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Total Ankle Arthroplasty: Long-term Survival and Factors that Influence it

E. Carlos Rodriguez-Merchan1, Inmaculada Moracia-Ochagavia1

1 Department of Orthopaedic Surgery, “La Paz” University Hospital-IdiPaz, Paseo de la Castellana 261. 28046-Madrid, Spain

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: E. Carlos Rodriguez-Merchan, Department of Orthopaedic Surgery, “La Paz” University Hospital-IdiPaz, Paseo de la Castellana 261, 28046-Madrid, Spain.
Email: ecrmerchan@hotmail.com
Telephone: +34-915712871

Received: June 26, 2019
Revised: July 15, 2019
Accepted: July 18 2019
Published online: August 28, 2019

ABSTRACT

Total ankle arthroplasty (TAA) and ankle arthrodesis are efficacious treatments of end-stage ankle osteoarthritis but the selection must be specially fit to individual patients. TAA offers a judicious option to ankle arthrodesis in prudently selected patients. Reoperation rates are greater in TAA compared with ankle arthrodesis. The primary diagnosis for TAA is 37% osteoarthritis, 34% traumatic arthritis, 15% rheumatoid arthritis, 14% other. Patients experiencing TAA tend to be older, female, and have rheumatoid arthritis compared with those being subjected to ankle arthrodesis. Aseptic loosening and infection are the most frequent complications of TAA needing revision. The 15-year survival of primary TAA ranges from 45% to 91%. A comparison between the HINTEGRA implant, the AGILITY implant, the MOBILITY implant, and the Scandinavian Total Ankle Replacement (STAR) implant exhibited reasonable results of four modern TAA designs. TAA is a demanding surgical technique and the survival is not similar to that following hip or knee arthroplasty. Revision TAA has a 10-year survival of 55%, which is lower than the 10-year survival of 74% for primary TAA.

Key words: Total ankle arthroplasty; Long-term survival; Risks factors of failure

© 2019 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Rodriguez-Merchan EC, Moracia-Ochagavia I. Total Ankle Arthroplasty: Long-term Survival and Factors that Influence it. International Journal of Orthopaedics 2019; 6(4): 1128-1131 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/2620

INTRODUCTION

Total ankle arthroplasty (TAA) has become more and more popular worldwide as an option to ankle arthrodesis for surgical management of end-stage ankle osteoarthritis[1]. In fact, the usage of TAA in the United States has augmented close to 50% over the past 14 years[2].

It has been reported that patients experiencing TAA tended to be older, female, and have rheumatoid arthritis compared with those going through ankle arthrodesis. Patients experiencing TAA had shorter length of stay, greater hospitalization costs, and more blood transfusions compared with those going through ankle arthrodesis. Moreover, lower hospital volume and shorter anaesthesia time were related to higher rates of complications following TAA[1].

The rate of TAA is augmenting in the United States as its reputation and indications increase[3]. In a study the primary diagnosis for TAA was 37.4% osteoarthritis, 34.3% traumatic arthritis, and 15.5% rheumatoid arthritis[3]. TAA has demonstrated a positive correlation with time, significantly augmenting from 2.4 cases per 100,000 admissions from 1997 to 2003 to 3.5 cases per 100,000 from 2004 to 2010[2].

It has been recenty published that reoperation rates are greater in TAA compared with ankle arthrodesis and TAA and ankle arthrodesis are efficacious treatments of end-stage ankle osteoarthritis but the election must be tailored to individual patients[4].

TAA offers a rational option to ankle arthrodesis in meticulously selected patients. Aseptic loosening and infection are the most frequent complications needing revision[5]. The uncemented mobile or fixed bearing designs had better results compared with their older counterparts.There was no evidence to insinuate supremacy of one design over another among the accesible implants.

However, we believe that the long-term survival of the different TAA designs and the factors that influence it must be defined more precisely. The purpose of this article has been to determine the long-term survival of the different types of existing TAA and also to know whether some risk factors can influence it. All this in order to help decide which TAA design has greater long-term survival and what risk factors we must control, so that said survival is not diminished.

