Techniques in Foot and Ankle Surgery 1(1):60–68, 2002 © 2002 Lippincott Williams & Wilkins, Inc.

, Philadelphia

T E C H N I Q U E

Arthrodesis After Failed Total

Ankle Arthroplasty
NICHOLAS B. BRUGGEMAN, M.D.
HAROLD B. KITAOKA, M.D.
Department of Orthopedics,
Mayo Clinic,
Rochester, Minnesota, U.S.A.

䡲 ABSTRACT considered for TAA. Comparison of published results is

Ankle replacement with contemporary devices may be
an effective choice for treatment of the severely arthritic
ankle in selected patients. As with any operative proce-
dure, it is necessary to adopt criteria for defining the
outcome and how to manage unsuccessful results. Sal-
vage of failed total ankle arthroplasty (TAA) is challeng-
ing due to extensive bone loss, osteopenia, disturbed soft
tissue envelope, and hindfoot pathology. A description of
operations featuring implant removal and arthrodesis for
failed TAA, including indications, preoperative plan-
ning, specific techniques, results, complications, and
postoperative management is discussed.
Keywords: ankle, arthritis, total ankle arthroplasty, fu-
sion, arthrodesis
䡲 HISTORICAL PERSPECTIVE
Operative treatment of the painful, stiff, arthritic ankle
joint includes soft tissue and bony debridement, ligamen-
tous reconstruction, corrective osteotomy, arthrodesis,
and total ankle arthroplasty (TAA).1 Implant arthroplasty
of the ankle has been performed since the 1970s as an
alternative to primary arthrodesis with varying degrees
of success.1 Indications for TAA include patients who
have pain and debilitation not responding to conservative
measures, with diagnosis of primary osteoarthritis, post
traumatic arthritis, and inflammatory arthritis such as
rheumatoid arthritis. Selection of patients for TAA is
critical to its success and establishing guidelines is nec-
essary. Rheumatoid arthritis patients with good bone
stock and minimal deformity appear to be good candi-
dates for TAA.2 Patients over 60 years of age with pri-
mary osteoarthritis and low functional demands may be
Address correspondence and reprint requests to Nicholas B. Bruggeman,
M.D., Department of Orthopedics, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905.
difficult because of variability in diagnosis, age, duration
of follow up, and differences in scoring. Short-term re-
sults have been promising3,4; however, long term analy-
sis have varied.5–8 A long term review of 41 cases re-
vealed a satisfactory outcome in 13 of 41 patients treated
with TAA.5 Another study reported a good result in 19%,
fair in 34%, poor in 11%, and failure defined as removal
on implant in 36%. A study in patients with RA as the
diagnosis reported a satisfactory result in 83% at an av-
erage of 5.6 years.8
Potential complications of TAA have been described
and are numerous.3,9 These complications resulted in re-
operation in as many as 38% of patients in one study,5
and removal of the prosthesis in 36% of patients in an-
other study.6 Problems may arise due to patient selection
and intraoperative complications with exposure, and
malpositioning or sizing of prosthesis. Postoperative
complications can occur early or late. Early complica-
tions include wound healing, syndesmotic nonunions (in
operations requiring syndesmotic fusion), swelling, in-
fection, and deep venous thrombosis. Late complications
include loosening of the prosthesis, loss of dorsiflexion,
deep infection reported in 3–5%,3,5 subsidence (Fig. 1),
polyethylene wear, impingement, dislocation, fractures,
heterotopic bone, peroneal impingement, and others.1,3,9
It is important to adopt criteria for defining implant
loosening. In 1996, Kitaoka defined loosening of an
ankle prosthesis. Definite loosening was characterized by
obvious migration of one or both components. Probable
loosening was defined as a continuous radiolucent line
surrounding the entire cement-bone interface but with no
evidence of migration. Possible loosening defined by a
radiolucent line extending along at least one half, but less
than the entire cement bone interface. Migration was
defined as any discernable change in the position of a
component.6 By these definitions, 8% of tibial compo-
nents, and 57% of talar components were loose. There
was no association with radiographic loosening and

