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Abstract

Background:

Surgical management of failed ankle fusion is challenging. The objective of this study is to present the clinical and radiographic results of tibiotalar fusion takedown via a lateral approach with conversion to transfibular, trabecular metal (TM) total ankle arthroplasty (TAA).

Methods:

Sixteen patients underwent an ankle fusion takedown with conversion to transfibular TAA: 9 patients had prior tibiotalar fusions, and 7 had tibiotalocalcaneal fusion. Patient demographics, complication profiles, and radiographic parameters were collected. Pre- and postoperative patient-reported outcome measures (PROMs) were analyzed with 12-Item Short Form Health Survey (SF-12), visual analog scale (VAS), and the Ankle Osteoarthritis Scale (AOS). Radiographic outcomes included coronal and sagittal alignment, tibiotalar plantarflexion (PF) and dorsiflexion (DF) range of motion, and incidence of periprosthetic radiolucency and/or implant subsidence.

Results

Average age was 56.8 (range, 25-75) years with 4.7 (2-11) years’ follow-up. There was significant improvement in VAS, AOS pain and disability, and SF-12 physical and mental component summary scores (all P < .05). There was 1 (6.3%) case of implant revision for periprosthetic fracture about the tibial component. There were 8 (50%) reoperations at an average of 20.9 ± 10.8 months following fusion takedown, 4 (25%) cases of fibular hardware removal, and 4 (25%) cases of medial gutter debridement. Average radiographic DF and PF postoperatively was 12.5 ± 5.6 degrees and 13.5 ± 9.1 degrees. There was no presence of periprosthetic cysts at final follow-up.

Conclusion:

Ankle fusion takedown with conversion to a TM ankle through a transfibular approach yielded significant improvement in PROMs and radiographic ROM, with a modest complication rate at average 4.7 years’ follow-up. Although technically challenging, transfibular TAA following ankle fusion takedown is a reasonable treatment option for symptomatic tibiotalar or pantalar fusion.

Level of Evidence:

Level IV, case series.

Keywords

fusion takedown ankle fusion revision total ankle arthroplasty transfibular total ankle

Introduction

Ankle fusion is a conventional procedure. It is effective at relieving pain but comes with the drawback of reduced ankle range of motion. Because of mitigation of joint contact pressure, adjacent joint degeneration is common after ankle fusion.^1,2 Other complications include nonunion rates as high as 18%.³ The majority of ankle fusions with a delayed union (71%) are likely to fail in 5 years.⁴ Usual treatment options for failed ankle fusion include revision fusion and extension of fusion to adjacent joints, but 20% may still not heal and amputation may be needed for refractory cases.⁵ Additionally, there are patients who may undergo an initial successful fusion who may not be satisfied with functional outcomes. Therefore, there has been growing interest in the efficacy of ankle fusion takedown (TD) and conversion to total ankle arthroplasty (TAA). In addition to pain relief, TAA is an attractive option compared with arthrodesis as it allows for better preservation of tibiotalar range of motion (ROM) with improved gait. Although TAA after primary fusion has historically been approached with caution because of concerns about implant stability, functionality, and long-term outcomes, recent studies have shown promising results.^6
-10

Traditional anterior approach has been the standard for ankle replacement but has the risk of neurovascular compromise and wound healing issues. In complex individuals with previous fusions or traumatic injury, anterior skin compromise may preclude an anterior approach to treat failed ankle fusion. Transfibular TAA is believed to enhance visualization and facilitate soft tissue handling in complex cases given its unique approach. Although results are promising for takedown fusions using an anterior-based ankle system, there is a scarcity of literature looking at takedown fusions using a transfibular total ankle system.

The primary aim of this study was to assess implant survivorship and clinical and radiographic outcomes in patients who underwent conversion of prior ankle arthrodesis to transfibular TAA. We hypothesized that patients would have significant overall improvement in patient-reported outcomes and radiographic findings postoperatively.

