Norkin I.A., Zuev P.P., Barabash Yu.A., Grazhdanov K.A., Kauts O.A. 

Scientific Research Institute of Traumatology, Orthopedics and Neurosurgery, V.I. Razumovsky Saratov State Medical University, Saratov, Russia

Modern approaches to the treatment of terminal stages of ankle osteoarthritis suggest total arthroplasty and osteoplastic arthrodesis as the methods of choice, each of which has its own advantages and disadvantages due to the peculiarities of the technology of their implementation, the design characteristics of the metal structures used and the specificity of potential complications [1-6]. The listed factors not only determine the choice of indications for surgical treatment, but also the chronological sequence of performing one or another method of reconstruction of the ankle joint during revision surgery. The main problem for the practicing physician at the present time is the decision on the choice of tactics of surgical treatment in each specific situation with a future perspective, where a high probability of instability of the metal structure or its wear can be traced. However, to date, there is no consensus in the literature regarding the choice of the method of surgical treatment for terminal stages of ankle osteoarthritis, and the authors' attempts to draw conclusions based on the meta-analysis performed do not make much sense due to the heterogeneity of clinical indications and surgical techniques used in this category of patients. [7, 8].

Objective - the systematic review of Russian and foreign practices of surgical management of patients with the total failures of ankle replacements


A search was carried out for publications in the electronic medical databases PubMed, Google Scholar, eLIBRARY, the Central Scientific Medical Library of   Sechenov First Moscow State Medical University, and VINITI RAS for the period 2000-2020. The key words were “unstable ankle endoprosthesis”, “arthrodesis after total ankle replacement”, “complications of total ankle replacement”, “failed total ankle replacement”, “arthrodesis after total ankle replacement”, “complications after total ankle replacement”. The preliminary analysis included 78 sources. The depth of the search was 10 years in accordance with the set goal of a scientific study aimed at assessing the evolution of the development of technology for performing arthrodesis of the ankle joint as a revision operation, and the periods of replacement of generations of endoprostheses.
The criteria for subsequent exclusion were the absence of a description of the surgical procedure (a set of surgical techniques), complications that developed in the postoperative period, as well as anatomical and functional treatment outcomes. As a result, 31 literature sources were analyzed, 11 additional sources were used to assess the evolution of ankle arthroplasty techniques and the corresponding expansion of the spectrum of complications causes, of which 37 are clinical studies and 5 are systematic literature reviews.

As a result, 42 sources were analyzed, of which 37 are clinical studies and 5 are systematic literature reviews; 31 sources were used to analyze the existing methods of surgical treatment of patients with total failure of arthroplasty, 11 sources were additionally used to assess the evolution of the technology of arthroplasty and osteoplastic arthrodesis of the ankle joint.

Of 31 selected sources for the analysis of existing surgical procedures for patients with total failure of ankle arthroplasty, 26 were clinical trials and 5 literature reviews. The content of the latter was devoted to the search for the optimal tactics of surgical treatment with an assessment of the causes of complications in the postoperative period in this category of patients. The description of the results of clinical studies in 5 sources contained data on a comprehensive assessment of the outcomes of revision arthroplasty in 178 patients. Four publications demonstrated the results of treatment of patients who underwent arthrodesis of the ankle joint using combined techniques for bone defect replacement and metal mesh/porous volumetric grafts. 17 publications describe the results of treatment of 296 patients who underwent arthrodesis using submerged extramedullary or intramedullary metal structures in combination with bone auto- or alloplasty.


Improvement of technologies for total ankle arthroplasty and design features of third-generation endoprostheses has led to an expansion of indications for the use of this operation, which allows providing a sufficient range of motion, in contrast to arthrodesis. The increase in the volume of ankle arthroplasty performed inexorably leads to an increase in the number of complications, but today, according to the literature, their frequency does not exceed the number of those in similar operations on large joints.
Noteworthy is a study in which a group of authors compares the results of treatment of patients after revision operations and primary arthrodesis of the ankle joint [9]. They reliably proved that revision arthrodesis leads to a deterioration in the quality of life and a more intense pain syndrome than the primary one. These results confirm the necessity of making a medical decision in favor of primary arthroplasty of the ankle joint with its subsequent arthrodesis when there are indications for revision surgery for complications that have arisen.

