Should 15° of valgus coronal-plane deformity be the upper limit for a total ankle arthroplasty?

Halai, Mansur; Pinsker, Ellie; Mann, Matthew A.; Daniels, Timothy R.

doi:10.1302/0301-620x.102b12.bjj-2020-0140.r1

Cited by 14 publications

(7 citation statements)

References 32 publications

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“…Concomitant procedures (foot and ankle osteotomy and/ or foot fusion) were also associated with early implant failure, suggesting that patients with associated arthritis or deformities should be aware of a higher early revision risk when they require concomitant osteotomy or fusion. Valgus deformity of >15°has led to more ancillary procedures during the primary implantation and more secondary procedures postoperatively 17 . Likewise, concomitant fusions are known to increase procedure duration, nonunion complications, osseous stress on both tibial and talar components, and foot kinematic abnormalities, leading to an increased risk of failure 33 .…”

Section: Discussionmentioning

confidence: 99%

“…More than is the case with other lower limb replacements, patient selection seems to play a role in the revision rate. However, risk factors (e.g., young age with high-demand activity 15 , sex 16 , or concomitant procedures 17,18 ) remain debated due to contradictory reports and could be better analyzed through use of high-volume databases with national coverage. Additionally, little is known about the revision rate of these replacements in France.…”

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confidence: 99%

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Survivorship of 4,748 Contemporary Total Ankle Replacements from the French Discharge Records Database

Dagneaux

Nogue

Mathieu

et al. 2022

Journal of Bone and Joint Surgery

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Background: Studies of survivorship of primary total ankle replacements (TARs) beyond 5 years have shown varying results among early and modern designs. National cohorts give valuable insights about TAR outcomes, revision risk factors, and specific designs. The purpose of this study was to investigate implant survivorship and risk factors for revision of contemporary TARs using our national database.Methods: This observational study included patients identified in the national PMSI (Programme médicalisé des systèmes d'information) database as having undergone TAR from 2010 to 2019. Demographics, discharge data, concomitant procedures, and type of implant were extracted. Kaplan-Meier estimations were performed to determine time to revision using metal component revision for implant failure and revision for deep infection as end points. Weighted Cox models were used for risk factor analysis, including risks of early revision (within the first 2 years). The adjusted hazard ratios (HR ADJ ) were reported with 95% confidence intervals.Results: A cohort of 4,748 patients was extracted. The mean age at surgery was 63 years; 43% of the patients were female. The mean follow-up was 5 years (range, 1 to 10 years). Revisions were noted in 817 cases (17%), including 734 with metal component revision and 83 with revision due to deep infection. The 1-year, 2-year, 5-year, and 10-year survivorship free of metal component revision was 95%, 90%, 84%, and 78%, respectively. Younger age, implants derived from second-generation designs, and an institutional volume of £10 TARs per year were found to be independent predictors of revision for any cause. In addition to the above factors (except for implant generation), male sex and concomitant osteotomies and/or fusion were found to be significant predictors for any early revision. Conclusions:The 10-year survivorship free of metal component revision after TAR was 78%, which was consistent with other national registries. Revisions were associated with young age, associated arthritis or deformities requiring concomitant fusion or osteotomy, and implants derived from second-generation designs. Institutions where >10 procedures were performed per year were associated with better TAR survivorship.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Survivorship of 4,748 Contemporary Total Ankle Replacements from the French Discharge Records Database

Dagneaux

Nogue

Mathieu

et al. 2022

Journal of Bone and Joint Surgery

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“…Some view a preoperative deformity of >10° to 15° as a contraindication to TAA 23,24 while others recommend prior or concomitant intervention to correct the deformity. 25-27 In our series, the rate of revision surgery for valgus preoperative alignment was nearly 3 times that of varus alignment (30% vs. 9%) and nearly 6 times that of neutral alignment (5%). Furthermore, failure requiring implant explantation was exclusively seen in those with preoperative valgus malalignment, associated with 4° of valgus.…”

Section: Discussionmentioning

confidence: 49%

Total Ankle Arthroplasty for Posttraumatic Fracture Versus Primary Osteoarthritis: An Analysis of Complications, Revisions, and Prosthesis Survival

