Traumatic Periprosthetic Fractures Following Total Ankle Replacement: A Systematic Review and Proposed Classification

Total ankle replacements (TAR) are increasingly utilized, but postoperative traumatic periprosthetic fractures remain a rare yet challenging complication. This systematic review aims to address the gap in literature by proposing a comprehensive classification system for these fractures, considering implant stability, fracture location, and surrounding bone quality. A systematic review identified 13 cases from 9 studies meeting inclusion criteria. Fractures were categorized using the proposed Hill-Brown classification: Type A (talus or fibula), Type B (distal tibial component), and Type C (diaphysis/proximal tibial metaphysis). Implant stability was a key factor, with Type B fractures further classified as B1 (stable), B2 (unstable with adequate bone stock), and B3 (unstable with poor bone stock). Most fractures occurred at or near the distal tibial component (Type B), with implant stability largely dependent on fracture location and bone quality. Surgical fixation, particularly minimally invasive plate osteosynthesis (MIPO) with locking plates, was the preferred treatment for stable implants, showing low complication rates. Unstable implants often required revision TAR or conversion to arthrodesis. Surgical intervention is recommended following all traumatic periprosthetic fractures in the setting of a TAR. Bone quality, particularly in patients with rheumatoid arthritis or osteoporosis, significantly impacted treatment decisions. Our findings emphasize the importance of fracture location, implant stability, and bone quality in managing these fractures. Future multicenter studies are necessary to validate this classification system and refine treatment protocols.Level of Evidence: Level III.