Chronic long-term pain after ankle replacement

• The majority of the revision surgeries had:
  • hardware component loosening, frequently of the talar component (38%).
  • In the cases that were revised to an ankle fusion, 81% fused after their first fusion procedure.
  • The overall complication rate was 18.2%, whereas the overall nonunion rate was 10.6%.

In 2016 research in the Journal of Foot and Ankle Surgery (2) followed up, also asking the question “why does a patient will still have chronic ankle pain following ankle replacement?”

The researchers suggested:

• “Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence, infection, bone fractures, and heterotopic ossification. However, patients can still experience unresolved pain even when these problems have been ruled out.”
• The researchers then initiated a study to more clearly define the relative risk of injury to the anatomic structures in the posterior (rear) ankle during total ankle replacement. They found:
  • High rates of posterior structural injury from the surgery was found.
  • Pins inserted during the surgery represented a high risk of damage to the tibial nerve posteromedial tendinous structures, in particular, the flexor digitorum longus tendon.
  • The proximal lateral pins were highly likely to encounter the Achilles tendon and the sural nerve.
• The researchers concluded: “Our results support our hypothesis that the tibial neurovascular structures are at the greatest risk when preparing for and completing the bony resection, particularly with the medial and proximal cuts. Posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. Further study of posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.”

A January 2019 study (3) assessed the survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants.

This was a long-term study as the assessment was made on implants done between November 1993 and February 2000.

A total of 84 patients (87 ankles) were alive by the end of this 2019 study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis diagnosis in 40 patients and osteoarthritis in 47 patients), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery.

• A total of 32 implants failed (16%), requiring revision surgery.
• The mean time to revision was 80 months (2 to 257).
• The implant survival at 15.8 years, using revision as an endpoint, was 76.16%
• We found a steady but low decrease in survival over the study period.

A March 2021 paper (4) writes: “Given the increasing usage of total ankle arthroplasty, a better understanding of the reasons leading to implant revision and the factors that might influence those indications is necessary to identify at-risk patients.

Using a single-design three-component ankle prosthesis, the researchers asked:

• (1) What is the cumulative incidence of implant revision at 5 and 10 years?
• (2) What are the indications for implant revision in our population?
• (3) What factors are associated with an increased likelihood of implant revision during the time frame in question?

The answers: “The cumulative incidence of implant revision at the mean (range) follow-up time of 8.8years average was was 9.8%. Five and 10 years after total ankle arthroplasty, cumulative incidence was 4.8% and 12.1%, respectively. The most common reason for revision was instability (34% [41 of 121]), followed by aseptic loosening of one or more metallic components (28% [34 of 121]), pain without another cause (12% [14 of 121]), cyst formation (10% [12 of 121]), deep infection (9% [11 of 121]), and technical error (7% [9 of 121]). Ankles with a major hindfoot deformity before total ankle arthroplasty were more likely to undergo revision than ankles with a minor deformity or neutral alignment. A preoperative hindfoot valgus deformity increased revision probability compared with a varus deformity.

Conclusion: “Instability was a more common reason for implant revision after total ankle arthroplasty with this three-component design than previously reported. All causes inducing either a varus or valgus hindfoot deformity must be meticulously addressed during total ankle arthroplasty to prevent revision of this implant.”

A January 2024 paper (5) however, suggests that understanding ankle instability caused by ankle replacement is controversial. The authors write: “Significant uncertainty exists regarding the universal definition of aseptic loosening of total ankle replacement, and many variations occur in terms of the assessment approach and criteria.” The authors clarify this as: “a precise definition of aseptic loosening is still lacking.” This makes post-surgical treatment options difficult to pinpoint.

A July 2022 study (6) measured the outcomes of revision surgery for a failed ankle arthroplasty (replacement). The researchers wrote: “Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty fails, it can either undergo revision to another ankle replacement, revision of the total ankle arthroplasty to ankle arthrodesis (fusion), or amputation.” Currently, they also note, there is not much information in the medical literature on the outcomes of these revisions.

The researchers then assessed the outcomes of revision total ankle arthroplasty with respect to surgery type, functional outcomes, and reoperations. They examined six previously published papers on all-cause reoperations of revision ankle arthroplasties, and 14 papers analyzing failures of conversion of a total ankle arthroplasty to fusion.

• It was found that 26.9% of revision ankle replacement required further surgical intervention and 13.0% of conversion to fusions; 14.4% of revision ankle arthroplasties failed and 8% of conversion to fusions failed.

The researchers concluded: “Conclusion: Revision of primary total ankle arthroplasty can be an effective procedure with improved functional outcomes, but has considerable risks of failure and reoperation, especially in those with periprosthetic joint infection. In those who undergo conversion of total ankle arthroplasty to fusion, there are high rates of nonunion.”

