Ankle pain in an active 71-year-old woman
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A 71-year-old woman presented to the clinic for evaluation of progressively worsening chronic left ankle pain at her anterolateral ankle, which is worse with ankle dorsiflexion and activities, such as walking and hiking.
Her pain has not adequately responded to nonoperative treatment modalities, such as anti-inflammatory medication, physical therapy and wearing an ankle foot orthosis, and her symptoms are now significantly impacting her quality of life.
Source: David E. Oji, MD
The patient has a past medical history of hypertension. She reports having several inversion ankle sprains for which she underwent an anterior talofibular ligament reconstruction and sinus tarsi debridement more than 10 years ago. On physical exam of her left lower extremity, she has a small ankle effusion with tenderness to palpation about the anterolateral ankle and anterolateral talus. She has pain with ankle range of motion. She has no ligamentous instability with the ankle anterior drawer test or talar tilt test. She has no tenderness over her deltoid ligament, Achilles tendon or peroneal tendons. She has no other foot pain and is neurovascularly intact with palpable dorsalis pedis and posterior tibial pulses.
Radiographic evaluation of the left ankle demonstrates evidence of ankle arthritis with joint space narrowing and osteophytes, which is worse laterally. There is also sclerosis of the talar body that is concerning for avascular necrosis (AVN) (Figure 1). CT scan of the left ankle demonstrates significant AVN of the talus, as well as tibiotalar joint arthritis. No significant subalar joint arthritis is appreciated (Figure 2).
What are the best next steps in management of this patient?
See answer below.
Combined total talus replacement and total ankle arthroplasty
The patient was indicated for a combined total talus replacement and total ankle arthroplasty to simultaneously address her talus AVN and debilitating ankle arthritis.
A direct anterior approach to the ankle was completed using the interval between the tibialis anterior and the extensor hallucis longus. The superficial peroneal nerve and neurovascular bundle were identified and protected. The distal tibia and talus were exposed. Using the Prophecy Infinity Total Ankle System (Wright Medical), superior, medial and lateral cuts were made for the distal tibia. The cut distal tibia bone block was removed. During this process, a small anterolateral distal tibia fracture occurred intraoperatively. A five-hole 2-mm mini-fragment plate in buttress mode was used to definitively stabilize this fracture.
The talus was then removed using osteotomes and an oscillating saw. Care was taken not to damage any adjacent subtalar cartilage. Using the Patient Specific Talus Spacer set (Paragon 28), the 100%, 95% and 90% total talus trials were placed and trialed with the trial tibia component and 8-mm polyethylene. The 100% talus was the best fit. All trial implants were removed, the tibia peg holes were broached and the surgical field was irrigated with 1L of normal saline.
The definitive Prophecy Infinity tibia component was implanted, and its position was confirmed fluoroscopically. The Patient Specific Talus was then implanted, followed by the definitive 8-mm polyethylene. There was excellent stability, range of motion, alignment and overall position of the implants, which was confirmed visually, by physical examination and on fluoroscopic imaging.
Postoperative protocol
Postoperatively, the patient was placed into a short leg splint and made non-weight-bearing for 2 weeks. Sutures were removed at the patient’s 2-week postoperative visit where radiographs confirmed excellent implant position and alignment (Figure 3). She was then made toe-touch weight-bearing for an additional 2 weeks while wearing a boot and was then made partial weight-bearing for an additional 2 weeks followed by weight-bearing as tolerated and weaned from the boot at 8 weeks postoperatively. At her most recent postoperative visit, she had excellent pain relief and range of motion.
Key points
- AVN of the talus poses a challenge when considering total ankle arthroplasty (TAA) and can result in talar component collapse.
- Iatrogenic medial malleolus or lateral distal tibia fractures can occur in patients with poor bone quality and must be recognized and addressed intraoperatively.
- Combined total talar replacement (TTR) and TAA is an effective treatment strategy for patients with ankle arthritis and severely deficient bone stock that is due to talar necrosis.
