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Tomasz Poboży

Infection after total ankle arthroplasty: an association with calcaneal osteotomy

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Tomasz Poboży

Polish version: Zakażenie po endoprotezie stawu skokowego — sygnał dotyczący osteotomii piętowej

Periprosthetic joint infection after total ankle arthroplasty (TAA) is uncommon but potentially serious. An analysis of 1,008 primary procedures found a strong association between concurrent calcaneal displacement osteotomy and infection. It does not prove that the osteotomy causes infection or that deformity correction should routinely be staged.

Why this study matters

TAA is less common than hip or knee arthroplasty, so individual centres have relatively few infections to analyse. Patients may have malalignment, previous surgery and a need for simultaneous corrective procedures. The study examined infection incidence, associated factors, subsequent treatment and limb and implant preservation.

Study design

This retrospective single-centre analysis included 1,008 primary TAAs performed during 2010–2023. Infection was diagnosed using previously applied microbiological and clinical criteria. Twenty-seven infections treated by four surgeons were identified, with each case matched to two controls by age and sex.

Patient characteristics, comorbidities, previous operations and procedural details were assessed. Bias-reduced logistic regression was used because infection events were sparse.

Main results

  • Infection occurred after 27/1,008 procedures (2.7%).
  • Concurrent calcaneal displacement osteotomy and a history of malignancy were significantly associated with infection.
  • After adjustment for previous ankle surgery, BMI, diabetes and tourniquet time, concurrent calcaneal osteotomy was associated with 9.75-fold higher odds of infection (95% CI 2.5–52.4).
  • Staphylococcus aureus was the most frequent organism, accounting for 36.7% of infections.
  • Eight infections (29.6%) were classified as chronic, lasting more than 4 weeks.
  • Two-stage revision was the most common surgical treatment, used in 59.3%.
  • At mean follow-up of 4.07 years, limb preservation was 96.2% and implant retention 69.2%.

Clinical interpretation for an orthopaedic surgeon

Calcaneal displacement osteotomy corrects hindfoot alignment to improve the mechanical environment for TAA. Patients requiring this correction are often more complex than those with normal alignment and isolated joint disease. The association may partly reflect greater surgical exposure, longer procedures, worse local tissues or deformity complexity. Statistical adjustment cannot fully capture these influences retrospectively.

The results support careful planning when TAA requires additional alignment correction. They justify further research into staged treatment for selected patients, but do not by themselves support recommending that strategy.

Limitations

  • The retrospective single-centre design is susceptible to confounding and local treatment-selection effects.
  • Only 27 infections occurred, producing imprecise estimates and a wide confidence interval.
  • Matching used age and sex rather than the full spectrum of deformity and procedural complexity.
  • Simultaneous and staged correction were not directly compared.
  • The reported infection-treatment outcomes do not establish superiority of two-stage revision over other strategies.

Implications for practice

TAA combined with substantial hindfoot correction warrants careful assessment of soft tissues, prior surgery, comorbidity and reconstruction extent. This study does not show that calcaneal osteotomy should be performed separately, omitted or considered an independent cause of infection. Larger multicentre cohorts and studies specifically comparing simultaneous with staged correction are needed.

References

Study reference:

  1. McCahon JAS, Thomas GM, Sherman M, Hsu A, O’Neil J, Parekh SG, Pedowitz DI. Prosthetic Joint Infection After Total Ankle Arthroplasty: A Propensity-Matched Analysis of Risk Factors and Outcomes. Foot & Ankle International. Published online 26 August 2026. DOI: 10.1177/10711007261472908. PMID: 42644599.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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