60 Techniques in Foot and Ankle Surgery DOI: 10.1097/01.BTF.0000027332.16991.89

 Arthrodesis After Failed Total Ankle Arthroplasty
FIG. 1. Lateral radiograph demonstrates subsidence of
talar component into the subtalar joint. (Copyright, Mayo
Foundation, Rochester, MN.)
clinical outcome.6 Another study noted methods for de-
termining migration and loosening based on determina-
tion of the center of rotation of the prosthesis, and
changes between the center of rotation and fixed loca-
tions on the calcaneus and distal tibia.8 Rotational
changes in the position of the talar component in refer-
ence to the calcaneus were also considered. This study
described radiolucent zones of the implant-cement and
cement-bone interfaces that correspond to landmarks on
the prosthesis.8 A grading system was applied to the
zones. Grade I was less than 1 mm radiolucency. Grade
II had 1–2 mm lucency, and grade III had 2 mm or
greater lucency.8 There was a lack of clinical correlation
with radiographic analysis in this study.8
Management of complications involves nonoperative
and operative means. Nonoperative treatment is recom-
mended for stress fractures of the tibia or fibula. Persis-
tent hindfoot pain can be treated with an orthotic device
such as an ankle foot orthosis. Operative management is
based on the specific problem and may consist of revi-
sion arthroplasty in cases with no evidence of infection,
good bone stock, failure due to correctable technical
Volume 1, Issue 1
problems, and a compliant patient.10 This method of sal-
vage has not been a routine approach in most series.
Decompression of symptomatic bony impingement of
either or both malleoli may be performed. Fixation of
unstable or displaced malleolar fracture is another option
for salvage with retention of the components. Skin graft-
ing may be used to cover superficial wound necrosis;
however, significant soft tissue loss may be treated with
local rotation flaps or free tissue transfer. Rarely, ampu-
tation has been used to treat severe complications of
infection and soft tissue necrosis. The standard treatment
of failed TAA is removal of the prosthesis and arthrod-
esis.3,5,12,13
䡲 INDICATIONS/CONTRAINDICATIONS
Salvage of failed TAA is challenging because of the
large bony deficit and poor quality of the soft tissue
envelope. Other factors such as subtalar stiffness, and
arthrosis also contribute to the difficulty with manage-
ment. Indications for implant removal and arthrodesis
include pain and impairment due to aseptic loosening of
the TAA in patients who fail nonoperative efforts.2
Contraindication to implant removal and arthrodesis
include acute infection, which requires a staged proce-
dure such as debridement with antibiotic impregnated
spacer and intravenous antibiotics before fusion. Vascu-
lar assessment should be performed before any operative
procedure. Patient compliance issues should be clarified
before proceeding with arthrodesis.
Preoperative Planning
The patient with persistent or recurrent pain following
implant surgery should undergo a careful history and
physical examination. The duration, location, quality, se-
verity of pain should be determined. Any early postop-
erative problems such as delayed wound healing persis-
tent drainage should be determined. The level of
impairment in daily activities is important in considering
treatment. Review of systems may be helpful to deter-
mine causes of lower extremity pain such as ischemic
claudication, neurogenic pain, or infection. Examination
should include a general musculoskeletal exam, includ-
ing neurologic and vascular exam. The patient’s gait
should be examined. Skin condition including prior in-
cisions should be considered in the planning of any sub-
sequent procedure. Erythema, warmth, or drainage
should be documented. Range of ankle and hindfoot mo-
tion and pain with motion are important to determine the
cause of pain. Examination while standing is important
to assess alignment and leg length discrepancy.
Plain film radiographs are reviewed for determining
extremity alignment, subtalar joint disease, bone loss,
bone quality, and location and size of the implant. It is
61
 N. B. Bruggeman and H. B. Kitaoka
important to obtain weightbearing AP ankle, weightbear-
ing lateral ankle, and mortise views, as well weightbear-
ing AP foot, weightbearing lateral foot, and oblique foot
views. Loosening and migration of the prosthesis should
be noted as discussed previously. The condition of the
subtalar joint is important in preoperative evaluation. A
symptomatic, arthritic subtalar joint may require arthrod-
esis. If the subtalar joint is in good condition, fixation
across it should generally be avoided.
The patient should undergo evaluation with appro-
priate laboratory studies to determine if the arthroplasty
is associated with sepsis. Determination of sepsis can
often be made based upon history and exam. There is
data available for infection after other joint arthroplas-
ties,11 which is relevant to TAA laboratory studies, in-
