Heterotopic Ossification in Total Ankle Arthroplasty: Case Series and Systematic Review

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Abstract

Heterotopic ossification after total ankle arthroplasty (TAA) is a known sequela and has been reported to contribute to reduced range of motion and poor functional outcomes. However, conflicting results have been reported in the literature. The present study documents the incidence of heterotopic ossification for a novel fourth-generation fixed-bearing 2-component prosthesis and reports a systematic review of the literature. We reviewed the incidence and functional outcome of consecutively enrolled patients who underwent primary Infinity TAA between 2013 and 2015 in a prospective observational study. Preoperative and postoperative radiographic and functional outcome data were collected. A systematic review was also conducted investigating all published studies between 1998 and 2018 reporting the incidence of heterotopic ossification after TAA. The incidence of heterotopic ossification was 70.5% in the 61 patients who underwent primary TAA in the case series. There was no association between heterotopic ossification and American Orthopaedic Foot and Ankle Society (AOFAS) score, foot function index (FFI), visual analogue scale (VAS), and ankle osteoarthritis scale (AOS). Sixteen studies on 1339 TAA implants were included. The overall incidence of heterotopic ossification after TAA was 66.0% at average 3.6 years (range 22.2% to 100%). Four studies (299 ankles) did not address functional outcomes. Eleven studies (960 ankles) reported no association between heterotopic ossification and functional outcomes. One study (80 ankles) reported a statistically significant difference in range of motion (7°) and AOFAS score (7 points). In conclusion, although the incidence of heterotopic ossification after TAA is considerable, there is insufficient literature to suggest that heterotopic ossification after TAA impacts range of motion or functional outcome.

Section snippets

Case Series

All patients >18 years old undergoing primary TAA from 2013 to 2015 were included. All patients underwent TAA under regional and/or general anesthesia. All procedures were performed by 1 of 6 orthopaedic surgeons with subspecialty foot and ankle fellowship training at 1 of 2 institutions. Patients were excluded if no radiographic data were available beyond 3 months postoperatively. Given the poorly understood natural history of heterotopic bone formation that is not well defined, the 3-month

Case Series

The incidence of posterior heterotopic ossification was 70.5% in the 61 patients who underwent primary Infinity TAA at an average follow-up of 27.8 months. Six patients were excluded from analysis for <3 months of radiographic follow-up. The grade of heterotopic ossification ranged from 0 to 3, with no evidence of grade 4 heterotopic ossification after TAA. Grade 0, 1, 2, and 3 were observed in 18 (29.5%), 17 (27.9%), 10 (16.4%), and 16 (26.2%), respectively. The mean VAS, FFI, SF-36 PCS, AOS,

Discussion

The purpose of this study was to better understand the prevalence and assess any correlation between postoperative radiographic evidence of heterotopic ossification after TAA and possible impact on clinical outcomes. In the case series of 61 patients after TAA with a fourth-generation fixed TAA implant, the incidence of heterotopic ossification was 70.5%, with no associated functional outcome. These findings were further corroborated in the systematic review of 16 studies including 1339 cases

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    Financial Disclosure: None reported.

    Conflict of Interest: The following are co-inventors of the Infinity TAA system and additionally report consulting fees from Wright Medical: Murray Penner; W. Hodges Davis; and Robert Anderson. Kevin Wing is a consultant for Wright Medical.

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