- Email: [email protected]
Post-Traumatic Periprosthetic Tibial and Fibular Fracture After Total Ankle Arthroplasty: A Case Report
The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Post-Traumatic Periprosthetic Tibial and Fibular Fracture After Total Ankle Arthroplasty: A Case Report Amanda K. Brock, BS 1, Eric W. Tan, MD 2, Babar Shafiq, MD 3 1
Medical Student, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD Orthopedic Surgeon, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD 3 Assistant Professor, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Periprosthetic fractures after total ankle arthroplasty are uncommon, with most cases occurring intraoperatively. We describe a post-traumatic periprosthetic fracture of the distal tibia and fibula after total ankle arthroplasty that was treated with minimally invasive plate osteosynthesis. It is important for orthopedic surgeons not only to recognize the risk factors for postoperative periprosthetic total ankle arthroplasty fractures, but also to be familiar with the treatment options available to maximize function and minimize complications. The design of the tibial prosthesis and surgical techniques required to prepare the ankle joint for implantation are important areas of future research to limit the risk of periprosthetic fractures. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: minimally invasive plate osteosynthesis periprosthetic fracture prosthetic design total ankle arthroplasty trauma
The prevalence of osteoarthritis in older adults has been reported to range from 5% to 18% (1). Arthrodesis has been the traditional approach to treating end-stage arthritisdproviding symptomatic relief by eliminating joint motion. In recent years, the evolution of prosthetic designs and surgical techniques has made total ankle arthroplasty a viable alternative to arthrodesis. Compared with ankle arthrodesis, total ankle arthroplasty has been associated with similar patient satisfaction, quality of life, and functional outcomes (2,3) and is the only motion-preserving surgical option for the treatment of end-stage ankle osteoarthritis. Despite the encouraging clinical results, the reported complication rates with total ankle arthroplasty have ranged from 1.3% to 54% (mean 12.4%) (4,5). Most complications have been related to subsidence, aseptic loosening, periprosthetic fractures, and/or wound healing. Most periprosthetic total ankle arthroplasty fractures occur intraoperatively, with a reported prevalence of 20% (6–8). With increasing surgeon experience and improvements in prosthetic design and instrumentation, the rate of intraoperative fractures appears to be declining (9). However, the incidence of postoperative periprosthetic total ankle arthroplasty fractures, although rare, seems to be increasing, with 9 reported cases to date (6,10–13). To the best of our knowledge, we present the first report of postoperative traumatic periprosthetic
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Babar Shafiq, MD, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21205. E-mail address: [email protected] (B. Shafiq).
fractures of the tibia and fibula after total ankle arthroplasty using the Salto-TalarisÒ total ankle prosthesis (Tornier, Bloomington, MN). Case Report The patient was informed that the case would be submitted for publication and provided consent. A 72-year-old male with a history of right ankle osteoarthritis presented to the emergency department with right leg pain of 10 weeks’ duration after undergoing total ankle arthroplasty using the Salto-TalarisÒ total ankle prosthesis (Tornier). Two hours earlier, the patient had sustained a mechanical fall while walking out of a sauna. The patient experienced immediate pain, swelling, and deformity and was unable to bear weight on the right leg. In the emergency department, radiographs were taken, which showed a short, oblique midshaft tibial fracture with a nondisplaced spiral extension to the metaphysis just above the tibial component of the total ankle arthroplasty (Fig. 1). In addition, a spiral fibular fracture was present at the level of the distal metaphysis just above the tibial plafond. No gross loosening or displacement of the prosthesis was seen. A computed tomography scan was obtained to further characterize the fractures and determine whether the prosthesis was involved. The fracture line clearly ended proximal to the tibial prosthesis (Fig. 2). To restore the length, alignment, and rotation of the leg and to preserve the well-fixed arthroplasty implants, we performed minimally invasive plate osteosynthesis of the tibia and open reduction and internal fixation of the fibula. With the patient in a supine position, we treated the midshaft tibial fracture first using a minimally invasive technique. The tibial
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.01.045
2
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Fig. 1. Radiographs of the injury. (A) Anteroposterior and (B) lateral radiographs of the tibia and (C) anteroposterior, (D) oblique, and (E) lateral radiographs of the ankle showing the traumatic periprosthetic fracture.
