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