The Science Behind Periprosthetic Aseptic Osteolysis in Total Ankle Replacement

  • Orfan Arafah
  • Murray J. PennerEmail author


In foot and ankle literature, firm evidence about the etiology, pathophysiology, natural history, and optimal treatments of ankle periprosthetic osteolysis is still lacking. In contrast to osteolysis around hip arthroplasty, factors other than polyethylene debris, such as reaction to necrotic tissue, micromotion at the implant-bone interface, and high fluid pressure may play a key role in osteolysis around total ankle replacement. Annual radiographic surveillance is recommended for early detection and treatment of osteolysis. Computerized tomography showed superiority in both detecting cysts and accurately determining their sizes if compared to standard radiography. The benefit of early surgical intervention in progressive osteolysis may outweigh the risks of catastrophic failure associated with longer conservative management. For total ankle replacement metallic components deemed to be stable, cysts debridement with impaction bone grafting and polyethylene exchange is usually all that is required. If one or both components are deemed to be unstable, component revision is required in addition to cyst debridement and impaction bone grafting. A foot and ankle surgeon who is an expert in both primary and revision total ankle replacement should manage treatment of osteolysis associated with total ankle replacement.


Arthroplasty Bone graft Complications Revision Subsidence 


  1. 1.
    Labek G, Thaler M, Janda W, et al. Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Joint Surg Br. 2011;93(3):293–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Harris WH, Schiller AL, Scholler JM, et al. Extensive localized bone resorption in the femur following total hip replacement. J Bone Joint Surg Am. 1976;58:612–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Willert HG. Reactions of the articular capsule to wear products of artificial joint prostheses. J Biomed Mater Res. 1977;11:157–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Valderrabano V, Hintermann B, Dick W. Scandinavian total ankle replacement: a 3.7-year average follow up of 65 patients. Clin Orthop. 2004;424:47–56.CrossRefGoogle Scholar
  5. 5.
    Besse JL, Brito N, Lienhart C. Clinical evaluation and radiographic assessment of bone lysis of the AES total ankle replacement. Foot Ankle Int. 2009;30(10):964–75. doi: 10.3113/FAI.2009.0964.CrossRefPubMedGoogle Scholar
  6. 6.
    Bonnin M, Judet T, Colombier JA, et al. Midterm results of the Salto total ankle prosthesis. Clin Orthop Relat Res. 2004;424:6–18.CrossRefGoogle Scholar
  7. 7.
    Hanna RS, Haddad SL, Lazarus ML. Evaluation of periprosthetic lucency after total ankle arthroplasty: helical CT versus conventional radiography. Foot Ankle Int. 2007;28(8):921–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Kim BS, Knupp M, Zwicky L, Lee JW, Hintermann B. Total ankle replacement in association with hindfoot fusion: outcome and complications. J Bone Joint Surg Br. 2010;92(11):1540–7. doi: 10.1302/0301-620X.92B11.24452.CrossRefPubMedGoogle Scholar
  9. 9.
    Koivu H, Kohonen I, Sipola E, et al. Severe periprosthetic osteolytic lesions after the Ankle Evolutive System total ankle replacement. J Bone Joint Surg Br. 2009;91(7):907–14. doi: 10.1302/0301-620X.91B7.22434.CrossRefPubMedGoogle Scholar
  10. 10.
    Rippstein PF, Huber M, Coetzee JC, Naal FD. Total ankle replacement with use of a new three-component implant. J Bone Joint Surg Am. 2011;93(15):1426–35. doi: 10.2106/JBJS.J.00913.CrossRefPubMedGoogle Scholar
  11. 11.