fracture was anatomically reduced using reduction clamps placed percutaneously through stab incisions near the short, oblique fracture. Next, a lag screw was placed perpendicularly to this major fracture line, and a second lag screw was placed across the nondisplaced spiral fracture in the distal diaphysis. Next, a 4.5/3.5-mm metaphyseal locking compression plate (Synthes, Paoli, PA) was prebent, contoured to the bone, and placed subcutaneously (and extraperiosteally) on the medial border of the tibia through a 2-cm €r distal window as described by the standard Arbeitsgemeinschaft fu Osteosynthesefragen (AO) technique. The plate extended well beyond the fracture proximally to provide balanced fixation and reduce strain. Placement of the plate and the overall alignment of the tibia were confirmed using fluoroscopy. Screws were placed percutaneously through stab incisions. The plate was first secured with conventional cortical screws to reduce the plate to the bone. Next, 3.5-mm locking screws were used in the metadiaphysis, maximizing the screw purchase in this area of osteopenic bone. Finally, 4.5-mm cortical screws were used in the diaphysis to complete the construct. The fibular fracture was exposed, reduced, and stabilized with the standard AO technique using a lag screw and a 3.5-mm distal fibula locking compression plate applied in neutralization mode. After surgery, the leg was placed in a short-leg plaster splint to protect the soft tissues and incisions. The patient was instructed to take calcium carbonate (500 mg 3 times daily) and vitamin D3 (1000 IU 2 times daily) supplementation in accordance with our fracture protocol. The patient’s hospital course was unremarkable. Two weeks after surgery, the wounds were healing well, and the sutures were removed. The patient was placed in a controlled ankle motion walker boot and instructed to remain non-weightbearing on the operative leg and to perform ankle dorsiflexion and plantarflexion (“ankle pumps”) and “alphabet” exercises 5 times daily (not wearing the controlled ankle motion boot) to prevent ankle stiffness. At 7 weeks after surgery, radiographs showed intact hardware and alignment with interval callus formation. All wounds had healed, and graduated weightbearing (50% partial weightbearing for 1 week, 75% for 1 week, and then as tolerated) was initiated (Fig. 3). At 6 months, the fracture had healed, with robust, mature callus and bridging trabecular bone. The patient was pain free and had returned to all activities. At 34 months after surgery, the patient was doing well, with a well-balanced, reciprocal gait
without asymmetry. He had a range of motion of the ankle of 10 of dorsiflexion and 30 plantarflexion, with 5 of inversion and eversion. The proximal screw head of the tibial fracture fixation hardware was palpable but asymptomatic. Radiographs showed healed tibial and fibular fractures with a stable total ankle arthroplasty (Fig. 4). Discussion Increasing functional demands and life expectancy, along with improvements in prosthesis design and instrumentation, have made total ankle arthroplasty an alternative to arthrodesis for patients with end-stage arthritis. Total ankle arthroplasty provides symptomatic relief of arthritic pain while preserving motion. However, arthrodesis and total ankle arthroplasty have been associated with similarly high complication rates (5,14). Periprosthetic total ankle arthroplasty fractures in the postoperative period are rare, with a prevalence of 4% to 5% (6,10). As the survival rates and total ankle arthroplasty outcomes continue to improve, the rates of periprosthetic fractures will likely increase. Manegold et al (6) reviewed 503 total ankle arthroplasties and identified 21 periprosthetic fractures. Of the 21 fractures, 11 occurred intraoperatively and 10 postoperatively. In the postoperative group, 8 were stress fractures in the medial malleolus, and 2 occurred within the tibia and had resulted from a distinct traumatic event. The specific type of implant involved in the posttraumatic cases was not reported. Only 7 additional cases of post-traumatic periprosthetic total ankle arthroplasty fracture have been reported in published studies. Haendlmayer et al (11) reported a traumatic periprosthetic fracture of the distal tibia after a direct blow to the right ankle during an assault. The type of implant was not described but appeared to be an Ankle Evolutive System (Biomet, Nimes, France). The fracture involved the proximal stem of the tibial implant and was treated with an anterolateral distal tibial locking plate. Yang et al (13) described a periprosthetic fracture after a mechanical fall involving the tibial component of the Mobility prosthesis (DePuy Orthopaedics, Warsaw, IN). Minimally invasive plate osteosynthesis was used to avoid the complications associated with open reduction, including wound infection, vascular disruption, delayed union, and nonunion (15). In both of these cases, total ankle arthroplasty had been performed for a
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
3
Fig. 3. Well-healed skin incisions 6 months after surgery.
