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HINTEGRA Total Ankle Replacement

The HINTEGRA Total Ankle Replacement (TAR) is an unconstrained, three-component system that provides inversion-eversion stability and was designed in 2000 by Beat Hintermann, Greta Dereymaeker, Ramon Viladot, and Patrice Diebold. The mobile bearing provides axial rotation and normal flexion-extension mobility.1-3 The HINTEGRA TAR includes two metallic components and an ultrahigh-density polyethylene mobile bearing. The non-articulating surfaces have a porous coating with 20% porosity and are covered by titanium fluid and hydroxyapatite.

The tibial component has a flat, 4-mm thick loading plate with pyramidal peaks against the tibia. Additional stability may be achieved by fixation with two screws. The talar component is conically shaped with a smaller radius medially than laterally, mimicking the normal anatomy of talus. It has 2.5-mm high rims on each side that ensure stable positioning and guide the anteroposterior translation of the mobile bearing. The anterior shield of this component increases primary bone support, especially in cases with weaker bone, and may prevent the adherence of scar tissue and avoid restriction of ROM in cases with arthrofibrosis.2

The HINTEGRA TAR has been used since 2000 in Europe, since 2004 in Canada and Korea, and since 2005 in Brazil.4-7 The use of this prosthesis is also documented in National Arthroplasty Registers of Finnland,8 Sweden,9 Norway,10 and New Zealand.11

In the current literature there are numerous studies addressing clinical outcome and biomechanical properties of the HINTEGRA TAR, published by the designer. In 2004, Hintermann et al published the first study reporting HINTEGRA design rationale, surgical technique, and short-term results of the first consecutive 122 ankles in 166 patients.12 All patients were reviewed at a mean follow up of 19 months. Eight ankles had to undergo revision surgery, four because of loosening of at least one component, one because of dislocation of the mobile bearing, and three for other reasons. All revisions were successful. Most patients experienced significant functional improvement postoperatively, as assessed by the AOFAS score; 68% were pain free at latest follow up. The clinically and radiographically measured ROM was 39° and 37°, respectively. Tibial components were stable in all reviewed ankles; in two ankles a slight migration of the talar component was observed.12 Similar results were published in a study by Valderrabano and Hintermann, including 125 HINTEGRA implants.13

In 2006, Hintermann et al presented mid-term results of 271 HINTEGRA TARs performed in 261 patients between 2000 and 2004.14 The mean follow-up was 36 months with a range between 12 and 64 months. Intraoperatively, four malleolar fractures occurred, which all healed within 6 weeks. Five ankles (1.8%) had to be converted to ankle fusion. Thirteen talar and two tibial components were later revised. In total, 39 revision surgeries (eg, open arthrolysis, lengthening of Achilles tendon, ligament reconstruction) were necessary to address late postoperative complications.14

Kim et al compared the outcome and complications of HINTEGRA TAR with and without hindfoot fusion.15 In total 60 ankles with HINTEGRA implants and subtalar or triple fusion were compared to a control group of 288 ankles treated with TAR alone. The mean follow up was 39.5 months. The authors found that the clinical outcome of TAR when combined with hindfoot fusion (subtalar or triple fusion) is comparable to that of ankle replacement alone. Therefore, the authors recommended that hindfoot fusion should be performed simultaneously with TAR in cases when indicated.15

Recently, Barg et al published clinical observation studies addressing clinical and radiological outcomes in patients who underwent HINTEGRA TAR because of end-stage osteoarthritis (OA) due to hemophilia 16 or hemochromatosis.17 In both patient cohorts, favorable outcomes with significant pain relief and functional improvement were observed, demonstrating TAR as a reliable option treatment.16,17

Valderrabano et al addressed the sporting and recreational activity of patients with end-stage ankle arthritis before and ankle TAR.18 The authors recommended specific Sports Frequency Score. A clinical evaluation was performed preoperatively and at a mean follow up of 2.8 years in 147 patients (152 ankles). All patients experienced significant functional improvement as assessed by the AOFAS score. After TAR, patients with sports activities had a higher AOFAS score. The three most frequent sports activities after TAR were hiking, biking, and swimming.18

Daniels et al published their results for 32 TARs in patients with significant preoperative varus talar deformities.19 In all patients, cementless, mobile-bearing, three-part component prostheses had been used: 26 HINTEGRA, four Mobility, and two STAR implants. A satisfactory radiographic correction was obtained in the most cases (30 ankles) at a mean follow up of 17 months. In 24 ankles, additional procedures after TAR were required to obtained a plantigrade foot.19

Lee et al addressed perioperative complications of HINTEGRA TAR in their 50 initial cases.20 The same author presented two case reports addressing HINTEGRA TAR in patients following revascularization of avascular necrosis of the talar body.21 The authors stated that in patients with avascular necrosis of the talus, healing of necrotic bone by creeping substitution TAR is a valuable option.21

