures and Other Information

DISCLOSURE: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from Integra. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Newdeal, Lyon, France).

Investigation performed at the Clinic of Orthopaedic Surgery, Kantonsspital, Liestal, Switzerland

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 91 -A, pp. 850—8, April 2009

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.

The line drawings in this article are the work of Joanne Haderer Müller of Haderer & Müller (biomedart@haderermuller.com).

J Bone Joint Surg Am, 2010 Mar 01;92(Supplement 1 Part 1):55-66. doi: 10.2106/JBJS.I.01301

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Abstract

BACKGROUND:

Pain following an ankle arthrodesis continues to be a challenging clinical problem. Recent reports on semiconstrained two-component ankle implants have demonstrated the feasibility of reversing a problematic ankle fusion and converting it to a total ankle arthroplasty. However, the failure rate is high. The objective of the present prospective study was to evaluate the intermediate-term outcome associated with the use of an unconstrained three-component ankle implant after taking down an ankle arthrodesis.

METHODS:

Thirty painful ankles in twenty-eight patients (average age, 58.2 years) who were managed with takedown of a fusion and total ankle arthroplasty were followed for a minimum of thirty-six months (average, 55.6 months). The outcome was assessed on the basis of clinical and radiographic evaluations.

RESULTS:

In twenty-nine ankles in twenty-seven patients, the American Orthopaedic Foot and Ankle Society hindfoot score increased from 34.1 preoperatively to 70.6 at the time of the latest follow-up. Twenty-four patients (82.7%) were satisfied with the results. While five ankles were completely pain-free, twenty-one ankles were moderately painful, and three remained painful. The average clinically measured range of motion of 24.3° amounted to 55.1% of that of the contralateral, unaffected ankle. Radiographically, the tibial component was stable in all ankles but one. The talar component was found to have migrated in four ankles but was asymptomatic in two of them. One ankle had to be revised to a tibiocalcaneal arthrodesis because of persistent pain and loosening of the talar component.

CONCLUSIONS:

For patients with pain at the site of a failed ankle arthrodesis, conversion to total ankle arthroplasty with the use of a three-component ankle implant is a viable treatment option that provides reliable intermediate-term results. Key factors for the success of this procedure may be the intrinsic coronal plane stability provided by the ankle implants and the use of wider talar implants.

LEVEL OF EVIDENCE:

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

ORIGINAL ABSTRACT CITATION:

"Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty" (2009;91:850—8).

Figures in this Article

INTRODUCTION

Most ankle arthrodeses relieve pain, at least in the short term¹. Loss of ankle motion, degenerative changes in the adjacent joints, and alteration of gait may cause increasing difficulties over time, ultimately resulting in an unsatisfactory functional result and pain^1—9. Arthrodesis of additional adjacent joints may increase limitations and morbidity¹. As an alternative, the painful ankle arthrodesis may be converted to a total ankle arthroplasty¹⁰.

THE PROSTHESIS

The technique of taking down a fusion and conversion to a total ankle arthroplasty is described for a three-component ankle prosthesis design that provides coronal plane stability through parallel joint surfaces of the tibial and talar components and a flat polyethylene insert with parallel articulating surfaces (Fig. 1). We have not used this technique with arthroplasty designs that allow some coronal plane motion, thus requiring full ligamentous support on both the medial and the lateral side to provide stability against eversion and inversion forces.

Fig. 1

The HINTEGRA ankle prosthesis provides coronal plane stability (black arrows) through parallel joint surfaces of the tibial and talar components and a flat polyethylene insert with parallel articulating surfaces. A 2.5-mm-high rim along the medial and lateral articulating surfaces of the talar component guides the polyethylene insert during dorsiflexion and plantar flexion (blue arrow).

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The HINTEGRA total ankle arthroplasty (Newdeal, Lyon, France) is a nonconstrained three-component system that provides intrinsic stability in the coronal plane (i.e., against eversion-inversion)¹¹. The anatomically shaped flat tibial component uses the whole resection surface for osseous support. Primary stability is obtained by six pyramidal peaks, and it can be increased by two screws if necessary. The talar component is also anatomically shaped, with a smaller radius on its medial side. Primary stability of the talar component is obtained by a press-fit and two pegs. The polyethylene insert is guided by a 2.5-mm-high rim on the medial and lateral aspects of the talus and is available in thicknesses of 5, 6, 7, and 9 mm.