Fig. 2. (A to C) Sequential axial computed tomography images showing the top of the tibial total ankle prosthesis without any fractures in the tibia.
diagnosis of primary osteoarthritis, with the fracture occurring after a specific traumatic episode. In addition, periprosthetic total ankle arthroplasty fractures have been reported in patients with inflammatory ankle arthritis. Doets et al (10) reported the outcomes of 93 total ankle arthroplasty procedures performed for inflammatory joint disease. Four patients had experienced “spontaneous postoperative fracture of the distal aspect of the tibia” (10). In each patient, a Buechel-Pappas prosthesis (Endotec, South Orange, NJ) was used, and severe osteopenia was noted at implantation. All patients were treated with cast immobilization and healed uneventfully. In an analysis of 93 total ankle arthroplasty cases using the Ankle Evolutive System prosthesis, 1 patient with rheumatoid arthritis sustained a distal tibial fracture involving the medial malleolus 4 years after surgery (12). Information on the mechanism of injury was not provided, but the patient required extraction of the prosthesis and subsequent arthrodesis. The risk of periprosthetic fractures in patients with inflammatory arthropathy is likely the result of osteopenic bone and chronic corticosteroid use (10).
Post-traumatic periprosthetic fractures of the ankle result not only from the same forces that cause fractures in bones without implants, but also from factors specifically related to the placement or presence of the implant. Up to 90% of periprosthetic fractures occur through a previously made drill hole (16). A drill hole of 20% of the diameter of the bone can weaken the bone by 40%. The prosthesis used in our case, as well as those used in the other reported cases, features a specialized tibial preparation that allows for placement of the implant. Each system requires cuts and drill holes into the tibia that result in iatrogenic weakening of the bone, which could potentially increase the risk of periprosthetic fracture (17,18). Implantation of the Salto-TalarisÒ prosthesis requires placement of pins into the distal tibia to secure the cutting jig. After surgery, these drill holes could represent a stress riser, allowing for the initiation or propagation of a periprosthetic fracture, as shown in the present case (Fig. 5). Similar findings have been described after unicondylar and total knee arthroplasty and after ligament reconstruction of the knee (19–21). Plate fixation remains the predominant method of repairing periprosthetic fractures around a stable prosthesis. However, plating of the distal tibia after trauma has historically been fraught with wound complications (22). In the present case, minimally invasive plate osteosynthesis with a locking plate helped avoid soft tissue complications and provided rigid fixation in the osteopenic bone. In addition, by restoring the length, alignment, and rotation of the tibia and fibula, we were able to maintain appropriate joint biomechanics (23). This is especially important, because failure to do so can result in a greater risk of revisions secondary to loosening or abnormal wear of the implants. In conclusion, to the best of our knowledge, we have reported the first case of periprosthetic fractures of both the tibia and the fibula
4
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Fig. 4. (A) Anteroposterior and (B) lateral radiographs of the tibia and (C) anteroposterior and (D) lateral radiographs of the ankle showing healing callus at the tibial shaft and good alignment of the tibia and fibula 34 months after surgery. No evidence of hardware failure, lucency, or subsidence of the total ankle prosthesis was seen.
after total ankle arthroplasty. As the use of total ankle arthroplasty becomes more widespread, it is likely the incidence of periprosthetic fractures will increase. The risk of fracture is in part caused by the design of the tibial prosthesis and the surgical techniques required for implementation. The designers of new prostheses should be cognizant of how each of the joint implantation steps can contribute to the future risk of fracture and complications. However, biomechanical
Fig. 5. Anteroposterior radiograph at the time of injury showing a fracture line through a drill hole made at the time of the initial total ankle arthroplasty.
and long-term clinical studies are needed to further elucidate the most effective method to minimize the risk of periprosthetic fractures.
