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)
Latest NJR annual report (2024)
Causes of failure
- infection
- aseptic loosening
- lysis / cyst formation
- polyethylene failure:
- wear
- fracture
- dislocation
- malalignment / instability
- stiffness
- soft tissue impingement
- unexplained pain
Diagnosis
- 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
Treatment options
Infection:
- Mostly will be 2 stage revision
- 1st stage revision with implant removal, thorough debridement, cement spacer
- Eradication rates for 2 stage revision around 90%
Aseptic loosening / revision options:
- 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 / fracture / dislocation:
- 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
Bone cyst:
- Usually from poly wear / infection: diagnose / exclude
- Treatment is curettage, take samples, and impaction bone graft (allograft mostly)
- Check implant stability intraop
Stiffness / instability:
- Poor evidence in literature
- Broström repair if pure instability with stable and well aligned implants
- Revision of components if they are the issue
- MUA / arthroscopic arthrolysis / TA lengthening for stiffness no evidence
Periprosthetic fracture:
- Rare, implants stable most of the time
- ORIF
Outcomes:
- Revision TAR 27% needed further surgery, 14% needed another revision
- Salvage fusion 87% union rate, 13% needed further surgery, 8% revision surgery
Prevention of failed TAR
Choose the optimal patient:
- older patient or one with lower physical demands
- good alignment and ligamentous stability
Avoid poor patient choice:
- neuromuscular deformity
- previous infection
- poor soft tissues / vascularity
- osteonecrosis / osteoporosis may cause problems with bony fixation
- poor host
Choose the optimal surgeon:
- implant-trained, higher volumes
- supportive infrastructure and colleagues, research team
- access to complex case MDT
- regional network for revision cases
Conclusion
- 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)
MCQ
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
References
- Clarke MJH, Salar O, Evans JP, Bayley MGR, Waterson BH, Toms AD, Phillips JRA. Prosthetic joint infection of the knee - arthroscopic biopsy identifies more and different organisms than aspiration alone. Knee. 2021 Oct;32:183-191. doi: 10.1016/j.knee.2021.08.016. Epub 2021 Sep 6. PMID: 34500431.
- 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.
https://www.orthobullets.com/foot-and-ankle/12133/total-ankle-arthroplasty