Despite advancements, revision rates following total ankle replacement (TAR) are high in comparison to other total joint replacements. This explant analysis study aimed to investigate whether there was appreciable metal particulate debris release from various contemporary TARs by describing patterns of material loss. Twenty-eight explanted TARs (9 designs: 3 fixed and 6 mobile bearing), revised for any reason, were studied. The articulating surfaces of the metal tibial and talar components as well as the polyethylene insert were assessed for damage features using light microscopy. Based on the results of the microscopic analysis, scanning electron microscopy with energy dispersive X-ray spectroscopy was performed to determine the composition of embedded debris identified, as well as non-contacting 3D profilometry. Pitting, indicative of material loss, was identified on the articulating surfaces of 54% of tibial components and 96% of talar components. Bearing constraint was not found to be a factor, with similar proportions of fixed and mobile bearing metal components showing pitting. More cobalt-chromium than titanium alloy tibial components exhibited pitting (63% versus 20%). Significantly higher average surface roughness (Sa) values were measured for pitted areas in comparison to unpitted areas of these metal components (p<0.05). Additionally, metallic embedded debris (cobalt-chromium likely due to pitting of the tibial and talar components or titanium likely from loss of their porous coatings) was identified in 18% of polyethylene inserts. The presence of hard 3. rd. body particles was also indicated by macroscopically visible sliding plane scratching, identified on 79% of talar components. This explant analysis study demonstrates that metal debris is released from the articulating surfaces and the coatings of various contemporary TARs, both fixed and mobile bearing. These findings suggest that metal debris release in TARs may be an under-recognised issue that should be considered in the study of painful or failed TAR moving forwards

Aims. Although absorbable sutures for the repair of acute Achilles tendon rupture (ATR) have been attracting attention, the rationale for their use remains insufficient. This study prospectively compared the outcomes of absorbable and nonabsorbable sutures for the repair of acute ATR. Methods. A total of 40 patients were randomly assigned to either braided absorbable polyglactin suture or braided nonabsorbable polyethylene terephthalate suture groups. ATR was then repaired using the Krackow suture method. At three and six months after surgery, the isokinetic muscle strength of ankle plantar flexion was measured using a computer-based Cybex dynamometer. At six and 12 months after surgery, patient-reported outcomes were measured using the Achilles tendon Total Rupture Score (ATRS), visual analogue scale for pain (VAS pain), and EuroQoL five-dimension health questionnaire (EQ-5D). Results. Overall, 37 patients completed 12 months of follow-up. No difference was observed between the two groups in terms of isokinetic plantar flexion strength, ATRS, VAS pain, or EQ-5D. No re-rupture was observed in either group. Conclusion. The use of absorbable sutures for the repair of acute ATR was not inferior to that of nonabsorbable sutures. This finding suggests that absorbable sutures can be considered for the repair of acute ATRs. Cite this article: Bone Joint J 2022;104-B(8):938–945

Introduction. When ankle arthroplasty fails the options are revision to arthrodesis or revision to arthroplasty. We report early outcomes of revision procedures for failed total replacement. Methods. Retrospective review of prospectively collected data including post-operative complications, union, survivorship and PROMS scores to compare revision to arthrodesis and revision to arthroplasty. Results. 31 revision procedures (10 revision to arthrodesis and 21 revision to arthroplasty) were performed for failed primary ankle arthroplasty (30 patients) between January 2012 and June 2019. 23 males: 8 females, average age of 68. Indications for revisions were aseptic loosening (13), cysts/lysis (6), pain (5), periprosthetic infection (3), fracture (2), fibula erosion (1), polyethylene dislocation (1). Union rate following arthrodesis was 77.9% after primary revision procedure. Impaction bone grafting technique was utilised in seven patients with a union rate of 83%. Survivorship following revision to arthroplasty was 100% at two years; 87.5% at three years and 75% at four years Failed revision arthroplasty was revised to arthrodesis successfully. Median MOxFQ was 73.5 for the arthrodesis group versus 17 in the arthroplasty group (p=0.02). Median AOS was 87 for the arthrodesis group versus 12 for the arthroplasty group (p=0.04). Discussion. This study demonstrated the potential advantages in the short term of revision arthroplasty over conversion to arthrodesis with statistically significant improvements in MOxFQ and AOS within the first two years following revision