SURGICAL TECHNIQUE

An anterior longitudinal incision, 10 to 12 cm long, is used to expose the extensor retinaculum. The fused ankle is then exposed between the extensor hallucis longus and the anterior tibial tendon. When the minimal distance between the old scar and the intended standard approach is not at least 4 cm, a modified approach through the prior incision is used. The retinaculum is dissected along the lateral border of the anterior tibial tendon, and the anterior aspect of the distal part of the tibia and the talar neck are exposed. While the soft tissues are dissected subperiosteally from the bone, attention is paid to the neuro-vascular bundle that lies behind the extensor hallucis longus tendon. A self-retaining retractor is inserted to protect and retract the soft tissue. The fibula usually cannot be fully visualized at this stage (Fig. 2).

Fig. 2

The tibiotalar fusion is exposed by reflecting the soft-tissue mantle. The fibula usually cannot be fully visualized at this stage.

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The original ankle joint is marked with four Kirschner wires under fluoroscopic control, as planned on radiographs pre-operatively (Figs. 3-A and 3-B). Care is taken to establish the joint line at the proper level. For this purpose, the radiographs of the contralateral ankle should be analyzed preoperatively. The tibial cutting block is then positioned with use of the Kirschner wires on the anteromedial and anterolateral corners of the ankle as a reference and the rod for alignment in the sagittal plane (Fig. 3-C). The tibial cut is made between the two Kirschner wires. The medial and lateral cuts are then made from distal to proximal with the reciprocating saw along the two other Kirschner wires. Finally, the tibial resection block is moved distally to the desired position for the superior talar cut, which is intended to remove 4 to 8 mm of bone (Fig. 4). After the cuts are completed, the bone segment is removed and the medial and lateral gutters are mobilized with a chisel until the talus becomes mobile within the mortise (Figs. 5-A and 5-B).

Fig. 3-A Fig. 3-B Fig. 3-C

Figs. 3-A, 3-B, and 3-C Intraoperative planning of cuts. Fig. 3-A Two Kirschner wires are inserted under fluoroscopic control to define the original height of the tibiotalar joint. Fig. 3-B Two Kirschner wires are inserted to define the original margin of the talar body. Fig. 3-C Intraoperative view of the tibial resection block.

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Fig. 4

After the cuts have been completed, the Kirschner wires are removed and the resection block is moved 4 to 8 mm distally for the superior talar cut. This photograph shows the tibial and talar cuts after the tibial resection block has been removed.

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Fig. 5-A Fig. 5-B

Figs. 5-A and 5-B Removal of the bone segment. Fig. 5-A The bone segment is mobilized with chisels and is removed. Fig. 5-B The removed bone segment has the same shape as the trial tibial component, indicating that the tibial component will have circumferential cortical osseous support.

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Two special distractors are used: one on the medial side and one on the lateral side. Each dis-tractor has two pins, which are slid into the appropriate holes in the spreading forceps and then introduced at the appropriate location into the bone fragments to be distracted; this allows controlled distraction of the ankle and exposure of the posterior soft tissue. The scarred tissues on the posterior aspect of the ankle are removed with caution so as not to damage the flexor hallucis longus tendon and the tibial nerve (Fig. 6). Next, a spacer is inserted into the created joint space to check hindfoot alignment and ligamentous stability of the ankle (Fig. 7). When ligament insufficiency is identified, ligament repair is performed following implantation of the prosthesis.

Fig. 6 Fig. 7

The recreated tibiotalar joint is carefully débrided of scarred capsule on its posterior aspect; care is taken to not damage the flexor hallucis longus tendon or the tibial nerve.

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Fig. 7

A spacer of 12 mm in thickness is inserted to test the medial and lateral stability of the recreated tibiotalar joint. Its 12-mm thickness corresponds to the minimal thickness of the ankle prosthesis.