Similarly, a March 2022 paper (7) discussed salvaging the ankle after a failed total ankle arthroplasty: “In some cases a failure rate of approximately 1% per year or a survival rate of 70% after 10 years has been reported. The most frequent reasons for revision of an ankle prosthesis are aseptic loosening, technical implantation errors and persisting pain. For the revision of an ankle prosthesis there are basically two treatment options. For a long time, ankle arthrodesis (fusion) was considered the gold standard after a failed prosthesis. In recent years, there has been an increasing trend towards re-implantation of an ankle prosthesis (redoing the ankle replacement), as this preserves the functionality and mobility of the ankle joint as far as possible.”

A March 2022 paper (8) compares ankle replacement to ankle fusion: “Surgical treatment of end-stage posttraumatic upper ankle arthrosis is challenging. Highly variable revision rates have been reported with total ankle arthroplasty of the upper ankle joint (talocrural joint or tibiotalar joint, where the ankle meet the lower leg).  This retrospective study compared revision rates with tibiotalar arthrodesis (fusion) and total ankle arthroplasty with a prosthesis to determine the superior treatment approach.

• Data for 148 patients (96 males and 52 females) with end-stage posttraumatic upper ankle arthrosis-including 88 treated with tibiotalar arthrodesis (fusion) and 60 with total ankle arthroplasty with a mean follow-up of 59 months-were analyzed.

Results: The overall revision rate was 28%; the rate was higher with total ankle arthroplasty (42%) than with tibiotalar fusion (18%). The total ankle arthroplasty group showed an increase in revisions from 12- to 24-month postsurgery. The most common cause of revision in the total ankle arthroplasty group was cysts (20%), and the most frequent reason for revision was nonunion (8%). Conclusion: “total ankle arthroplasty is associated with a high rate of revisions, especially from the 2nd year postsurgery. Therefore, tibiotalar fusion is the treatment of choice for end-stage posttraumatic upper ankle arthrosis.”

Researchers found good success in a December 2023 paper (9) which assessed the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of the INFINITY total ankle implant.

In a survey of patients who had undergone a combined 116 ankle replacements  the researchers reported:

• The ankle implant survivorship at 2 years was 97.79%.
• There were 17 reoperations (11.5%), with 4 of the implants requiring revision (2.7%).
• Significant improvements in all patient reported outcomes were observed.

If you have chronic ankle pain, have had painkillers, physical therapy, and other conservative care options that have not helped, and, now you are being told to have surgery. We may be able to help reduce pain and increase function.

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References

1 Gross C, Erickson BJ, Adams SB, Parekh SG. Ankle arthrodesis after failed total ankle replacement: a systematic review of the literature. Foot & ankle specialist. 2015 Apr;8(2):143-51.
2 Reb CW, McAlister JE, Hyer CF, Berlet GC. Posterior Ankle Structure Injury During Total Ankle Replacement. J Foot Ankle Surg. 2016 Jun 9.
3 Clough T, Bodo K, Majeed H, Davenport J, Karski M.Survivorship and long-term outcome of a consecutive series of 200 scandinavian total ankle replacement (star) implants. Bone Joint J. 2019 Jan;101(1):47-54.
4 Richter D, Krähenbühl N, Susdorf R, Barg A, Ruiz R, Hintermann B. What are the indications for implant revision in three-component total ankle arthroplasty?. Clinical orthopaedics and related research. 2021 Mar;479(3):601.
5 Kvarda P, Mills A, Shepherd D, Schneider T. Lack of Consensus on the Definition of Aseptic Loosening in Total Ankle Replacement: A Narrative Systematic Review. Journal of Clinical Medicine. 2024 Jan 30;13(3):786.
6 Jennison T, Spolton-Dean C, Rottenburg H, Ukoumunne O, Sharpe I, Goldberg A. The outcomes of revision surgery for a failed ankle arthroplasty: a systematic review and meta-analysis. Bone & Joint Open. 2022 Jul 28;3(7):596-606.
7 Buchhorn T, Baumbach SF, Böcker W, Szymski D, Polzer H. Salvage options following failed total ankle arthroplasty. Der Unfallchirurg. 2022 Jan 28.
8 Fischer S, Klug A, Faul P, Hoffmann R, Manegold S, Gramlich Y. Superiority of upper ankle arthrodesis over total ankle replacement in the treatment of end-stage posttraumatic ankle arthrosis. Archives of Orthopaedic and Trauma Surgery. 2022 Mar;142(3):435-42.
9 Doty J, Murphy GA, Bohay D, Fortin P, Vora A, Strasser N, Friscia D, Newton W, Gross CE. Two-Year Survivorship and Patient-Reported Outcomes of a Prospectively Enrolled Cohort of INFINITY Total Ankle Arthroplasties. Foot Ankle Int. 2023 Dec 22:10711007231212484.