References 1. Muehleman C, Bareither D, Huch K, Cole AA, Kuettner KE. Prevalence of degenerative morphological changes in the joints of the lower extremity. Osteoarthritis Cartilage 5:23–37, 1997. 2. Daniels TR, Younger ASE, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am 96:135–142, 2014. 3. Zaidi R, Cro S, Gurusamy K, Siva N, Macgregor A, Henricson A, Goldberg A. The outcome of total ankle replacement: a systematic review and meta-analysis. Bone Joint J 95:1500–1507, 2013. 4. Glazebrook MA, Arsenault K, Dunbar M. Evidence-based classification of complications in total ankle arthroplasty. Foot Ankle Int 30:945–949, 2009. 5. Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger AS. Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement. J Bone Joint Surg Am 93:830–839, 2011. 6. Manegold S, Haas NP, Tsitsilonis S, Springer A, Mardian S, Schaser KD. Periprosthetic fractures in total ankle replacement: classification system and treatment algorithm. J Bone Joint Surg Am 95:815–820, 2013. 7. McGarvey WC, Clanton TO, Lunz D. Malleolar fracture after total ankle arthroplasty: a comparison of two designs. Clin Orthop 424:104–110, 2004. 8. Myerson MS, Mroczek K. Perioperative complications of total ankle arthroplasty. Foot Ankle Int 24:17–21, 2003. 9. Lee KT, Lee YK, Young KW, Kim JB, Seo YS. Perioperative complications and learning curve of the Mobility Total Ankle System. Foot Ankle Int 34:210–214, 2013. 10. Doets HC, Brand R, Nelissen RG. Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. J Bone Joint Surg Am 88:1272– 1284, 2006. 11. Haendlmayer KT, Fazly FM, Harris NJ. Periprosthetic fracture after total ankle replacement: surgical technique. Foot Ankle Int 30:1233–1234, 2009. 12. Henricson A, Knutson K, Lindahl J, Rydholm U. The AES total ankle replacement: a mid-term analysis of 93 cases. Foot Ankle Surg 16:61–64, 2010. 13. Yang JH, Kim HJ, Yoon JR, Yoon YC. Minimally invasive plate osteosynthesis (MIPO) for periprosthetic fracture after total ankle arthroplasty: a case report. Foot Ankle Int 32:200–204, 2011. 14. SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am 89:2143–2149, 2007. 15. Hasenboehler E, Rikli D, Babst R. Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients. Injury 38:365–370, 2007.
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5 16. Koval KJ, Frankel VH, Kummer F, Green S. Complications of fracture fixation devices. In: Complications in Orthopaedic Surgery, pp. 131–154, edited by CH Epps Jr, JB Lippincott, Philadelphia, 1994. 17. Brooks DB, Burstein AH, Frankel VH. The biomechanics of torsional fractures: the stress concentration effect of a drill hole. J Bone Joint Surg Am 52:507–514, 1970. 18. Johnson BA, Fallat LM. The effect of screw holes on bone strength. J Foot Ankle Surg 36:446–451, 1997. 19. Brumby SA, Carrington R, Zayontz S, Reish T, Scott RD. Tibial plateau stress fracture: a complication of unicompartmental knee arthroplasty using 4 guide pinholes. J Arthroplasty 18:809–812, 2003.
