Total Ankle Arthroplasty Combined with Iliac Bone Grafting for End-Stage Ankle Osteoarthritis Complicated by Giant Bone Cyst: A Case Report

Total Ankle Arthroplasty Combined with Iliac Bone Grafting for End-Stage Ankle Osteoarthritis Complicated by Giant Bone Cyst: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Total Ankle Arthroplasty Combined with Iliac Bone Grafting for End-Stage Ankle Osteoarthritis Complicated by Giant Bone Cyst: A Case Report Haining Zhang, Ying Liu, Weiqiang Pang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6819728/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Total ankle arthroplasty and iliac bone grafting in treating end-stage ankle arthritis with multiple large bone cysts are rare. There is a lack of research on the combination of total ankle arthroplasty and bone cyst treatment. However, a large number of patients with end-stage ankle arthritis often find bone cysts outside the scope of total ankle arthroplasty resection on preoperative imaging, so the impact of these lesions needs to be considered in preoperative planning. Case presentation This case report describes a 60-year-old male patient with end-stage ankle arthritis who underwent total ankle arthroplasty with a giant bone cyst of tibia, fibula, and talus (up to 3 cm in diameter) who underwent total ankle arthrodedgence with iliac bone grafting. Postoperative follow-up showed significant relief of symptoms and no signs of recurrence of cysts. Conclusion Total ankle arthroplasty combined with iliac bone grafting is an effective method for treating end-stage ankle arthritis accompanied by large bone cysts in the tibia, fibula, and talus. Simultaneous management of bone cysts during the procedure is more beneficial for optimal prosthesis placement and postoperative recovery. End-stage ankle arthritis Bone cysts Total ankle arthroplasty Iliac bone grafting Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background Ankle osteoarthritis is a common clinical disease, and patients with end-stage ankle arthritis often have severe pain, joint stiffness, and dysfunction that significantly affect their quality of life [1] . Total ankle arthroplasty is widely used in clinical practice as an effective treatment for end-stage ankle arthritis because it preserves some range of motion and maintains a relatively normal gait pattern [2] . However, patients with large bone cysts in the distal tibia and talus may face bone defects during surgery, affecting the prosthesis's stability and postoperative efficacy. There are no published reports of concurrent management of bone cysts during total ankle arthroplasty, which makes the treatment of such complex cases challenging. This article reports for the first time a case of end-stage ankle arthritis complicated with giant bone cysts of the tibia, fibula and talus (up to 3 cm in diameter) and discusses in detail the strategies and clinical effects of simultaneous treatment of giant bone cysts during total ankle arthroplasty, to provide a reference for the treatment of similar cases. Case presentation The patient, a 60-year-old male, had pain in both ankles for 8 years, and his pain symptoms had worsened significantly in the past 2 months, and his activities were restricted. Preoperative X-rays and CT scans showed bony hyperplasia at the bony articular surface margin of the left foot. The left ankle is osteoid articular sclerosis, osteophyte formation can be seen at some joint margins, bone density in the medial malleolus is uneven, and the joint space is narrow. A well-circumscribed circular hypodense shadow (about 2.5 cm in diameter) can be seen on the distal lateral side of the left tibia, corresponding to fibula compression and cortical defect. In addition, multiple small rounded hypodense opacities are seen in the distal tibia fibula and talus, with sclerotic margins .(Figure A) Figure 1 Preoperative imaging features of osseous cysts. Intraoperative exploration revealed many synovial tissue and osteophytes in the ankle joint. After osteotomy with tibia and talus osteotomy, cystic lesions were found on the distal tibia, talus and medial distal fibula, among which the tibial capsule was about 3×2×2cm, and the talus and fibula were about 1×1×1cm. (Figure B) After thoroughly scraping the diseased tissue, it is sent for routine pathological examination. A ball drill removes the diseased tissue from the cyst cavity wall until the normal cancellous bone is exposed. Subsequently, medial hyperplasia and scarring are cleaned up, and the deltoid ligament is released. The left