Ankle arthrodesis

Factors Affecting the Outcomes of Uncomplicated Primary Open Ankle Arthrodesis

BACKGROUND

The objective of this study was to identify factors influencing operative outcomes in straightforward, uncomplicated open ankle fusions.

METHODS

We reviewed all primary open ankle fusions conducted at 1 institution over an 11-year period to identify straightforward, uncomplicated open ankle fusions. Inclusion required a minimum of 6 months follow-up. Patients were excluded for neuropathic arthropathy, insensate limb, failed total ankle replacement, simultaneous arthrodesis of the subtalar joint, or fusions performed within 1 year of injury to salvage failed fixation and painful function due to (1) open fractures, (2) segmental bone loss greater than 1 cm, (3) infection, or (4) talar body fractures. The primary outcome variable was radiographic union at 6 months. Other operative complications were analyzed as secondary outcomes. Five hundred twenty-eight ankle fusion surgeries were performed on 440 patients at 1 institution during the study period. Two hundred fifteen surgeries met inclusion/exclusion eligibility criteria for uncomplicated open ankle fusions.

RESULTS

The overall union rate was 91%. In this cohort of uncomplicated open ankle fusions, bivariate analysis over a broad range of potential factors and further focused multivariate analysis found that nonunion was more than 3 times more likely to occur after previous subtalar fusion, and 2 times more likely to occur in patients with preoperative varus ankle alignment. The rate of reoperation was 19%, with nonunion revision as the leading reason, followed by hardware removal and incision and drainage for presumed infection. Diabetes was not a significant risk factor of either deep or superficial infection.

CONCLUSION

Open ankle fusion failed in 9% of uncomplicated ankles with arthritis. Patients who had an open ankle fusion done after previous subtalar joint fusion, as well as those who had preoperative varus ankle alignment, had a significantly higher rate of nonunion.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Effects of Ankle Arthrodesis on Biomechanical Performance of the Entire Foot

Background/Methodology

Ankle arthrodesis is one popular surgical treatment for ankle arthritis, chronic instability, and degenerative deformity. However, complications such as foot pain, joint arthritis, and bone fracture may cause patients to suffer other problems. Understanding the internal biomechanics of the foot is critical for assessing the effectiveness of ankle arthrodesis and provides a baseline for the surgical plan. This study aimed to understand the biomechanical effects of ankle arthrodesis on the entire foot and ankle using finite element analyses. A three-dimensional finite element model of the foot and ankle, involving 28 bones, 103 ligaments, the plantar fascia, major muscle groups, and encapsulated soft tissue, was developed and validated. The biomechanical performances of a normal foot and a foot with ankle arthrodesis were compared at three gait instants, first-peak, mid-stance, and second-peak.

Principal Findings/Conclusions

Changes in plantar pressure distribution, joint contact pressure and forces, von Mises stress on bone and foot deformation were predicted. Compared with those in the normal foot, the peak plantar pressure was increased and the center of pressure moved anteriorly in the foot with ankle arthrodesis. The talonavicular joint and joints of the first to third rays in the hind- and mid-foot bore the majority of the loading and sustained substantially increased loading after ankle arthrodesis. An average contact pressure of 2.14 MPa was predicted at the talonavicular joint after surgery and the maximum variation was shown to be 80% in joints of the first ray. The contact force and pressure of the subtalar joint decreased after surgery, indicating that arthritis at this joint was not necessarily a consequence of ankle arthrodesis but rather a progression of pre-existing degenerative changes. Von Mises stress in the second and third metatarsal bones at the second-peak instant increased to 52 MPa and 34 MPa, respectively, after surgery. These variations can provide indications for outcome assessment of ankle arthrodesis surgery.

Ankle Joint Fusion With an Anatomically Preshaped Anterior Locking Plate

We present a novel fixation plate for primary ankle joint fusion. A single anatomically preshaped angular stable plate was used with an anterior approach. An excellent result with good bone consolidation was present at the 1-year follow-up examination.