5
20. Radler C, Wozasek GE, Seitz H, Vecsei V. Distal femoral fracture through the screw hole of a ligament augmentation device fixation. Arthroscopy 16:737– 739, 2000. 21. Wilson TC, Rosenblum WJ, Johnson DL. Fracture of the femoral tunnel after an anterior cruciate ligament reconstruction. Arthroscopy 20:e45–e47, 2004. 22. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma 6:195–200, 1992. 23. Figgie MP, Goldberg VM, Figgie HE III, Sobel M. The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 5:267–276, 1990.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Post-Traumatic Periprosthetic Tibial and Fibular Fracture After Total Ankle Arthroplasty: A Case Report Amanda K. Brock, BS 1, Eric W. Tan, MD 2, Babar Shafiq, MD 3 1
Medical Student, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD Orthopedic Surgeon, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD 3 Assistant Professor, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Periprosthetic fractures after total ankle arthroplasty are uncommon, with most cases occurring intraoperatively. We describe a post-traumatic periprosthetic fracture of the distal tibia and fibula after total ankle arthroplasty that was treated with minimally invasive plate osteosynthesis. It is important for orthopedic surgeons not only to recognize the risk factors for postoperative periprosthetic total ankle arthroplasty fractures, but also to be familiar with the treatment options available to maximize function and minimize complications. The design of the tibial prosthesis and surgical techniques required to prepare the ankle joint for implantation are important areas of future research to limit the risk of periprosthetic fractures. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: minimally invasive plate osteosynthesis periprosthetic fracture prosthetic design total ankle arthroplasty trauma
The prevalence of osteoarthritis in older adults has been reported to range from 5% to 18% (1). Arthrodesis has been the traditional approach to treating end-stage arthritisdproviding symptomatic relief by eliminating joint motion. In recent years, the evolution of prosthetic designs and surgical techniques has made total ankle arthroplasty a viable alternative to arthrodesis. Compared with ankle arthrodesis, total ankle arthroplasty has been associated with similar patient satisfaction, quality of life, and functional outcomes (2,3) and is the only motion-preserving surgical option for the treatment of end-stage ankle osteoarthritis. Despite the encouraging clinical results, the reported complication rates with total ankle arthroplasty have ranged from 1.3% to 54% (mean 12.4%) (4,5). Most complications have been related to subsidence, aseptic loosening, periprosthetic fractures, and/or wound healing. Most periprosthetic total ankle arthroplasty fractures occur intraoperatively, with a reported prevalence of 20% (6–8). With increasing surgeon experience and improvements in prosthetic design and instrumentation, the rate of intraoperative fractures appears to be declining (9). However, the incidence of postoperative periprosthetic total ankle arthroplasty fractures, although rare, seems to be increasing, with 9 reported cases to date (6,10–13). To the best of our knowledge, we present the first report of postoperative traumatic periprosthetic
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Babar Shafiq, MD, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21205. E-mail address: [email protected] (B. Shafiq).
fractures of the tibia and fibula after total ankle arthroplasty using the Salto-TalarisÒ total ankle prosthesis (Tornier, Bloomington, MN). Case Report The patient was informed that the case would be submitted for publication and provided consent. A 72-year-old male with a history of right ankle osteoarthritis presented to the emergency department with right leg pain of 10 weeks’ duration after undergoing total ankle arthroplasty using the Salto-TalarisÒ total ankle prosthesis (Tornier). Two hours earlier, the patient had sustained a mechanical fall while walking out of a sauna. The patient experienced immediate pain, swelling, and deformity and was unable to bear weight on the right leg. In the emergency department, radiographs were taken, which showed a short, oblique midshaft tibial fracture with a nondisplaced spiral extension to the metaphysis just above the tibial component of the total ankle arthroplasty (Fig. 1). In addition, a spiral fibular fracture was present at the level of the distal metaphysis just above the tibial plafond. No gross loosening or displacement of the prosthesis was seen. A computed tomography scan was obtained to further characterize the fractures and determine whether the prosthesis was involved. The fracture line clearly ended proximal to the tibial prosthesis (Fig. 2). To restore the length, alignment, and rotation of the leg and to preserve the well-fixed arthroplasty implants, we performed minimally invasive plate osteosynthesis of the tibia and open reduction and internal fixation of the fibula. With the patient in a supine position, we treated the midshaft tibial fracture first using a minimally invasive technique. The tibial
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.01.045
2
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Fig. 1. Radiographs of the injury. (A) Anteroposterior and (B) lateral radiographs of the tibia and (C) anteroposterior, (D) oblique, and (E) lateral radiographs of the ankle showing the traumatic periprosthetic fracture.