Methods

Study Design and Patient Selection

This retrospective study was conducted using the senior author’s (L.C.S.) total ankle replacement database, a single-surgeon and co-designer series. Inclusion criteria consisted of patients 18 years or older undergoing conversion of ankle fusion to transfibular TAA using the Zimmer Trabecular Metal (Zimmer Biomet) prosthesis between 2013 and 2022. Indications for conversion to TAA included relief of pain and stiffness, with the goal of improving ankle range of motion and offloading stress on the adjacent, unfused hindfoot and/or midfoot joints. Institutional review board approval was obtained prior to data collection. This study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement on strengthening the reporting of observational studies.¹¹

Retrospective chart review of the electronic medical record identified patient demographics, comorbidities, perioperative data, and radiographic information (Table 1). Demographic variables included age at the time of the index procedure, sex, and body mass index. Comorbidity data collected included the American Society of Anesthesiologists (ASA) score, history of tobacco use, diabetes, and/or malignancy. Perioperative data encompassed the length of follow-up, laterality, underlying etiology of ankle arthritis (classified as posttraumatic, primary osteoarthritis, or inflammatory arthritis), and history of prior ankle and/or hindfoot surgeries.

Table 1.

Patient Demographics and Surgical History (N = 16).^a

Characteristic	Mean (Range) or n (%)
Follow-up, y	4.7 (2-11)
Age at surgery, y	56.8 (25-75)
Sex
Female	10 (62)
Male	6 (38)
Etiology
Posttraumatic arthritis	14 (88)
Primary osteoarthritis	1 (6)
Inflammatory arthritis	1 (6)
Laterality
Left	5 (31)
Right	11 (69)
BMI	30.6 (20-47)
Smoking status
Former	8 (50)
Never	5 (31)
Current	3 (19)
Diabetes	4 (25)
ASA score
1	1 (6)
2	8 (50)
3	7 (44)
Time to takedown, y	11.6 (1-36)

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index.

Values are reported as mean (range) or n (%).

The length of follow-up was defined as time from surgery to the latest postoperative visit where patient-reported outcome measures (PROMs) and weightbearing ankle radiographs were collected. Adverse events and reoperations were reported using the Canadian Orthopaedic Foot and Ankle Society (COFAS) Reoperation Coding System (CROCS).¹² Reoperation was defined as surgery performed on the ipsilateral ankle after the index surgery that did not require removal of the metal components. Revision was defined as removal of one or both of the metal components, conversion to arthrodesis, or amputation.

Patient-Reported Outcomes

PROMs included the 12-item Short Form Health Survey (SF-12) physical (PCS) and mental component summary (MCS) scores, Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) for pain. All PROMs included are validated measures that have been applied to numerous foot and ankle pathologies.^13
-15 The SF-12 and AOS are scored ranging from 0 to 100. VAS is scored from 0 to 10. A higher score indicates impairment for VAS and AOS, whereas a lower score indicates impairment for SF-12.

Radiographic Outcomes

Radiographic assessment included weightbearing anteroposterior (AP), mortise, and lateral view radiographs of the ankle obtained at latest follow-up. All radiographs were analyzed by a foot and ankle fellowship-trained fellow and an orthopaedic surgery resident, with final review by the senior author.

Postoperative tibiotalar plantarflexion and dorsiflexion range of motion (PF, DF) were measured by tibiopedal excursion on standing flexion-extension radiographs.^16,17 The AP radiograph was used to measure the tibial coronal alignment angle (alpha angle [α]), whereas the lateral radiograph was used to measure the tibial sagittal alignment angle (beta angle [β]) and talar sagittal alignment angle (gamma angle [γ]).^18
-21 Tibial and talar periprosthetic radiolucency was assessed on lateral weightbearing radiographs with the 12-zone classification scheme described by Barg et al.¹⁸ The zones were categorized as normal, lucency (<2-mm radiolucent line), cyst (>2mm radiolucency), or not accessible (ie, superimposed fibular hardware).

