Dependence of Total Ankle Tibial Baseplate Stability Upon Bone Density
Authors: Clarke Gabriel , Johnson Joshua E. , Anderson Donald D. , Netto Cesar de Cesar 
Published: December 2023

Category: Ankle Arthritis Introduction/Purpose: The success of total ankle replacement (TAR) in improving patient outcomes is linked to its initial stability after implantation. Limiting early micromotion between implant and bone improves longer-term stability. Tibial component design fixation features play a critical role in determining early stability, with retention of medial and lateral bone sidewalls and interference press-fit both used to supplement fixation. However, tibial component stability is likely also influenced by regional bone density characteristics, and the exact relationship between the two is not adequately understood. The goal of this study was to investigate how bone density affects tibial component stability and bone-implant interface micromotion between the tibial component of a specific TAR and the distal tibia, by using finite element analysis (FEA) during simulated gait. Methods: A commercially available TAR tibial component baseplate was virtually inserted into a computer model of the distal tibia from two patients with end-stage ankle arthritis. These patients were selected based on having different bone density profiles in the affected ankle. The tibia models were generated from patient CT scans, having a CT density-based inhomogeneous material distribution (Fig. 1a) that allowed for bone compaction after press-fit. The tibial component was modeled as titanium alloy material. Two different fixation cases were simulated using FEA: (1) retained medial/lateral sidewalls + line-to-line fit, and (2) retained sidewalls + 50µm interference press-fit. FEA was performed using body weight-scaled kinetic (forces/moments) profiles representing the stance phase of gait, applied to the distal implant surface, while the proximal tibia was held fixed. Press-fit was simulated prior to gait simulation (interference press-fit cases). Micromotions were defined as displacement differences between bone-implant closest nodal pairs, computed from FEA output. Results: For the case with sidewalls+line-to-line fit, micromotions were largest early and late in the stance phase of gait (Fig. 1b), with the largest micromotions observed at heel strike (0% stance). Dorsiflexion and inversion moments dominate in early stance, stressing the anterior edge of the tibia in contact with the implant, leading to relatively large posterior/lateral gapping (Fig. 1b, inset). The observed differences in micromotion between the two patients correlated with differences in bone quality at the tibia contact surface, particularly around the implant pegs (Fig. 1a). However, when interference press-fit was modeled, the differences in micromotion between the two subjects largely disappeared (Fig. 1c), as adequate bone compaction was generated around the interference regions with sufficient bone quality to resist micromotion (Fig. 1d). Conclusion: This study presents novel insight into the effect of TAR fixation features and the associated micromotion at the bone- implant interface in patients with varying distal tibia bone density. We found the stability of the tibial implant to be considerably affected by surrounding bone quality, but the influence of bone quality on implant stability was minimized when interference press- fit was introduced. While a more comprehensive understanding of TAR implant features and their performance is needed, we believe the results of this study clearly demonstrate the importance of bone quality and particularly implant interference press-fit in the stability of TAR implants.