As the orthopaedic community continues to solve complex issues related to joint replacement, it has become apparent that deformity correction and component positioning are keys to long-term success. In terms of hip, knee, and shoulder arthroplasty, we have progressed throughout the last 50 years with improved functional outcomes and component longevity. Elbow arthroplasty development has lagged somewhat because indications for that procedure are much less common.
Meanwhile, total ankle arthroplasty (TAA) experienced a short-lived decade of enthusiasm in the late 1970s and early 1980s before it became apparent that improved component designs and surgical techniques were needed. Progress with TAA stalled until the late 1990s, but TAA has now become more predictable, and several successful designs are available with reasonable revision rates demonstrated during 10-plus years of follow-up. As with all arthroplasties, component alignment in TAA is critical, and we have therefore assumed that significant preoperative frontal plane deformity is a contraindication for this procedure.
However, in the December 18, 2019 issue of The Journal, Lee et al. challenge that assumption with midterm follow-up data on 146 TAAs that suggest patients with frontal plane deformities >20° should not necessarily be disqualified from having this procedure. In this study, prior to surgery, 107 ankles had moderate frontal plane deformity (5° to <15° of varus or valgus) and 41 ankles had severe deformity (>20° to 35° of varus or valgus). The authors found no difference between these groups in terms of functional outcomes, complications, or implant survival at a mean follow-up of 6 years. Lee et al. conclude that frontal malalignment >20° in patients with end-stage ankle osteoarthritis may not be a contraindication to proceeding with TAA. However, the authors emphasize that concomitant realignment procedures at the time of index arthroplasty (including ligament releases and corrective osteotomies) were much more common in the severe group.
These findings need confirmation from other groups and with longer-term follow-up so that data from lower-volume surgeons can be analyzed and later complications can be investigated. Still, it just may be that ankle arthroplasty is not as finicky as we have been thinking.
Marc Swiontkowski, MD