iliac bone (5×2×1 cm) was taken from the left iliac bone to repair the bone defect, and the hyperplasia osteophytes and synovial tissue were cleaned up. After the bone defect is repaired, talus, tibial prostheses, and liners are installed. Intraoperative exploration revealed scarring and relaxation of the anterior talofibular ligament, which was reconstructed and repaired with a wire band anchor. In addition, intraoperative evaluation showed high ankle dorsal extension, so Achilles tendon lengthening was performed. (Figure B、C) Figure 2 Following intraoperative osteotomy using an osteotomy guide and bone cyst debridement, tibial and fibular bone defects were observed. Histopathological examination showed that the tibia, fibula and talus bone cysts of the left ankle joint, all three cyst walls, were characterized by fibrous tissue hyperplasia, chronic inflammatory cell infiltration and bone fragment deposition. Tibial lesions may show focal adipose tissue attachment and hemorrhage, and the inner layer of the cyst wall is not lined with cells. Synovial cell clusters and hyperplasia are present in the fibula and talus, respectively, and cartilage fragments are seen in the fibular capsule wall. Postoperatively, ankle joint function significantly improved with restoration of the mechanical axis in the affected foot. Radiographic examinations at 3 and 6 months postoperatively demonstrated stable prosthesis positioning, absence of bone cyst recurrence, and satisfactory overall recovery progress. (Figure D、E、F、J、G、H) Discussion Here, we report a list of cases in which a 60-year-old male patient underwent total ankle arthroplasty, with a large bone cyst treated at the same time as the operation. First proposed by Lord and Marotte in the 70s of the 20th century, total ankle arthroplasty is a revolutionary procedure that aims to preserve joint mobility and provide a new treatment option for patients with primary osteoarthritis, traumatic arthritis, and inflammatory arthritis in addition to traditional fusion [2] . With advances in prosthetic design, materials science, and biomechanics research, and optimization of preoperative planning, total ankle arthroplasty has become the standard treatment for end-stage ankle arthritis, with expanding indications, increasing number of beneficiaries, and posing a strong challenge to the long-standing "gold standard" ankle fusion at the expense of range of motion [3] . Studies have shown that total ankle arthroplasty significantly reduces the incidence of adjacently adjacent arthritis compared with ankle fusion, which is prone to complications such as degeneration of adjacent joints [4] . Thus, total ankle arthroplasty may be a preferred treatment strategy over ankle fusion in patients with end-stage ankle arthritis with pre-existing adjacent joint degeneration and may be a potential advantage in reducing the risk of secondary arthropathy [5] . Studies have shown that 78 percent of patients with end-stage ankle arthritis who undergo total ankle arthroplasty have bone cysts that cannot be removed entirely by prosthetic resection, and 30 percent of these lesions have a maximum diameter of ≥ 5 mm [6] . The preoperative imaging and intraoperative observations showed multiple substantial bone cysts (up to 3 cm in diameter) in the distal tibia, fibula and talus. Despite the osteotomy during the operation, there were still cystic lesions with clear boundaries, which affected the initial stability of the prosthesis and the postoperative biomechanical conduction efficiency. Therefore, simultaneous intraoperative management of bone cysts is essential for the smooth implementation of total ankle arthroplasty for patients with bone cysts. The treatment of bone cysts is also evolving with the improvement of technology and technology. Current treatment of bone cysts includes non-surgical treatment (regular testing, medical therapy) and surgical treatment (curettage, bone grafting, decompression, and combination therapy) [7] . At the same time, related studies have further confirmed that bone grafting has become a reliable treatment for periprosthetic cystic osteolysis after total ankle arthroplasty [8] . Based on the preoperative imaging evaluation, histopathological analysis and real-time assessment of the degree of intraoperative bone defect, an individualized treatment strategy was adopted in this case, and autologous iliac bone grafting was finally selected as the radical treatment method for bone cysts to realize the reconstruction of biomechanical stability of the bone-prosthesis interface, to