Long-term survival

In a systematic review, the comprehensive survivorship at ten years was 89% with a yearly failure rate of 1.2%[6]. In the Swedish Ankle Arthroplasty Register, the overall survival rate at 5 years is 78%[7]. In the Finnish ArthroplastyRegister the yearly prevalence of TAA is 1.5 per 105 inhabitants[8]. The 5-year overall survivorship for the whole TAA group is 83%. The most common reasons for revision are aseptic loosening of one or both of the prosthesis components (39%) and instability (39%). Moreover, no difference was found in survival rate between the STAR and Ankle Evolution System (AES) prostheses. Age, sex, diagnosis, and hospital volume did not influence the TAA survival.

In the Swedish Ankle Register the comprehensive survival rate declined from 81% at 5 years to 69% at 10 years[9]. Women below the age of 60 with osteoarthritis were at a greater risk of revision, but age did not affect the result in men or women with rheumatoid arthritis. In a study, implant survival for several national joint registries was 94% at 2-years, 87% at 5-years and 81% at 10-years[10].

Different TAA designs: 5, 10 and 15 year survivals

Table 1 summarizes the 5, 10 and 15 year survivals of different existing TAA designs[11-39]. The reported 5-year survival rate in United Sytes was 90.1%[40]. Kamrad et al found that revision TAA has a 10-year survival of 55%, which is lower than the 10-year survival of 74% for primary TAA published from the same registry[41].

Table 1 Survivorship of different designs of total ankle arthroplasty (TAA) in the literature [11-39].
Authors

Year

Design

5-Year Survival

10-Year Survival

15-Year Survival

Comments

Buechel and Pappas [11]1992Buechel-PappasNA94.75%.NA 
Kitaoka et al [12]1994Mayo79%65%61%The authors did not recommend the use of the Mayo TAA
Kofoed et al [13]1995Cylindrical cementedNA70% (*)NA(*) At 12 years
Schill et al [14]1998Thompson-Richards NA87% (*)NA(*) At 12 years
Schill et al [14]1998STAR94.3% (*)NANA(*) At 6 years
Anderson et al [15]2003STAR70%NANA 
Wood et al [16]2008STAR93.30%80.30%NA 
Karantana et al [17]2010STAR90%84% (*)NA(*) At 8 years
Morgan et al [18]2010AES94.7% (*)NANA(*) At 6 years
Henricson et al [19]2010AES90%NANA 
Wood et al [20]2010MOBILITYNANANAThe three-year survival was 97%. The four-year survival was 93.6%
Bonnin et al [21]2011SALTONANANASurvivorship at 7 to 11 years: The survival rate was 65% with any reoperation of the ankle and 85% with revision of a component as the end points.
Mann et al [22]2011STAR96%90%NA 
Hintermann et al [23]2013HINTEGRANA83% (*)NA(*) At 9 years
Barg et al [24]2013HINTEGRA94%84%NA 
Brunner et al [25]2013STARNA70.70%45.6% (*)(*) At 14 years
Adams et al [26]2014INBONE89% (*)NANA(*) At 3.7 years
Henricson and Carlsson [27]2015STAR (single-coated) NANA47% (*)(*) At 14 years
Henricson and Carlsson [27]2015STAR (double-coated)NA64% (*)NA(*) At 12 years
Hofmann et al [28]2016SALTO TALARIS97.50%NANA 
Kerkhoff et al [29]2016MOBILITY95%NANA 
Kerkhoff et al [30]2016STARNA78%NA 
Koiwu et al [31]2017AES87.30%74.80%NA 
Koivu et al [32]2017STAR93.90%86.70%63.60% 
Frigg et al [33]2017STARNA(def. 1) 94%, (def. 2) 90%, and (def. 3) 78% (def. 1) 91%, (def. 2) 75%, and (def. 3) 55%(*) At 19 years. The primary endpoint was defined as exchange of the whole prosthesis or conversion to ankle arthrodesis (def. 1), exchange of at least one metallic component (def. 2), or exchange of any component including the inlay (due to breakage or wear) (def. 3).
Raikin et al [34]2017AGILITYNA80% (*)70.4% (**)(*) At 9 years. (**) At 14 years
Giannini et al [35]2017LIGAMENTS-COMPATIBLE97.30%NANA 
Palanca et al [36]2018STARNANA73% (*)(*) Metal implant survival was 73% at 15 years
Koo et al [37]2018SALTO93.30%NANA 
Penner et al [38]2018INFINITY97% (*)NANA(*) At 2.9 years
Clough et al [39]2019STARNANA76.16% (*)(*) At 15.8 years
NA = Non-available; STAR = Scandinavian Total Ankle Replacement; AES = Ankle Evolution System