Two main reasons for revision surgeries after total ankle arthroplasty have been identified - aseptic instability with migration of endoprosthesis components and infectious complications. Before performing or during revision surgery, it is extremely important that peri-implant infection is excluded [10], since the latter complicates the choice of surgical treatment tactics and increases the rehabilitation period for patients. However in these cases there is a chance to save the implant after revision and debridement of the wound. With a long-term infection with the possible formation of bacterial biofilms on the surface of the components of the endoprosthesis, the removal of constructions is required [10, 11]. The need to repair the defect in the bones that form the ankle joint leads to the division of surgical treatment into several stages using spacers with or without antibacterial drugs. In cases of small bone defects with the possibility of achieving a satisfactory contact between the bones, the most optimal treatment option is simultaneous arthrodesis with an external fixation apparatus [12].

Currently, only a few models of revision ankle endoprostheses are known in the world, the design features of which allow them to be used in the presence of bone defects formed after the removal of the primary implant. Based on the analysis of case histories of 70 patients [13], it was revealed that less than 50 % of them were satisfied with the result of revision arthroplasty, but their functional indicators were lower, the 5-year survival rate of revision ankle arthroplasty was 76 %, and the 10-year - only 55 %.

Most authors agree that large bone defects that do not allow providing the necessary support for the components of the endoprosthesis are an unambiguous contraindication for revision arthroplasty [10, 13-17]. As a result, the rescue operation in this category of patients remains osteoplastic arthrodesis, which provides the possibility of painless loading on the limb, but a lower functional result in comparison with endoprosthetics [18, 19].

Performing osteoplastic arthrodesis contributes to the correction of existing deformities and the creation of an osteoinductive environment due to bone grafting in combination with metal fixation. However, the use of an autograft to replace large bone defects is limited by the available volume of bone mass, its osteosclerosis with potential osteolysis during consolidation [20-22]. The use of allografts solves the problem of the deficit of donor zones, but does not guarantee a loss of the height of the bone block with possible subsequent nonunion, which occurs in 24 % of cases.

Despite this, some authors [26] report the successful use of a structural allograft from the femoral head in 5 patients for defect replacement in combination with arthrodesis with an intramedullary lockable nail. They come to the conclusion that the use of a combination of plastic with metal fixation is justified and allows a good functional result to be achieved with a reasonable ankylosing time. Other authors share the same opinion [27, 28], using similar tactics of surgical treatment of patients with total failure of ankle arthroplasty. In support of intramedullary metal fixation, the results of treatment of 23 patients are promising. The authors of the study [29] managed to achieve bone ankylosis of the ankle joint in 95.6 %.

Other researchers [30] publish the results of treatment of 23 patients with this pathology, comparing the method of fixation with an intramedullary nail and screws. In 6 cases, where osteoplastic arthrodesis of the ankle joint was performed with compression screws, it was not possible to achieve fusion, which confirms the validity of the thesis about the need for intramedullary osteosynthesis.

In the search for the optimal tactics of surgical treatment of patients with instability of an ankle joint endoprosthesis, some authors resorted to alternative methods, using a trabecular tantalum implant or mesh cages filled with bone chips to replace bone tissue defects [31-34]. Hypothetically, this approach should ensure stability at all phases of bone graft remodeling without loss of the length of the lower limb, and also promote the consolidation of the bones that form the ankle joint. The results of clinical trials were disappointing. Thus, a group of authors [34] found that after more than one year of observation, 13 patients were diagnosed with unsatisfactory clinical results (the average AOFAS score was 56 (21-78)) and a large number of cases of lack of consolidation and integration of tantalum were revealed. Other scientists [32] also do not recommend the use of titanium mesh cages filled with an autograft for ankle arthrodesis.

One of the authors [35] describes the satisfactory results of treatment of patients with total failure of ankle arthroplasty, including arthrodesis in the form of bone grafting with metal fixation with an extra-bone plate and screws.

In the available literature, we came across the only formulated algorithm for the surgical treatment of patients with complications of total ankle arthroplasty [14]. It is based on the volume of the talus defect, depending on which the type of bone grafting and the method of surgical fixation are proposed.


Based on the literature data, we see that the maximum survival rate of ankle joint endoprostheses is no more than 10 years (80 %). In the historical aspect, this indicator has a positive trend, but in the near future it will not exceed the existing values. This conclusion is based on similar results of hip and knee arthroplasty [31, 36]. The high probability of wear of the implantable structure and the occurrence of instability of the components of the endoprosthesis requires revision interventions. Most foreign and domestic authors believe that osteoplastic arthrodesis should be preferred during reoperations [37, 38].
The increase in the frequency of revision interventions performed using the technique of osteoplastic arthrodesis has raised questions about the use of the most promising combinations of the use of types of auto-/allografts and types of fixators - intramedullary, extraosseous and transosseous ones, depending on the type of bone defects formed after removal of the components of the endoprosthesis [39-42].