optimize postoperative functional recovery and reduce the risk of complications. Conclusion This case is the first report of total ankle arthroplasty combined with iliac bone grafting for the treatment of end-stage ankle arthritis with giant bone cysts, which provides valuable clinical experience for similar cases. The biomechanical stability of the bone-prosthesis interface was successfully reconstructed through accurate preoperative imaging evaluation, complete curettage of cystic lesions during surgery, and repair of bone defects by autologous iliac bone grafting. Follow-up at 3 and 6 months postoperatively demonstrated significant improvement in the patient's ankle joint range of motion, stable prosthesis positioning, and no recurrence of bone cysts. This case confirms that for complex cases with residual bone cysts after osteotomy, the concurrent implementation of bone grafting can effectively solve the problem of prosthesis matching and provides an evidence-based basis for the individualized treatment of end-stage ankle arthritis complicated with bone defects. Further long-term follow-up studies are needed to evaluate prosthetic survival and long-term efficacy. Declarations Acknowledgements None. Author contributions Haining Zhang: literature search, data collection, follow-up, and writing; Weiqiang Pang: data collection, follow-up; Ying Liu: supervision, revision, and final approval. Funding No external funding sources were used. Data availability No datasets were generated or analysed during the current study. Ethical approval and consent to participate This case report was approved by the Research Ethics Committee of the Binzhou Medical University Hospital (Reference number: LW-108). All procedures involving human participants in this study conformed to the ethical standards of the institutional and/or national research councils as well as the 1964 Declaration of Helsinki and its subsequent amendments or similar ethical standards. Written informed consent were obtained from the patient and/or guardian's of all patients for publication of this case report. Consent for publication Written informed consent for publication of their therapeutic images was obtained from the patients. Competing interests The authors declare no competing interests. References Anastasio AT, Lau B, Adams S, Ankle Osteoarthritis. J Am Acad Orthop Surg. 2024;32(16):738–46. 10.5435/JAAOS-D-23-00743 . Ha J, Jones G, Staub J, Aynardi M, French C, Petscavage-Thomas J. Current Trends in Total Ankle Replacement. Radiographics. 2024;44(1):e230111. 10.1148/rg.230111 . Kostuj T, Hönning A, Mittelmeier W, Malzahn J, Baums H, Osmanski-Zenk M. Outcome after total ankle replacement or ankle arthrodesis in end-stage ankle osteoarthritis on the basis of german-wide data: a retrospective comparative study over 10 years. BMC Musculoskelet Disord. 2024;25(1):492. 10.1186/s12891-024-07612-w . Published 2024 Jun 25. Manke E, Yeo Eng Meng N, Rammelt S. Ankle Arthrodesis - a Review of Current Techniques and Results. Artrodéza hlezna – přehled současných technik a výsledků. Acta Chir Orthop Traumatol Cech. 2020;87(4):225–36. Dekker TJ, Walton D, Vinson EN, et al. Hindfoot Arthritis Progression and Arthrodesis Risk After Total Ankle Replacement. Foot Ankle Int. 2017;38(11):1183–7. 10.1177/1071100717723130 . Najefi AA, Ghani Y, Goldberg AJ. Bone Cysts and Osteolysis in Ankle Replacement. Foot Ankle Int. 2021;42(1):55–61. 10.1177/1071100720955155 . Noordin S, Allana S, Umer M, Jamil M, Hilal K, Uddin N. Unicameral bone cysts: Current concepts. Ann Med Surg (Lond). 2018;34:43–9. 10.1016/j.amsu.2018.06.005 . Published 2018 Jun 28. Lundeen GA, Barousse PS, Moles LH, Whitlow SR, Cassinelli S. Technique Tip: Endoscopic-Assisted Curettage and Bone Grafting of Periprosthetic Total Ankle Arthroplasty Bone Cysts. Foot Ankle Int. 2021;42(2):224–9. 10.1177/1071100720961090 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6819728","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":485596776,"identity":"2b250105-8b19-4684-8bd2-aebf98075e5b","order_by":0,"name":"Haining Zhang","email":"","orcid":"","institution":"Binzhou Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haining","middleName":"","lastName":"Zhang","suffix":""},{"id":485596777,"identity":"73db6397-b7d1-4ea7-8d07-bd5fd85837c0","order_by":1,"name":"Ying 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11:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6819728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6819728/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87047419,"identity":"cbb196e0-6365-4661-a2e3-d1bc8fa5681f","added_by":"auto","created_at":"2025-07-18 14:42:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76757,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative imaging features of osseous cysts.