fracture was anatomically reduced using reduction clamps placed percutaneously through stab incisions near the short, oblique fracture. Next, a lag screw was placed perpendicularly to this major fracture line, and a second lag screw was placed across the nondisplaced spiral fracture in the distal diaphysis. Next, a 4.5/3.5-mm metaphyseal locking compression plate (Synthes, Paoli, PA) was prebent, contoured to the bone, and placed subcutaneously (and extraperiosteally) on the medial border of the tibia through a 2-cm €r distal window as described by the standard Arbeitsgemeinschaft fu Osteosynthesefragen (AO) technique. The plate extended well beyond the fracture proximally to provide balanced fixation and reduce strain. Placement of the plate and the overall alignment of the tibia were confirmed using fluoroscopy. Screws were placed percutaneously through stab incisions. The plate was first secured with conventional cortical screws to reduce the plate to the bone. Next, 3.5-mm locking screws were used in the metadiaphysis, maximizing the screw purchase in this area of osteopenic bone. Finally, 4.5-mm cortical screws were used in the diaphysis to complete the construct. The fibular fracture was exposed, reduced, and stabilized with the standard AO technique using a lag screw and a 3.5-mm distal fibula locking compression plate applied in neutralization mode. After surgery, the leg was placed in a short-leg plaster splint to protect the soft tissues and incisions. The patient was instructed to take calcium carbonate (500 mg 3 times daily) and vitamin D3 (1000 IU 2 times daily) supplementation in accordance with our fracture protocol. The patient’s hospital course was unremarkable. Two weeks after surgery, the wounds were healing well, and the sutures were removed. The patient was placed in a controlled ankle motion walker boot and instructed to remain non-weightbearing on the operative leg and to perform ankle dorsiflexion and plantarflexion (“ankle pumps”) and “alphabet” exercises 5 times daily (not wearing the controlled ankle motion boot) to prevent ankle stiffness. At 7 weeks after surgery, radiographs showed intact hardware and alignment with interval callus formation. All wounds had healed, and graduated weightbearing (50% partial weightbearing for 1 week, 75% for 1 week, and then as tolerated) was initiated (Fig. 3). At 6 months, the fracture had healed, with robust, mature callus and bridging trabecular bone. The patient was pain free and had returned to all activities. At 34 months after surgery, the patient was doing well, with a well-balanced, reciprocal gait
without asymmetry. He had a range of motion of the ankle of 10 of dorsiflexion and 30 plantarflexion, with 5 of inversion and eversion. The proximal screw head of the tibial fracture fixation hardware was palpable but asymptomatic. Radiographs showed healed tibial and fibular fractures with a stable total ankle arthroplasty (Fig. 4). Discussion Increasing functional demands and life expectancy, along with improvements in prosthesis design and instrumentation, have made total ankle arthroplasty an alternative to arthrodesis for patients with end-stage arthritis. Total ankle arthroplasty provides symptomatic relief of arthritic pain while preserving motion. However, arthrodesis and total ankle arthroplasty have been associated with similarly high complication rates (5,14). Periprosthetic total ankle arthroplasty fractures in the postoperative period are rare, with a prevalence of 4% to 5% (6,10). As the survival rates and total ankle arthroplasty outcomes continue to improve, the rates of periprosthetic fractures will likely increase. Manegold et al (6) reviewed 503 total ankle arthroplasties and identified 21 periprosthetic fractures. Of the 21 fractures, 11 occurred intraoperatively and 10 postoperatively. In the postoperative group, 8 were stress fractures in the medial malleolus, and 2 occurred within the tibia and had resulted from a distinct traumatic event. The specific type of implant involved in the posttraumatic cases was not reported. Only 7 additional cases of post-traumatic periprosthetic total ankle arthroplasty fracture have been reported in published studies. Haendlmayer et al (11) reported a traumatic periprosthetic fracture of the distal tibia after a direct blow to the right ankle during an assault. The type of implant was not described but appeared to be an Ankle Evolutive System (Biomet, Nimes, France). The fracture involved the proximal stem of the tibial implant and was treated with an anterolateral distal tibial locking plate. Yang et al (13) described a periprosthetic fracture after a mechanical fall involving the tibial component of the Mobility prosthesis (DePuy Orthopaedics, Warsaw, IN). Minimally invasive plate osteosynthesis was used to avoid the complications associated with open reduction, including wound infection, vascular disruption, delayed union, and nonunion (15). In both of these cases, total ankle arthroplasty had been performed for a
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
3
Fig. 3. Well-healed skin incisions 6 months after surgery.
