SLR - March 2018 - Joseph M. Greschner

Mid- to Long-Term Results of Total Ankle Replacement in Patients with Haemophiic Arthropathy: A 10-Year Follow-Up

Reference: Eckers F, Bauer DA, Hingsammer A, et al. Mid- to Long-Term Results of Total Ankle Replacement in Patients with Hemophilic Arthropathy: A 10-Year Follow-Up. Haemophilia. 2017;00:1–9.

Scientific Literature Review

Reviewed By: Joseph M. Greschner, DPM    
Residency Program: Grant Medical Center, Columbus, OH

Podiatric Relevance: Hemophilia is a rare, congenital, hematological disease associated with recurrent spontaneous hemorrhaging. Hemophilic arthropathy can lead to accelerated degenerative joint disease, most commonly in the knee, elbow and the ankle. While ankle arthrodesis has traditionally been the procedure of choice for end-stage arthritis, total ankle replacement (TAR) has gained acceptance as a viable treatment alternative. An increasing number of publications have provided evidence to show the ability of the TAR to reduce pain while preserving ankle motion. The long-term outcomes of TAR in the literature remain sparse. This study aims to investigate the mid- to long-term clinical and radiographic results after TAR in patients with hemophilic ankle arthropathy.

Methods: Retrospective review of 14 patients who underwent 17 consecutive cases of TAR performed between 1998 and 2012. During the 15-year long observational study, four different implants were used: 6 AGILITY, 6 HINTEGRA, 3 STAR and 2 MOBILITY. Clinical outcomes were measured with AOFAS hindfoot scores, VAS pain scores, SF-36 scores and radiographically. Radiographs were examined regarding component position, component loosening, periprosthetic lucency, periprosthetic fracture, polyethylene wear or fracture, soft-tissue abnormality and progressive degenerative changes in adjacent joints.

Results: Seventeen consecutive cases in 14 male patients with a mean age of 43 were included in the study. Implant survival was assessed at a mean of 9.3 years. As result of component loosening, three cases (17.6 percent) underwent revision surgery with component removal (one arthrodesis, two TAR) at a mean postoperative interval of 7.5 ± 4.9 years. The estimated implant survival was 94 percent at five, 85 percent at 10 and 70 percent at 15 years. The mean estimated implant survival was 14.77 years. AOFAS hindfoot score reached 81 ± 5.9 points (range, 73–90). SF-36 scores were 47 ± 13.0 for physical and 57 ± 5.0 for mental health. All patients were able to pursue work and activities of daily living. Twelve ankles were reviewed radiographically, six prosthesis were considered well aligned and six were malaligned. Periprosthetic lucency was present in nine cases in the tibia and in 11 cases in the talus. There were no cases of periprosthetic fracture. Component wear or fracture as well as adjacent degenerative joint disease were rare.

Conclusions: The authors conclude that TAR in the setting of advanced hemophilic ankle arthropathy is a viable treatment option with favorable clinical mid- /long-term results. Implant survival based on this 10-year follow-up is similar to that of patients in the inflammatory arthropathy and general population. While the clinical results are promising, there was evident periprosthetic loosening visualized radiographically in the majority of cases. Microhaemorrhages around prosthetic components leading to destructive reactions may have increased rates of aseptic loosening. Hemophiliacs tend to be young males due to the mode of inheritance, thus a high-demand patient population could also explain the rates of loosening seen in this study. The optimal age for prosthetic longevity in TAR remains a topic of conversation in the literature. Nevertheless, the patient age and specific risk factors remain as variables influencing revision surgery. Further studies with larger patient populations and longer follow-up are warranted.

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