Introduction. Acute ankle injuries are commonly seen in musculoskeletal practice. Surgical management is the gold standard for lateral ligament injury in those with failed conservative treatment for a minimum of six months. Several studies have shown good functional outcome and early rehabilitation after MBG repair with an internal brace augmentation which is a braided ultrahigh molecular weight polyethylene ligament used to enhance the repair that acts as a secondary stabiliser. Hence the aim of the study was to compare the results with and without augmentation. Methods. A single centre retrospective review conducted between November 2017 and October 2019 and this included 172 patients with symptomatic chronic lateral ligament instability with failed conservative management. The diagnosis was confirmed by MRI. All patients had an ankle arthroscopy followed by open ligament repair. Patients were grouped into isolated MBG and internal brace groups for analyses and all had dedicated rehabilitation. Results. A total of 148 patients were available for final follow up with 87 patients in the MBG group and 61 patients in the IBA group. Mean Age was 38 years and mean follow up was 22 months. The internal brace group showed better Manchester Oxford foot and ankle score (19.7 vs 18.2) and more patients returning to preinjury activity levels (73 vs 55) as compared to isolated repair. Conclusion. Internal brace augmentation with MBG repair facilitated early rehabilitation and return to pre injury activity level in majority of patients compared to isolated MBG repair

Insertional Achilles tendinitis with considerable degeneration that failed non-operative treatment typically requires tendon debridement and reattachment to bone. It is common practice for tendons to be reattached back with anchor sutures, but this poses a challenge to patients who are not able to afford them. Bony anchorage of tendons may be performed by passing sutures through tunnels, but the strength of repair compared to by using anchors is not known. We investigated the load at clinical and catastrophic failure of these two methods of reattachment. Sixteen paired Achilles tendons along with the calcaneus were harvested from eight fresh frozen cadavers. Paired randomization was done. For the anchor suture group, two 5’0 anchors with polyethylene #2 sutures were used for reattachment whereas for the suture only group, tendons were reattached to bone using braided polyester #2 sutures via two bony tunnels. All samples were mounted on a materials testing system and preloaded at 50N for 60sec before load to failure at a rate of 1mm/sec. With the assumption that preloading has removed tendon crimp and any subsequent extension is a result of gapping at the repair site, loads at 5mm, 10mm, 15mm, and 20mm of extension were noted as well as the maximal load at failure. We found higher loads were needed to cause an extension of 5 to 20mm in the suture only group compared to the anchor suture group but these data were not significant. On the other hand, the anchor suture group required higher loads before catastrophic failure occurred compared to the suture only group, but this again is not significant. We conclude that suture only reattachment of the Achilles tendon is comparable in strength with anchor suture reattachment, and this method of reattachment can be considered for patients who do not have access to anchor sutures

Introduction. Total ankle arthroplasty (TAA) is an increasingly popular treatment option for patients with end-stage ankle arthritis. However, for most implant systems, failure rates of 10–20% have been reported within the first 10 years after primary TAA. Pain is the primary symptom that indicates failure of TAA but cause of it can be difficult to establish. Methods. All patients who underwent a primary TAA at our center were included in the study. The clinical outcomes were studied for patients requiring a further revision procedure following primary TAA. The reasons for revision surgery and outcomes of surgery were analyzed using appropriate inferential statistical tests. Results. Between 2007 and 2018, 42 primary TAA required revisions in 40 patients. There were 25 men (59.5%) and 15 women (35.7%) with mean age of 57.5 years the time of primary TAA. All patients had undergone primary procedure at a mean duration of 3.5 years previously (range: 3 months to 10 years). Of the total revision procedures, 12/40 (30%) of revisions were carried out due to malalignment, 10/42 (23.8%) due to loosening of the implants or bone subsidence, 5/42 procedures (11.9%) following infection, 4/42 (9.5%) due to polyethylene migration, 1/42 (2.3%) due to fracture and 1/42 (2.3%) due to Charcot arthropathy. In 9/42 (21.4%) cases, imaging showed no objective reason for pain. 50% of patients who underwent revision TAA reported 78.5% satisfaction with results of surgery at 2 years follow up post-operatively. Conclusion. Major reasons for revising primary TAR at our centre are mal-alignment, implant loosening / bone subsidence and suspicion of infection and pain. In-spite of undergoing a complex revision surgery, patients report 78.5% satisfaction from outcomes of surgery

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)

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The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

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The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

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Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK.

Aims. Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. Patients and Methods. A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants. Results. There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature. Conclusion. Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent. Cite this article: Bone Joint J 2018;100-B:1352–8

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We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre.

