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Total Ankle Arthroplasty With a Current Three-Component Design (HINTEGRA Prosthesis)


Indications

  • Primary osteoarthritis (e.g., degenerative disease)

  • Systemic arthritis (e.g., rheumatoid arthritis)

  • Posttraumatic osteoarthritis (if instability and malalignment are manageable)

  • Secondary osteoarthritis (e.g., infection, avascular necrosis; if at least two thirds of the talar surface is preserved)

  • Salvage for failed total ankle replacement or for nonunion and malunion of ankle fusion (if bone stock is sufficient)

  • Low demands for physical activities (e.g., hiking, swimming, biking, golfing)

  • Relative indications

    • Severe osteoporosis

    • Immunosuppressive therapy

    • Increased demands for physical activities (e.g., jogging, tennis, downhill skiing)

Indications Pitfalls

  • Infection

  • Avascular necrosis of more than one third of talus

  • Nonmanageable instability

  • Nonmanageable malalignment

  • Neuromuscular disorder

  • Neuroarthropathy (Charcot arthropathy)

  • Diabetic syndrome

  • Suspected or documented metal allergy or intolerance

  • Highest demands for physical activities (e.g., contact sports, jumping)

Indications Controversies

  • Diabetic syndrome without polyneuropathy

  • Avascular necrosis of talus

Treatment Options

  • Medication

  • Local therapy

  • Shoe modifications and orthoses

Examination/Imaging

  • While the patient is standing, perform a thorough clinical investigation of both lower extremities to assess

    • Alignment

    • Deformities

    • Foot position

    • Muscular atrophy

  • While the patient is sitting with free-hanging feet, perform an assessment of

    • Extent to which a present deformity is correctable

    • Preserved joint motion at the ankle and subtalar joints

    • Ligament stability of the ankle and subtalar joints with anterior drawer and tilt tests

    • Supination and eversion power (e.g., function of posterior tibial and peroneus brevis muscles)

  • Plain weight-bearing radiographs, including anteroposterior views of ankle ( Fig. 57.1A ) and foot ( Fig. 57.1B ), and lateral view of the foot ( Fig. 57.1C ), to determine/rule out

    • Extent of destruction of tibiotalar joint (e.g., tibia, talus, fibula)

    • Status of neighboring joints (e.g., associated degenerative disease)

    • Deformities of the foot and ankle complex (e.g., heel alignment, foot arch, talonavicular alignment)

    • Tibiotalar malalignment (e.g., varus, valgus, recurvatum, antecurvatum)

    • Bony condition (e.g., avascular necrosis, bony defects)

    FIG. 57.1

  • Computed tomography scan may be obtained for assessment of

    • Destruction of joint surfaces and incongruency

    • Bony defects

    • Avascular necrosis

  • Single-photon emission computed tomography with superimposed bone scan ( Fig. 57.2 ) may be used to visualize

    • Morphologic pathologies and associated activity process

    • Biologic bone pathologies and associated activity process

    FIG. 57.2

  • Magnetic resonance imaging may be used to identify

    • Injuries to ligament structures

    • Morphologic changes of tendons

    • Avascular necrosis of bones (e.g., talar body, tibial plafond)

Surgical Anatomy

  • The superior extensor retinaculum is a thickening of the deep fascia above the ankle, running from the tibia to the fibula ( Fig. 57.3 ). It includes, from medially to laterally, the tendons of the tibialis anterior, extensor hallucis longus, and extensor digitorum longus.

    FIG. 57.3

  • The anterior neurovascular bundle lies roughly halfway between the malleoli ( Fig. 57.4A ); it can be found consistently between the extensor hallucis longus and extensor digitorum longus tendons.

    FIG. 57.4

  • The neurovascular bundle contains the tibialis anterior and the deep peroneal nerve. The nerve supplies the extensor digitorum brevis and extensor hallucis brevis and a sensory space (interdigital I–II).

  • On the height of the talonavicular joint, the medial branches of the superficial peroneal nerve cross from lateral to medial ( Fig. 57.4B ). This nerve supplies the skin of the dorsum of the foot.

  • On the posterior aspect of the ankle, the medial neurovascular bundle is located behind its posteromedial corner, and the flexor hallucis longus tendon on its posterior aspect ( Fig. 57.4C ).

Positioning

  • The patient is positioned with the feet on the edge of the table.

  • The ipsilateral back is lifted until a strictly upward position of the foot is obtained.

  • The tourniquet is mounted at the ipsilateral thigh.

Positioning Pearls

  • The affected foot is supported with a block to facilitate fluoroscopy during surgery.

  • The contralateral nonaffected leg is also draped if there is significant deformity to be corrected.

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