Fig. 2. (A to C) Sequential axial computed tomography images showing the top of the tibial total ankle prosthesis without any fractures in the tibia.
diagnosis of primary osteoarthritis, with the fracture occurring after a specific traumatic episode. In addition, periprosthetic total ankle arthroplasty fractures have been reported in patients with inflammatory ankle arthritis. Doets et al (10) reported the outcomes of 93 total ankle arthroplasty procedures performed for inflammatory joint disease. Four patients had experienced “spontaneous postoperative fracture of the distal aspect of the tibia” (10). In each patient, a Buechel-Pappas prosthesis (Endotec, South Orange, NJ) was used, and severe osteopenia was noted at implantation. All patients were treated with cast immobilization and healed uneventfully. In an analysis of 93 total ankle arthroplasty cases using the Ankle Evolutive System prosthesis, 1 patient with rheumatoid arthritis sustained a distal tibial fracture involving the medial malleolus 4 years after surgery (12). Information on the mechanism of injury was not provided, but the patient required extraction of the prosthesis and subsequent arthrodesis. The risk of periprosthetic fractures in patients with inflammatory arthropathy is likely the result of osteopenic bone and chronic corticosteroid use (10).
Post-traumatic periprosthetic fractures of the ankle result not only from the same forces that cause fractures in bones without implants, but also from factors specifically related to the placement or presence of the implant. Up to 90% of periprosthetic fractures occur through a previously made drill hole (16). A drill hole of 20% of the diameter of the bone can weaken the bone by 40%. The prosthesis used in our case, as well as those used in the other reported cases, features a specialized tibial preparation that allows for placement of the implant. Each system requires cuts and drill holes into the tibia that result in iatrogenic weakening of the bone, which could potentially increase the risk of periprosthetic fracture (17,18). Implantation of the Salto-TalarisÒ prosthesis requires placement of pins into the distal tibia to secure the cutting jig. After surgery, these drill holes could represent a stress riser, allowing for the initiation or propagation of a periprosthetic fracture, as shown in the present case (Fig. 5). Similar findings have been described after unicondylar and total knee arthroplasty and after ligament reconstruction of the knee (19–21). Plate fixation remains the predominant method of repairing periprosthetic fractures around a stable prosthesis. However, plating of the distal tibia after trauma has historically been fraught with wound complications (22). In the present case, minimally invasive plate osteosynthesis with a locking plate helped avoid soft tissue complications and provided rigid fixation in the osteopenic bone. In addition, by restoring the length, alignment, and rotation of the tibia and fibula, we were able to maintain appropriate joint biomechanics (23). This is especially important, because failure to do so can result in a greater risk of revisions secondary to loosening or abnormal wear of the implants. In conclusion, to the best of our knowledge, we have reported the first case of periprosthetic fractures of both the tibia and the fibula
4
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Fig. 4. (A) Anteroposterior and (B) lateral radiographs of the tibia and (C) anteroposterior and (D) lateral radiographs of the ankle showing healing callus at the tibial shaft and good alignment of the tibia and fibula 34 months after surgery. No evidence of hardware failure, lucency, or subsidence of the total ankle prosthesis was seen.
after total ankle arthroplasty. As the use of total ankle arthroplasty becomes more widespread, it is likely the incidence of periprosthetic fractures will increase. The risk of fracture is in part caused by the design of the tibial prosthesis and the surgical techniques required for implementation. The designers of new prostheses should be cognizant of how each of the joint implantation steps can contribute to the future risk of fracture and complications. However, biomechanical
Fig. 5. Anteroposterior radiograph at the time of injury showing a fracture line through a drill hole made at the time of the initial total ankle arthroplasty.
and long-term clinical studies are needed to further elucidate the most effective method to minimize the risk of periprosthetic fractures.