Surgical Technique

Patients were positioned supine with the operative extremity elevated. When possible, removal of prior ankle fusion hardware was performed through the same lateral transfibular approach. In patients with an anterior plate and screw construct, additional anterior exposure was performed through the previous surgical incision.

TAA was performed in all patients using the Zimmer Trabecular Metal Total Ankle through a transfibular approach based on the manufacturer’s technique guide (Figure 1).²² Fibular osteotomy was performed to provide exposure of the ankle joint. Once final components were implanted, the fibular osteotomy was reduced and fixed with a precontoured locking plate. Autogenous bone graft from the tibia or ipsilateral iliac crest was applied to the osteotomy site to promote healing. Additional procedures were concomitantly performed as needed to achieve appropriate alignment and stability (Table 2).

Figure 1.

Weightbearing plain films of a 69-year-old man who underwent fusion takedown to transfibular total ankle arthroplasty (TAA). Anteroposterior (AP) and lateral radiographs demonstrate his initial presentation with painful subtalar arthritis in the setting of previous tibiotalar arthrodesis (A and B). He underwent fusion takedown with conversion to transfibular TAA and subtalar fusion (C and D).

Table 2.

Concomitant Procedures (N = 16).

Procedure	n (%)
Fusion takedown with removal of hardware	16 (100)
Medial gutter debridement	4 (25)
Primary subtalar fusion	4 (25)
Revision subtalar fusion^a	3 (18.8)
Prophylactic fixation of medial malleolus	6 (37.5)
Open reduction internal fixation of medial malleolus fracture	1 (6.3)
Open reduction internal fixation of syndesmosis	2 (12.5)
Exostectomy	2 (12.5)
Peroneal repair	1 (6.3)
Forefoot procedures	1 (6.3)

Previous tibiotalocalcaneal arthrodesis with subtalar nonunion requiring a revision subtalar fusion.

Postoperatively, patients were immobilized in a well-padded short leg splint with the ankle in neutral. Following suture removal at 2 weeks, patients were transitioned to a removable night splint and controlled ankle motion (CAM) walking boot. At this time, weightbearing deep knee bends and Achilles stretching was initiated, as described previously.²³ No weightbearing ambulation was permitted in the first 6 weeks. After 6 weeks, weightbearing with ambulation was permitted, with progression to full weightbearing in a walking boot over the course of 4 weeks. At 12 weeks postoperatively, patients transitioned out of the boot to a cloth brace, which they weaned as tolerated.

Statistical Analysis

Descriptive statistics for characteristics of patients and clinical measurements were presented as means and SDs, and frequencies for categorical variables. Paired t tests were used to compare mean preoperative and latest postoperative radiographic alignment measures and PROMs. A variable with P value <.05 indicates a significant difference between 2 groups. All analysis was performed using SAS 9.4 (SAS Institute Inc).

Results

A total of 16 ankles (16 patients; 9 ankle fusion, 7 tibiotalocalcaneal fusion) met the inclusion and exclusion criteria and were included in the current study with an average follow-up of 4.7 (range, 2-11) years. All patients had presented with pain and stiffness of the ankle and adjacent joints. Of the 7 patients who had previously underwent tibiotalocalcaneal fusion, 1 patient presented with subtalar nonunion and 1 patient presented with tibiotalar nonunion. There were no nonunions in the 9 patients who previously underwent tibiotalar fusion.

The study cohort consisted of 62% females, with an average age of 56.8 (range, 25-75) and body mass index of 30.6 (range, 20-47). A quarter of patients (n = 4) had a diagnosis of diabetes, and 15 (93.8%) patients had an ASA score of 2 or 3 (Table 1). All but 1 patient underwent additional concomitant procedures at the time of fusion takedown (Table 2), the most common procedures being prophylactic fixation of the medial malleolus (n = 6), subtalar fusion (n = 4), and medial gutter debridement (n = 4). One patient underwent staged revision for failed tibiotalocalcaneal fusion with subtalar nonunion, treated first with removal of hardware, revision subtalar fusion, and fibular reconstruction, followed by conversion to TM TAA 7 months later (Figure 2).

