Should Surgeons Stage TAR With Adjunct Procedures?

Point

Yes. The authors agree that staging total ankle arthroplasty should be considered in situations of significant and/or complex deformity, major soft tissue reconstruction, and major hindfoot bony procedures.

By John M. Thompson, DPM, AACFAS; Cody J. Togher, DPM, AACFAS; Christopher F. Hyer, DPM, FACFAS

Patients with ankle arthritis can present with significant deformity, soft tissue imbalance, and adjacent joint pathology. Often with total ankle replacement, a well-positioned implant can be inserted in a single-stage approach. In other instances, variables including retained hardware, masked instability, and multi-planar deformity add substantial complexity to the approach of total ankle replacement (TAR).

When addressing multiple factors during a total ankle replacement, the length of the procedure increases. Operative time itself can predispose patients to an elevated risk of postoperative complications.^1–3 In certain instances, significant deformity and instability may indeed be best addressed with a multiple-stage approach, or a double operation technique where the primary procedure addresses deformity, adjacent joint pathology, and soft tissue balancing. The secondary operation then includes the total ankle replacement. This methodology aims to mitigate risks and complications of the procedure and improves the predictability of a properly aligned and stable ankle replacement.

When Is a Staged Approach Appropriate?

When determining the necessity of a staged approach, it is important to consider the risks associated with a given case. It is best to analyze the risks of prolonged tourniquet time, complex deformity, instability, soft tissue strain with deformity reduction, as well as surgeon and surgical team experience/ability. These factors can play a role in determination of approach.

However, the authors also identified specific procedures that, in their experience, should be strongly considered exclusively with a staged approach. The first group of procedures includes hindfoot fusions, most predominantly subtalar fusion, talonavicular fusion, and navicular-cuneiform fusion. Operative time to perform these procedures, which is then compounded with the consideration of fixation type and the relative location of hardware with relation to total ankle replacement placement components, can add significant difficulty.

Another consideration for staged total ankle replacement is significant soft tissue pathology requiring extensive reconstruction; for example, deltoid ligament reconstruction in the setting of significant valgus deformity. Discrepancies can exist between ideal postoperative protocols and rehabilitation for total ankle replacement compared to common soft tissue reconstructions. Therefore, it is important to consider balancing the needs of both procedures’ rehabilitation, even when staging them.

The next point involves osseous defects. This theme is often encountered with secondary changes due to end-stage degenerative arthritis as well as in the setting of post-traumatic arthritis. Large cystic changes of bone and poor bone quality can lead to malpositioning with primary surgery or subsidence of the implant postoperatively.

What Are the Benefits of Staging?

The obvious advantage of a staged approach is the associated decrease in operative and tourniquet time in a single setting. Studies have positively correlated increased wounding and infection prevalence with the anterior ankle incision directly with prolonged tourniquet and operative time.1–3 The arbitrary time period cited to limit infection and wound complications is 120 minutes.^1–2 Performing an ankle and hindfoot reconstruction along with proper TAR implantation in under 120 minutes can be difficult, meaning complex deformity correction cases are likely to get better results via a 2-stage approach.

Deformity of the tibiotalar joint can be complex and multifactorial in nature. Large deformities often require osteotomies as well as hindfoot fusions. The literature has documented TAR revision rates as high as 35% in patients who underwent adjacent hindfoot fusion in a single-stage approach with a TAR.⁴ Additional evidence has suggested higher fusion rates in patients who underwent a staged arthrodesis and TAR compared to that with single surgery correction.⁵

Furthermore, with major deformity correction, soft tissue stress can be significant. Over-tensioning and straining of prior adapted soft tissues can create an elevated risk of complications. If tissues are strained, a staged approach allows for mitigated risk by allowing soft tissues to adapt to reduced positioning prior to total ankle replacement.

Another benefit of the staged approach of TAR is the advantage of having 2 opportunities to assess the stability and deformity reduction of the ankle. The complex biomechanics of the foot are often altered with osteotomies, hindfoot, and midfoot fusions. The staged approach allows for unmasked instability or unfavorable mechanics, from the initial staged surgery, to be accounted for at the time of total ankle replacement.

An additional valued point of the staged approach is the ability to adhere to an early weight-bearing protocol. The authors’ experience, as well as the literature, supports early weight-bearing, range of motion exercises, and neuromotor training to improve patient outcomes associated with total joint replacement.^6–8 This notion is often difficult to enforce when significant reconstruction arthrodesis, soft tissue, and osteotomies are performed in a single-stage setting. Therefore, a suboptimal postoperative regimen is often utilized, with more extensive non-weight-bearing and immobilization.

