International Journal of Surgery Case Reports 116 (2024) 109336

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Partial revision of a dislocated periprosthetic tibial fracture after total ankle

replacement with a stemmed implant and plate fixation: A case report
Giuseppe De Rito a, Roberto Biscione a, Antonio Volpe c, Luca Liverani a,
Gustavo Alberto Zanoli a, Martina Maritati a, b, *
a
Orthopaedic Ward, Casa di Cura Santa Maria Maddalena, Via Gorizia, Occhiobello, Rovigo, Italy
b
Department of Translational Medicine, University of Ferrara, Via Aldo Moro, Ferrara, Italy
c
Policlinico Abano, Piazza Cristoforo 1, Abano Terme, Padova, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Total ankle arthroplasty (TAR) procedures have become more reliable and incidence is increasing. A
Total ankle arthroplasty growing number of postoperative complications can be expected and should be correctly addressed.
Revision arthroplasty Presentation of case: A 43-year-old woman suffering from severe ankle osteoarthritis underwent TAR (Stryker’s
Periprosthetic fracture
Infinity with Prophecy alignment guides, uncemented tibial component and cemented talus component). After a
Orthopedics
Ankle arthrosis
fall, one month after the surgery, she presented with a fracture of the medial malleolus and an anterior peri­
Ankle dislocation prosthetic fracture of the tibia, with anterior dislocation of the tibial prosthetic component. Fracture fixation and
partial revision surgery was planned using the same anterior surgical access. To restore length, rotation and joint
articulation, the medial malleolus was first reduced and synthesized with a plate and 6 screws through additional
minimally invasive medial ankle incisions. Once the medial malleolus was stabilized, the already mobilized tibial
component was removed. Freehand cuts under fluoroscopic guidance on the anterior surface of the tibia were
performed. After a final check with a trial component, a Stryker’s Inbone II stem, which matched the previously
inserted talar component, was implanted and partially cemented to fill the remaining bone gaps.
Discussion: Only few case reports of periprosthetic ankle fractures exist, and none of them were similar to ours.
There are no published precedents for this revision approach from a stemless to a stemmed tibial implant without
changing the talar implant.
Conclusion: Partial revision after a complex periprosthetic fracture results in a satisfactory outcome if surgery is
performed in specialized centers.

1. Introduction As with all arthroplasties, complications during revisions, particu­

larly infections, occur more frequently compared to primary procedures,
Osteoarthritis of the ankle is an increasingly frequent problem, with incidence rates of 4 % and 2.4 %, respectively [7].
affecting a growing number of people worldwide [1]. Total ankle By far, the most frequent complications in primary TAR are loos­
replacement (TAR) has emerged as a viable solution, aiming to restore ening, surrounding joint osteoarthritis, rupture or damage of the poly­
joint function and alleviate pain. The evolution of newer implants has ethylene, joint deformity and periprosthetic fracture (PF)2 [5] which
garnered attention for their improved surgical reproducibility and out­ represents the major challenge [7].
comes, leading to a rise in both reported cases [2] and national registries We illustrate the case of a patient who underwent TAR at “Casa di
[3,4]. Cura Santa Maria Maddalena” and, after discharge, suffered from a
However, this surge in TAR procedures has been accompanied by a traumatic PF, and was successfully treated with replacement of the tibial
corresponding increase in post-operative complications, with revision component and a medial malleolus plate. The present work has been
rates soaring to as high as 49 % [5,6]. described in line with the SCARE criteria [8].

Abbreviations: TAR, Total ankle replacement; PF, Periprosthetic fracture; WOMAC, The Western Ontario and McMaster Universities Osteoarthritis Index; ORIF,
Open reduction and internal fixation; MIPO, Minimally invasive plate osteosynthesis.
* Corresponding author at: Department of Translational Medicine, University of Ferrara, Via Aldo Moro, Ferrara, Italy.
E-mail address: [email protected] (M. Maritati).

https://doi.org/10.1016/j.ijscr.2024.109336
Received 5 November 2023; Received in revised form 30 January 2024; Accepted 31 January 2024
Available online 2 February 2024
2210-2612/© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
G. De Rito et al. International Journal of Surgery Case Reports 116 (2024) 109336

To our knowledge, only a few similar cases have been reported, all
treated with different surgical options; therefore, we believe this case
report holds potential relevance for practitioners involved in treating PF
of the ankle.