cluding complete blood count with white blood cell
count. This test should be performed, although following
other joint arthroplasty operations only 15% of patients
with infected prostheses had leukocytosis.11 Erythrocyte
sedimentation rate (ESR or sed rate) values of greater
than 30 to 35 mm per hour are considered abnormal and
indicative of infection unless proved otherwise.11 While
the ESR is a nonspecific test, when used in conjunction
with history and physical exam, it can be helpful. C-
reactive protein (CRP) has been used as an acute phase
reactant, and a nonspecific indicator of inflammation.
The CRP has been shown to be more sensitive and spe-
cific than ESR for infection after joint arthroplasty.11
CRP levels of greater than 10 mg/l are considered ab-
normal. While neither study is diagnostic of infection
alone, a combination of ESR and CRP may improve
accuracy of diagnosis.
Radiographic studies are helpful in the diagnosis of
infection after arthroplasty. Determination of loosening
of a prosthesis on plain films can be an indication of deep
sepsis. Magnetic resonance imaging is usually not appli-
cable due to artifact from the metal components, and is
not recommended. Other options include the technetium-
99m bone scan. This study may be helpful; however, it is
considered sensitive but not specific for infection. Mul-
tiple conditions, such as fractures, tumors, heterotopic
ossification, and inflammatory disorders result in in-
creased uptake in periprosthetic tissues.11 Another study
available is the white blood cell (WBC) tagged indium
scan. The indium scan offered improved specificity, es-
pecially when used in combination with technetium
scans in patients following hip and knee arthroplasty.11
Preoperative aspiration of the ankle for culture can be
performed prior to proceeding with surgery, if sepsis is a
diagnostic consideration. Standard aerobic, anaerobic,
and fungal culture with sensitivities should be performed
on specimens obtained through aspiration. The results of
this test will be improved by stopping antibiotics 2–3
weeks before aspiration. Local anesthetics prior to aspi-
62 Techniques in Foot and Ankle Surgery
ration should only be used on the skin as they are bac-
teriostatic and may alter growth of bacteria.11
In cases where the determination of the cause of pain
is uncertain, a bone scan may be helpful. Again, this
study is very nonspecific, but may clarify the location of
pathology. Selective injections of the ankle joint, areas of
impingement, or the subtalar joint may be both diagnos-
tic and therapeutic.
After the diagnosis of failed arthroplasty is made,
optimum treatment of the specific patient should be de-
termined. In some instances of aseptic loosening, there is
a role for nonoperative treatment such as long-term use
of an ankle-foot orthosis. Operative treatment could be
considered, such as implant removal and arthrodesis
(Figure 2, 3). A general medical evaluation prior to sur-
gery is needed. Postoperative management should be dis-
cussed and compliance should be determined.
䡲 TECHNIQUE
Chuinard and Peterson14 described an ankle arthrodesis
technique featuring a corticocancellous block of iliac
crest interposed between the resected tibial and talar
bone surfaces15 (Fig. 3). In the original description of the
procedures, no fixation was used due to soft tissue com-
pression secondary to distraction during the procedure.
Because of the interposed graft, this procedure does not
further shorten the limb. A modification to this procedure
was proposed by Stauffer,12 in which external fixation
was used specifically for patients with failed TAA.
The patient is placed supine on the operating table.
After anesthesia is administered, the lower extremity and
the ipsilateral hip should be prepared and draped. If sep-
sis remains a question, prophylactic antibiotics should
not be given until tissue from the ankle is obtained for
pathology and deep cultures. The prior incision may be
used, which often is anterior. Another option, if the soft
tissue envelope permits (i.e., quality of skin and distance
from prior incision), is to use medial and lateral inci-
sions. If the old incision is used, care should be taken to
make full thickness flaps to lessen the potential for skin
necrosis. The anterior soft tissue structures at risk for
injury include the deep peroneal nerve, anterior tibialis
tendon, extensor hallucis tendon, as well as branches of
the superficial peroneal nerve. The exposure may be dif-
ficult due to distorted anatomy, and adhesions. The soft
tissues should be elevated off the tibia. After exposure of
the joint, specimens should be sent for culture. Speci-
mens may also be sent to pathology for evaluation of
acute inflammation. Values greater than 5 polymorpho-
nuclear leukocytes (PMN) per high power field has been
used as a sign of infection in total hip arthroplasty.19 If
the intraoperative pathology is negative the case may
 Arthrodesis After Failed Total Ankle Arthroplasty