Figure 2.

Weightbearing plain films of a 55 year-old woman with previous history of multiple ankle surgeries in the setting of posttraumatic arthritis who underwent conversion of ankle arthrodesis to transfibular total ankle arthroplasty (TAA). Anteroposterior (AP) and lateral radiographs demonstrate her initial presentation with painful subtalar nonunion in the setting of a failed tibiotalocalcaneal arthrodesis (A and B). She underwent a staged revision; the first stage consisted of hardware removal, revision subtalar fusion, and fibular reconstruction using a femoral head allograft (C and D). At 7 months she successfully underwent conversion to transfibular TAA. Weightbearing films obtained 30 months following conversion to TAA demonstrate satisfactory alignment and implant retention (E and F).

There was significant mean improvement in all PROMs at final follow-up (Table 3). Average SF-12 PCS increased from 36.0 ± 4.2 to 42.2 ± 6.6, SF-12 MCS increased from 46.7 ± 8.1 to 54.2 ± 8.3, VAS pain improved from 7.0 ± 1.8 to 3.3 ± 1.4, AOS pain improved from 55.4 ± 19.1 to 25.0 ± 20.2, and AOS disability improved from 57.6 ± 17.2 to 41.1 ± 20.9 (all P < .05).

Table 3.

Patient-Reported Outcome Measures (PROMs).

PROM	Preoperative	Postoperative	P Value
SF-12 PCS	36.0 ± 4.2	42.2 ± 6.6	.038
SF-12 MCS	46.7 ± 8.1	54.2 ± 8.3	.047
VAS pain	7.0 ± 1.8	3.3 ± 1.4	<.001
AOS pain	55.4 ± 19.1	25.0 ± 20.2	.011
AOS disability	57.6 ± 17.2	41.1 ± 20.9	.046

Abbreviations: AOS, Ankle Osteoarthritis Scale; MCS, mental component summary; PCS, physical component summary; SF-12, 12-Item Short Form Health Survey; VAS, visual analog scale.

Boldface indicates statistical significance.

Radiographic coronal and sagittal tibiotalar alignment is recorded in Table 4. Postoperatively, the mean tibiotalar dorsiflexion and plantarflexion were 12.5 ± 5.6 degrees and 13.5 ± 9.1 degrees, respectively. In terms of periprosthetic radiolucency, a single zone of radiolucency (<2 mm) was observed in 12 (75%) ankles at final follow-up, most commonly about the anterior and posterior tibial tray. No periprosthetic cysts (radiolucency >2 mm) were observed in any cases.

Table 4.

Radiographic Outcomes and Range of Motion (N = 16).

Variable	Mean ± SD or n (%)
Alpha angle, degrees	90.4 ± 2.9
Beta angle, degrees	91.1 ± 8.3
Gamma angle, degrees	15.8 ± 4.4
Tibiotalar dorsiflexion, degrees	12.5 ± 5.6
Tibiotalar plantarflexion, degrees	13.5 ± 9.1
Radiographic lucency (<2 mm)	12 (75)
Radiographic cyst (>2 mm)	0 (0)

Adverse events occurred in 9 patients (56.3%); 1 patient (6.3%) underwent implant revision, 8 patients (50%) underwent a total of 10 reoperations. Reoperations were performed at an average of 1.5 years and included: isolated removal of fibular hardware (n = 4), medial gutter debridement (n = 4), irrigation and debridement with polyethylene liner exchange (n = 1), and tendon Achilles lengthening (n = 1). The one patient who underwent implant revision had sustained an acute, traumatic periprosthetic fracture requiring revision of the tibial component at 10 weeks postoperatively.

There was 1 incidence of delayed incisional healing that prompted delayed suture removal at 4 weeks. Another patient had a superficial infection that resolved after course of oral antibiotics.