2. Case report

A 43-year-old woman presented with severe ankle pain. Imaging

showed ankle osteoarthritis with chondritis of the talus and initial signs
of osteonecrosis (Fig. 1A). She had failed previous conservative treat­
ments, including local and systemic pharmacological treatment, intra­
articular injections, physiotherapy and foot orthoses. The overall range
of motion in the sagittal plane was 25–20◦ . After six months of pro­
gressively worsening pain and limited daily activities (80/96 according
to the Western Ontario and McMaster Universities Osteoarthritis Index,
WOMAC3), TAR was proposed.
The surgery was performed using patient-specific cutting templates, Fig. 2. X-rays (A, B) and CT-Scan (C, D, E) show Displaced medial tibial mal­
created using a 3D printer which analyzed the patient’s preoperative CT leolus fracture and tibial implant component dislocation.
scan. The implanted prosthesis was Stryker’s Infinity Total Ankle System
with Prophecy alignment guides (Wright Medical Technology, Inc. 1023 cuts were made under fluoroscopic guidance on the anterior surface of
Cherry Road Memphis, TN 38117); an uncemented tibial component the tibia. Consequently, the tibial canal was reamed with flexible
and cemented talus component were implanted. (Fig. 2B). National Kuntscher burs to create the right fit for the new tibial component. A
guidelines for the prevention of surgical site infections in arthroplasty Stryker’s Inbone II stem (Wright Medical Technology, Inc. 1023 Cherry
were strictly observed [9]. The patient was discharged with a 90◦ short Road Memphis, TN 38117), which matched the previously inserted talar
leg cast and partial (50 %) weight-bearing. component, was implanted and partially cemented (COPAL G + C,
One month later, during a scheduled follow-up visit, the patient Heraeus Medical GmbH Philipp-Reis-Str. 8/13, 61,273 Wehrheim,
arrived with a visibly damaged cast. Upon further inquiry, she Germany) to fill the remaining bony gaps (Fig. 3). Multiple samples of
acknowledged non-compliance with the provided instructions, admit­ synovial fluid and periprosthetic tissue were taken for cultural and
ting to walking with unrestricted weight-bearing most of the time. The histological examination and resulted negative for infection.
patient revealed an incident where she had experienced a fall in a wet
bathroom.
Radiographs and CT showed a fracture of the medial malleolus and
an anterior PF of the tibia, with anterior dislocation of the tibial pros­
thetic component (Fig. 2).
Revision surgery was therefore planned, and an infectious diseases
consultation was requested as for all revision surgeries in our
department.
Using the same anterior surgical access, the joint plane was reached
and exposed by blunt dissection and no macroscopic evidence of infec­
tion was found.
To restore length, rotation and articulation, the medial malleolus
was first reduced and synthesized with the AxSOS 3 Ti distal tibia plating
system (Stryker GmbH Bohnackerweg 12,545 Selzach, Switzerland),
inserted extraperiosteally and secured with 6 screws through minimally
invasive medial ankle incisions.
Once the medial malleolus was stabilized, the already mobilized
Fig. 3. Medial malleolus osteosynthesis with plates and screws, replacement of
tibial component was removed.
the tibial component of the prosthesis with Stryker’s Inbone II stem (Wright
Since there is no dedicated instrumentation to implant the revision Medical Technology, Inc. 1023 Cherry Road Memphis, TN 38117).
tibial component without removing the astragalic component, freehand

Fig. 1. A. Pre-operative antero-posterior and antero-lateral X-ray of right ankle showing right ankle arthrosis. B. Antero-posterior and antero-lateral X-ray after right
ankle arthroplasty showing correct position of the implant.

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G. De Rito et al. International Journal of Surgery Case Reports 116 (2024) 109336

The patient was discharged with a short leg-cast, no weightbearing

for 40 days, and periodic clinical and radiographic follow-up, following
the same protocol as for other joint implants at our institution [10].
The cast was removed after 6 weeks and incremental weightbearing
was allowed, prescribing a full rehabilitation protocol. Three months
after surgery, the patient no longer reported pain, was already able to
ambulate without aids and preserved ROM (Womac3 Scale 16/96). After
1 year follow-up the patient is still pain-free and has a satisfactory range
of motion with a complete functional recovery (Womac3 Scale 6/96)
(Fig. 4).
On x-ray, the prosthetic components are stable, unchanged from
discharge x-rays, the medial malleolus fracture seems healed with a
good bony callus formation and initial signs of remodeling (Fig. 5).