FIG. 2. (A) Drawing of failed arthro-

plasty showing loosening, subsidence,
malleolar impingement, and shortening.
(B) Implant components and cement
removed, leaving large central defect.
(Copyright, Mayo Foundation, Roches-
ter, MN.)

proceed as planned, recognizing that cultures are more including removal of the implant and cement, as well as
definitive for infection. all nonviable bone and scar tissue. After debridement, a
If pathology is suggestive of infection, and gross generous volume of crystalloid fluid should be used for
findings correlate, joint debridement must be performed irrigation. An antibiotic-impregnated methylmethacra-

Volume 1, Issue 1 63
 N. B. Bruggeman and H. B. Kitaoka

FIG. 3. Techniques of ankle arthrodesis for failed arthroplasty. (A) Malleolar resection. (B) Modified Chuinard arthrodesis.
(C) Modified Campbell arthrodesis. (D) Posterior tibiotalocalcaneal arthrodesis. (Copyright, Mayo Foundation, Rochester,
MN.)

64 Techniques in Foot and Ankle Surgery

 Arthrodesis After Failed Total Ankle Arthroplasty
late bead or spacer can be placed into the defect. There
are different protocols available for preparing the antibi-
otic cement; the type and concentration of antibiotic can
be varied depending upon the specific patient. One op-
tion is 1.0 g of vancomycin and 1.2 g of gentamycin for
one-half batch of cement. Higher concentrations of an-
tibiotics have been used successfully. The severity of
necrotic tissue may warrant a further debridement in 2–4
days. Appropriate intravenous antibiotics should be ad-
ministered for 4–6 weeks, initially empirically, then
based upon cultures and sensitivities. Laboratory studies
can be followed to document resolution of inflammation
such as CRP. Adequate treatment of infection should be
used prior to attempts at arthrodesis.
In cases where pathology is negative for infection,
the procedure can continue as planned. The components
should be removed. An effort should be made to preserve
as much bone as possible, as poor bone stock is a concern
for any successful arthrodesis technique.
After removal of the implants and cement (Fig. 2), a
tricortical block of iliac crest is placed horizontally into
the defect to act as a spacer. The method for obtaining
the graft is obtained by making an incision along the
subcutaneous border of the iliac crest. The dissection
should be taken down to the bone and should be sub-
periosteal. The gluteal muscles should be dissected off
the inferior table of the ilium and the trunk muscles, as
well as the iliacus muscle, should be dissected off the
superior ilium. A saw or osteotome may be used to re-
move the graft, which should be measured to fit the
defect. After the graft is removed, a curette can be used
to remove more cancellous bone from the pelvis. Bone
wax or Gelfoam can be placed into the defect to avoid
excessive bleeding. A drain is placed before closure.16
After placement of the graft, alignment is adjusted
and maintained temporarily by a percutaneous longitu-
dinal Steinmann pin through the heel, directed into the
tibia. Additional cancellous graft is packed around the
tricortical graft. The external fixator should then be
placed. Numerous options for type of external fixation
are available, including the Ace-Fischer (DePuy Ace
Medical Company, El Segundo, CA), the EBI Dynafix
ankle fixator (EBI Medical Systems, Parsippany, NJ), the
Calandruccio triangular compression device (Smith and
Nephew, Memphis, TN), the Orthofix fixator (Richard-
son, TX), and others. Most of these systems are modular
and the specific frame construction and pin placement
can be tailored to the patient. Some are uniaxial and thus
have a lower profile. While internal fixation may be suc-
cessfully applied, the small talar bone stock following
implant loosening may not allow adequate purchase for
screw fixation.
The Ace Fisher frame consists of partial rings con-
nected by bars that compress the joint. The talar pins are
Volume 1, Issue 1
transfixing (full) pins, with one placed transversely
through the talar body and one through the neck. The
talar pins should be drilled from medial to lateral to
avoid neurovascular injury. After the first hole is drilled,
the centrally threaded transfixing pin is placed in the
talar body. A 2-pin holder is placed as a guide for the
second pin. The second hole is drilled in the talar neck,
the pin is placed, and the 2-pin holders are attached to a