Discussion

Symptomatic, failed ankle fusion remains a challenging clinical scenario in which revision options are limited. To our knowledge, this is the first study investigating takedown fusion with conversion to transfibular total ankle arthroplasty. In this series of 16 ankles, patients were found to have significant improvements in patient-reported outcomes and improved tibiotalar ROM at an average of 4.7 years follow-up. Half of the patients required at least one reoperation, and overall implant survivorship during the study period was 93.7%.

The decision to undergo transfibular TAA over conventional anterior approach requires a comprehensive assessment of patient risk factors and previous surgical history. Data for transfibular total ankle arthroplasty is favorable in the primary setting; however, there is a scarcity of evidence in the takedown setting.^20,24 Previous studies have reported favorable results in subjective and functional patient outcomes following takedown fusion with conversion to an anterior ankle system, including the Agility (DePuy) Salto Talaris (Smith & Nephew), Scandinavian Total Ankle Replacement (STAR, Enovis), Infinity (Stryker), Inbone (Stryker), and Hintegra (DT MedTech) prostheses.^7
-9,25
-27 Our study adds to this growing body of literature with a novel method of management.

An advantage of this study is the inclusion of pre- and postoperative clinical and radiographic outcomes at a minimum of 2-years follow-up. At an average of 4.7 years following fusion takedown with conversion to TM TAA, there was significant improvement in pre- to postoperative PROMs. Furthermore, mean postoperative VAS, AOS pain, AOS disability, SF-12 PCS, and SF-12 MCS scores are consistent with the 5-year results of a series of 130 cases of primary transfibular TAA.²⁴ Our findings suggest that although fusion takedown with conversion to TAA may be more complex of a procedure, patients with painful, failed tibiotalar fusions can achieve reasonable symptomatic and functional improvement.

All patients regained varying degrees of radiographic ROM following fusion takedown with conversion to TM TAA, from 0 degrees of tibiotalar motion preoperatively. Furthermore, it was observed that ROM increased over the course of follow-up, which is consistent with previous published findings.^7,28 These findings suggest that patients can reasonably expect to have improved tibiotalar dorsiflexion and plantarflexion following conversion of tibiotalar arthrodesis to TAA within the first 2 years.

Implant survivorship in this series was 93.7%, with 1 patient requiring implant revision. Although this may be slightly lower than that of primary TM TAA,^29,30 these findings are within the range of implant survivorship reported in previous takedown studies by Schuberth et al⁸ (88%) and Lundeen et al⁷ (98%). The patient who underwent revision had sustained a traumatic fall at 10 weeks postoperatively, resulting in a periprosthetic tibial fracture through a bone void from previous hardware removal. This necessitated revision of the tibial component, and the patient recovered well postoperatively.

It is important to counsel patients that risk for surgical reoperation is relatively high. In a systematic review of 919 primary TM TAA cases across 7 countries, Fa-Binefa et al³⁰ reported that about a quarter of patients experienced adverse events postoperatively, and 18% of patients required surgical reoperation within a follow-up period of 3 years. In contrast, half of the patients in this current series required surgical reoperation at an average of 1.5 years following fusion takedown. This finding is likely attributed to the complex surgical history and revision nature of the patients in this current series. Indications for surgical reoperation, however, are similar to that of primary TM TAA, with removal of symptomatic hardware and gutter debridement for impingement being the most common reoperations.^29,30

Results of the current study should be interpreted in light of several limitations, including its retrospective design, the use of a single-surgeon database, and limited sample size. Future prospective studies with larger cohorts and longer follow-up are recommended to further validate these findings. Furthermore, we acknowledge that fusion takedown and conversion to TAA is a challenging procedure with a moderate reoperation rate, and should be performed by experienced surgeons.