Megerian

Harlow

LaTulip

et al. 2023

J Am Acad Orthop Surg

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Background: Most outcome studies of total ankle arthroplasty (TAA) do not discriminate by arthritis etiology. The primary purpose of this study was to compare the complications of TAA between posttraumatic fracture osteoarthritis (fracture PTOA) and primary osteoarthritis (POA). Methods: Ninety-nine patients who underwent TAA were retrospectively evaluated with a mean follow-up of 3.2 years (range 2 to 7.6 years). 44 patients (44%) had a diagnosis of POA while 55 patients (56%) had a diagnosis of fracture PTOA (40 malleolar fractures [73%], 14 pilon fractures[26%], and 1 talar fracture [1%]). Patient demographics, preoperative coronal plane alignment, postoperative complications, and revision surgery data were collected. Categorical variables were compared with chi square and Fisher exact tests and means with the Student t-test. Survival was assessed with Kaplan-Meier and log-rank analyses. Results: A higher overall complication rate was associated with fracture PTOA (53%) compared with POA (30%) (P = 0.04). No difference was observed in rates of any specific complication by etiology. Survival, defined as revision surgery with TAA prosthesis retention, was comparable between POA (91%) and fracture PTOA (87%) (P = 0.54). When defined as failure requiring prosthesis explant, POA demonstrated significantly greater survival (100%) as compared with fracture PTOA (89%) (P = 0.03). A higher rate of talar implant subsidence and loosening was noted in TAA with prior pilon (29%) as compared to malleolar fractures (8%) that was not statistically significant (P = 0.07). Fracture PTOA was associated with preoperative valgus deformity (P = 0.04). Compared with varus and normal alignment, preoperative valgus deformity was associated with the need for any revision surgery (P = 0.01) and prosthesis explant (P = 0.02). Conclusions: Compared with POA, fracture PTOA was associated with a markedly higher complication rate after TAA and was at higher risk of failure requiring prosthesis explant. Fracture PTOA was markedly associated with preoperative valgus malalignment, an identified risk factor in this series for revision surgery and prosthesis explant. Pilon fractures may represent a group at risk of complications related to talar implant subsidence and loosening compared with malleolar fractures and thus warrants additional investigation. Level of Evidence: III

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“…21 Interestingly, similar results have been reported for preoperative talar valgus deformity of greater than 15 degrees, but patients required more adjunctive procedures during and after total ankle arthroplasty. 8 The difficulty in coronally malaligned ankles is further demonstrated in the study from Henricson and Ågren. 10 In their study, 61% of the ankles requiring revision had a preoperative coronal deformity with an overall 2-fold higher rate of revision in these ankles.…”

Section: Discussionmentioning

confidence: 89%

The Impact of Coronal Plane Deformity on Ankle Arthrodesis and Arthroplasty

et al. 2021

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Background: Ankle coronal plane deformity represents a complex 3-dimensional problem, and comparative data are lacking to guide treatment recommendations for optimal treatment of end-stage ankle arthritis with concomitant coronal plane deformity. Methods: In total, 224 patients treated for end-stage ankle arthritis were enrolled in an observational trial. Of 112 patients followed more than 2 years, 48 patients (19 arthrodesis, 29 arthroplasty) had coronal plane deformity and were compared to 64 patients without coronal plane deformity (18 arthrodesis, 46 arthroplasty) defined as greater than 10 degrees of varus or valgus. The arthroplasty implants used had different internal constraints to intracomponent coronal plane tilting. Patients completed Musculoskeletal Functional Assessment (MFA) and SF-36 preoperatively and at 3, 6, 12, 24, and 36 months postoperatively. Measures included change in SF-36 and MFA, as well as compared reoperation rates and pain scales. Results: For the groups with coronal plane ankle deformity, the median for the arthrodesis group was 19.0 degrees and the median for the arthroplasty group was 16.9 degrees. In the deformity cohort during the follow-up period, we had 7 major reoperations: 2 in the arthrodesis group and 5 in the arthroplasty group, all with the less constrained implant design. MFA, vitality, and social function of the SF-36 improved for all groups. Patients without preoperative deformities had greater improvement with fusion or replacement at both 2 and 3 years. There was no difference in improvement between those patients with coronal deformity who received arthroplasty vs arthrodesis. Conclusion: Patients with and without coronal plane deformity may benefit from ankle arthroplasty and arthrodesis, although greater improvements may be expected in those without preoperative deformity. In this study, at final follow-up of 3 years, overall we found no meaningful difference in patient-reported outcomes between the patients with preoperative coronal plane deformities whether they had a fusion or a replacement as treatment for end-stage ankle arthritis. Level of Evidence: II, comparative study.

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Should 15° of valgus coronal-plane deformity be the upper limit for a total ankle arthroplasty?

Cited by 14 publications

References 32 publications

Survivorship of 4,748 Contemporary Total Ankle Replacements from the French Discharge Records Database

Survivorship of 4,748 Contemporary Total Ankle Replacements from the French Discharge Records Database

Total Ankle Arthroplasty for Posttraumatic Fracture Versus Primary Osteoarthritis: An Analysis of Complications, Revisions, and Prosthesis Survival

The Impact of Coronal Plane Deformity on Ankle Arthrodesis and Arthroplasty

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