In Conclusion

Total ankle replacement can be successfully performed in a single stage or staged approach. Fundamental principles in determining when to stage a total ankle replacement include hindfoot fusion, significant soft tissue reconstruction, and osseous defects. Ultimately, the patients’ characteristics, severity of deformity, projected operative time and surgeon ability should be weighed when assessing for applicability of a staged approach. With proper execution and patient selection, the staged total ankle approach can decrease risk of complications and improve patient outcomes.

Dr. Thompson, DPM, AACFAS completed his fellowship at Orthopedic Foot & Ankle Center in Columbus, OH. He now practices at Atlanta Foot and Ankle Center in Atlanta, GA.

Dr. Togher practices at the Joint Replacement Institute in Naples, FL. He completed his fellowship training at the Orthopedic Foot & Ankle Center in Worthington, OH.

Dr. Hyer is co-director at the Orthopedic Foot & Ankle Center fellowship program in Worthington, OH. He is a Fellow of the American College of Foot and Ankle Surgeons.

Counterpoint

No. These authors argue surgeons can use a single-stage approach to attain the same results as a staged procedure and avoid potential complications.

By Jeffrey McAlister, DPM and Keegan Duelfer, DPM

End-stage ankle arthritis can arise in a neutral joint or in one with deformity. This deformity may arise from the level of the foot and contribute to the degenerative process of the ankle. When considering total ankle arthroplasty for end-stage ankle arthritis, current literature recommends correction of the ankle joint with 10 degrees of coronal plane deformity or more.^1–2 These corrections can come in the form of a combination of hindfoot and midfoot osteotomies or fusions, as well as soft tissue procedures.

The question is not if the deformity should be corrected, but rather when. We will argue against staging deformity correcting procedures with a separate operation from that of the total ankle replacement.

Recent literature has argued for this separation of the deformity correcting operation from the total ankle arthroplasty operation in an effort to avoid excessive immobilization of the total ankle implant and reduce the trauma that the body has to heal from to one operation. Unfortunately, none of the long-term outcomes and survivorship studies in the total ankle literature explore the effects of single versus staged procedures.^3–8 As with all things in medicine, the choice ultimately depends on patient selection and surgeon experience.

A Note on the Risks of Exposure to General Anesthesia

When discussing the benefits and negatives associated with a single or staged approach, it is important to consider what will be occurring at the opposite end of the OR table during surgery. While great strides have been made in the field of anesthesiology since its inception, it is still important to remember that general anesthesia comes with risks.

Some important complications include: cardiovascular collapse, respiratory depression, anaphylaxis, aspiration pneumonitis, hypoxic brain damage, embolism, and sometimes even death. Specific conditions that may increase the risk of complications are as follows: older adults, smoking, seizures, obesity, high blood pressure, diabetes, obstructive sleep apnea, and history of heavy alcohol use. In patients with one or more of these risks, it may be appropriate to lengthen the amount of time between anesthesia events or to perform a single operation.

Selecting the Best Procedure

As stated above, it is important to walk the total ankle patient as quickly as possible to avoid overtightening of the surrounding soft tissues or capsule. Oftentimes the length of time spent non-weight-bearing is determined based on the involvement of the osseous procedures necessary to correct deformity. Preoperative stress imaging of the varus or valgus ankle is a useful tool that may indicate if the ankle will solely require soft tissue correction if the joint neutralizes with manual stress. Deformity correction that may require hindfoot and midfoot osteotomies may also be able to walk before the standard 6-week mark based on the number of osteotomies, the involvement of the osteotomies, and the type of fixation used.

In cases where hastened weight-bearing is not an option, there may be additional resources aside from staging procedures. In this setting, frequent and aggressive physical therapy may be able to replace the benefits of protected weight-bearing in a boot. The patient may be advised to bring a trusted family member or friend to the first physical therapy session to observe and subsequently be able to replicate the same passive range of motion exercises a couple of times per day to combat the soft tissues from adhering and scarring in a tightened position.

Case Study: Degenerative Changes Following a Pilon Fracture

As is true of all things, procedural selection and timing of surgery should be performed to the surgeon’s comfort level. In the authors’ experience, staging should be considered if a hindfoot fusion or a supramalleolar osteotomy is necessary to achieve deformity correction, which tends to occur in cases with greater than 10 degrees of ankle valgus. Additionally, varus deformities or less than 10 degrees of ankle joint valgus will usually respond well to a combination of osteotomies and soft tissue procedures to correct deformity, which may be done in a single procedure. We will now present an example of a single staged varus ankle deformity correction with total ankle replacement.

The patient is a 51-year-old female who presents 5 years after a pilon fracture surgically corrected via open reduction and internal fixation (ORIF) (Figure 1). Over the last 6 months she noticed she was having more difficulty with ambulation and remarked on decreased range of motion of the ankle joint.

