Review
Positive and negative factors for the treatment outcomes following total ankle arthroplasty? A systematic review

https://doi.org/10.1016/j.fas.2018.12.003Get rights and content

Highlights

  • Patient selection, surgeon’s experience and implant design play an integral role and affect the treatment outcomes of total ankle arthroplasty.

  • Some positive and negative factors for different clinical and radiographic outcomes were found based on multilevel mixed-effects logistic regression anaylsis.

  • These factors should be taken into consideration in clinical practice and ankle implant design.

Abstract

Background

Patient selection, surgeon’s experience and implant design play an integral role and affect the treatment outcomes of total ankle arthroplasty (TAA). The aims of this study were to investigate the positive and negative attributes that correlate with different clinical and radiographic outcomes.

Methods

Eight-nine studies matched the inclusion criteria: (1) studies of primary TAA with uncemented prosthesis; (2) mean follow-up of no less than 2-year; (3) reports of clinical and radiographic outcomes, and exclusion criteria: (1) non-English study; (2) more than one type of prosthesis without separated data; (3) kin studies with shorter follow-up or smaller cohort. Age, etiology, preoperative deformity, surgeon’s experience, follow-up duration and prosthetic type were studied with respect to different outcomes by mixed-effects logistic regression analysis.

Results

Patients factor: older patients reported less pain or stiffness and demonstrated less radiographic loosening which did not require additional surgical intervention. More traumatic arthritis experienced adjacent joints degeneration after TAA. Surgeon factor: less experienced surgeons had more intraoperative complications. Lack of experience for complications management without implant retrieval during early period might result in more revisions or fusion was done. Prosthetic factor: updated instrumentation decreased malalignment. If the polyethylene (PE) insert was significantly narrower than the metal components more implant instability and subsequent severe particulate wear was seen. Designs with flat-on-flat articulation and ridge at the center of the talar component associated with more PE fracture. Minimal bone resection reduced postoperative fractures. A flat cut of the tibial component and a flat undersurface with press-fit by two screws or pegs of the talar component demonstrated less postoperative fractures, whereas a syndesmosis fusion and a small triangular shape with one central fin of the talar component experienced more loosening which did not require additional surgery. Anatomic conical shape of the talar component seemed to reduce adjacent joint degeneration. Finally, fewer failures were found in patients who received HINTEGRA and Salto Talaris.

Conclusions

Based on our investigation, some positive and negative factors for different clinical and radiographic outcomes were found, which should be taken into consideration in clinical practice and ankle implant design.

Introduction

Early result of total ankle arthroplasty (TAA) experienced many clinical failures and the design rationale of the first-generation implants have been invalidated [1], [2]. Newly designed prostheses, based on the studies of ankle anatomy and kinematics, consist of two or three components and have improved clinical outcomes [3], [4], [5]. Advantages of current TAA include restoring ankle kinematics and decreasing the risk of subtalar arthritis [6], [7], [8].

The survivorship of the second and third-generation implants has remarkably improved with a 10-year implant survival rate now about 70% [9], [10], [11]. Nevertheless long-term implant survival is not yet comparable to hip or knee arthroplasty [12], [13]. Also the complication rate is also much higher than hip or knee arthroplasty [3], [4], [14], [15]. Recent publications have shown that the incidence of complications after TAA is higher in patients with post-traumatic arthritis and therefore refined patient selection could possibly improve outcomes [16]. Also complications decreased after surgeons completed a training course [17], [18]. Another study found many complications could be avoided with increased surgical experience however others persisted unchanged [19]. Unlike the implants of hip or knee, the designs of current ankle systems are quite different [1], [2], [20], [21], [22], [23], and it has also been suggested that different implant design might affect the outcomes [22], [24].

Patient factors including age, etiology and preoperative deformity, surgeon’s factors, prosthetic factors, or a combination of these factors could all affect the treatment outcome of TAA [25], [26], [27], [28], [29]. However, it is inappropriate to attribute any complication or radiographic finding to a single factor without taking all factors into comprehensive consideration and analyze the potential positive and negative attributes in each and their relationship to each other. The purpose of the present study was to determine the positive and negative factors for the different clinical and radiographic outcomes which have been observed.

Section snippets

Search strategy and study selection

A manual systematic literature search of MEDLINE, EMBASE™ and Cochrane Library for “total ankle arthroplasty” OR “total ankle replacement” OR “total ankle arthroplasties” OR “total ankle replacements” was performed by three of the authors (DZ, DH, GZ). The search was performed by each reviewer independently with any disagreements in article eligibility resolved by consensus discussion among all authors. Each study was read as a full-text. Inclusion criteria were: (1) studies of primary TAA with

Patient factors for treatment outcome

Older patients reported less postoperative pain or stiffness comparing to younger patients (P = 0.009, odds ratio = 0.89). Implant loosening in either the tibia or talus, which was not symptomatic to require surgical intervention, was less common in older patients (P = 0.008, odds ratio = 0.88; P = 0.006, odds ratio = 0.86). Patients with traumatic arthritis were more likely to experience adjacent joint degeneration after TAA (P = 0.007, odds ratio = 100.03). Age, primary etiology and preoperative deformity

Discussion

The survival rates of TAA have been improving [3], [4]. However, the majority of the studies with superior results were conducted by the implant designer, and the etiology of the arthritis or preoperative deformity was often different from subsequent studies. Furthermore, a wide variety of implants is currently available, which are different from each other in term of bearing type, articular congruency, surface geometry, size of component, and bone cut or fixation [1], [2], [21], [22]. To the

Conflict of interest

The authors declare no conflicts of interest to disclose.

Funding

This work was funded by National Natural Science Foundation of China (Grant No. 81702109), China Postdoctoral Science Foundation Grant (Grant No. 2016M601508 and Grant No. 2018T110349), Scientific and Technological Innovation of Shanghai Science and Technology Committee (Grant No: 18441902200).

Author’s contributions

Dahang Zhao: manual literature search, reviewed and screened all the papers, collected the data, wrote the manuscript, revised the manuscript. Dichao Huang: manual literature search, reviewed and screened all the papers, collected the data. Gonghao Zhang: manual literature search, reviewed and screened all the papers, collected the data. Xu Wang: collected the data. Tiansong Zhang: designed the study, analyzed the data and reviewed the manuscript, revised the manuscript. Xin Ma: designed the

Acknowledgments

We thank Henricson Anders MD, Alexej Barg MD, Fabrice Gaudot MD, Daniël Haverkamp MD, C. Thomas Haytmanek Jr MD, Kurt J. Hofmann MD, Andrew R. Hsu MD, Yeok Gu Hwang MD, Dong Oh Lee MD, Gun Woo Lee MD, Jin Woo Lee MD, Keun Bae Lee MD, Jan Willem K. Louwerens MD, Caio A. Nery MD, James A. Nunley MD, Charles L. Saltzman MD, Nelson F. SooHoo MD, Peter LR. Wood MD who unselfishly retrieved their raw data for us, and also thank our friends Stephen Eisenstein MD, Ken N. Kuo MD, Soon Hyuck Lee MD, Jose

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    Dahang Zhao, Dichao Huang and Gonghao Zhang contributed equally to this work and should be considered as co-first authors.

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