Patient History

65 year old male with long history of ankle surgeries:

• 2003 – ankle fusion takedown, Agility TAR, subtalar fusion, calcaneal osteotomy, TAL
• 2004 – Agility revision of all components, cemented
• 2005 – I and D, Agility explanted, cement spacer
• 2006 – custom Agility total ankle with stems (Figure 1a, b)
• 2010 – ankle gutter debridement, poly exchange

Current Symptoms

• Severe daily pain
• Brace dependent
• On high dose opiates
• Can walk only 15 minutes, then must sit
• Not smoking…..yet

Radiograph (Figures 2a, b, c)

• Ballooning osteolysis around implant
• Mechanical loosening of the prosthetic joint
• Severe poly wear

CT scan (Figures 3a,b,c)

• Pathologic fractures of the malleoli
• Mechanical loosening is confirmed

Treatment options discussed

• Amptuation at the below knee level. The patient declined.
• Re-fusion. The patient had had his ankle fused previously and declined
• Revision prosthetic arthroplasty. The patient preferred this option.

Surgical procedure

• The cysts were curettaged and grafted with calcium phosphate cement
• The malleoli fractures were plated (Figures 4a,b)
• The stemmed talar component was removed posteriorly through the back of the heel with curved osteotomes and bone tamps. (Figures 5a, b, c, d)
• The tibial component was removed with an anterior cortical window
• The cutting jig was positioned to freshen up the bony cuts and resect minimal bone. (Figures 6a, b, c)
• The tibial component of the revision prosthesis was constructed to maximally fill the canal of the tibia
• The talar component was trialed and the bony cut touched up freehand until it sat level. The longest stem available was used.  (Figures 7a, b)
• The anterior cortical window was plated.

At one year postoperative

• The calcium phosphate has been incorporated into bone and the cysts have healed.
• The implant is stable and unchanged from previous films. (Figures 8a, b)
• The patient has pain over the fibula hardware which was removed.

At 3.5 years postoperative

• The implant remains stable
• Despite buildup of bone in the ankle gutters, there is no pain (Figures 9a,b)
• Patient satisfied despite very little ankle motion (Figures 10a, b)

Figures

 

 

 

 

 

 

 

 

Figures 1a, b

 

 

 

 

 

 

 

 

Figures 2a, b, c

 

 

 

 

 

 

 

 

Figures 3a, b ,c

 

 

 

 

 

 

 

 

 

Figures 4a, b

 

 

 

 

 

 

 

 

Figures 5a, b, c, d

 

 

 

 

 

 

 

 

Figures 6a, b, c

 

 

 

 

 

 

 

 

Figures 7a,b

 

 

 

 

 

 

 

 

Figures 8a, b

 

 

 

 

 

 

 

 

Figures 9a, b

 

 

 

 

 

 

 

 

Figures 10a,b

Bibliography

• Rahm S, Kalmmer G, et al: Inferior results of salvage arthrodesis after failed total ankle replacement compared to primary arthrodesis.  Foot Ankle Int, 2015: 349-259.
• Hintermann B, Zwicky L, et al: Hintegra revision arthroplasty for failed total ankle prostheses.  J Bone Joint Surg AM: 2013; 166-74.