Pathogenesis, Evaluation, and Management of Osteolysis Following Total Ankle Arthroplasty

Abstract

Periprosthetic osteolysis is a common occurrence after total ankle arthroplasty (TAA) and poses many challenges for the foot and ankle surgeon. Osteolysis may be asymptomatic and remain benign, or it may lead to component instability and require revision or arthrodesis. In this article, we present a current and comprehensive review of osteolysis in TAA with illustrative cases. We examine the basic science principles behind the etiology of osteolysis, discuss the workup of a patient with suspected osteolysis, and present a review of the evidence of various management strategies, including grafting of cysts, revision TAA, and arthrodesis. Level of Evidence: Level V, expert opinion.

Low Rate of Peri-implant Osteolysis in Trabecular Metal Total Ankle Replacement on Short- to Midterm Follow-up

“…1 The surface coating has been a significant risk factor for the development of osteolysis at least in AES (Transystème) and STAR (Stryker GmbH) implants. 3,21,22,37 In addition to the coating material, the implant design, alignment, and the quality of bone may have an influence on the amount of micromotion at the bone-implant interface and the initial stability of the implant, 12,13,26,27,32 although no difference was found in the preoperative bone density between patients with and without peri-implant osteolysis after Hintegra TAR (Integra) in a study by Lee et al 23 Regarding the bony ingrowth providing better initial stability of the TAR implant, the tantalum metal could be beneficial material to decrease the risk of osteolysis. In addition, the kinematics of the TMTA ankle are different from the conventional TAR implants, which also may contribute to the initial stability of the implant.…”

Evaluating and Managing the Painful Total Ankle Replacement

“…7,38 Although this has substantially improved with newer generations of TAR design, osteolysis-and its potential for loosening and subsidence-is still a primary concern. 16,60,73 Importantly, osteolysis and cysts may be asymptomatic but still problematic; management of these cases has been detailed elsewhere. 30,73,86 Osteolysis is associated with multiple processes: the presence of intracellular and extracellular polyethylene particles; the activation of the receptor activator of nuclear factor κ-Β ligand (RANK-L) pathway; the inflammatory deluge of macrophages, giant cells, and lymphocytes; and the release of proinflammatory cytokines that recruit osteoclasts.…”

“…16,60,73 Importantly, osteolysis and cysts may be asymptomatic but still problematic; management of these cases has been detailed elsewhere. 30,73,86 Osteolysis is associated with multiple processes: the presence of intracellular and extracellular polyethylene particles; the activation of the receptor activator of nuclear factor κ-Β ligand (RANK-L) pathway; the inflammatory deluge of macrophages, giant cells, and lymphocytes; and the release of proinflammatory cytokines that recruit osteoclasts. 8,23,33,91,93 In one series of patients revised due to osteolysis, the number of polyethylene particles counted in cysts did not correlate with the length of time from index surgery to revision, suggesting that osteolysis is not purely time dependent but also related to factors such as biomechanical alignment, implant design, and local anatomy and physiology.…”

“…73 Grafting provides immediate implant support and can improve the overall stability of the construct. 73 Graft options include autograft, allograft, calcium phosphate, and polymethylmethacrylate (PMMA) cement. 6,9 Oral bisphosphonates can be a beneficial adjunct for patients with cysts larger than 1 cm in diameter.…”

“…53 Although graft options are variable and widely debated, it is important to fill as much of the osteolytic defect as possible because residual defects that are left unsealed at are risk for infiltration by wear particles, which will lead to lesion progression. 49,51,53,73,87 On the talar side, revision is often complicated by the residual bone voids that occur after removal of the loose talar component. 67 The location of bone loss and the amount of talar subsidence in relation to the subtalar joint must be considered prior to revision.…”