Foot & Ankle International - September 2019 - 1038

1038
joints.1,5 Recently, the number of total ankle arthroplasty
(TAA) procedures has increased,18,20 although debate
remains as to whether the ankle should be fused or replaced.
One of the theoretical benefits of TAA over ankle arthrodesis is the presumed improvement in gait due to preservation of ankle motion9 and a decrease in stress on the midfoot
and subtalar joints.23 However, TAA for RA patients should
be undertaken carefully because underlying inflammatory
arthritis was reported to be the significant risk factor for
major wound complications associated with an odds ratio of
14.03 for reoperation.19 The aim of this study was to evaluate the clinical and radiographic outcomes of TAA in
patients with RA.

Methods
The study was approved by our institutional review board.
The study was a retrospective observational design to analyze the clinical and radiographic outcomes of RA patients
who had undergone primary TAA and included patients with
a minimum follow-up of 2 years. A total of 42 consecutive
ankles in 40 RA patients were treated with TAA between
August 2006 and March 2016. All patients in the study
underwent mobile-bearing TAA performed by or under the
supervision of staff surgeons who had extensive experience
in rheumatoid foot and ankle surgery. Inclusion criteria for
undergoing TAA were as follows: (1) symptomatic ankle
joint destruction with Larsen grade 3 to 57; (2) no or only
slight collapse of the talus; and (3) valgus or varus deformity
with a tibiocalcaneal angle of less than 20 degrees. Of these,
3 ankles in 3 patients were lost to follow-up, with the remaining 39 ankles in 37 patients forming the study cohort. RA
patients stopped taking biologic disease-modifying antirheumatic drugs (DMARDs) during the perioperative period
according to the Japanese guidelines for the use of these
agents. All conventional synthetic DMARDs, including
methotrexate and prednisolone, were continued throughout
the perioperative period.
The baseline characteristics of the patients are shown in
Table 1. Mean age at surgery was 61.0 ±10.8 (range, 36-79)
years, and mean duration of RA affliction was 16.6 ± 8.8
(range, 2-33) years. Mean DAS28 at surgery was 3.3 ± 1.1
(range, 0.8-5.5). The mean duration of follow-up for the entire
cohort was 5.0 ± 2.0 (range, 2.1-10.1) years. Nine (23.1%)
ankles received arthrodesis of the subtalar joint simultaneously. Of the 39 ankles, one was excluded from the assessment of radiographic outcomes because the prosthesis was
removed 6 months after surgery because of a deep infection.

Operative Technique
Since 2006, we have performed 3-component mobile-bearing TAA (FINE Total Ankle System; Teijin-Nakashima
Medical, Okayama, Japan) for patients with RA. The FINE

Foot & Ankle International 40(9)
Table 1. Patient Demographics.
Characteristic
Age, y, mean ± SD (range)
Gender, female, %
Disease duration, years, mean ±
SD (range)
DAS28, mean ± SD (range)
PSL use, %
MTX use, %
Biologic DMARDs use, %
Larsen grade, n
3
4
5

61.0 ± 10.8 (36-79)
92.3
16.8 ± 8.8 (2-33)
3.3 ± 1.1 (0.8-5.5)
40.5
81.1
50.0
11
23
5

Abbreviations: DAS28, Disease Activity Score 28; DMARDs, diseasemodifying antirheumatic drugs; MTX, methotrexate; PSL, prednisolone.

Total Ankle System was developed based on a study of
bony shape in the Japanese population, and consisted of
cobalt-chromium-molybdenum alloy for the tibial and talar
components with a mobile-bearing ultrahigh-molecularweight polyethylene insert that was designed to use bone
cement to fix the tibial and talar components.4 The FINE
total ankle system was released in 2003, the newer of the 2
TAA systems that have been approved in Japan up until
2017. Both of them were sold only in Japan.
The operation was performed through an anterior
approach using a longitudinal incision between the tibialis
anterior tendon and the extensor hallucis longus tendon.
Spurs of the distal tibia were resected, followed by insertion of a talus cutting guide. An osteotomy of the talus was
then performed parallel to the plantar surface of the foot
using fluoroscopy. A tibial cutting guide was subsequently
placed on the anterior aspect of the distal tibia to make the
surface perpendicular to the tibial axis. After reaming
stem holes of the tibia and talus, the prostheses were
implanted and fixed with cement. When the subtalar joint
had destruction greater than Larsen grade 3 (medium
destructive abnormality), arthrodesis of the subtalar joint
was added using screws with minimal soft tissue release
around the talus. The extensor retinaculum was sutured
tightly, followed by normal skin closure. A short leg cast
was placed with the patient nonweightbearing postoperatively. The patients were allowed to start weightbearing
gait with the cast 2 weeks after surgery. After the cast was
removed 3 weeks after the surgery, the patients began to
walk with an ankle brace and performed range of motion
exercises until 3 months postoperatively.

Clinical Evaluations
Information on the clinical characteristics of the patients was
obtained from medical records. Patient-reported outcomes

Foot & Ankle International - September 2019

Table of Contents for the Digital Edition of Foot & Ankle International - September 2019