The only discovered algorithm for choosing the tactics of surgical treatment of patients after total failure of ankle arthroplasty also has its drawbacks [14]. In our opinion, it is impossible not to take into account the size of the defect in the bones of the distal tibia and their interposition, as well as to assume as the main method of treatment arthrodesis only with extramedullary plates and screws, although in some cases the use of an intramedullary blocking rod in the form of a fixator is quite justified. Unity of views can be traced only with the predominant choice of allograft used for bone grafting during revision arthrodesis.


Currently, there are two most common methods for treating patients with instability of the components of the endoprosthesis against the background of re-implant osteolysis, which develops due to an infectious process or without it - revision arthroplasty and osteoplastic arthrodesis of the ankle joint. The outcomes of revision ankle arthroplasty, unfortunately, are not satisfactory from a functional point of view, and also require the preservation of significant volumes of bone mass, which is absent in the vast majority of observations in the long-term postoperative period in cases of repeated surgeries due to the limited survival time of implanted structures. Analysis of long-term results of treatment of patients with total failure of primary ankle arthroplasty has demonstrated the effectiveness of osteoplastic arthrodesis as a reliable and safe method of restorative treatment, predictably leading to satisfactory results, subject to ankylosis and compliance with the requirements for the choice of the optimal combination of implantable hardware and bone grafting, depending on the available bone defect.

Funding information and conflicts of interest

The work was carried out at the expense of the federal budget within the framework of the state contract from February 5, 202, No. 056-00030-21-01 of the Ministry of Health of the Russian Federation, the executor of which is the Saratov State Medical University named after V.I. Razumovsky of the Ministry of Health of Russia. R&D registration card 121032300174-6 on the topic "Development of a personalized approach to the choice of tactics for surgical rehabilitation of patients with consequences of intra-articular injuries to the distal leg bones."
The authors declare no obvious and potential conflicts of interest related to the publication of this article.


1.     Gougoulias NE, Khanna A, Maffulli N. History and evolution in total ankle arthroplasty. Br Med Bull. 2009; 89(1): 111-151. doi: 10.1093/bmb/ldn039
     Gross CE, Lampley A, Green CL, DeOrio JK, Easley M, Adams S, et al. The effect of obesity on functional outcomes and complications in total ankle arthroplasty. Foot Ankle Int. 2016; 37(2): 137-141. doi: 10.1177/1071100715606477

     Demetracopoulos CA, Adams SB, Jr, Queen RM, DeOrio JK, Nunley JA 2nd, Easley ME. Effect of age on outcomes in total ankle arthroplasty. Foot Ankle Int. 2015; 36(8): 871-880. doi: 10.1177/1071100715579717
     Lewis JS, Jr, Green CL, Adams SB Jr, Easley ME, DeOrio JK, Nunley JA. Comparison of first- and second-generation fixed-bearing total ankle arthroplasty using a modular intramedullary tibial component. Foot Ankle Int. 2015; 36(8): 881-890. doi: 10.1177/1071100715576568

     Barg A, Zwicky L, Knupp M, Henninger HB, Hintermann B. HINTEGRA total ankle replacement: survivorship analysis in 684 patients. J Bone Joint Surg Am. 2013; 95(13): 1175-1183. doi: 10.2106/JBJS.L.01234
     Schenk K, Lieske S, John M, Franke K, Mouly S, Lizee E, et al. Prospective study of a cementless, mobile-bearing, third generation total ankle prosthesis. Foot Ankle Int. 2011; 32(1): 755-763. doi: 10.3113/FAI.2011.0755
     Mohammad HR, Debrock W, Mellon SJ, Cooke P. Response to review article published titled 'Total ankle arthroplasty versus ankle arthrodesis – a comparison of outcomes over the last decade'. J Orthop Surg Res. 2019; 14(1): 142. doi: 10.1186/s13018-019-1190-1

     Muller P, Skene SS, Chowdhury K, Cro S, Goldberg AJ, Doré CJ. A randomised, multi-centre trial of total ankle replacement versus ankle arthrodesis in the treatment of patients with end stage ankle osteoarthritis (TARVA): statistical analysis plan. Trials. 2020; 21(1): 197. doi: 10.1186/s13063-019-3973-4

      Rahm S, Klammer G, Benninger E, Gerber F, Farshad M, Espinosa N. Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis. Foot Ankle Int. 2015; 36(4): 349-359. doi: 10.1177/1071100714559272

