A Systematic Review of the Literature

Total ankle arthroplasty provides an alternative to arthrodesis for management of ankle arthritis. What is the outcome of total ankle arthroplasty implants currently in use? We conducted a systematic literature search of studies reporting on the outcome of total ankle arthroplasty. We included peer-reviewed studies reporting on at least 20 total ankle arthroplasties with currently used implants, with a minimum followup of 2 years. The Coleman Methodology Score was used to evaluate the quality of the studies. Thirteen Level IV studies of overall good quality reporting on 1105 total ankle arthroplasties (234 Agility, 344 STAR, 153 Buechel-Pappas, 152 HINTEGRA, 98 Salto, 70 TNK, 54 Mobility) were included. Residual pain was common (range, 27%–60%), superficial wound complications occurred in 0% to 14.7%, deep infections occurred in 0% to 4.6% of ankles, and ankle function improved after total ankle arthroplasty. The overall failure rate was approximately 10% at 5 years with a wide range (range, 0%–32%) between different centers. Superiority of an implant design over another cannot be supported by the available data. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. Introduction Total ankle arthroplasty (TAA) has been performed in selected patients with end-stage ankle idiopathic, posttraumatic osteoarthritis, and inflammatory arthritis since the 1970s [24]. Initial implant designs were associated with failures requiring revision or fusion as high as 72% at 10 years [10], raising substantial concern about the devices. Studies of normal ankle biomechanics and review of previous implant failures have led to the development of new TAA designs [5, 8, 10]. First-generation implants were constrained, had an all-polyethylene tibial component, and used cement for implant fixation [9, 10]. Implants used today may have either twoor three-components with either fixed or mobile bearings. Cementless fixation is considered better by most implant manufacturers and surgeons [3, 5, 7, 10, 11, 14, 19, 20, 34]. The procedure is considered by some a reasonable alternative to ankle arthrodesis [12], and the demand by younger and more active patients likely will increase as failure rates diminish. Therefore, it is in the interest of clinicians and patients to evaluate the outcome of current TAAs for management of ankle arthritis. We therefore systematically reviewed the literature to determine: (1) the quality of the literature reporting outcomes of TAA; (2) the indications for TAA (eg, inflammatory arthropathy, osteoarthritis) in different centers; (3) the clinical failure rate and survivorship for different implants; (4) the methods used to salvage failures; (5) the wound complication and deep infection rates; (6) the functional outcome and the ability to participate in sports after TAA; (7) the range of motion (ROM) after TAA; (8) whether pain is eliminated; and (9) the radiographic outcome. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. N. Gougoulias, A. Khanna, N. Maffulli (&) Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK e-mail: n.maffulli@qmul.ac. uk; n.maffulli@keele.ac. uk 123 Clin Orthop Relat Res (2010) 468:199–208 DOI 10.1007/s11999-009-0987-3