Conclusion

Although technically challenging, fusion takedown with conversion to transfibular, trabecular metal total ankle arthroplasty is a reasonable treatment option for symptomatic ankle arthrodesis, yielding improvements in clinical and functional outcomes at an average of 4.7 years’ follow-up. Although implant survivorship in this series was high, patients should be counseled on a moderate risk for surgical reoperation.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114261422697 – Supplemental material for Outcomes Following Conversion of Ankle Fusion to Transfibular Total Ankle Arthroplasty

Supplemental material, sj-pdf-1-fao-10.1177_24730114261422697 for Outcomes Following Conversion of Ankle Fusion to Transfibular Total Ankle Arthroplasty by Mark Arthur, Thomas Wood, Morgan Motsay, Jonathan Day, Zijun Zhang and Lew Schon in Foot & Ankle Orthopaedics

Footnotes

ORCID iDs

Jonathan Day, MD,

Zijun Zhang, MD, PhD,

Lew Schon, MD,

Ethical Considerations

Ethical approval for this study was obtained from Mercy Medical Center Institutional Review Board (Approval ID: 1648405-15).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Lew Schon, MD, reports general disclosures of Zimmer: IP royalties; paid consultant; paid presenter or speaker; research support. Disclosure forms for all authors are available online.

References

Coester

Saltzman

Leupold

Pontarelli

Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83(2):219-228. doi:10.2106/00004623-200102000-00009

Jung

Parks

Nguyen

Schon

LC.

Effect of tibiotalar joint arthrodesis on adjacent tarsal joint pressure in a cadaver model. Foot Ankle Int. 2007;28(1):103-108. doi:10.3113/FAI.2007.0019

Krause

Younger

ASE

Baumhauer

, et al. Clinical outcomes of nonunions of hindfoot and ankle fusions. J Bone Joint Surg Am. 2016;98(23):2006-2016. doi:10.2106/JBJS.14.00872

Lause

Parker

Stupay

, et al. The fate of delayed unions after isolated ankle fusion. Foot Ankle Int. 2023;44(9):815-824. doi:10.1177/10711007231178541

Easley

Montijo

Wilson

Fitch

Nunley

2nd . Revision tibiotalar arthrodesis. J Bone Joint Surg Am. 2008;90(6):1212-1223. doi:10.2106/JBJS.G.00506

Chu

Wilson

Houng

Thompson

Outcomes of ankle arthrodesis conversion to total ankle arthroplasty: a systematic review. J Foot Ankle Surg. 2021;60(2):362-367. doi:10.1053/j.jfas.2020.06.025

Lundeen

Raduan

Stone McGaver

, et al. Takedown of ankle fusions and conversion to total ankle replacements. Foot Ankle Int. 2022;43(11):1402-1409. doi:10.1177/10711007221115170

Schuberth

King

Jiang

Ross

Christensen

Steck

JK.

Takedown of painful ankle arthrodesis to total ankle arthroplasty: a case series of 77 patients. J Foot Ankle Surg. 2020;59(3):535-540. doi:10.1053/j.jfas.2020.01.002

Hintermann

Barg

Knupp

Valderrabano

Conversion of painful ankle arthrodesis to total ankle arthroplasty. J Bone Joint Surg Am. 2009;91(4):850-858. doi:10.2106/JBJS.H.00229

10.

Coetzee

Raduan

McGaver

RS.

Converting ankle arthrodesis to a total ankle arthroplasty. Orthop Clin North Am. 2021;52(2):181-190. doi:10.1016/j.ocl.2020.12.005

11.

von Elm

Altman

Egger

Pocock

Gøtzsche

Vandenbroucke

JP.

The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-1457. doi:10.1016/S0140-6736(07)61602-X

12.

Younger

ASE

Glazebrook

Veljkovic

, et al. A coding system for reoperations following total ankle replacement and ankle arthrodesis. Foot Ankle Int. 2016;37(11):1157-1164. doi:10.1177/1071100716659037

13.

Ware

Kosinski

Keller

SD.

A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220-233. doi:10.1097/00005650-199603000-00003

14.

Domsic

Saltzman

CL.

Ankle Osteoarthritis Scale. Foot Ankle Int. 1998;19(7):466-471. doi:10.1177/107110079801900708

15.

Scott

Huskisson

EC.