Kim et al described clinical outcome of TAR in 23 patients with moderate to severe varus deformity and compared results to those in 22 patients with neutral alignment.22 All patients were reviewed at a mean follow-up of 27 months and showed substantial pain relief and functional improvement in both groups as assessed by VAS and AOFAS score, respectively. Failure of the implant with conversion to ankle fusion occurred in one case in each group. The authors stated that the TAR is a valuable treatment for severe ankle OA, including patients with hindfoot misalignment. However, the appropriate additional procedures to address the deformity are necessary to obtain good clinical results including prosthesis stability and ROM.22

Recently, Bai et al compared clinical outcome and revision rate after TAR between patients with posttraumatic and primary OA.23 Sixty-seven consecutive TARs were performed using HINTEGRA prosthesis in 65 patients between 2005 and 2007. All patients were divided into two groups: posttraumatic OA group (37 ankles) and primary OA group (30 ankles). At a mean follow-up of 38 months the clinical (AOFAS score, ROM) and radiographic outcome were comparable. However, the incidence of postoperative complications was significantly higher in the posttraumatic OA group.23

Valderrabano et al published a series of studies addressing muscle biomechanics and muscle rehabilitation in patients with severe ankle OA who underwent TAR.24-27 A prospective study performed including 15 patients who were reviewed preoperatively and postoperatively in 3-month intervals up to 1 year showed that TAR surgery may improve muscle biomechanics as assessed by torque measurement and EMG intensity.24 However, in most patients the muscle rehabilitation was not complete at a follow up of 1 year.24

Müller et al used a Heidelberger foot and ankle analysis model to address the 3D kinematics and foot and ankle shape in 12 patients who underwent HINTEGRA TAR.28 The authors detected some decreased ROM after ankle replacement compared with contralateral ankles free of degenerative changes. However, these differences did not affect the gait kinematics, showing TAR may be able to preserve ROM which, in turn, may avoid or at least decelerate the degenerative changes in adjacent joints.28

Lee et al investigated static and dynamic postural balance after TAR using HINTEGRA in 30 patients and compared the results to an age- and sex-matched control group.29 The authors showed that patients who underwent TAR have a higher degree of dynamic postural imbalance. Some motor control deficits were also detected in the TAR group. The authors stated that more intensive postoperative balance training may decrease the observed deficits.29

In conclusion, the mid-term results in patients with HINTEGRA TAR are favorable.12,14 However, most clinical studies have been published by the designer. Comparable studies by independent authors and studies with longer follow-ups should be performed.