Total ankle replacement in patients with von Willebrand disease: mid-term results of 18 procedures

von Willebrand disease (VWD) is a recognized cause of secondary ankle osteoarthritis (OA). Few studies have examined orthopaedic complications and outcomes in VWD patients treated for end-stage ankle OA with total ankle replacement (TAR). To determine the clinical presentation, intraoperative and postoperative complications and evaluate the mid-term outcome in VWD patients treated with TAR. Eighteen patients with VWD with mean age 47.3 years (range = 34.0-68.7) were treated for end-stage ankle OA with TAR. The mean duration of follow-up was 7.5 years (range = 2.9-13.2). Intraoperative and perioperative complications were recorded. Component stability was assessed with weight-bearing radiographs. Clinical evaluation included range of motion (ROM) tests using a goniometer and under fluoroscopy using a lateral view. Clinical outcomes were analysed by a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score and Short Form (36) Health Survey (SF-36) health survey. One patient sustained an intraoperative medial malleolar fracture. In two patients delayed wound healing was observed. Two secondary major surgeries were performed. Pain level decreased from 8.2 ± 0.9 (range = 7-10) preoperatively to 1.1 ± 1.2 (range = 0-4) postoperatively. Significant functional improvement including ROM was observed. All categories of SF-36 score showed significant improvement in quality of life. Mid-term results of TAR in patients with VWD are encouraging. The total rate of intraoperative and postoperative complications was 33.3%. However, longer term outcomes are necessary to fully understand the clinical benefit of TAR in patients with VWD.

Distraction arthroplasty with arthroscopic microfracture in a patient with rheumatoid arthritis of the ankle joint

We treated a 39-year-old female who had experienced destruction of her ankle joint owing to rheumatoid arthritis. This relatively young patient wished to avoid ankle fusion and joint replacement. Therefore, distraction arthroplasty with arthroscopic microfracture was performed to improve her symptoms and preserve motion. A microfracture procedure specifically for cartilage defects of the tibial plafond and talar dome was performed with the arthroscope, after which a hinged external fixator was applied to distract the ankle joint. The ankle joint space was enlarged by the external device and joint movement allowed. After 3 months, removal of the external device and repeat arthroscopy revealed newly formed fibrocartilage on the surfaces of both the tibia and the talus. At 2 years after the surgery, a radiograph showed that the joint space enlargement of the ankle had been maintained. The American Orthopaedic Foot and Ankle Society score improved from 37 points preoperatively to 82 points at 2 years postoperatively. Our findings suggest that good clinical results can be achieved with distraction arthroplasty and arthroscopic microfracture in a relatively young patient with rheumatoid arthritis.

Locking plate versus retrograde intramedullary nail fixation for tibiotalocalcaneal arthrodesis: A retrospective analysis

BACKGROUND

Tibiotalocalcaneal arthrodesis (TTCA) surgery is indicated for the end-stage disease of the tibiotalar and subtalar joints. Although different fixation technique of TTCA has been proposed to achieve high fusion rate and low complication rate, there is still no consensus upon this point. The purpose of this study is to compare the clinical efficacy of retrograde intramedullary nail fixation (RINF) and locking plate fixation (LPF) for TTCA.

MATERIALS AND METHODS

Fifty four patients who underwent TTCA through the lateral approach with lateral fibular osteotomy using RINF (32 patients, 18 male/14 female, mean age: 48) or LPF (22 patients, 12 male/10 female, mean age: 51) between January 2007 and January 2010 were retrospectively analyzed. Demographic and clinical characteristics, surgery (operation time, blood loss) outcomes (postoperative fusion rates, visual analog scale and foot and ankle surgery score and complications) were compared.

RESULTS

The LPF group had a shorter operation time (72.3 ± 9.2 vs. 102.8 ± 11.1 min, P < 0.001), less blood loss (75.9 ± 20.2 vs. 140.0 ± 23.8 ml, P < 0.001) and less intraoperative fluoroscopy sessions (3.6 ± 0.9 vs. 8.4 ± 1.3, P < 0.001) than the RINF group. Patients were followed up for 12-24 months (mean of 16.2 months). Both groups had similar postoperative fusion rates (90.6% and 95.4%) and the LPF group showed a nonsignificant lower complication rate (18.2% vs. 28.1% respectively). Patients at higher risk on nonunion due to rheumatoid diseases may have a lower nonunion rate with LPF than RINF (one out of eight vs. three out of nine, P < 0.001).

CONCLUSIONS

The LPF for TTCA was simpler to perform compared with RINF, but with similar postoperative outcomes and complication rates.