2/3 ring. If fixation across the subtalar joint is needed,
these pins are placed into the calcaneus, from medial to
lateral, and are connected to the 2/3 ring. The ring is
placed anterior to the ankle, although some prefer plac-
ing it laterally.
The short connecting rods are applied to the distal
ring and tibial pins placed at about the mid tibial level.
The first tibial half pin is placed, making a 0.5 to 1 cm
incision through the skin, and introducing the sheath and
trochar onto the anteromedial tibia. The trochar is re-
moved and both tibial cortices are drilled in a plane
parallel to the ankle joint line. A half pin is placed. A
2-pin holder is placed onto the pin so that a 1/3 ring
segment may be attached to the pin, with the ring on the
anterior aspect of the leg. The ring should be spaced to
allow room for swelling. The 2-pin holder is used as a
drill guide for the next half pin. A third half pin can be
placed on the side of the ring opposite the first 2 pins
(either above or below) in the anterolateral tibia. The pin
should be placed roughly perpendicular to the other 2
tibial half pins.
The proximal and distal rings are attached to each
other by four connecting rods. The position and align-
ment of the arthrodesis, as well bony apposition and
hardware placement, must be assessed visually and ra-
diologically. If satisfactory, bolts are tightened. The con-
necting rods are used to apply compression to the ar-
throdesis. The Steinmann pin is then removed. A drain
can be placed. A meticulous wound closure with gentle
handling of the soft tissues is important to lessen the
potential for skin necrosis. A compressive dressing is
applied. Immediate elevation of the leg is important. The
advantage of the modified Chuinard procedure includes
good preservation of length, which is beneficial for leg
length and tendon function15 (Figures 4, 5).
Malleolar resection arthrodesis is a simpler technique
of ankle arthrodesis for a failed TAA (Fig. 3). This pro-
cedure involves implant and cement removal, as well as
resection of the margins of the tibia, talus, and fibula to
achieve satisfactory bone apposition. Supplemental bone
graft can be placed; however, no interpositional graft is
placed. Rigid external or internal fixation is then applied.
If internal fixation is used, it is important to avoid place-
ment of hardware into the subtalar joint. The advantages
of this procedure are the greater direct bony apposition
65
 N. B. Bruggeman and H. B. Kitaoka

FIG. 4. A 57-year-old male carpenter had a painful total ankle arthroplasty. (A) Preoperative radiograph. (B) Immediately
after implant removal and modified Chuinard procedure with external fixation. (C) Three years later, the patient had no
significant pain, returned to work without functional restrictions. (D) Lateral radiograph shows good alignment and pres-
ervation of ankle height. (Copyright, Mayo Foundation, Rochester, MN.)

achieved without structural graft, which adds to the po-
tential for rapid union. Malleolar resection is useful in
the treatment of failed TAA with history of sepsis where
avascular bone graft is less attractive. The disadvantage
of this procedure is the degree of shortening caused by
resection. Shortening can contribute to leg length dis-
crepancy and tendon dysfunction.16
The modified Campbell arthrodesis technique in-
volves vertically oriented struts of tricortical iliac crest
bone graft inserted into a rectangular shaped mortise
(Fig. 3). The mortise created by osteotomies in the origi-
nal report17 is similar to the gap created by removal of an
ankle implant. Morcellated corticocancellous graft is
then placed around the struts, and an external fixator is
applied in compression. This procedure is useful in large
defects. The procedure, like the modified Chuinard pro-
cedure, does require a separate incision for iliac crest
harvesting.16
Posterior tibiotalocalcaneal arthrodesis (Fig. 3) is a
procedure described by Russotti et al.18 It is an operation
involving fusion of both the tibiotalar and the subtalar
levels for patients with failed TAA and hindfoot disease
requiring arthrodesis. This procedure is considered when
the talar component has subsided into the subtalar joint,
in cases of severe talar bone loss, and subtalar arthrosis.
The patient must be placed prone on the operating table.
A longitudinal incision is made on the lateral border of
the Achilles tendon. The tendon is transected and the

