BlueCross BlueShield of Tennessee Medical Policy Manual

Total Ankle Replacement

DESCRIPTION

Total ankle replacement (TAR), also known as ankle arthroplasty, is the replacement of an injured ankle joint with an artificial joint.  TAR has been used as an alternative to tibiotalar fusion (arthrodesis) in individuals with debilitating end-stage arthritis, loss of ankle function, and pain that is refractory to conservative treatment.

Ankle fusion involves the removal of the articular surfaces of the ankle joint and the fusion of the tibia bone to the talus bone.  A fused ankle prevents flexion and extension of the foot and limits side-to-side motion.  TAR aims to relieve pain without limiting the ankle’s range of motion or affecting the other leg joints.

A variety of total ankle replacement (TAR) system designs, including fixed-bearing and mobile-bearing, have received FDA approval for the management of moderate-to-severe tibiotalar pain.  The fixed-bearing devices are implanted with cement fixation (e.g., the Agility™ LP Total Ankle Replacement System; the Topez Total Ankle Replacement; the Eclipse Total Ankle Implant; the Inbone™ Total Ankle System; the Salto Talaris Total Ankle Prosthesis; the Infinity™ Total Ankle System).  The mobile-bearing Scandinavian Total Ankle Replacement (STAR® system) is indicated for use as a noncemented implant and relies on bearings that move across a surface of polyethylene, a flexible plastic.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Published evidence of well-designed studies in peer review journals and randomized controlled trials with long-term follow-up are not available for other conditions/diseases.

SOURCES

American College of Foot and Ankle Surgeons (ACFAS). (2013, July). ACFAS position statement on total ankle replacement surgery. Retrieved June 30, 2015 from http://www.acfas.org/Health-Policy-and-Advocate/Policy-Statements/Position-Statements.

American Orthopaedic Foot & Ankle Society. (2014, March). Position statement: the use of total ankle replacement for the treatment of arthritic conditions of the ankle. Retrieved July 2, 2015 from http://www.aofas.org/medical-community/health-policy/Documents/Total-Ankle-Replacement-Position-Statement-3-2014-FINAL.pdf.

Pederson, E., Pinsker, E., Younger, A.S., Penner, M.J., Wing, K.J., Dryden, P.J., et al.  (2014). Outcome of total ankle arthroplasty in patients with rheumatoid arthritis and noninflammatory arthritis. A multicenter cohort study comparing clinical outcome and safety. The Journal of Bone & Joint Surgery, 96 (21), 1768-1775. Abstract retrieved July 1, 2015 from PubMed database.

Preis, M., Bailey, T., Jacxsens, M., & Barg, A. (2017). Total ankle replacement in patients with haemophilic arthropathy: primary arthroplasty and conversion of painful ankle arthrodesis to arthroplasty. Haemophilia, 2017 Mar 17. Doi:10.1111/hae.13200 [Epub ahead of print] Abstract retrieved May 2, 2017 from PubMed database.

U. S. Food and Drug Administration. (2002, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K020541. Retrieved May 15, 2012 from http://www.accessdata.fda.gov/cdrh_docs/pdf2/K020541.pdf.

U. S. Food and Drug Administration. (2005, November). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K051023. Retrieved May 15, 2012 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/K051023.pdf.

U. S. Food and Drug Administration. (2006, November). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K061749. Retrieved May 15, 2012 from http://www.accessdata.fda.gov/cdrh_docs/pdf6/K061749.pdf.

U. S. Food and Drug Administration. (2009, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K090076. Retrieved May 15, 2012 from http://www.accessdata.fda.gov/cdrh_docs/pdf9/K090076.pdf.

U. S. Food and Drug Administration. (2009, May). Center for Devices and Radiological Health. Scandinavian total ankle replacement (S.T.A.R. ankle) - P050050. Retrieved May 15, 2012 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050050b.pdf.

van Heiningen, J., Vliet Vlieland, T.P., & van der Heide, H.J. (2013). The mid-term outcome of total ankle arthroplasty and ankle fusion in rheumatoid arthritis: a systematic review. BMC Musculoskeletal Disorders, 26 (14), 306. Abstract retrieved July 1, 2015 from PubMed database.

Younger, A., Wing, K., Glazebrook, M., Daniels, T., Dryden, P., Lalonde, K., et al. (2015). Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot & Ankle International, 36 (2), 123-134. Abstract retrieved May 2, 2017 from PubMed database.

ORIGINAL EFFECTIVE DATE:  4/12/2007

MOST RECENT REVIEW DATE:  6/8/2017

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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