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/b7da102b3d5ca8cf12ee0f95.jpg"},{"id":87048454,"identity":"4c0e5fed-796b-4edb-8c71-5976e8c25d2b","added_by":"auto","created_at":"2025-07-18 14:50:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":400916,"visible":true,"origin":"","legend":"\u003cp\u003eFollowing intraoperative osteotomy using an osteotomy guide and bone cyst debridement, tibial and fibular bone defects were observed.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/0019b14345e53472ef4165dd.jpg"},{"id":87050686,"identity":"ac6caf09-ccf0-4249-9cb3-88b3c6d9d0a1","added_by":"auto","created_at":"2025-07-18 14:58:42","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":512610,"visible":true,"origin":"","legend":"\u003cp\u003eFollowing intraoperative osteotomy using an osteotomy guide and bone cyst debridement, talar bone defects were observed.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/c6b2b6a6f91b058452874559.jpg"},{"id":87047422,"identity":"c6d15bda-0001-4f1c-acaa-0de023e43864","added_by":"auto","created_at":"2025-07-18 14:42:42","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":47947,"visible":true,"origin":"","legend":"\u003cp\u003e3-month postoperative imaging examinations.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/e272c0344a359329000f2410.jpg"},{"id":87048458,"identity":"b15c5383-154a-4bc4-a520-078623c240c7","added_by":"auto","created_at":"2025-07-18 14:50:42","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":58981,"visible":true,"origin":"","legend":"\u003cp\u003e6-month postoperative imaging examinations.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/25c092bb0c4f2c296f95682f.jpg"},{"id":87047425,"identity":"31e702e3-9bb0-4c0b-8e1b-0ca657a8b14c","added_by":"auto","created_at":"2025-07-18 14:42:42","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":76543,"visible":true,"origin":"","legend":"\u003cp\u003e6-month postoperative imaging examinations.\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/dc1d86ad64feacb457444c01.jpg"},{"id":87048467,"identity":"be1246cb-693e-46b6-be42-64f6b5dc5254","added_by":"auto","created_at":"2025-07-18 14:50:42","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":140481,"visible":true,"origin":"","legend":"\u003cp\u003ePlantar flexion of the ankle joint was observed in the affected limb at 6 months postoperatively.\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/e7229e27dcde05d60800e979.jpg"},{"id":87047439,"identity":"a6731688-1c1c-43bc-a222-b465748f1860","added_by":"auto","created_at":"2025-07-18 14:42:42","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":138883,"visible":true,"origin":"","legend":"\u003cp\u003eDorsiflexion of the ankle joint was maintained in the affected limb at 6 months postoperatively.\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/70617e058684aafc6ab96158.jpg"},{"id":87053632,"identity":"279fc061-7752-4aca-919e-14245166bd7e","added_by":"auto","created_at":"2025-07-18 15:14:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1857480,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6819728/v1/853eaad0-8bca-4cfb-93a6-6fadbde84308.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Total Ankle Arthroplasty Combined with Iliac Bone Grafting for End-Stage Ankle Osteoarthritis Complicated by Giant Bone Cyst: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eAnkle osteoarthritis is a common clinical disease, and patients with end-stage ankle arthritis often have severe pain, joint stiffness, and dysfunction that significantly affect their quality of life \u003csup\u003e[1]\u003c/sup\u003e. Total ankle arthroplasty is widely used in clinical practice as an effective treatment for end-stage ankle arthritis because it preserves some range of motion and maintains a relatively normal gait pattern \u003csup\u003e[2]\u003c/sup\u003e. However, patients with large bone cysts in the distal tibia and talus may face bone defects during surgery, affecting the prosthesis's stability and postoperative efficacy. There are no published reports of concurrent management of bone cysts during total ankle arthroplasty, which makes the treatment of such complex cases challenging. This article reports for the first time a case of end-stage ankle arthritis complicated with giant bone cysts of the tibia, fibula and talus (up to 3 cm in diameter) and discusses in detail the strategies and clinical effects of simultaneous treatment of giant bone cysts during total ankle arthroplasty, to provide a reference for the treatment of similar cases.