After a proper physical examination and full foot and ankle radiographic series, it was determined that the patient had degenerative changes to the ankle with less than 10 degrees of varus and a rearfoot-driven cavus deformity. After standard preoperative workup and planning, the patient was consented for a single-stage total ankle replacement with lateralizing calcaneal slide and Brostrom-Gould repair of lateral ankle ligaments (Figure 2).

The patient was non-weight-bearing until 4 weeks after surgery. However, she performed passive range of motion exercises at home and at physical therapy starting at 2 weeks. She was back to full activity at 6 months without any limitations and is currently 2 years postop without complaints.

Concluding Remarks

The practice of staging deformity correction procedures from total ankle replacement is one that comes with additional monetary cost, and risks. To date there does not exist any mention in the literature establishing a correlation between staging procedures and long-term survivorship in total ankle implants. Staged approaches may also expose higher-risk patients to multiple general anesthesia events within a one-month timeframe. While the benefits associated with staged procedures are obvious, they can easily be replicated with a single stage approach under the right environment in a way that saves health care dollars and lessens the complication rate for at risk patients. The flowchart here provides a simplified version of the protocol developed from the authors’ experience.

Dr. McAlister is a Fellow of the American College of Foot and Ankle Surgeons and practices in Phoenix and Scottsdale, AZ.

Dr. Duelfer is a current Fellow at the Phoenix Foot and Ankle Institute Fellowship in Phoenix and Scottsdale, AZ.

Point References

1.     Usuelli FG, Indino C, Maccario C, Manzi L, Liuni FM, Vulcano E. Infections in primary total ankle replacement: Anterior approach versus lateral transfibular approach. Foot Ankle Surg. 2019;25(1):19-23. doi:10.1016/j.fas.2017.07.643
2.  Cheng H, Clymer JW, Po-Han Chen B, et al. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res. 2018;229:134-144. doi:10.1016/j.jss.2018.03.022
3.      Ravi B, Jenkinson R, O’Heireamhoin S, et al. Surgical duration is associated with an increased risk of periprosthetic infection following total knee arthroplasty: A population-based retrospective cohort study. EClinicalMedicine. 2019;16:74-80. doi:10.1016/j.eclinm.2019.09.015
4.     Cody EA, Lachman JR, Gausden EB, Nunley JA, Easley ME. Lower bone density on preoperative computed tomography predicts periprosthetic fracture risk in total ankle arthroplasty. Foot Ankle Int. 2019;40(1):1-8. doi:10.1177/1071100718799102
5.    Gross CE, Lewis JS, Adams SB, Easley M, DeOrio JK, Nunley JA. Secondary arthrodesis after total ankle arthroplasty. Foot Ankle Int. 2016;37(7):709-714. doi:10.1177/1071100716641729
6.    Massobrio M, Pellicanò G, Santilli V, Tognolo L (2018) Total ankle replacement: indications, rehabilitation and results. Int J Foot Ankle. 2:019. doi.org/10.23937/ijfa-2017/1710019
7.    Lisi C, Caspani P, Bruggi M, et al. Early rehabilitation after elective total knee arthroplasty. Acta Bio Medica Atenei Parm. 2017;88(Suppl 4):56-61. doi:10.23750/abm.v88i4-S.5154
8.    Masaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K. Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis. PLoS ONE. 2017;12(6). doi:10.1371/journal.pone.0178295

Counterpoint References

1.    Trincat S, Kouyoumdjian P, Asencio G. Total ankle arthroplasty and coronal plane deformities. Orthop Traumatol Surg Res. 2012 Feb; 98(1):75–84.
2.    Saito G, Sanders A, Demetracopoulos C. Total ankle replacement with advanced varus and valgus deformities. Tech Foot Ankle Surg. 2018; 17(2):43–50.
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).
4.    Henricson A. Nilsson JA, Carlsson A. 10-year survival of total ankle arthroplasties. Acta Orthopaedica. 2011 Dec; 82(6).
5.    Perry T, Silman A, Culliford D, Gates L, Arden N, Bowen C. Survival of primary ankle replacements: data from global joint registries. J Foot Ankle Res. 2022 May; 15(33).
6.    Stadler C, Stobich M, Ruhs B, Kaufmann C, Pisecky L, Stevoska S, Gotterbarm T, Klotz M. Intermediate to long- term clinical outcomes and survival analysis of the salto mobile bearing total ankle prothesis. Arch Orthop Trauma Surg. 2021.
7.    Bartel A, Roukis T. Total ankle replacement survival rates based on Kaplan- Meier survival analysis of national joint registry data. Clin Podiatr Med Surg. 2015.
8.    Stadler C, Luger M, Stevoska S et al. High reoperation rate in mobile-bearing total ankle arthroplasty in young patients. Medicina. 2022.