References 1. Muehleman C, Bareither D, Huch K, Cole AA, Kuettner KE. Prevalence of degenerative morphological changes in the joints of the lower extremity. Osteoarthritis Cartilage 5:23–37, 1997. 2. Daniels TR, Younger ASE, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am 96:135–142, 2014. 3. Zaidi R, Cro S, Gurusamy K, Siva N, Macgregor A, Henricson A, Goldberg A. The outcome of total ankle replacement: a systematic review and meta-analysis. Bone Joint J 95:1500–1507, 2013. 4. Glazebrook MA, Arsenault K, Dunbar M. Evidence-based classification of complications in total ankle arthroplasty. Foot Ankle Int 30:945–949, 2009. 5. Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger AS. Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement. J Bone Joint Surg Am 93:830–839, 2011. 6. Manegold S, Haas NP, Tsitsilonis S, Springer A, Mardian S, Schaser KD. Periprosthetic fractures in total ankle replacement: classification system and treatment algorithm. J Bone Joint Surg Am 95:815–820, 2013. 7. McGarvey WC, Clanton TO, Lunz D. Malleolar fracture after total ankle arthroplasty: a comparison of two designs. Clin Orthop 424:104–110, 2004. 8. Myerson MS, Mroczek K. Perioperative complications of total ankle arthroplasty. Foot Ankle Int 24:17–21, 2003. 9. Lee KT, Lee YK, Young KW, Kim JB, Seo YS. Perioperative complications and learning curve of the Mobility Total Ankle System. Foot Ankle Int 34:210–214, 2013. 10. Doets HC, Brand R, Nelissen RG. Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. J Bone Joint Surg Am 88:1272– 1284, 2006. 11. Haendlmayer KT, Fazly FM, Harris NJ. Periprosthetic fracture after total ankle replacement: surgical technique. Foot Ankle Int 30:1233–1234, 2009. 12. Henricson A, Knutson K, Lindahl J, Rydholm U. The AES total ankle replacement: a mid-term analysis of 93 cases. Foot Ankle Surg 16:61–64, 2010. 13. Yang JH, Kim HJ, Yoon JR, Yoon YC. Minimally invasive plate osteosynthesis (MIPO) for periprosthetic fracture after total ankle arthroplasty: a case report. Foot Ankle Int 32:200–204, 2011. 14. SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am 89:2143–2149, 2007. 15. Hasenboehler E, Rikli D, Babst R. Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients. Injury 38:365–370, 2007.
A.K. Brock et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5 16. Koval KJ, Frankel VH, Kummer F, Green S. Complications of fracture fixation devices. In: Complications in Orthopaedic Surgery, pp. 131–154, edited by CH Epps Jr, JB Lippincott, Philadelphia, 1994. 17. Brooks DB, Burstein AH, Frankel VH. The biomechanics of torsional fractures: the stress concentration effect of a drill hole. J Bone Joint Surg Am 52:507–514, 1970. 18. Johnson BA, Fallat LM. The effect of screw holes on bone strength. J Foot Ankle Surg 36:446–451, 1997. 19. Brumby SA, Carrington R, Zayontz S, Reish T, Scott RD. Tibial plateau stress fracture: a complication of unicompartmental knee arthroplasty using 4 guide pinholes. J Arthroplasty 18:809–812, 2003.
5
20. Radler C, Wozasek GE, Seitz H, Vecsei V. Distal femoral fracture through the screw hole of a ligament augmentation device fixation. Arthroscopy 16:737– 739, 2000. 21. Wilson TC, Rosenblum WJ, Johnson DL. Fracture of the femoral tunnel after an anterior cruciate ligament reconstruction. Arthroscopy 20:e45–e47, 2004. 22. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma 6:195–200, 1992. 23. Figgie MP, Goldberg VM, Figgie HE III, Sobel M. The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 5:267–276, 1990.