Failure risk factors of TAA

A study demonstrated significant racial disparities with lower TAA usage and suboptimal results in Blacks compared to Whites[42]. It has been reported that patients who are male, have a history of community-acquired pneumonia, and have a larger number of preoperative comorbidities had a significant augmented risk of suffering one complication within 30 days of surgery[43].

Patients experiencing TAA had shorter length of stay, greater hospitalization costs, and more blood transfusions compared with those experiencing ankle arthrodesis. Lower hospital volume and shorter anaesthesia time were related to greater rates of complications following TAA[1].

It has ben observed that patients with rheumatoid arthritis or who were readmitted within 90 days of TAA had significantly augmented risk of failure. Risk factors for readmission were Charlson-Deyo Score ≥ 2 and increased length of stay during TAA[40].

It has beem observed that the 30-day complication rate was 2.4% with 0.5% mortality and 0.2% infection rate. Length of hospital stay, both as an end point at >5 days and as a continuous variable, was related to overall adverse events. Patient characteristics that anticipated perioperative morbidity included presence of three or comorbidities, American Society of Anaesthesiologists class III, and history of preceding cardiac surgery[44].

It has been reported that patients who experience staged bilateral TAA benefit as much as patients who go through unilateral TAA, in spite of having a worse preoperative health status[45]. It has been found that survival rates of TAA in patients under age of 55 years are similar to those in patients older than 55 years in the intermediate-term follow-up[46].

Comparative studies

A comparison between two 3-component total ankle implants (HINTEGRA versus MOBILITY systems) showed favourable clinical result without significant differences. However, in terms of adverse events, ankle impingement syndrome was more common in the HINTEGRA group, while intraoperative malleolar fracture was found only in the MOBILITY group[47]. A study demonstrated similar results between HINTEGRA, STAR, and AGILITY implants[48].

Conversion of ankle arthrodesis to total ankle arthroplasty

In 2015 Pellegrini et al analysed 23 TAAs in patients who had experienced a prior or an attempted ankle arthrodesis[49]. They performed concurrent surgical procedures in eighteen ankles (78%), with the most frequent procedure being prophylactic malleolar fixation (70%). Short-term follow-up following conversion of ankle arthrodesis to TAA showed pain relief and ameliorated function in a most patients.

Conclusion

Total ankle arthroplasty (TAA) offers a ratiocinative alternative to ankle arthrodesis in prudently selected patients. The primary diagnosis for TAA is 37% osteoarthritis, 34% traumatic arthritis, 15% rheumatoid arthritis, 14% other. Patients receiving TAA tend to be older, female, and have rheumatoid arthritis compared with those receiving ankle arthrodesis. Aseptic loosening and infection are the most prevalent complications of TAA needing revision. The 15-year survival of primary TAA ranges from 45% to 91%. A comparison between the HINTEGRA implant, the AGILITY implant, the MOBILITY implant, and the Scandinavian Total Ankle Replacement (STAR) implant showed acceptable results of four modern TAA prostheses. TAA is a demanding surgical procedure and the survival is not comparable to that after hip or knee arthroplasty. Revision TAA has a 10-year survival of 55%, which is lower than the 10-year survival of 74% for primary TAA published.

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