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient, a 60-year-old male, had pain in both ankles for 8 years, and his pain symptoms had worsened significantly in the past 2 months, and his activities were restricted. Preoperative X-rays and CT scans showed bony hyperplasia at the bony articular surface margin of the left foot. The left ankle is osteoid articular sclerosis, osteophyte formation can be seen at some joint margins, bone density in the medial malleolus is uneven, and the joint space is narrow. A well-circumscribed circular hypodense shadow (about 2.5 cm in diameter) can be seen on the distal lateral side of the left tibia, corresponding to fibula compression and cortical defect. In addition, multiple small rounded hypodense opacities are seen in the distal tibia fibula and talus, with sclerotic margins .(Figure A)\u003c/p\u003e\u003cp\u003eFigure 1 Preoperative imaging features of osseous cysts.\u003c/p\u003e\u003cp\u003eIntraoperative exploration revealed many synovial tissue and osteophytes in the ankle joint. After osteotomy with tibia and talus osteotomy, cystic lesions were found on the distal tibia, talus and medial distal fibula, among which the tibial capsule was about 3\u0026times;2\u0026times;2cm, and the talus and fibula were about 1\u0026times;1\u0026times;1cm. (Figure B) After thoroughly scraping the diseased tissue, it is sent for routine pathological examination. A ball drill removes the diseased tissue from the cyst cavity wall until the normal cancellous bone is exposed. Subsequently, medial hyperplasia and scarring are cleaned up, and the deltoid ligament is released. The left iliac bone (5\u0026times;2\u0026times;1 cm) was taken from the left iliac bone to repair the bone defect, and the hyperplasia osteophytes and synovial tissue were cleaned up. After the bone defect is repaired, talus, tibial prostheses, and liners are installed. Intraoperative exploration revealed scarring and relaxation of the anterior talofibular ligament, which was reconstructed and repaired with a wire band anchor. In addition, intraoperative evaluation showed high ankle dorsal extension, so Achilles tendon lengthening was performed. (Figure B、C)\u003c/p\u003e\u003cp\u003eFigure 2 Following intraoperative osteotomy using an osteotomy guide and bone cyst debridement, tibial and fibular bone defects were observed.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eHistopathological examination showed that the tibia, fibula and talus bone cysts of the left ankle joint, all three cyst walls, were characterized by fibrous tissue hyperplasia, chronic inflammatory cell infiltration and bone fragment deposition. Tibial lesions may show focal adipose tissue attachment and hemorrhage, and the inner layer of the cyst wall is not lined with cells. Synovial cell clusters and hyperplasia are present in the fibula and talus, respectively, and cartilage fragments are seen in the fibular capsule wall.\u003c/p\u003e\u003cp\u003ePostoperatively, ankle joint function significantly improved with restoration of the mechanical axis in the affected foot. Radiographic examinations at 3 and 6 months postoperatively demonstrated stable prosthesis positioning, absence of bone cyst recurrence, and satisfactory overall recovery progress. (Figure D、E、F、J、G、H)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHere, we report a list of cases in which a 60-year-old male patient underwent total ankle arthroplasty, with a large bone cyst treated at the same time as the operation. First proposed by Lord and Marotte in the 70s of the 20th century, total ankle arthroplasty is a revolutionary procedure that aims to preserve joint mobility and provide a new treatment option for patients with primary osteoarthritis, traumatic arthritis, and inflammatory arthritis in addition to traditional fusion \u003csup\u003e[2]\u003c/sup\u003e. With advances in prosthetic design, materials science, and biomechanics research, and optimization of preoperative planning, total ankle arthroplasty has become the standard treatment for end-stage ankle arthritis, with expanding indications, increasing number of beneficiaries, and posing a strong challenge to the long-standing \"gold standard\" ankle fusion at the expense of range of motion \u003csup\u003e[3]\u003c/sup\u003e. Studies have shown that total ankle arthroplasty significantly reduces