A Closer Look At Total Ankle Replacement Revision

Thomas S. Roukis, DPM, PhD, FACFAS, and Mark A. Prissel, DPM

(1) A same size revision talar component with a front-loaded 0 mm UHMWPE insert.
(2) A same size revision talar component with a front-loaded +1 mm UHMWPE insert (see photos on page 53).
(3) A same size LP talar component with a front-loaded 0 mm UHMWPE insert. (Note: this is only possible if one corrects the talar component subsidence back to its original state with the use of polymethylmethacrylate cement augmentation. Otherwise, an unstable joint will result.)
(4) A same size LP talar component with a front-loaded +1 mm UHMWPE insert.
(5) A one size larger revision talar component with a front-loaded mismatch UHMWPE insert (i.e., retained size 4 LP tibial tray with size 5 revision talar component and size 5/4 mismatch UHMWPE insert).
(6) A one size larger LP talar component with a front-loaded mismatch UHMWPE insert. We should note that the mismatch UHMWPE insert does not independently add any additional height.

   As with tibial component subsidence, we recommend implanting multiple 0.062-inch Kirschner wires bent and twisted into geometric shapes packed within the osseous defect, and the subsequent insertion of polymethylmethacrylate cement to augment the deficient talar body.65,90 It is important to achieve proper talar height so the medial and lateral ankle ligaments are properly tensioned and the mechanical axis of the ankle joint is restored. Whenever possible, we try to achieve a talar height that allows for use of a 0 mm UHMWPE insert and a non-revision talar component in order to preserve these options for a future revision if necessary.

Keys To Addressing Aseptic Osteolysis When It Affects Tibial And Talar Components

When it comes to aseptic osteolysis involving both the tibial tray and talar components, surgeons can manage this with either retention of the Agility Total Ankle Replacement System tibial tray and replacement of the talar component and UHMWPE adhering to the aforementioned options, or explantation and conversion to the INBONE Total Ankle Replacement Systems.

   The use of an anterior distal tibia plate abutting the superior portion of the tibial tray can be invaluable to support or buttress the tibial tray realignment, and one can also employ this plate as a fixation point for a modified Evans peroneal tendon lateral ankle stabilization.31,91 Finally, it is frequently necessary to perform soft-tissue balancing most commonly with release of the deltoid ligament complex and/or a posterior tibial tendon recession and lateral ankle stabilization with a modified Evans peroneus brevis tendon transfer secured to the distal tibia or fibula.40,41,92,93

   In regard to explantation of the failed Agility total ankle replacement and implantation of a permanent polymethylmethacrylate cement spacer, conversion to an extended tibio-talo-calcaneal arthrodesis with bulk femoral head allograft or a below-knee amputation, surgeons should reserve these options for non-reconstructable talar body destruction, non-reconstructable soft tissue defects, unremitting pain with joint stiffness or uncontrollable infection.84-86,93 Arthrodesis or below-knee amputation are also indicated in situations in which the patient does not desire or is medically unable to undergo revision surgery.

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