   Wünschel M, Leichtle UG, Leichtle CI, Walter C, Mittag F, Arlt E, et al. Fusion following failed total ankle replacement. Clin Podiatr Med Surg. 2013; 30(2): 187-198. doi: 10.1016/j.cpm.2012.10.009

        Giulieri SG, Graber P, Ochsner PE, Zimmerli W. Management of infection associated with total hip arthroplasty according to a treatment algorithm. Infection. 2004; 32(4): 222-228. doi: 10.1007/s15010-004-4020-1

        Kliushin NM, Ermakov AM. Two-stage arthrodesis of the ankle joint in the treatment of periprosthetic infection. Genius of Orthopedics. 2020; 26(1): 99-102. Russian (Клюшин Н.М., Ермаков А.М. Двухэтапное артродезирование голеностопного сустава при лечении перипротезной инфекции //Гений ортопедии. 2020. Т. 26, № 1. С. 99-102)
    Kamrad I, Henricson A, Magnusson H, Carlsson Å, Rosengren BE. Outcome after salvage arthrodesis for failed total ankle replacement. Foot Ankle Int. 2016; 37(3): 255-561. doi: 10.1177/1071100715617508

    Espinosa N, Wirth SH. Ankle arthrodesis after failed total ankle replacement. Orthopade. 2011; 40(11): 1008, 1010-2, 1014-1017. (German). doi: 10.1007/s00132-011-1830-6
    Gross C, Erickson BJ, Adams SB, Parekh SG. Ankle arthrodesis after failed total ankle replacement: a systematic review of the literature. Foot Ankle Spec. 2015; 8(2): 143-151. doi: 10.1177/1938640014565046

    Lachman JR, Ramos JA, Adams SB, Nunley JA 2nd, Easley ME, DeOrio JK. Patient-reported outcomes before and after primary and revision total ankle arthroplasty. Foot Ankle Int. 2019; 40(1): 34-41. doi: 10.1177/1071100718794956

    Morita S, Taniguchi A, Miyamoto T, Kurokawa H, Tanaka Y. Application of a customized total talar prosthesis for revision total ankle arthroplasty. JB JS Open Access. 2020; 5(4): e20.00034. doi: 10.2106/JBJS.OA.20.00034

    Kotnis R, Pasapula C, Anwar F, Cooke PH, Sharp RJ. The management of failed ankle replacement. J Bone Joint Surg Br. 2006; 88(8): 1039-1047. doi: 10.1302/0301-620X.88B8.16768

    Egrise F, Parot J, Bauer C, Galliot F, Kirsch M, Mainard D. Complications and results of the arthrodesis after total ankle arthroplasty failure: a retrospective monocentric study of 12 cases. Eur J Orthop Surg Traumatol. 2020; 30(2): 373-381. doi: 10.1007/s00590-019-02561-w

    DeOrio JK, Farber DC. Morbidity associated with anterior iliac crest bone grafting in foot and ankle surgery. Foot Ankle Int. 2005; 26(2): 147-151
    Boone DW. Complications of iliac crest graft and bone grafting alternatives in foot and ankle surgery. Foot Ankle Clin. 2003; 8(1): 1-14. doi: 10.1016/S1083-7515(02)00128-6
    Culpan P, Le Strat V, Piriou P, Judet T. Arthrodesis after failed total ankle replacement. J Bone Joint Surg Br. 2007; 89-B(9): 1178-1183. doi: 10.1302/0301-620X.89B9.19108

    Lareau CR, Deren ME, Fantry A, Donahue RM, DiGiovanni CW. Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature. Foot Ankle Surg. 2015; 21(3): 150-159. doi: 10.1016/j.fas.2015.03.008
    Aponte-Tinao LA, Ayerza MA, Muscolo DL, Donahue RM, DiGiovanni CW. What are the risk factors and management options for infection after reconstruction with massive bone allografts? Clin Orthop Relat Res. 2016; 474(3): 669-673. doi: 10.1007/s11999-015-4353-3
    Ayerza MA, Piuzzi NS, Aponte-Tinao LA, Farfalli GL, Muscolo DL. Structural allograft reconstruction of the foot and ankle after tumor resections. Musculoskelet Surg. 2016; 100(2): 149-156. doi: 10.1007/s12306-016-0413-4
    Halverson AL, Goss DA Jr, Berlet GC. Ankle arthrodesis with structural grafts can work for the salvage of failed total ankle arthroplasty. Foot Ankle Spec. 2020; 13(2): 132-137. doi: 10.1177/1938640019843317