the incidence of adjacently adjacent arthritis compared with ankle fusion, which is prone to complications such as degeneration of adjacent joints \u003csup\u003e[4]\u003c/sup\u003e. Thus, total ankle arthroplasty may be a preferred treatment strategy over ankle fusion in patients with end-stage ankle arthritis with pre-existing adjacent joint degeneration and may be a potential advantage in reducing the risk of secondary arthropathy \u003csup\u003e[5]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eStudies have shown that 78 percent of patients with end-stage ankle arthritis who undergo total ankle arthroplasty have bone cysts that cannot be removed entirely by prosthetic resection, and 30 percent of these lesions have a maximum diameter of \u0026ge;\u0026thinsp;5 mm \u003csup\u003e[6]\u003c/sup\u003e. The preoperative imaging and intraoperative observations showed multiple substantial bone cysts (up to 3 cm in diameter) in the distal tibia, fibula and talus. Despite the osteotomy during the operation, there were still cystic lesions with clear boundaries, which affected the initial stability of the prosthesis and the postoperative biomechanical conduction efficiency. Therefore, simultaneous intraoperative management of bone cysts is essential for the smooth implementation of total ankle arthroplasty for patients with bone cysts. The treatment of bone cysts is also evolving with the improvement of technology and technology. Current treatment of bone cysts includes non-surgical treatment (regular testing, medical therapy) and surgical treatment (curettage, bone grafting, decompression, and combination therapy) \u003csup\u003e[7]\u003c/sup\u003e. At the same time, related studies have further confirmed that bone grafting has become a reliable treatment for periprosthetic cystic osteolysis after total ankle arthroplasty \u003csup\u003e[8]\u003c/sup\u003e. Based on the preoperative imaging evaluation, histopathological analysis and real-time assessment of the degree of intraoperative bone defect, an individualized treatment strategy was adopted in this case, and autologous iliac bone grafting was finally selected as the radical treatment method for bone cysts to realize the reconstruction of biomechanical stability of the bone-prosthesis interface, to optimize postoperative functional recovery and reduce the risk of complications.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case is the first report of total ankle arthroplasty combined with iliac bone grafting for the treatment of end-stage ankle arthritis with giant bone cysts, which provides valuable clinical experience for similar cases. The biomechanical stability of the bone-prosthesis interface was successfully reconstructed through accurate preoperative imaging evaluation, complete curettage of cystic lesions during surgery, and repair of bone defects by autologous iliac bone grafting. Follow-up at 3 and 6 months postoperatively demonstrated significant improvement in the patient's ankle joint range of motion, stable prosthesis positioning, and no recurrence of bone cysts. This case confirms that for complex cases with residual bone cysts after osteotomy, the concurrent implementation of bone grafting can effectively solve the problem of prosthesis matching and provides an evidence-based basis for the individualized treatment of end-stage ankle arthritis complicated with bone defects. Further long-term follow-up studies are needed to evaluate prosthetic survival and long-term efficacy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHaining Zhang: literature search, data collection, follow-up, and writing;\u003c/p\u003e\n\u003cp\u003eWeiqiang Pang: data collection, follow-up; Ying Liu: supervision, revision, and final approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding sources were used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was approved by the Research Ethics Committee of the Binzhou Medical University Hospital (Reference number: LW-108). All procedures involving human participants in this study conformed to the ethical standards of the institutional and/or national research councils as well as the 1964 Declaration of Helsinki and its subsequent amendments or similar ethical standards. Written informed consent were obtained from the patient and/or guardian's of all patients for publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of their therapeutic images was obtained from the patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAnastasio AT, Lau B, Adams S, Ankle Osteoarthritis. J Am Acad Orthop Surg. 2024;32(16):738\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5435/JAAOS-D-23-00743\u003c/span\u003e\u003c/span\u003e.