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The length of the tibial resection surface in the antero-posterior direction is measured to determine the size of the tibial implant, which in turn determines the size of the talar resection block. First, an anterior vertical cut is made in the talus with a reciprocating saw to create the anterior step to accommodate the talar resection block. Once the desired position is achieved, the cutting block is fixed to the talus with use of two, three, or four pins. The aim is to resect approximately 2 mm of bone from both the medial and the lateral side of the talus. First, the medial and lateral cuts are made, to a depth of 6 to 8 mm, with a reciprocating saw. Then, the posterior cut is performed with an oscillating saw. After removal of the resection block, the excess bone is removed with use of a chisel and rongeur. The first trial talar component is then inserted to check the alignment under fluo-roscopic control. If the desired position has been achieved, the anterior oblique resection of the talus is performed with a rongeur. The first trial component is then replaced by the second trial component, which permits drilling of the two holes for the pegs. The tibial trial component is then inserted. If the created space is not wide enough, additional bone is carefully resected from the medial or lateral side of the tibia, with care taken to not weaken the resulting malleoli. To avoid fractures of the malleoli, one should avoid squeezing the tibial component into place. Once the tibial component is inserted, the contact of the anterior flange of the component with the anterior tibial bone is inspected. If necessary, the anterior tibial rim is carefully smoothed to achieve a wide contact area with the anterior flange of the implant. A trial polyethylene inlay is then inserted, and alignment and stability are checked clinically. The position of the implant is checked with fluoroscopy. After removal of all trial implants, final débridement of all compartments of the created ankle joint is accomplished (Fig. 8).

Fig. 8

The talar resection cuts have been finalized as described in the text.

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The talar component is inserted first, and then the tibial component is placed. The thickness of the polyethylene mobile bearing is determined with the use of trial implants, and the appropriate polyethylene mobile bearing is then inserted (Fig. 9). The position of the implants is checked with fluoroscopy (Figs. 10-A and 10-B). Sagittal plane motion and stability are checked clinically.

Fig. 9

After insertion of the components and the polyethylene insert, the recreated ankle joint is well aligned. Note that the tibial component extends over the polyethylene insert on both the medial and the lateral side.

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Fig. 10-A Fig. 10-B

Figs. 10-A and 10-B Fluoroscopic check of the implants. Fig. 10-A The contact of the implant with the resected surfaces of the bones is checked on the anteroposterior image. The distance created between the fibula and the talus is approximately 3 mm, indicating that there is ligament tension but not overdistraction of the recreated joint. The two screws were inserted to stabilize an impending fracture of the medial malleolus at its shoulder. Fig. 10-B The contact of the implant with the resected surfaces of the bones is checked on the lateral image as well. The talar component is well centralized on the original talar body (white dotted circle), and its point of contact with the tibia (arrow) is between the intersection line of the tibia (white dotted line) and the mid-distance of the tibial component (black line), indicating that load transfer will occur at the center of the osseous-implant interface.

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Additional Surgical Procedures Before Takedown of Fusion (Accomplished During Same Anesthesia Session) Subtalar joint fusion: If there is symptomatic osteoarthritis of the subtalar joint, that joint is fused before the ankle fusion is taken down and converted to the total ankle arthroplasty. A 2 to 3-cm-long incision is made laterally over the sinus tarsi. The posterior aspect of the subtalar joint is carefully exposed, and a special distractor (Hintermann distractor; Newdeal) is used to distract the subtalar joint (Fig. 11). Attention is paid to the soft tissues around the talar neck, which are preserved in order to avoid damage to the blood supply of the talus. The joint surfaces are débrided to subchondral bone, and demineralized bone matrix can be added to stimulate bone-healing. The incision is closed in layers. Later, when the talar resection is done, a Kirschner wire is inserted into the center of the talar body, directed to the inferior edge of the calcaneal tuberosity, and advanced to penetrate the skin. A cannulated screw is inserted through the calcaneus into the talar body with care taken to preserve a distance of 8 to 10 mm between the tip of the screw and the talar resection surface. Finally, an additional screw is inserted from the talar neck to the anterolateral aspect of the calcaneus (Figs. 12-A and 12-B).

Fig. 11

The osteoarthritic subtalar joint is exposed through the sinus tarsi, distracted, and carefully débrided.

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Fig. 12-A Fig. 12-B

Figs. 12-A and 12-B Fluoroscopically controlled positioning of the screws. Fig. 12-A On the anteroposterior image, the two screws are located in the center of the talus in order to be far enough away from the implant. Fig. 12-B On the lateral image, one screw is positioned posteriorly and the other is positioned anteriorly to obtain maximum stability against rotational forces.

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Talonavicular fusion: If there is symptomatic osteoarthritis of the talonavicular joint, that joint is fused before the ankle fusion is taken down and converted to the total ankle arthroplasty. Once the fused ankle is exposed, the incision is extended distally to the navicular bone. The talonavicular joint is opened, and a Hintermann distractor is used to distract the joint. The joint surfaces are débrided to subchondral bone. The distractor is then removed, and the fusion is secured in the desired position with use of two or three screws.