Single-stage supramalleolar osteotomy for coronal plane deformity

A variety of surgical procedures are utilized for management of ankle osteoarthritis. The most common etiology in patients with ankle osteoarthritis is post-traumatic often resulting in asymmetric ankle osteoarthritis with concomitant valgus or varus deformity. A substantial part of tibiotalar joint is often preserved, therefore, in appropriate patients, joint-preserving surgery holds the potential to be a superior treatment option than joint-sacrificing procedures including total ankle replacement or ankle arthrodesis. This review is designed to describe indications and contraindications for single-stage supramalleolar realignment surgery. Complications associated with this type of surgery and postoperative outcome are highlighted using recent literature.

A biomechanical comparison of internal fixation techniques for ankle arthrodesis

The purpose of the present study was to compare the primary bending stiffness characteristics of 5 different ankle arthrodesis fixation techniques: 3 compression screws, an anterior locking plate, a lateral locking plate, an anterior locking plate with a compression screw, and a lateral locking plate with a compression screw. A total of 25 full-scale anatomic models consisting of fourth-generation composite tibiae and tali were tested using an Instron 4505 Universal Testing System. We hypothesized that the use of a compression screw with a locking plate would add considerable stiffness to the fixation construct compared with the use of a locking plate alone. The data have shown that an anterior or lateral plate with a compression screw provides significantly greater stiffness than both a plate and 3 compression screws used individually. No significant difference was seen between the anterior plate with a compression screw and the lateral plate with a compression screw. No significant differences were found among the use of an anterior plate, a lateral plate, or 3 compression screws. We have concluded that when using a locking plate in an anterior or lateral configuration, the addition of a compression screw will considerably increase the primary bending stiffness of ankle arthrodesis.

Fashioning autologous bone graft from the fibula in the transfibular approach to open ankle arthrodesis

Open ankle arthrodesis is one of the primary operations for disabling ankle arthrosis. The transfibular lateral approach to ankle fusion is a common approach for open ankle arthrodesis. Autologous bone graft can be harvested from the osteotomised fibula. We describe a safe technique of taking graduated slices of fibula bone graft, which allows optimal fibula length excision and are suitable in shape to pack into defects at the fusion site.

A historical review of common bone graft materials in foot and ankle surgery

Foot and ankle fusion is an important treatment for arthritis and deformities of the ankle and hindfoot. The literature has shown that there are improvements in fusion rates with the addition of bone graft and bone graft substitutes. Today autografts, specifically the iliac crest bone graft (ICBG), continue to be the gold standard despite significant donor site morbidity and nonunion rates, persisting around 10%. To address these drawbacks, bone graft substitutes have been developed. This article includes a historical review of the use, outcomes, and safety of autografts, allografts, and bone graft substitutes, such as ceramics, demineralized bone matrix, and platelet-derived growth factor.

Functional results and complication analysis after total ankle replacement: early to medium-term results from a Portuguese and Spanish prospective multicentric study

BACKGROUND

Ankle arthroplasty is increasingly being used to treat end-stage ankle osteoarthritis.

METHODS

Between January 2005 and January 2011, 159 patients have been included in an ongoing prospective multicentric study analysing the results of total ankle arthroplasty in Portugal and Spain. 119 patients (119 replacements) were available for review and were evaluated for range of motion (ROM), clinical status (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score), complications and survivorship rate.

RESULTS

Mean follow-up was 39 months. A total of 17 complications were reported, with 7 leading to subsequent surgery (94.1% survivorship rate). Of these, there were two infections (98.3% survivorship rate), two painful subtalar arthritis, one instability, one malalignment and one tibial bone cyst. Complications not requiring further surgery were 6 intra-operative malleolar fractures and 4 cases of skin necrosis.

CONCLUSIONS

Adequate patient selection and a thorough knowledge of the surgical technique are mandatory to reduce the number of complications and increase ankle arthroplasty survivorship.

HINTEGRA total ankle replacement: survivorship analysis in 684 patients

BACKGROUND

Total ankle replacement is increasingly recommended for patients with end-stage ankle osteoarthritis. We analyzed the survivorship of 722 arthroplasties performed with one type of three-component total ankle prosthesis.