References

  1. Valderrabano,V., Pagenstert,G.I., and Hintermann,B.: Total ankle replacement - three-component prosthesis. Tech Foot & Ankle, 2:84-90, 2005.
  2. Hintermann,B. and Barg,A.: The HINTEGRA total ankle arthroplasty, in Wiesel,S.W. (ed), Operative Techniques in Orthopaedic Surgery Lippincott Williams & Wilkins, 2010, pp. 4022-4031.
  3. Hintermann,B.: Surgical techniques, in Hintermann,B. (ed), Total ankle arthroplasty: Historical overview, current concepts and future perspectives. Springer , Wien New York, 2005, pp. 105-126.
  4. Kim,B.S., Choi,W.J., Kim,Y.S., and Lee,J.W.: Total ankle replacement in moderate to severe varus deformity of the ankle. J Bone Joint Surg Br, 91:1183-1190, 2009.
  5. Gougoulias,N.E., Khanna,A., and Maffulli,N.: History and evolution in total ankle arthroplasty. Br Med Bull, 89:111-151, 2009.
  6. Goldberg,A.J., Sharp,R.J., and Cooke,P.: Ankle replacement: current practice of foot & ankle surgeons in the United kingdom. Foot Ankle Int, 30:950-954, 2009.
  7. Besse,J.L., Colombier,J.A., Asencio,J., Bonnin,M., Gaudot,F., Jarde,O., Judet,T., Maestro,M., Lemrijse,T., Leonardi,C., and Toullec,E.: Total ankle arthroplasty in France. Orthop Traumatol Surg Res, 96:291-303, 2010.
  8. Skytta,E.T., Koivu,H., Eskelinen,A., Ikavalko,M., Paavolainen,P., and Remes,V.: Total ankle replacement: a population-based study of 515 cases from the Finnish Arthroplasty Register. Acta Orthop, 81:114-118, 2010.
  9. Henricson,A., Skoog,A., and Carlsson,A.: The Swedish Ankle Arthroplasty Register: An analysis of 531 arthroplasties between 1993 and 2005. Acta Orthop, 78:569-574, 2007.
  10. Fevang,B.T., Lie,S.A., Havelin,L.I., Brun,J.G., Skredderstuen,A., and Furnes,O.: 257 ankle arthroplasties performed in Norway between 1994 and 2005. Acta Orthop, 78:575-583, 2007.
  11. Hosman,A.H., Mason,R.B., Hobbs,T., and Rothwell,A.G.: A New Zealand national joint registry review of 202 total ankle replacements followed for up to 6 years. Acta Orthop, 78:584-591, 2007
  12. Hintermann,B., Valderrabano,V., Dereymaeker,G., and Dick,W.: The HINTEGRA ankle: rationale and short-term results of 122 consecutive ankles. Clin Orthop Relat Res, 424:57-68, 2004.
  13. Valderrabano,V. and Hintermann,B.: HINTEGRA-Sprunggelenkprothese: Präliminäre Resultate der ersten 125 Fälle. Fuss Sprungg, 2:7-16, 2004.
  14. Hintermann,B., Valderrabano,V., Knupp,M., and Horisberger,M.: The HINTEGRA ankle: short- and mid-term result. Orthopade, 35:533-545, 2006.
  15. Kim,B.S., Knupp,M., Zwicky,L., Lee,J.W., and Hintermann,B.: Total ankle replacement in association with hindfoot fusion: Outcome and complications. J Bone Joint Surg Br, 92:1540-1547, 2010.
  16. Barg,A., Elsner,A., Hefti,D., and Hintermann,B.: Haemophilic arthropathy of the ankle treated by total ankle replacement: a case series. Haemophilia, 16:647-655, 7-1-2010.
  17. Barg,A., Elsner,A., Hefti,D., and Hintermann,B.: Total Ankle Arthroplasty in Patients with Hereditary Hemochromatosis. Clin Orthop Relat Res, 7-28-2010.
  18. Valderrabano,V., Pagenstert,G., Horisberger,M., Knupp,M., and Hintermann,B.: Sports and recreation activity of ankle arthritis patients before and after total ankle replacement. Am J Sports Med, 34:993-999, 2006.
  19. Daniels,T.R., Cadden,A.R., and Lim,K.: Correction of varus talar deformities in ankle joint replacement. Oper Tech Orthop, 18:282-286, 2008.
  20. Lee,K.B., Cho,S.G., Hur,C.I., and Yoon,T.R.: Perioperative complications of HINTEGRA total ankle replacement: our initial 50 cases. Foot Ankle Int, 29:978-984, 2008
  21. Lee,K.B., Cho,S.G., Jung,S.T., and Kim,M.S.: Total ankle arthroplasty following revascularization of avascular necrosis of the talar body: two case reports and literature review. Foot Ankle Int, 29:852-858, 2008.
  22. Kim,B.S., Choi,W.J., Kim,Y.S., and Lee,J.W.: Total ankle replacement in moderate to severe varus deformity of the ankle. J Bone Joint Surg Br, 91:1183-1190, 2009.
  23. Bai,L.B., Lee,K.B., Song,E.K., Yoon,T.R., and Seon,J.K.: Total ankle arthroplasty outcome comparison for post-traumatic and primary osteoarthritis. Foot Ankle Int, 31:1048-1056, 2010.
  24. Valderrabano,V., Nigg,B.M., von,T., V, Frank,C.B., and Hintermann,B.: J. Leonard Goldner Award 2006. Total ankle replacement in ankle osteoarthritis: an analysis of muscle rehabilitation. Foot Ankle Int, 28:281-291, 2007.
  25. Valderrabano,V., von Tscharner,V., Nigg,B.M., Goepfert,B., Frank,C.B., and Hintermann,B.: Unterschenkel-Muskelatrophie bei Arthrose des oberen Sprunggelenks und deren Rehabilitation nach Implantation einer Sprunggelenksprothese. Fuss Sprungg, 5:33-43, 2007.
  26. Valderrabano,V., Hintermann,B., von,T., V, Gopfert,B., Dick,W., and Nigg,B.M.: Muscle biomechanics in total ankle replacement. Orthopade, 35:513-520, 2006.
  27. Valderrabano,V., Nigg,B.M., von,T., V, Stefanyshyn,D.J., Goepfert,B., and Hintermann,B.: Gait analysis in ankle osteoarthritis and total ankle replacement. Clin Biomech (Bristol , Avon ), 22:894-904, 2007.
  28. Muller,S., Wolf,S., and Doderlein,L.: [Three-dimensional analysis of the foot following implantation of a HINTEGRA ankle prosthesis: evaluation with the Heidelberg foot model]. Orthopade, 35:506-512, 2006.
  29. Lee,K.B., Park,Y.H., Song,E.K., Yoon,T.R., and Jung,K.I.: Static and dynamic postural balance after successful mobile-bearing total ankle arthroplasty. Arch Phys Med Rehabil, 91:519-522, 2010.

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