Hello, my name is Evan Lowy, and first I'd like to thank my co-authors for the opportunity to work on this project with them, as well as the OrthoCarolina Research Institute for assisting in this study. Today I'm presenting on minimum five-year follow-up evaluation of third-generation fixed-bearing total ankle arthroplasty with an intramedullary tibial component and a central sulcus talus. End-stage ankle arthritis has been shown to have an equivalent impact on quality of life as end-stage hip arthritis. Unfortunately, however, ankle arthritis is a disease of younger and typically more active patients. Ankle fusion has been regarded as the gold standard surgical treatment for this condition. However, it has been shown that following ankle fusion, there is progression of hindfoot arthritis within three years and virtually 100% advancement of adjacent joint arthritis with associated impact on activity and disability. There are limited valuable studies comparing fusion and total ankle replacement, as often they are cohort studies with different patient populations, making direct comparison difficult. Initially, there were higher rates of reoperation and revision shown with total ankle replacement. However, this gap is narrowing as implant design improves and surgeons are becoming more experienced. This is from a Yellow Journal article in 2019 that used the largest inpatient database in the United States. It shows the prevalence of primary total ankle arthroplasty compared to ankle fusion. From 2007 to 2013, the yearly incidence of total ankle replacement per capita increased 421%, whereas the incidence of ankle fusion per capita decreased 18%. In 2008, Gautier reported Level 5 evidence on total ankle arthroplasty in regards to coronal plane deformity. He suggested an arbitrary limit of 15 degrees of deformity with a hard cutoff of 20 degrees. However, in 2009, Valderrabano reported that only 37% of end-stage ankle arthritis cases have neutral alignment, with a good proportion having deformity at or beyond these limits proposed by Gautier. Cody et al. reported last year on 532 ankle arthroplasties with at least five years of follow-up. They concluded that preoperative deformity of greater than 20 degrees did not portend an increased risk of failure at five years. The implant used in our study is a third-generation, two-part, fixed-bearing total ankle arthroplasty. A modular intramedullary stem on the tibial component allows for increased on-growth surface area. The flat-cut tailored component features an exaggerated central sulcus dorsal that conforms with a polyethylene component that engages into the tibial component. This exaggerated and conforming interface offers increased coronal plane constraint, which may confer a tolerance for larger preoperative deformity. Patients undergoing a primary total ankle arthroplasty at a single institution by one of four fellowship-trained orthopedic foot and ankle surgeons with the study implant that were at least five years post-operative follow-up were reviewed from a prospectively collected database. 126 total ankle arthroplasties with this implant were performed in 124 patients between 2010 and 2013. 75 met inclusion criteria for our study. The mean duration of follow-up for living patients that retained both initial tibial and tailored components at final follow-up was 6.2 years. The primary outcome is implant survival, defined as retention of both initial tibial and tailored components at final follow-up. Secondary outcomes included coronal plane radiographic alignment and failure mode when applicable. All reoperation events were recorded using the Canadian Orthopedic Foot and Ankle Society reoperations coding system. There were six implant failures that occurred at a mean two years post-op. Estimated five-year survival is 92%. In 2010, the Canadian Orthopedic Foot and Ankle Society published a classification system for end-stage ankle arthritis. This consists of types one through four with generally increasing complexity. Type one involves isolated ankle arthritis. Type two has an associated intra-articular deformity. Type three is with an associated extra-articular deformity or foot malalignment, and type fours have associated arthritis in the subtalar, talomavicular, or calcaneocuboid joint. This table demonstrates the distribution of our patients among the four types. Important points to take away from this table are 84% of our patients were at type three or type four, signifying a generally complex patient population. Also, all six failures occurred in class four patients, which correlates to an 85% survival in COFAS type four patients alone. Coronoplane alignment was measured as the angle between the long axis of the tibia and the talar dome on weight-bearing preoperative radiographs. 36% of ankles in our cohort had a preoperative coronoplane deformity of at least 10 degrees, and 12% had deformity of at least 20 degrees. All six failures occurred in patients with neutral preoperative coronoplane alignment, and none of the failures were attributed to coronoplane instability. Coronoplane alignment was corrected and maintained in all patients at final follow-up. Two failures were due to deep infection. Both of these patients had delayed wound healing following the index surgery and eventually were managed with X-plant and cement spacer. One failure was in a patient with persistent post-op pain and aortic symptoms that chose to undergo elective bologna amputation at eight months post-op. Only one failure was related to tibia, excuse me, only one failure was related to tibia and this was in a patient that had undergone a subtalar fusion at the time of total ankle replacement. One failure was due to persistent post-op gutter impingement, and this patient underwent a gutter debridement and talar component revision at just over one and a half years post-op and did much better following this. The final failure was in an unfortunate patient who presented to her first post-op appointment with a dysvascular limb, and this was managed with a bologna amputation. In order to improve uniformity and comparability of total ankle arthroplasty outcome studies, the Canadian Orthopedic Foot and Ankle Society Ankle Arthritis Study Group recently published a coding system for adverse events and complications recurring re-operation following total ankle arthroplasty. This table displays the coding system and it's a busy slide, however, the important concepts to take away are that there are 11 codes with increasing code value correlating to an increasing severity of the re-operation event. This shows the percentage of patients in our study with some of the various CROCS codes with the percentage reported in the CROCS study in parentheses for comparison. As you can see, we compared quite favorably in all categories. The main one I would direct your attention to is at the top. Eighty-one percent of our patients were category one, meaning they required no re-operations throughout our follow-up period. In conclusion, we reviewed a consecutive series of patients with at least five years of follow-up after primary total ankle arthroplasty with a single implant at a single institution. We demonstrated an acceptable failure rate with only one true implant failure, a comparable re-operation rate, and tolerance of increased preoperative coronal plane deformity. Thank you.

five-year follow-up evaluation

third-generation fixed-bearing total ankle arthroplasty

ankle fusion

total ankle replacement

implant survival