Discussion
The case presented demonstrates a surgical option in treating chronic ankle instability leading to end-stage ankle arthritis with concomitant AVN of the talus. While the literature reports on concurrent TAA and TTR are sparse, other case reports have demonstrated satisfactory clinical outcomes. However, prior to discussing these studies, highlighting the good clinical outcomes following TTR is critical to point out the clinical relevance of this case report.
Thos Harnrrongroj, MD, and colleagues studied 36 patients who underwent TTR for traumatic AVN of the talus at a mean follow-up of 23.5 years. The authors reported 20 of the 28 patients retained the ability to ambulate at least 1 hour and 26 of 28 patients had a plantigrade foot at final follow-up. Similarly, Akira Taniguchi, MD, PhD, and colleagues reported on 22 patients who underwent first-generation and second-generation ceramic partial talar body replacements for talus AVN at a mean follow-up of 96 months. The authors reported that, while all patients who underwent first-generation talar body replacements had significant improvement in American Orthopaedic Foot & Ankle Society scores, all patients also had evidence of talar neck AVN and prosthesis loosening.
When analyzing the second-generation partial talus replacements, patients were also found to have a significant improvement in AOFAS scores with a lower rate of talar neck pathology and prosthesis loosening (29% in the second-generation vs. 100% in the first-generation cohort). Taken together, these results demonstrate that satisfactory clinical results can be obtained following TTR, especially as prosthesis technology has advanced to include patient-specific cutting guides and 3D-printed TTR.
There is a dearth of robust clinical studies reporting on combined TAA and TTR. Noriyuki Kanzaki, MD, PhD, and colleagues reported on 22 cases of combined TAA/TTR for primary degenerative arthritis, rheumatoid arthritis and idiopathic talar AVN. The authors reported range of motion between 26.6° and 46.5° at mean 34.9 month follow-up. Furthermore, the postoperative Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale improved across the pain, function and total subscores from preoperative status to final follow-up. The most common complication reported in this series was either intraoperative or postoperative medial malleolus fracture. In a similar but smaller case series, Hiroaki Kurokawa, MD, and colleagues compared 10 patients undergoing combined TAA/TTR for talar bone loss with 10 matched patients undergoing isolated TAA. At mean follow-up of 58 months, the JSSF ankle-hindfoot score improved from 44 to 89 in the combined TAA/TTR cohort and from 49 to 72 in the isolated TAA cohort. Although there were small sample sizes, these two cases series demonstrate promising clinical results at midterm follow-up for combined TAA/TTR. Further studies are needed to identify patients who will benefit most from combining TAA and TTR. Moreover, further studies are needed to optimize TTR technology and surgical techniques to optimize the compatibility and longevity with current TAA implants.
- References:
- Akoh CC, et al. J Foot Ankle Surg. 2020;doi:10.1053/j.jfas.2020.08.013.
- Harnroongroj T, et al. J Bone Joint Surg Am. 1997;doi:10.2106/00004623-199709000-00005.
- Kanzaki N, et al. Foot Ankle Int. 2019; doi:10.1177/1071100719847135.
- Kurokawa H, et al. Bone Joint J. 2019;doi:10.1302/0301-620X.101B4.BJJ-2018-0812.R2.
- Taniguchi A, et al. Foot Ankle Clin. 2019;doi:10.1016/j.fcl.2018.10.004.
- For more information:
- Mark E. Cinque, MD, MS; Galvin J. Loughran, MD; and David E. Oji, MD, a clinical assistant professor, foot and ankle surgery at Stanford University School of Medicine, can be reached at Stanford Medicine, Department of Orthopaedic Surgery, 450 Broadway Ave., Redwood City, CA 94063. Cinque’s email: mec89@stanford.edu. Loughran’s email: gjl42@stanford.edu. Oji’s email: davidoji@stanford.edu.
- Edited by Mark E. Cinque, MD, MS, and Filippo F. Romanelli, DO, MBA. Cinque is a chief resident in the department of orthopedic surgery at Stanford. He will pursue a fellowship in sports medicine at The Steadman Clinic/Steadman Philippon Research Institute following residency completion. His interest is in complex knee surgery and multiligament reconstruction. Romanelli is a chief orthopedic resident at Rutgers – Jersey City Medical Center with an interest in adult reconstruction. He will be at New York University for his fellowship. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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