Aims. Retrospective review of a consecutive series of 1,168 total ankle replacements (TAR) performed at Wrightington, to analyse modes of failure and clinical outcomes following TAR failure. Methods. All patients undergoing TAR between November 1993 – June 2019 were collated (4–25 year follow-up; mean 13.7 years). 6 implants were used (300 STAR, 100 Buechal Pappas, 509 Mobility, 118 Zenith, 41 Salto and 100 Infinity). 5 surgeons, all trained in TAR, performed the surgery. Modes of failure were collated and clinical and radiological outcomes recorded for the revisional surgery following failure of the TAR. Results. 156 (13.4%) TARs failed (47STAR 15.6%, 16BP 16%, 77Mobility 15.1%, 6Salto 14.6%, 10Zenith 8.5% and 0Infinity 0%). Mean time to failure 5.8 years (0.1- 21.4 years). The 4 most common modes of failure were 44.9% aseptic loosening, 11.5% gutter pain, 10.9% infection and 10.3% recurrent edge loading. 50 underwent conversion to tibiotalocalcaneal (TTC) fusion with nail with 9 (18%) failing to fuse. 31 underwent revision TAR with 2 (6.5%) subsequently failed. 22 underwent ankle fusion with 10 (45%) failing to fuse. 21 underwent polyethylene exchange of which 8 (38%) had further poly failure. 20 (12.8%) were managed conservatively, 2 (1.3%) required below knee amputation and 6 were listed but lost to follow-up. 81 of the 1168 (7%) consecutive cohort were lost to follow-up. Conclusions. 13.4% of the TAR cohort have failed at average follow-up 13.7 years. There was no difference in failure modes across the implant designs. Whilst the fixed bearing has the shortest follow-up, it may be performing better as there have been no failures so far. Prior to October 2016, most revisions were to fusion (TTC 18% failure rate, ankle 45% failure rate), whereas post 2016, 57% patients elected for revision TAR (6.5% failure)

We carried out 123 consecutive total ankle replacements in 111 patients with a mean follow-up of four years (2 to 8). Patients with a hindfoot deformity of up to 10° (group A, 91 ankles) were compared with those with a deformity of 11° to 30° (group B, 32 ankles). There were 18 failures (14.6%), with no significant difference in survival between groups A and B. The clinical outcome as measured by the post-operative American Orthopaedic Foot and Ankle Surgeons score was significantly better in group B (p = 0.036). There was no difference between the groups regarding the post-operative range of movement and complications. Correction of the hindfoot deformity was achieved to within 5° of neutral in 27 ankles (84%) of group B patients. However, gross instability was the most common mode of failure in group B. This was not adequately corrected by reconstruction of the lateral ligament. Total ankle replacement can safely be performed in patients with a hindfoot deformity of up to 30°. The importance of adequate correction of alignment and instability is highlighted

Aims

The traditional transosseus flexor hallucis longus (FHL) tendon transfer for patients with Achilles tendinopathy requires two incisions to harvest a long tendon graft. The use of a bio-tenodesis screw enables a short graft to be used and is less invasive, but lacks supporting evidence about its biomechanical behaviour. We aimed, in this study, to compare the strength of the traditional transosseus tendon-to-tendon fixation with tendon-to-bone fixation using a tenodesis screw, in cyclical loading and ultimate load testing.

We performed a systematic review and meta-analysis of modern total ankle replacements (TARs) to determine the survivorship, outcome, complications, radiological findings and range of movement, in patients with end-stage osteoarthritis (OA) of the ankle who undergo this procedure. We used the methodology of the Cochrane Collaboration, which uses risk of bias profiling to assess the quality of papers in favour of a domain-based approach. Continuous outcome scores were pooled across studies using the generic inverse variance method and the random-effects model was used to incorporate clinical and methodological heterogeneity. We included 58 papers (7942 TARs) with an interobserver reliability (Kappa) for selection, performance, attrition, detection and reporting bias of between 0.83 and 0.98. The overall survivorship was 89% at ten years with an annual failure rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean American Orthopaedic Foot and Ankle Society score changed from 40 (95% CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up of 8.2 years (7 to 10) (p < 0.01). Radiolucencies were identified in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The mean total range of movement improved from 23° (95% CI 19 to 26) to 34° (95% CI 26 to 41) (p = 0.01).

Our study demonstrates that TAR has a positive impact on patients’ lives, with benefits lasting ten years, as judged by improvement in pain and function, as well as improved gait and increased range of movement. However, the quality of evidence is weak and fraught with biases and high quality randomised controlled trials are required to compare TAR with other forms of treatment such as fusion.

Cite this article: Bone Joint J 2013;95-B:1500–7.

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.