Managing Osteolysis Following A Failed Ankle Implant

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Author(s): 
Mark A. Prissel, DPM, and Thomas S. Roukis, DPM, PhD, FACFAS

These authors provide a guide to reconstructive treatment for an 80-year-old patient who developed massive tibial and talar osteolysis after an ankle implant failed.

One common etiology of the failure of the Agility Total Ankle Replacement (DePuy Orthopaedics) is periprosthetic cyst formation resulting from ultra-high molecular weight polyethylene (UHMWPE) wear debris, leading to bone erosion, component loosening or subsidence.1-6 These cystic changes sometimes enlarge progressively over time and may remain relatively asymptomatic until catastrophic failure is imminent.8

   Once one has identified these periprosthetic cysts, the physician should regularly check them for progression. If they are progressive or symptomatic, we recommend operative management.3-17 On occasion, when massive periprosthetic cysts are present, they can penetrate the cortex, resulting in an uncontained defect with cortical disruption.

   Historically, some have proposed impaction bone grafting to manage contained defects while ambiguity remains regarding management of massive periprosthetic osteolytic defects with cortical breach following total ankle replacement. Although polymethylmethacrylate cement use with total ankle replacement remains controversial, some authors promote it in specific instances and metallic reinforced cement augmentation warrants consideration.16-20

What You Should Know About The Patient Presentation And Treatment

An 80-year-old man presented 10 years after primary Agility Total Ankle Replacement with a posterior augmented talar component, responding to a surveillance program that the senior author conducted. Prior radiographs demonstrated early tibial periprosthetic cystic changes that progressed before he was lost to follow-up. Updated radiographs and computed tomography (CT) demonstrated a massive periprosthetic osteolytic tibial defect breaching the anterior, medial and posterior cortices as well as talar head and neck osteolytic lesions with progressive talar component subsidence and loosening. When the senior author initially evaluated the patient, he reported intermittent, relatively mild pain with ambulation and weightbearing, but noted his symptoms were increasing over the past year and beginning to limit his daily activities.

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