    Thomason K, Eyres KS. A technique of fusion for failed total replacement of the ankle: tibio-allograft-calcaneal fusion with a locked retrograde intramedullary nail. J Bone Joint Surg Br. 2008; 90(7): 885-888. doi: 10.1302/0301-620X.90B7.20221
    Deleu PA, Devos Bevernage B, Maldague P, Gombault V, Leemrijse T. Arthrodesis after failed total ankle replacement. Foot Ankle Int. 2014; 35(6): 549-557. doi: 10.1177/1071100714536368
    Ali AA, Forrester RA, O'Connor P, Harris NJ. Revision of failed total ankle arthroplasty to a hindfoot fusion: 23 consecutive cases using the Phoenix nail. Bone Joint J. 2018; 100-B(4): 475-479. doi: 10.1302/0301-620X.100B4.BJJ-2017-0963

    Hopgood P, Kumar R, Wood PL. Ankle arthrodesis for failed total ankle replacement. J Bone Joint Surg Br. 2006; 88(8): 1032-1038. doi: 10.1302/0301-620X.88B8.17627

   Henricson A, Nilsson JÅ, Carlsson A. 10-year survival of total ankle arthroplasties: a report on 780 cases from the Swedish Ankle Register. Acta Orthop. 2011; 82(6): 655-959. doi: 10.3109/17453674.2011.636678

    Carlsson A. Unsuccessful use of a titanium mesh cage in ankle arthrodesis: a report on three cases operated on due to a failed ankle replacement. J Foot Ankle Surg. 2008; 47(4): 337-342. doi: 10.1053/j.jfas.2008.02.016

    Bullens P, de Waal Malefijt M, Louwerens JW. Conversion of failed ankle arthroplasty to an arthrodesis. Technique using an arthrodesis nail and a cage filled with morsellized bone graft. Foot Ankle Surg. 2010; 16(2): 101-104. doi: 10.1016/j.fas.2009.01.001

    Aubret S, Merlini L, Fessy M, Besse JL. Poor outcomes of fusion with Trabecular metal implants after failed total ankle replacement: early results in 11 patients. Orthop Traumatol Surg Res. 2018; 104(2): 231-237. doi: 10.1016/j.otsr.2017.11.022

   Espinosa N, Wirth S, Jankauskas L. Ankle fusion after failed total ankle replacement. Tech Foot Ankle Surg. 2010; 9(4): 199-204. doi: 10.1097/BTF.0b013e3181fc85f6

    Doets HC, Zürcher AW. Salvage arthrodesis for failed total ankle arthroplasty. Acta Orthop. 2010; 81(1): 142-147. doi: 10.3109/17453671003628764
   Huch K, Kuettner KE, Dieppe P. Osteoarthritis in ankle and knee joints. Semin Arthritis Rheum. 1997; 26(4): 667-674. doi: 10.1016/s0049-0172(97)80002-9

   Pugely AJ, Lu X, Amendola A, Callaghan JJ, Martin CT, Cram P. Trends in the use of total ankle replacement and ankle arthrodesis in the United States Medicare population. Foot Ankle Int. 2014; 35(3): 207-215. doi: 10.1177/1071100713511606

   Pakhomov IA. Complications of the ankle joint endoprosthesis. Polytrauma. 2011; (4): 17-22. Russian (Пахомов И.А. Осложнения эндопротезирования голеностопного сустава //Политравма. 2011. № 4. С. 17-22)
   Tikhilov RM, Koryshkov NA, Yemelyanov VG, Stoyanov AV, Zhuravlev AV, Privalov AM. Experience in total ankle replacement at Russian Scientific-Research Institute of Traumatology and Orthopaedics named after R.R. Vreden. N.N. Priorov Journal of Traumatology and Orthopedics. 2009; (3): 56-60. Russian (Тихилов Р.М., Корышков Н.А., Емельянов В.Г., Стоянов А.В., Журавлев А.В., Привалов А.М. Опыт эндопротезирования голеностопного сустава в российском научно-исследовательском Институте травматологии и ортопедии им. Р.Р. Вредена //Вестник травматологии и ортопедии им. Н.Н. Приорова. 2009. № 3. С. 56-60)
   Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger AS. Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement. J Bone Joint Surg Am. 2011; (93): 830-839. doi:10.2106/JBJS.J.00103

    Wimmer MD, Hettchen M, Ploeger MM, Hintermann B, Wirtz DC, Barg A. Aseptic loosening of total ankle replacement and conversion to ankle arthrodesis. Oper Orthop Traumatol. 2017; 29(3): 207-219. doi: 10.1007/s00064-017-0492-x

Статистика просмотров

Загрузка метрик ...


  • На текущий момент ссылки отсутствуют.