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This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes.

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Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

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To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA).

We describe the results of a randomised, prospective study of 200 ankle replacements carried out between March 2000 and July 2003 at a single centre to compare the Buechel-Pappas (BP) and the Scandinavian Total Ankle Replacement (STAR) implant with a minimum follow-up of 36 months. The two prostheses were similar in design consisting of three components with a meniscal polyethylene bearing which was highly congruent on its planar tibial surface and on its curved talar surface. However, the designs were markedly different with respect to the geometry of the articular surface of the talus and its overall shape. A total of 16 ankles (18%) was revised, of which 12 were from the BP group and four of the STAR group. The six-year survivorship of the BP design was 79% (95% confidence interval (CI) 63.4 to 88.5 and of the STAR 95% (95% CI 87.2 to 98.1). The difference did not reach statistical significance (p = 0.09). However, varus or valgus deformity before surgery did have a significant effect) (p = 0.02) on survivorship in both groups, with the likelihood of revision being directly proportional to the size of the angular deformity. Our findings support previous studies which suggested that total ankle replacement should be undertaken with extreme caution in the presence of marked varus or valgus deformity

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The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon.

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We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

Introduction:. Total ankle replacement is a recognised treatment for disabling end stage ankle arthritis and an alternative to arthrodesis, although results are not yet comparable to other joint replacements. This has stimulated a constant evolution in design of implants and instrumentation. The Nottingham Foot and Ankle Unit used the STAR until 2005, when it switched to Mobility, due to the perceived advantages of less bone resection, improved instrumentation and potentially less polyethylene insert wear. The aim of this study is to report the unit's results and review the different outcomes between the two ankle replacements used. Methods:. A retrospective analysis of all total ankle replacements carried out by the foot and ankle unit at Nottingham City Hospital between March 1999 and June 2013. Post operative complications, associated reoperations and revisions were recorded. The American Orthopaedic Foot and Ankle Score (AOFAS), Foot Function Index (FFI), European five dimension quality of life scores (EQ-D5) and patient satisfaction was independently assessed at each follow up visit. Other ankle replacements or those performed elsewhere or with less than 12 month follow up were excluded. Results:. 162 Mobility and 148 STARs' were assessed. The mean follow up was 7 years (1–13 yrs,) STAR and 3.5 years (1–8 yrs) Mobility. Post-operative complication rate of 15% STAR and 13% Mobility, associated operation rate of 15% STAR and 10% Mobility with revision rate of 19% STAR at 13 years and 4.3 % Mobility at 8 years. Both STAR and Mobility groups showed improvements in AOFAS, FFI, EQ-D5 and patient satisfaction, but there were no significant differences between the two groups. Conclusion:. This is one of the largest comparative series of total ankle replacements and shows that patient satisfaction, pain and function is improved. The Mobility total ankle replacement had fewer revisions and complications compared to STAR

Introduction. With increasing numbers of primary total ankle replacements being performed, the number of revision ankle surgeries is expected to rise also. We present the results of the revision procedures for failed Scandinavian total ankle replacements. Patients and methods. We retrospectively reviewed all the Scandinavian TAR done by the senior author from March 1999 till Jan 2006. Patients who underwent revision surgery were identified and their data was collected including indications for revision surgery, procedure performed, symptoms and the overall outcome. Results. 25 patients underwent revision of Scandinavian TARs between April 2000 and April 2012 out off a total of 213 primary STARs (11%). Average age was 68 years (45 to 82), with male to female ratio of 4:1. The causes of failure of primary implants included broken polyethylene inserts in 12 patients, aseptic loosening in 6 and ankle instability in 7 patients. No septic loosening was found in any of our patients. Revision procedures which were performed in these patients included exchange of inserts in 13 patients, revision of all components in 2, revision of tibial component in 3, talar component in 2 and ankle arthrodesis with hindfoot nail in 4 and with ilizarov frame in 1 patient. The average time from the primary procedure to revision surgery was 78 months (12 to 156). The average follow up after revision surgery was 26.5 months (2 to 57). Four patients have died. Two patients were symptomatic with mild pain and stiffness while the rest are asymptomatic after their revision surgery. Conclusion. In our study the mechanical failure was found to be the most common cause of failure of Scandinavian TARs. The outcome of revision surgery has been found to be satisfactory and comparable to other series that is reported in the literature