Additional Surgical Procedures Before Total Ankle Replacement (Accomplished During Same Anesthesia Session) Fibular reconstruction: The fibula might be too weak to withstand translational forces or it may be missing because of a prior resection at the time of the ankle fusion (Fig. 13). If so, a lateral longitudinal incision is made to approach the distal aspect of the residual fibula. An osteotomy is performed 6 to 8 cm proximal to its distal end. Then, the fibula is mobilized and moved distally until its distal end comes into contact with the lateral aspect of the talus. The lateral aspect of the distal part of the tibia is débrided, and the fibula is secured to the tibia with use of a plate and screws. Cancellous bone from the tibial and talar resections is used for bone graft. If fixation of the fibula directly onto the tibia creates a mortise that is too narrow, the bone segment removed from between the tibia and the talus can be interposed between the fibula and tibia (Fig. 14-A).

Fig. 13

The distal part of the fibula was resected at the time of the ankle fusion. The lateral ankle ligaments also have been sacrificed, and the peroneal tendons might be dislocated anteriorly.

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Fig. 14-A Fig. 14-B

Figs. 14-A and 14-B Fibular reconstruction. Fig. 14-A The osteotomized fibula is moved distally and is fixed with a plate and screws to the tibia. Note that the resected tibiotalar segment has been interposed between the fibula and tibia to widen the mortise. Fig. 14-B The peroneal tendons are repositioned, and transosseous nonresorbable sutures are used for tenodesis.

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Lateral ligament reconstruction: If there is ligamentous insufficiency, the residual lateral ligaments are usually too weak for use in the reconstruction. Therefore, the peroneal tendons are used as they are often nonfunctional as a result of longstanding dislocation, in particular after partial or complete fibular resection. They are exposed at the level of the distal part of the fibula and transposed behind the fibula. While the foot is held in a neutral position, transosseous sutures are used to obtain strong fixation to the posterior aspect of the distal part of the fibula (Fig. 14-B).

Medial ligament reconstruction: When the anterosuperior layers of the deltoid ligament are incompetent, which can typically be demonstrated by increased anteromedial translation of the talus when the foot is pulled out of the mortise, repair is accomplished with transosseous sutures to the medial malleolus. When the deep layers of the deltoid ligament are incompetent, ligamentoplasty may be achieved by using the posterior tibial tendon in a manner similar to the way that the peroneal tendons are used on the lateral side. In our experience, medial-side reconstruction has been critical.

Calcaneal osteotomy: When the heel is not well aligned at the end of the procedure, a sliding calcaneal osteotomy should be considered. It is particularly useful when there is residual valgus malalignment that would overload the medial ankle ligament and lead to medial shifting of the talus. An oblique incision is made approximately 5 mm posterior to the peroneal tendons to expose the calcaneus. The osteotomy is accomplished with use of an oscillating saw and chisels. After mobilization, the tuberosity fragment is moved medially or laterally until appropriate alignment is achieved. One or two Kirschner wires are inserted, and cannulated screws are used for definitive fixation.

Achilles tendon lengthening: Unless dorsifiexion of =10° is achieved at the end of the surgery, percutaneous triple hemisection lengthening of the Achilles tendon is considered. First, a hemicut is made a few millimeters proximal to the tuberosity of the calcaneus on the medial side; second, a hemicut is made approximately 3 cm proximally on the lateral side; and third, a hemicut is made another 3 cm proximal to the previous cut on the medial side. The foot is then passively dorsifiexed to achieve 10° of dorsifiexion.

POSTOPERATIVE CARE

After the surgery (Fig. 15), a well-padded short leg splint is used to support the foot in a neutral position. After two days, a short leg walking cast is applied. Full weight-bearing is then allowed. The cast is removed at six weeks if only the ankle has been replaced and at eight weeks when additional surgical procedures such as realignment, ligament reconstruction, and/or adjacent joint fusions have been performed. After cast removal, patients perform walking exercises to improve walking and receive training in ankle motion, balance, and proprioception.

Fig. 15

A stable ankle mortise at eight weeks after the arthroplasty.

