Managing Osteolysis Following A Failed Ankle Implant

These authors provide a guide to reconstructive treatment for an 80-year-old patient who developed massive tibial and talar osteolysis after an ankle implant failed.

One common etiology of the failure of the Agility Total Ankle Replacement (DePuy Orthopaedics) is periprosthetic cyst formation resulting from ultra-high molecular weight polyethylene (UHMWPE) wear debris, leading to bone erosion, component loosening or subsidence.1-6 These cystic changes sometimes enlarge progressively over time and may remain relatively asymptomatic until catastrophic failure is imminent.8

   Once one has identified these periprosthetic cysts, the physician should regularly check them for progression. If they are progressive or symptomatic, we recommend operative management.3-17 On occasion, when massive periprosthetic cysts are present, they can penetrate the cortex, resulting in an uncontained defect with cortical disruption.

   Historically, some have proposed impaction bone grafting to manage contained defects while ambiguity remains regarding management of massive periprosthetic osteolytic defects with cortical breach following total ankle replacement. Although polymethylmethacrylate cement use with total ankle replacement remains controversial, some authors promote it in specific instances and metallic reinforced cement augmentation warrants consideration.16-20

What You Should Know About The Patient Presentation And Treatment

An 80-year-old man presented 10 years after primary Agility Total Ankle Replacement with a posterior augmented talar component, responding to a surveillance program that the senior author conducted. Prior radiographs demonstrated early tibial periprosthetic cystic changes that progressed before he was lost to follow-up. Updated radiographs and computed tomography (CT) demonstrated a massive periprosthetic osteolytic tibial defect breaching the anterior, medial and posterior cortices as well as talar head and neck osteolytic lesions with progressive talar component subsidence and loosening. When the senior author initially evaluated the patient, he reported intermittent, relatively mild pain with ambulation and weightbearing, but noted his symptoms were increasing over the past year and beginning to limit his daily activities.

   We discussed reconstructive surgical options including revision of the current Agility Total Ankle Replacement, conversion to an Inbone Total Ankle Replacement System (Wright Medical Technology), a custom-stemmed total ankle replacement, a tibiotalocalcaneal arthrodesis with bulk allograft or a below-knee amputation.21-27

   Ultimately, we performed revision total ankle replacement by maintaining the stable original tibial component while revising the UHMWPE insert and talar component in order to recreate the height lost by the talar subsidence.16,17 We debrided the periprosthetic tibial cysts and filled them with three-dimensional, geometric metal reinforced polymethylmethacrylate cement to employ immediate stability. Pathologic findings included an abundance of granular histiocytes consistent with a particulate-mediated inflammatory response due to UHMWPE wear debris.

   Thirteen months after the surgery, he continues to do well with planned annual surveillance.

In Conclusion

Our early results, publication pending, with utilizing three-dimensional metallic reinforced cement augmentation are promising for the management of massive, progressive periprosthetic osteolytic cysts and may provide a useful alternative to impaction bone grafting in specific instances (e.g. elderly patients, periprosthetic cysts with cortical breaches).18

   The decision to maintain the Agility Total Ankle Replacement as opposed to alternate options, as we have described above, hinges largely on the stability of the tibial component. Although the massive cysts were present adjacent to the tibial component, the bone-component interface remained stable with osseous ongrowth into the porous coating where the cysts were not present. Accordingly, we did not consider the tibial component itself to have failed or required removal. Interestingly, we have observed this in other patients as well and the talar component is much more frequently unstable when osteolysis occurs.3

   When both the tibial and talar components are unstable and have failed, we advise against maintaining the Agility Total Ankle Replacement system and recommend considering alternate reconstructive options. Follow-up is short and anticipated long-term surveillance will provide additional insight to the efficacy of these techniques as further revision would be challenging.

   Dr. Prissel is a third-year resident in Podiatric Medicine and Surgery with Distinction in Rearfoot/Ankle Surgery Residency at the Gundersen Medical Foundation within the Gundersen Health System in La Crosse, Wis.

   Dr. Roukis is attending staff in the Department of Orthopaedics, Podiatry and Sports Medicine at Gundersen Health System. He is the President-Elect and a Fellow of the American College of Foot and Ankle Surgeons.

