1032 THE JOURNAL OF BONE AND JOINT SURGERY Ankle arthrodesis for failed total ankle replacement P. Hopgood, R. Kumar, P. L. R. Wood From Wrightington Hospital, Wigan, England  P. Hopgood, MSc, FRCS(Orth), Consultant Orthopaedic Surgeon Department of Orthopaedic Surgery Norfolk and Norwich University Hospital, Colney Road, Norwich NR4 7YZ, UK.  R. Kumar, FRCS(Orth), Consultant Orthopaedic Surgeon Department of Orthopaedic Surgery Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston PR2 9HT, UK.  P. L. R. Wood, FRCS, Consultant Orthopaedic Surgeon Department of Orthopaedic Surgery Wrightington Hospital, Wigan WN6 9EP, UK. Correspondence should be sent to Mr P. L. R. Wood; e-mail: peter.wood@wwl.nhs.uk ©2006 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.88B8. 17627 $2.00 J Bone Joint Surg [Br] 2006;88-B:1032-8. Received 9 January 2006; Accepted after revision 31 March 2006 Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience. The improvement in outcomes of the mobile- bearing design of total ankle replacement (TAR) 1-4 compared with those achieved with earlier designs 5,6 has led to a resurgence of interest in replacement as an alternative to arthrodesis in some patients. However, TAR can fail because of infection, mechanical fail- ure or aseptic loosening. Aseptic loosening may be associated with extensive bone loss, especially when the bone is osteoporotic, as is frequently the case in rheumatoid arthritis (RA) (Fig. 1). The shape of the talus, in particular the absence of a shaft, means that there is very little bone available for fixation of a revision component following a failed ankle replace- ment. Nevertheless, some surgeons advocate con- version to another replacement. 7,8 In 1982 Stauffer 9 had poor results with the reinsertion of prosthetic components and recommended fusion using an iliac crest bone block and an external compression device. Other surgeons have described various techniques of fusion using either internal or external fixation. 10-13 We describe our experience with tibiotalar and tibiotalocalcaneal arthrodesis using internal fixation for the management of failed TAR in patients with RA or osteoarthritis (OA). Patients and Methods Between 1999 and 2005 the senior author (PLRW) performed 23 arthrodeses in 22 patients (13 men, nine women) who had a failed TAR. Their mean age was 62 years (30 to 76). The underlying diagnosis was OA in 12 cases and RA in 11. In the OA group there were eight Scandinavian total ankle replace- ments (STAR) (Waldemar Link, Hamburg, Germany) and four Buechel Pappas (BP) pros- theses (Endotec Inc., South Orange, New Jer- sey). In the RA group there were seven STAR, two BP and two other designs (the Liverpool and Imperial College London Hospital) that are now obsolete. Operative technique. The joints were exposed through the previous anterior incision. The implants were removed and the joints cleared of fibrous tissue and necrotic material until healthy, viable bone was exposed. In some cases the bone loss was so extensive that this initial debridement led to opening of the sub- talar joint. The tibia and talus were brought into contact with each other, albeit sometimes only over a small area such as the neck of the talus to the anterior tibia, or the medial mal- leolus to the calcaneum. With this technique, shortening was inevitable, but with one excep- tion, total excision of the malleoli was avoided in order to preserve rotational stability. The entrapment of soft tissue between the bone ends was avoided. Any healthy, resected frag- ments of bone were packed into the resulting cavity and, in addition, bone graft from the iliac crest was used in six cases and a synthetic Lower limb