Graphic representation of pain. Pain. 1976;2(2):175-184. doi:10.1016/0304-3959(76)90113-5

16.

Coetzee

Castro

MD.

Accurate measurement of ankle range of motion after total ankle arthroplasty. Clin Orthop Relat Res. 2004;424:27-31. doi:10.1097/01.blo.0000132180.69464.84

17.

Johnson

Fletcher

, et al. Tibiopedal motion following tendo-Achilles lengthening or gastrocnemius recession in total ankle replacement: a comparative cohort study. Foot Ankle Int. 2022;43(12):1622-1630. doi:10.1177/10711007221132284

18.

Barg

Bettin

Burstein

Saltzman

Gililland

Early clinical and radiographic outcomes of trabecular metal total ankle replacement using a transfibular approach. J Bone Joint Surg Am. 2018;100(6):505-515. doi:10.2106/JBJS.17.00018

19.

Bianchi

Martinelli

Hosseinzadeh

, et al. Early clinical and radiological evaluation in patients with total ankle replacement performed by lateral approach and peroneal osteotomy. BMC Musculoskelet Disord. 2019;20(1):132. doi:10.1186/s12891-019-2503-6

20.

Usuelli

Maccario

Granata

Indino

Vakhshori

Tan

EW.

Clinical and radiological outcomes of transfibular total ankle arthroplasty. Foot Ankle Int. 2019;40(1):24-33. doi:10.1177/1071100718798851

21.

Kim

Gagne

Rajan

, et al. Clinical outcomes of the lateral trabecular metal total ankle replacement at a 5-year minimum follow-up. Foot Ankle Spec. 2023;16(3):288-299. doi:10.1177/19386400221139525

22.

Tan

Maccario

Talusan

Schon

LC.

Early complications and secondary procedures in transfibular total ankle replacement. Foot Ankle Int. 2016;37(8):835-841. doi:10.1177/1071100716644817

23.

Fletcher

Day

Motsay

Manchester

Zhang

Schon

LC.

Transfibular total ankle arthroplasty: clinical, functional, and radiographic outcomes and complications at a minimum of 5-year follow-up. Foot Ankle Int. 2025;46(1):1-8. doi:10.1177/10711007241290222

24.

Day

Fletcher

Motsay

, et al. Outcomes of transfibular total ankle arthroplasty: clinical and radiographic analysis of 130 cases with minimum 5-year follow-up. J Bone Joint Surg Am. Published online April 29, 2025. doi:10.2106/JBJS.24.00983

25.

Greisberg

Assal

Flueckiger

Hansen

ST.

Takedown of ankle fusion and conversion to total ankle replacement. Clin Orthop Relat Res. 2004;424:80-88. doi:10.1097/01.blo.0000132460.27102.d6

26.

Preis

Bailey

Marchand

Barg

Can a three-component prosthesis be used for conversion of painful ankle arthrodesis to total ankle replacement?

Clin Orthop Relat Res. 2017;475(9):2283-2294. doi:10.1007/s11999-017-5343-4

27.

Pellegrini

Schiff

Adams

Jr , et al. Conversion of tibiotalar arthrodesis to total ankle arthroplasty. J Bone Joint Surg Am. 2015;97(24):2004-2013. doi:10.2106/jbjs.o.00396

28.

Ajis

Henriquez

Myerson

Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013;34(5):645-656. doi:10.1177/1071100713481433

29.

Abarquero-Diezhandino

Vacas Sánchez

Diaz Fernandez

Vilá

Rico

Results of transfibular total ankle arthroplasty. A series of 50 implants. J Foot Ankle Surg. 2023;62(4):671-675. doi:10.1053/j.jfas.2023.02.005

30.

Fa-Binefa

López-Hervás

López-Capdevila

Fernández de Retana

Schon

Survival and complications of transfibular trabecular metal total ankle replacement - a systematic review. Foot Ankle Surg. 2024;30(7):612-617. doi:10.1016/j.fas.2024.05.007

Supplementary Material

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