Management of the Failed Total Ankle Replacement

Introduction

TAR survivorship is around 90% at 10 years on the national joint registry (89.6% at 13 years as max)

History:
- Pain, stiffness, instability, swelling, symptoms of infection
- Are symptoms new, or been there since day 1?
- Patient background

Examination:
- Soft tissue (swelling, skin, scars, Achilles tendon)
- Joint (mobility, stability)
- Alignment (midfoot, hindfoot, ankle, lower limb overall)

Investigations:
- Weight bearing ankle x-rays:
  - radiolucency >2mm and/or progression with time suggests loosening
  - >5 degrees or >5mm change in position in serial x-rays suggests migration
- CT: bony morphology, quantify bone cysts
- MRI: soft tissue collection / infection
- SPECT / gallium scan: location of pain source / diagnose infection
- Arthroscopic biopsy:
  - 5 micro sample and 2 histology samples
  - More accurate than aspiration

IDEALLY, CASES SHOULD BE DISCUSSED IN A MUTLIDISCIPLINARY TEAM MEETING FOR PATIENT MANAGEMENT AND SURGICAL PLANNING

larger units will have more experience
characterise degree and location of bone loss
options are:
- revision with revision components (Inbone II / Invision)
- salvage fusion (TTC with femoral head / impaction bone grafting / 3D printed cage)
- total talus replacement with total ankle replacement (still early stages, last resort)
- amputation

Poly wear usually leads to implant loosening  if loose then revision is the answer (see above)
If purely fracture / need poly exchange:
- if still available then poly exchange
- if not available then revision

Usually from poly wear / infection: diagnose / exclude
Treatment is curettage, take samples, and impaction bone graft (allograft mostly)
Check implant stability intraop

Revision TAR  27% needed further surgery, 14% needed another revision
Salvage fusion  87% union rate, 13% needed further surgery, 8% revision surgery

Choose the optimal patient:

Avoid poor patient choice:

Choose the optimal surgeon:

90% survival at 10 years
Most reported complications are preventable with good patient selection and surgical technique
Failed TARs need appropriate investigation, work-up and team discussion before proceeding with appropriate revision / salvage options
The solution should be tailored to the clinical scenario (i.e. no one-size-fits-all algorithm)

What is the main priority in working up a possible failing total ankle replacement?

- Exclude infection
- Identify and quantify bone defects
- Send the patient to physiotherapy to optimise function before proceeding
- Check for signs of loosening
- Discuss case at MDT

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Antonio Izzo, Claudia Carbone, Vincenzo De Matteo, François Lintz, Enrico Festa, Giovanni Balato, Alessio Bernasconi, Eradication rate after debridement, antibiotics, and implant retention (DAIR), 1.5-stage revision or 2-stage revision in periprosthetic ankle joint infection: A systematic review, Foot and Ankle Surgery, 2025
Jennison T, Spolton-Dean C, Rottenburg H, Ukoumunne O, Sharpe I, Goldberg A. The outcomes of revision surgery for a failed ankle arthroplasty. Bone Jt Open. 2022;3(7):596-606. doi:10.1302/2633-1462.37.BJO-2022-0038.R1
Lee MS, Lee GW, Lee KB. Bone grafting for periprosthetic bone cysts following total ankle arthroplasty. Bone Joint J. 2024 May 1;106-B(5):475-481. doi: 10.1302/0301-620X.106B5.BJJ-2023-1091.R1. PMID: 38688515.