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CRITICAL CONCEPTS

INDICATIONS:

A painful ankle arthrodesis with osteoarthritis of adjacent joints (e.g., the subtalar and talonavicular joints)
A painful malunited ankle arthrodesis
An ununited tibiotalar arthrodesis

CONTRAINDICATIONS:

Deep infection
A neuropathic joint
Breakdown of soft tissues
Chronic pain syndrome

RELATIVE CONTRAINDICATIONS:

Absence of the distal part of the fibula
Extensive injuries to the collateral ligaments
Nonmanageable malalignment (e.g., severe valgus malalignment)

PITFALLS:

Fracture of the medial malleolus. This pitfall can be avoided by insertion of one or two Kirschner wires into the medialmalleolus before the horizontal resection cuts are made.
Fracture of the lateral malleolus. This pitfall can be avoided by insertion of one or two Kirschner wires into the lateralmalleolus before the horizontal resection cuts are made.
Injury to the flexor hallucis longus tendon. This pitfall can be avoided by careful use of the saw during resection cuts of the tibia (e.g., by not extending the cut beyond the posterior border of the tibia).
Injury to the tibial nerve. This pitfall can be avoided by careful débridement of the posteromedial aspect of the created ankle joint, especially when removing scar tissue.
Breakdown of soft tissues/wound-healing problems. This pitfall can be avoided by immobilizing the foot in neutral alignment with a splint until wound-healing has been achieved.
Ossification and arthrofibrosis. This pitfall can be avoided by careful and not too aggressive mobilization of the surrounding periarticular soft tissues of the ankle during the first two months.
Malpositioning of the joint line. This pitfall can be avoided by careful preoperative planning and use of fluoroscopy during the surgery.

AUTHOR UPDATE:

Residual valgus malalignment has been found to be detrimental to the success of this conversion to total ankle arthroplasty with use of the three-component ankle prosthesis. Eccentric pull of the Achilles tendon leads to a valgus thrust within the joint, shifting the talus against the medial malleolus at the interface between the tibial component and the polyethylene insert. This can result in painful overstress of the medial malleolus. Therefore, we do not tolerate any hindfoot valgus, which is often present at the time of the surgery. In these cases, a medial sliding osteotomy of the calcaneus is done.

Another specific, common problem is the poor bone quality of the recreated malleoli. If either malleolus is considered to be at risk for failure, a screw is inserted to protect it.

REFERENCES

Coester LM; Saltzman CL; Leupold J; Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83:219-28.[PubMed]

Lance EM; Paval A; Fries I; Larsen I; Patterson RL Jr. Arthrodesis of the ankle joint. A follow-up study. Clin Orthop Relat Res. 1979;142:146-58.[PubMed]

Lynch AF; Bourne RB; Rorabeck CH. The long-term results of ankle arthrodesis. J Bone Joint Surg Br. 1988;70:113-6.[PubMed]

Mazur JM; Schwartz E; Simon SR. Ankle arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg Am. 1979;61:964-75.[PubMed]

Morgan CD; Henke JA; Bailey RW; Kaufer H. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg Am. 1985;67:546-50.[PubMed]

Boobbyer GN. The long-term results of ankle arthrodesis. Acta Orthop Scand. 1981;52:107-10.[PubMed][CrossRef]

Hefti FL; Baumann JU; Morscher EW. Ankle joint fusion—determination of optimal position by gait analysis. Arch Orthop Trauma Surg. 1980;96:187-95.[PubMed][CrossRef]

Fuchs S; Sandmann C; Skwara A; Chylarecki C. Quality of life 20 years after arthrodesis of the ankle. A study of adjacent joints. J Bone Joint Surg Br. 2003;85:994-8.[PubMed][CrossRef]

Lidor C; Ferris LR; Hall R; Alexander IJ; Nunley JA. Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot. J Bone Joint Surg Am. 1997;79:558-64.[PubMed][CrossRef]

Greisberg J; Assal M; Flueckiger G; Hansen ST Jr. Takedown of ankle fusion and conversion to total ankle replacement. Clin Orthop Relat Res. 2004;424:80-8.[PubMed][CrossRef]

Hintermann B; Valderrabano V; Derey-maeker G; Dick W. The HINTEGRA ankle: rationale and short-term results of 122 consecutive ankles. Clin Orthop Relat Res. 2004;424:57-68.[PubMed] [CrossRef]

Topics

ankle ; prostheses and implants ; talus ; tibia ; ankle pain ; ankle arthrodesis ; ankle replacement arthroplasty ; arthrodesis ; kirschner wires

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Beat Hintermann, Alexej Barg, Markus Knupp, Victor Valderrabano; Conversion of Painful Ankle Arthrodesis to Total Ankle ArthroplastySurgical Technique. The Journal of Bone & Joint Surgery. 2010 Mar;92(Supplement_1_Part_1):55-66.

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