66 Techniques in Foot and Ankle Surgery

 Arthrodesis After Failed Total Ankle Arthroplasty

FIG. 5. Radiographs of a 41-year-old man with a painful ankle after total ankle arthroplasty. (A) Anteroposterior (AP) view
shows loosening, subsidence and malleolar impingement. (B) Lateral radiograph. (C) AP view 14.5 years after successful
modified Chuinard operation with external fixation. (D) Lateral view. (Copyright, Mayo Foundation, Rochester, MN.)

ankle and subtalar joints are exposed through the interval
between the flexor hallucis longus tendon medially and
peroneus brevis tendon laterally. The implant and cement
are removed and a trough is created in the posterior tibia,
talus, and calcaneus. Morcellated iliac crest bone graft is
packed into the trough and an external fixator is applied.
Posterior tibiotalocalcaneal arthrodesis procedure has the
advantage of using a posterolateral approach in which
the soft tissue envelope is less disturbed. This procedure
also requires a separate incision for iliac crest graft.15
Regardless of the procedure chosen, care should be
taken to plan incisions based on prior incisions and con-
sider the condition of soft tissues. Full thickness flaps
should be created. Excessive traction on the skin should
be avoided and this may require longer incisions. A me-
ticulous closure is very important. With good attention to
soft tissues, risk of wound necrosis can be decreased.
The positioning of the ankle arthrodesis should ad-
here to the principles outlined by Morrey et al.19 The
ankle should be placed in neutral flexion, zero to 5 de-
grees of valgus angulation of the hindfoot and 5 to 10
degrees of external rotation. This position allows the
greatest compensatory motion at the foot and places less
strain on the knee.19