References
1. Roukis TS. Incidence of revision after primary implantation of the Agility total ankle replacement system: A systematic review. J Foot Ankle Surg. 2012; 51(2):198-204.
2. Gougoulias NE, Khanna A, Maffulli N. How successful are current ankle replacements? A systematic review of the literature. Clin Orthop Relat Res. 2010; 468(1):199-208.
3. Spirt AA, Assal M, Hansen ST. Complications and failure after total ankle arthroplasty. J Bone Joint Surg. 2004; 86-A(6):1172-1178, 2004.
4. Ollivere B, Wimhurst JA, Clark IM, et al. Current concepts in osteolysis. J Bone Joint Surg. 2012; 94-B(1):10-15, 2012.
5. Gaden MTR, Ollivere BJ. Periprosthetic aseptic osteolysis in total ankle replacement: Cause and management. Clin Podiatr Med Surg. 2013; 30(2):145-155.
6. Reiley MA. Total ankle arthroplasty with bone defects. Foot Ankle Spec. 2009; 2(1):32-34.
7. Rippstein PF, Huber M, Naal FD. Management of specific complications related to total ankle arthroplasty. Foot Ankle Clin. 2012; 17(4):707-717.
8. Jonck JH, Myerson MS. Revision total ankle replacement. Foot Ankle Clin. 2012; 17(4):687-706.
9. McCollum G, Myerson MS. Failure of the Agility total ankle replacement system and salvage options. Clin Podiatr Med Surg. 2013; 30(2):207-223.
10. Gupta S, Ellington JK, Myerson MS. Management of specific complications after revision total ankle replacement. Semin Arthroplasty. 2010; 21:310-319.
11. Gould JS. Revision total ankle arthroplasty. Am J Orthop. 2005; 34(8):361.
12. Espinosa N, Wirth SH. Revision of the aseptic and septic total ankle replacement. Clin Podiatr Med Surg. 2013; 30(2):171-185.
13. Myerson MS. Revision total ankle replacement. In: Myerson MS (ed.) Reconstructive Foot and Ankle Surgery: Management of Complications, 2nd ed, Elsevier Saunders, Philadelphia, 2010, pp. 295-316.
14. Haddad SL. Revision Agility total ankle arthroplasty. In: Easley ME, Wiesel SW (eds.) Operative Techniques in Foot and Ankle Surgery, Lippincott, Williams & Wilkins, Philadelphia, 2011, pp. 622-642.
15. Raikin SM, Myerson MS. Avoiding and managing complications of the Agility total ankle replacement system. Orthopedics. 2006; 29(10):931-938.
16. Prissel MA, Roukis TS. Management of extensive tibial osteolysis with the Agility™ total ankle replacement systems using geometric metal-reinforced cement augmentation. J Foot Ankle Surg. 2013; In press corrected proof published online: 16 May 2013; DOI: 10.1053/j.jfas.2013.03.038.
17. Roukis TS, Prissel MA. Management of extensive talar osteolysis with the Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation. J Foot Ankle Surg. 2013; In press corrected proof published online: 13 August 2013; DOI: 10.1053/j.jfas.2013.07.005.
18. Besse JL, Beverhage BD, Leemrijse T. Revision total ankle replacements. Tech Foot Ankle Surg. 2011; 10:176-188.
19. Whalen J, Kitaoka HB. Complications and salvage of failed total ankle arthroplasty. In: Morrey BF, Berry DJ (eds.) Joint Replacement Arthroplasty Volume II: Basic Science, Hip, Knee, and Ankle, 4th ed, Lippincott, Williams & Wilkins, Philadelphia, 2011, pp.1110-1118.
20. Schuberth JM, Christensen JC, Rialson JA. Metal-reinforced cement augmentation for complex talar subsidence in failed total ankle arthroplasty. J Foot Ankle Surg. 2011; 50(6):766-772.
21. Penner MJ. Failed ankle replacement and conversion to arthrodesis: a treatment algorithm. Tec Foot Ankle. 2012; 11:125-132.
22. DeVries JG, Scott RT, Berlet GC, et al. Agility™ to INBONE™: Anterior and posterior approaches to the difficult revision total ankle replacement. Clin Podiatr Med Surg. 2013; 30(1):81-96.
23. DeVries JG, Berlet GC, Lee TH, et al. Revision total ankle replacement: An early look at Agility to INBONE. Foot Ankle Spec. 2011; 4(4):235-244.
24. Meeker J, Wegner N, Francisco R, et al. Revision techniques in total ankle arthroplasty utilizing a stemmed tibial arthroplasty system. Tech Foot Ankle Surg. 2013; 12:99-108.
25. Roukis TS. Salvage of a failed “DePuy Alvine Total Ankle Prosthesis” with AgilityTM LP custom stemmed tibial and talar components. Clin Podiatr Med Surg. 2013; 30(1):101-109.
26. Donnenwerth M, Roukis TS. Tibio-talo-calcaneal arthrodesis with retrograde intramedullary compression nail fixation for salvage of failed total ankle replacement: A systematic review. Clin Podiatr Med Surg. 2013; 30(2):199-206.
27. Berkowitz MJ, Clare MP, Walling AK, et al. Salvage of failed total ankle arthroplasty with fusion using structural allograft and internal fixation. Foot Ankle Int. 2011; 32(5):493-502.