3. Discussion Fig. 5. One year follow-up antero-posterior (A) and antero-lateral (B) X-ray of
the right ankle showing healed fracture and well-integrated prosthesis without
PFs after TAR are rare but not uncommon. Improvement in implants signs of loosening.
and surgical techniques have resulted in a reduction of intraoperative
fracture rates [11]. Fewer data are available on postoperative fractures Not many other cases of fractures around a TAR have been published.
[12]. Haendlmayer et al. [18] presented a plate fixation of a tibial PF with a
In their review, Lawton et al. reported an overall fracture rate of stable tibial component. In their discussion they cite 2 cases of distal
0.9–9.5 %, combining both perioperative and postoperative PF [13]. tibial fractures around a TAR in which the tibial component was revised,
Classifications and treatment algorithms have been proposed for ankle reported as a podium presentation of which we found no published re­
PF [12,14]. cord. In 2011, Yang et al. reported another PF of the distal tibial with
According to Manegold’s classification, our case was classified as 2- involvement of the distal third of the shaft, treated by minimally inva­
BC-U, a category predicted but not represented in their original series: 2 sive plate osteosynthesis (MIPO)5 without implant revision [15]. Roukis
for postoperative, BC because it involved both the medial malleolus and presented a revision of the talar component with plate fixation of post-
the tibial pilon, and U for unstable [12]. These fractures should be traumatic midfoot PF in a patient who had previously been diagnosed
treated surgically in most cases. with severe talar component failure [19].
Our choice for the first implant had been the Infinity Total Ankle In a well-documented and discussed case report, Brock et al. pre­
System, the most implanted prosthesis according to Australian and sented another example of an ankle PF that required MIPO of the tibial
British records [3,4], preferring the stemless implant in view of some shaft and ORIF4 of the distal fibular shaft [20].
evidence of a higher frequency of post-traumatic PF in stem models These authors state that 9 previous cases had been reported at the
[15,16]. time (2016) and our search could not find any other published cases,
Furthermore, even considering the increasing survivorship of avail­ only an abstract of a procedure reporting a series of 5 PF of the talus
able models, implant registries show a gradual decline in TAR survival [11].
between 5 and 19 years [17]. Our case differs from the others because we had to revise the tibial
In planning the revision surgery, we decided to reduce and synthe­ component while stabilizing the medial malleolar fracture. To the best
size the medial malleolus, but also to revise the tibial component, using of our knowledge, this is the first documented case of revision from an
an Inbone II prosthesis with a stem to be housed in the tibia for a “better Infinity implant without stem to an Inbone II with stem. Although there
grip” on the bone tissue away from the fracture site. We were able to is probably no single PF that is identical to another, we think it is
achieve stable fixation of the medial malleolus through the open interesting to share it, as it may be a source of inspiration for surgeons
reduction and internal fixation (ORIF)4 with the same incision, which dealing with similarly complex cases.
reduced surgical invasiveness and operative time while minimizing the In conclusion, we have reported a solution to an uncommon but
risk of infection. Given the amount of bone loss in the distal tibia, we potentially disruptive postoperative complication after TAR. Only a few
added cement around the distal tibial implant interface to fill in the gaps cases of reported ankle PF exist, and none of them were similar to ours.
and achieve stronger fixation in the short term. Since revision arthro­ Two features contribute to the uniqueness of this case and make it
plasty generally carries a high risk of infectious complications, a high- worthy of publication. First, this type of fracture was predicted by
loading dual antibiotic bone cement (1 g gentamicin +1 g clindamy­ Manegold’s classification, but no similar cases were reported in the
cin) with a broad spectrum of activity against approximately 90 % of original series. Second, there is no published precedent for this revision
clinically relevant pathogens and a rapid achievement of effective in situ approach from a stemless tibial implant to one with a stem without
concentrations was applied. changing the talar implant. However, as with new implants and

Fig. 4. One-year clinical follow-up after revision showing good implant motility and stability.

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