Volume 1, Issue 1 67
 N. B. Bruggeman and H. B. Kitaoka
䡲 POSTOPERATIVE MANAGEMENT
Postoperative treatment with external fixation methods
requires removal of the fixator at the 8 to 12 weeks
postoperatively. The ankle is immobilized in a short leg
cast for an additional 1 to 3 months.15
䡲 RESULTS
Results of arthrodesis after failed TAA have been pub-
lished. In one series of 11 cases that were treated with a
modified Chuinard arthrodesis, all achieved bony union.
Nine of 11 were rated as good, one case was rated as
poor because of undiagnosed pain, and one rated fair due
to subtalar pain.10 Another study reported 17 ankles that
underwent revision and arthrodesis. Five of these were
done for infection, 11 for loose prosthesis, and one for
continued pain. Each of these had a solid fusion. Sixteen
were rated as good. One was fair secondary to subtalar
joint pathology. This study used the modified Chuinard
arthrodesis.12
The largest series of arthrodesis for failed TAA was
reported by Kitaoka and Romness,20 in which 38 ankles
underwent surgery. Patients were followed for an aver-
age of 8.3 years after revision. The cause of failure was
infection in six ankles, avascular necrosis in one, neuro-
pathic arthropathy in one, major ankle trauma in one, and
undetermined in the remainder. Patient age was less than
60 at the time of arthroplasty in 69%. These patients
underwent salvage of the failed TAA 3.5 years after the
arthroplasty on average. Four fusion techniques previ-
ously described were used. Malleolar resection was per-
formed in 13 ankles, the modified Chuinard procedure
was performed in 18 ankles, the modified Campbell op-
eration was used in 2 ankles, and a posterior tibiotalo-
calcaneal arthrodesis was used in 5. Fusion was at-
tempted at the ankle level in 30 and the ankle and
subtalar joint in 8. At the completion of this study, union
was obtained in 33 of 37 ankles. All patients in whom the
modified Chuinard procedure was performed resulted in
union. Clinical results were available for 31 ankles. Pa-
tients were satisfied with results in 24, satisfied with
reservations in 4, and dissatisfied in 3.
䡲 COMPLICATIONS
Potential complications of arthrodesis include nonunion,
infection, donor site morbidity, pin site complications,
wound necrosis, fracture, and others. Kitaoka and Rom-
ness reported perioperative complications in 5 of 38
ankles (13%).20 One of these was an avulsion fracture of
the anterior superior iliac spine, and one included ongo-
ing infection after a malleolar resection fusion in a pa-
tient with rheumatoid arthritis and failed TAA due to
deep sepsis. A superficial ulcer was noted in one patient
and a tibial stress fracture as a result of the external
68 Techniques in Foot and Ankle Surgery
fixator occurred. Nonunion requiring reoperation oc-
curred in one patient.
䡲 REFERENCES
1. Nuefeld S, Lee T. Total ankle arthroplasty: indication, re-
sults, and biomechanical rationale. Am J of Orthop
2000;593–602.
2. Kitaoka HB, Johnson KA. Ankle replacement arthroplasty.
In: Morrey ed. Reconstructive Surgery of the Joints. 2nd ed.
Churchill-Livingstone. 1996:1757–1769.
3. Stauffer RN, Segal MN. Total ankle arthroplasty: four
years experience. Clin Orthop 1981;160:217.
4. Pyevich MT, Saltzman CL, Callaghan JJ, et al. Total ankle
arthroplasty: a unique design: two to twelve year follow
up. J BoneJoint Surg 1998;80A: 1410–1420.
5. Bolton-Maggs BG, Sudlow RA, Freeman MA. Total ankle
arthroplasty: a long term review of the London hospital
experience. J Bone Joint Surg 1985;67B:785.
6. Kitaoka HB, Patzer GL. Clinical results of the mayo total
ankle arthroplasty. J Bone Joint Surg 1996;78A(11):1658–
1664.
7. Kitaoka HB, Patzer GL, Ilstrup DM, et al. Survivorship
analysis of the mayo total ankle arthroplasty. J Bone Joint
Surg 1994;76A:974.
8. Unger AS, Cluglis AE, Mow CS, et al. Total ankle arthro-
plasty in rheumatoid arthritis: a long term follow-up study.
Foot Ankle Int 1988;8:173.
9. Conti SF, Wong YS. Complications of total ankle arthro-
plasty. Clin Orthop 2001;391(1);105–114.
10. Groth HE, Fitch HF. Salvage procedures for complications
of total ankle arthroplasty. Clin Orthop1987;224:244.
11. Spengehl MJ, et al. Diagnosis on infection following total
hip arthroplasty. AAOS Instr Course Lect 1998;47:285.
12. Stauffer RN. Salvage of painful total ankle arthroplasty.
Clin Orthop 1982;170:184.
13. Newton SE. Total ankle arthroplasty: clinical study of fifty
cases. J Bone Joint Surg 1982;64A:104.
14. Chuinard EG, Peterson RE. Distraction-compression bone
graft arthrodesis of the ankle: a method especially appli-
cable in children. J Bone Joint Surg 1963;45A:481.
15. Kitaoka HB. Fusion techniques for failed ankle arthro-
plasty. Semin Arthoplasty 1992;3:51.
16. Crenshaw AH. Surgical techniques and approaches. In:
Canale ST ed. Campbell’s Operative Orthopaedics. 9th ed.
Mosby 1998.
17. Campbell CJ, Rinehart WT, Kalenak A. Arthrodesis of the
ankle: deep autogenous inlay grafts with maximum can-
cellous-bone apposition. J Bone Joint Surg 1974;56A:63.
18. Russoti GM, Johnson KA, Cass JR. Tibiotalocalcaneal ar-
throdesis for arthritis and deformity of the hind part of the
foot. J Bone Joint Surg 1988;70A:1304.
19. Buck P, Morrey BF, Chao EYS. The optimum position of
arthrodesis of the ankle: a gait analysis study of the knee
and ankle. J Bone Joint Surg 1987;69A:1052.
20. Kitaoka HB, Romness DW. Arthrodesis for failed ankle
arthroplasty. J Arthroplasty 1992;7:277.