\u003c/li\u003e\n\u003cli\u003eHa J, Jones G, Staub J, Aynardi M, French C, Petscavage-Thomas J. Current Trends in Total Ankle Replacement. Radiographics. 2024;44(1):e230111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/rg.230111\u003c/span\u003e\u003c/span\u003e.\u003c/li\u003e\n\u003cli\u003eKostuj T, H\u0026ouml;nning A, Mittelmeier W, Malzahn J, Baums H, Osmanski-Zenk M. Outcome after total ankle replacement or ankle arthrodesis in end-stage ankle osteoarthritis on the basis of german-wide data: a retrospective comparative study over 10 years. BMC Musculoskelet Disord. 2024;25(1):492. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12891-024-07612-w\u003c/span\u003e\u003c/span\u003e. Published 2024 Jun 25.\u003c/li\u003e\n\u003cli\u003eManke E, Yeo Eng Meng N, Rammelt S. Ankle Arthrodesis - a Review of Current Techniques and Results. Artrod\u0026eacute;za hlezna \u0026ndash; přehled současn\u0026yacute;ch technik a v\u0026yacute;sledků. Acta Chir Orthop Traumatol Cech. 2020;87(4):225\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003eDekker TJ, Walton D, Vinson EN, et al. Hindfoot Arthritis Progression and Arthrodesis Risk After Total Ankle Replacement. Foot Ankle Int. 2017;38(11):1183\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1071100717723130\u003c/span\u003e\u003c/span\u003e.\u003c/li\u003e\n\u003cli\u003eNajefi AA, Ghani Y, Goldberg AJ. Bone Cysts and Osteolysis in Ankle Replacement. Foot Ankle Int. 2021;42(1):55\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1071100720955155\u003c/span\u003e\u003c/span\u003e.\u003c/li\u003e\n\u003cli\u003eNoordin S, Allana S, Umer M, Jamil M, Hilal K, Uddin N. Unicameral bone cysts: Current concepts. Ann Med Surg (Lond). 2018;34:43\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amsu.2018.06.005\u003c/span\u003e\u003c/span\u003e. Published 2018 Jun 28.\u003c/li\u003e\n\u003cli\u003eLundeen GA, Barousse PS, Moles LH, Whitlow SR, Cassinelli S. Technique Tip: Endoscopic-Assisted Curettage and Bone Grafting of Periprosthetic Total Ankle Arthroplasty Bone Cysts. Foot Ankle Int. 2021;42(2):224\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1071100720961090\u003c/span\u003e\u003c/span\u003e.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"End-stage ankle arthritis, Bone cysts, Total ankle arthroplasty, Iliac bone grafting, Case report","lastPublishedDoi":"10.21203/rs.3.rs-6819728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6819728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Total ankle arthroplasty and iliac bone grafting in treating end-stage ankle arthritis with multiple large bone cysts are rare. There is a lack of research on the combination of total ankle arthroplasty and bone cyst treatment. However, a large number of patients with end-stage ankle arthritis often find bone cysts outside the scope of total ankle arthroplasty resection on preoperative imaging, so the impact of these lesions needs to be considered in preoperative planning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e This case report describes a 60-year-old male patient with end-stage ankle arthritis who underwent total ankle arthroplasty with a giant bone cyst of tibia, fibula, and talus (up to 3 cm in diameter) who underwent total ankle arthrodedgence with iliac bone grafting. Postoperative follow-up showed significant relief of symptoms and no signs of recurrence of cysts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e Total ankle arthroplasty combined with iliac bone grafting is an effective method for treating end-stage ankle arthritis accompanied by large bone cysts in the tibia, fibula, and talus. Simultaneous management of bone cysts during the procedure is more beneficial for optimal prosthesis placement and postoperative recovery.\u003c/p\u003e","manuscriptTitle":"Total Ankle Arthroplasty Combined with Iliac Bone Grafting for End-Stage Ankle Osteoarthritis Complicated by Giant Bone Cyst: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 14:42:37","doi":"10.21203/rs.3.rs-6819728/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a4e1f8f7-2e34-4a63-a5f9-0bd604daa6cd","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-18T14:42:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-18 14:42:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6819728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6819728","identity":"rs-6819728","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}