    Schutte BG, Louwerens JW. Short-term results of our first 49 Scandinavian total ankle replacements (STAR). Foot Ankle Int. 2008;29(2):124–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Rodriguez D, Bevernage BD, Maldague P, Deleu PA, Tribak K, Leemrijse T. Medium term follow-up of the AES ankle prosthesis: high rate of asymptomatic osteolysis. Foot Ankle Surg. 2010;16(2):54–60. doi: 10.1016/j.fas.2009.05.013. Epub 2009 Jul 9.CrossRefPubMedGoogle Scholar
  13. 13.
    Yoon HS, Lee J, Choi WJ, Lee JW. Periprosthetic osteolysis after total ankle arthroplasty. Foot Ankle Int. 2014;35(1):14–21. doi: 10.1177/1071100713509247. Epub 2013 Oct 16.CrossRefPubMedGoogle Scholar
  14. 14.
    Kohonen I, Koivu H, Pudas T, Tiusanen H, Vahlberg T, Mattila K. Does computed tomography add information on radiographic analysis in detecting periprosthetic osteolysis after total ankle arthroplasty? Foot Ankle Int. 2013;34(2):180–8. doi: 10.1177/1071100712460224. Epub 2013 Jan 10.CrossRefPubMedGoogle Scholar
  15. 15.
    Kobayashi A, Minoda Y, Kadoya Y, Ohashi H, Takaoka K, Saltzman CL. Ankle arthroplasties generate wear particles similar to knee arthroplasties. Clin Orthop Relat Res. 2004;(424):69–72.
  16. 16.
    Kobayashi A, Freeman MAR, Bonefield W, et al. Number of polyethylene particles and osteolysis in total joint replacements. J Bone Joint Surg. 1997;79B:844–8.CrossRefGoogle Scholar
  17. 17.
    Fevang BT, Lie SA, Havelin LI, et al. 257 ankle arthroplasties performed in Norway between 1994 and 2005. Acta Orthop. 2007;78:575–83.CrossRefPubMedGoogle Scholar
  18. 18.
    Font-Rodriguez DE, Scuderi GR, Insall JN. Survival ship of cemented total knee arthroplasty. Clin Orthop. 1997;345:79–86.CrossRefGoogle Scholar
  19. 19.
    Koivu H, Mackiewicz Z, Takakubo Y, Trokovic N, Pajarinen J, Konttinen YT. RANKL in the osteolysis of AES total ankle replacement implants. Bone. 2012;51(3):546–52. doi: 10.1016/j.bone.2012.05.007. Epub 2012 May 14.CrossRefPubMedGoogle Scholar
  20. 20.
    Arafah O, Penner MJ. Is polyethylene particulate debris present in osteolytic cysts in total ankle replacement? [Abstract]. Poster presentation (e-102) at the IFFAS/AOFAS 2014 meeting, Chicago.Google Scholar
  21. 21.
    Dalat F, Barnoud R, Fessy MH, Besse JL, French Association of Foot Surgery AFCP. Histologic study of periprosthetic osteolytic lesions after AES total ankle replacement. A 22 case series. Orthop Traumatol Surg Res. 2013;99(6 Suppl):S285–95. doi: 10.1016/j.otsr.2013.07.009. Epub 2013 Aug 23.CrossRefPubMedGoogle Scholar
  22. 22.
    Vaupel Z, Baker E, Baker KC, et al. Analysis of retrieved agility total ankle arthroplasty systems. Foot Ankle Int. 2009;30(9):815–23.CrossRefPubMedGoogle Scholar
  23. 23.
    Pyevich MT, Saltzman CL, Callaghan JJ, Alvine FG. Total ankle arthroplasty: a unique design. Two to twelve-year follow-up. J Bone Joint Surg Am. 1998;80(10):1410–20.CrossRefPubMedGoogle Scholar
  24. 24.
    Knecht SI, Estin M, Callaghan JJ, et al. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up. J Bone Joint Surg Am. 2004;86-A(6):1161–71.CrossRefPubMedGoogle Scholar
  25. 25.
    Burton L, Paget D, Binder NB, et al. Orthopedic wear debris mediated inflammatory osteolysis is mediated in part by NALP3 inflammasome activation. J Orthop Res. 2013;31(1):73–80.CrossRefPubMedGoogle Scholar
  26. 26.
    Gallo J, Slouf M, Goodman SB. The relationship of polyethylene wear particle size, distribution and number: a possible factor explaining the risk of osteolysis after hip arthroplasty. J Biomed Mater Res B Appl Biomater. 2010;94(1):171–7.PubMedGoogle Scholar
  27. 27.
    Goodman S. Wear particulate and osteolysis. Orthop Clin North Am. 2005;36(1):41–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Hozack WJ, Mesa JJ, Carey C, Rothman RH. Relationship between polyethylene wear, pelvic osteolysis, and clinical symptomatology in patients with cementless acetabular components. A framework for decision making. J Arthroplasty. 1996;11:769–72.CrossRefPubMedGoogle Scholar
  29. 29.
    Ishikawa SN, Murphy GA, Richardson EG. The effect of cigarette smoking on hindfoot fusions. Foot Ankle Int. 2002;23:996–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Kim BS, Lee JW. Total ankle replacement for the varus unstable osteoarthritic ankle. Tech Foot Ankle Surg. 2010;9(4):157–64.CrossRefGoogle Scholar
  31. 31.
    Trincat S, Kouyoumdjian P, Asencio G. Total ankle arthroplasty and coronal plane deformities. Orthop Traumatol Surg Res. 2012;98(1):75–84.CrossRefPubMedGoogle Scholar
  32. 32.
    Haskell A, Mann RA. Ankle arthroplasty with preoperative coronal plane deformity: short term result. Clin Orthop Relat Res. 2004;424:98–103.CrossRefGoogle Scholar
  33. 33.
    Leung S, Naudie D, Kitamura N, Walde T, Engh CA. Computed tomography in the assessment of periacetabular osteolysis. J Bone Joint Surg. 2005;87-A:592–7.CrossRefGoogle Scholar
  34. 34.
    Resnick D, Fix CF, Trudell D. Bone and joint imaging. 2nd ed. Philadelphia: W. B. Saunders; 1996.Google Scholar
  35. 35.
    Puri L, Wixson R, Stern SH, Kohli J, Hendrix RW, Stuberg D. Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty. J Bone Joint Surg. 2002;84-A:609–14.CrossRefPubMedGoogle Scholar
  36. 36.
    Balter S, Zanzonico P, Reiss GR, Moses JW. Radiation is not the only risk. AJR Am J Roentgenol. 2011;196(4):762–7. doi: 10.2214/AJR.10.5982.CrossRefPubMedGoogle Scholar
  37. 37.
    Biswas D, Bible JE, Bohan M, et al. Radiation exposure from musculoskeletal computerized tomographic scans. J Bone Joint Surg Am. 2009;91:1882–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Brenner DJ, Doll R, Goodhead DT, Hall EJ, Land CE, Little JB, Lubin JH, Preston DL, Preston RJ, Puskin JS, Ron E, Sachs RK, Samet JM, Setlow RB, Zaider M. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A. 2003;100:13761–6.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Saha S, Burke C, Desai A, Vijayanathan S, Gnanasegaran G. Review article. SPECT-CT: applications in musculoskeletal radiology. Br J Radiol. 2013;86(1031):20120519.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Knupp M, Pagenstert GI, Barg A, Bolliger L, Easley M, Hintermann B. SPECT-CT compared with conventional imaging modalities for the assessment of the varus and valgus malaligned hindfoot. J Orthop Res. 2009;27:1461–6.CrossRefPubMedGoogle Scholar
  41. 41.
    Rippstein PF, Huber M, Naal FD. Management of specific complications related to total ankle arthroplasty. Foot Ankle Clin. 2012;17(4):707–17. doi: 10.1016/j.fcl.2012.08.010. Epub 2012 Oct 23.CrossRefPubMedGoogle Scholar
  42. 42.
    Jonck JH, Myerson MS. Revision total ankle replacement. Foot Ankle Clin. 2012;17(4):687–706. Epub 2012 Sep 18.CrossRefPubMedGoogle Scholar
  43. 43.
    Bonnin M, Gaudot F, Laurent J-R, et al. The Salto total ankle arthroplasty: survivorship and analysis of failures at 7 to 11 years. Clin Orthop Relat Res. 2011;469(1):225–36.CrossRefPubMedGoogle Scholar
  44. 44.
    Prissel MA, Roukis TS. Management of extensive tibial osteolysis with the Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation. J Foot Ankle Surg. 2014;53(1):101–7. doi: 10.1053/j.jfas.2013.10.008.CrossRefPubMedGoogle Scholar
  45. 45.
    Restrepo C, Ghanem E, Houssock C, et al. Isolated polyethylene exchange versus acetabular revision for polyethylene wear. Clin Orthop Relat Res. 2009;467:194–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Maloney WJ, Herzwurm P, Paprosky W, et al. Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am. 1997;79:1628–34.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Orthopaedic (49)College of Medicine, King Khalid University Hospital/King Saud UniversityRiyadhSaudi Arabia
  2. 2.Department of OrthopaedicsUniversity of British ColumbiaVancouverCanada
  3. 3.Department of OrthopaedicsSt. Paul’s Hospital, Vancouver Coastal Health Authority and Providence Health CareVancouverCanada

Personalised recommendations