METHODS

Seven hundred and seventy-nine primary total ankle arthroplasties (741 patients) were performed between May 2000 and July 2010 with use of the HINTEGRA three-component prosthesis. A logistic multiple regression model was used to identify independent risk factors for prosthesis failure in 684 patients (722 ankles). The mean time to final follow-up (and standard deviation) was 6.3 ± 2.9 years.

RESULTS

Seven hundred and twenty-two ankles (684 patients) were available for survivorship analysis at the latest follow-up. The overall survival rates were 94% and 84% after five and ten years, respectively. Sixty-one ankles had a revision arthroplasty (twenty-seven both components, thirteen the tibial component only, and fourteen the talar component only) or were converted to a fusion (seven ankles).There were no polyethylene failures. There were no amputations. The generation category of the prosthesis, the cause of ankle osteoarthritis, and the age of the patient were identified as independent risk factors for prosthesis failure.

CONCLUSIONS

The midterm survivorship of the HINTEGRA implant was comparable with that of other third-generation total ankle replacements.

Mobile- and fixed-bearing total ankle prostheses: is there really a difference?

Approximately 1% of the world's adult population is affected by ankle osteoarthritis (OA). Therapeutic options include conservative and surgical measures. Because of substantial progress in total ankle replacement, ankle fusion is no longer the "gold standard" therapy for end-stage ankle OA. Various ankle prostheses have been designed and are currently available. This article reviews the in vitro studies addressing the biomechanics and kinematics of the replaced ankle. Furthermore, a systematic literature review was conducted to assess possible differences in clinical outcomes, including prosthesis survivorship and postoperative range of motion between mobile- and fixed-bearing total ankle prostheses.

Treatment of the arthritic valgus ankle

The ankle joint is part of a biomechanical hindfoot complex. Approximately 1% of the world's adult population is affected by ankle osteoarthritis (AO). Trauma is the primary cause of ankle OA, often resulting in varus or valgus deformities. Only 50% of patients with end-stage ankle OA have a normal hindfoot alignment. The biomechanics and morphology of the arthritic valgus ankle is reviewed in this article and therapeutic strategies, including joint preserving and nonpreserving modalities are presented. Pitfalls are discussed and the literature is reviewed regarding outcomes in patients with valgus deformity who underwent total ankle replacement.

Total ankle replacement for treatment of end-stage osteoarthritis in elderly patients

End-stage osteoarthritis of the ankle is a disabling problem, particularly in elderly patients who experience an overall loss of mobility and functional impairment and who then need compensatory adaption. Ankle arthrodesis, which has been demonstrated to provide postoperative pain relief and hindfoot stability, leaves the patient with a stiff foot and gait changes. For elderly patient, these changes may be more critical than generally believed. Additionally, the long duration of healing and rehabilitation process needed for ankle arthrodesis may be problematic in the elderly. In contrast to ankle arthrodesis, total ankle replacement has significant advantages including a less strenuous postoperative rehabilitation and preservation of ankle motion which supports physiological gait. Recently, total ankle replacement has evolved as a safe surgical treatment in patients with end-stage ankle osteoarthritis with reliable mid- to long-term results. Total ankle replacement needs less immobilization than arthrodesis and does allow for early weight-bearing and should be considered as a treatment option of first choice in many elderly patients with end-stage osteoarthritis of the ankle, especially in elderly patients with lower expectations and physical demands.

Ankle arthrodesis

This article presents an overview of current ankle arthrodesis techniques. Surgical indications, pathophysiology of the ankle joint, preoperative assessment of the patient, surgical techniques for ankle fusion, and complications/sequelae are discussed. The surgical techniques section focuses on crossed screws arthrodesis and intramedullary nailing for tibiotalocalcaneal arthrodesis. Other techniques, including arthroscopic fusion, are also discussed.

Total ankle arthroplasty in patients with hereditary hemochromatosis

BACKGROUND

More than half of patients with hereditary hemochromatosis (HH) have painful arthritis, often including hindfoot osteoarthritis. Total ankle arthroplasty (TAA) is increasingly recommended for patients with painful ankle osteoarthritis. However, the pain relief and function experienced by patients continues to be debated particularly as compared with ankle fusion.

QUESTIONS/PURPOSES

We asked whether (1) the complication rates were low; (2) the components were stable; (3) the patients achieved pain relief; and (4) the patients had satisfactory midterm function, ROM, and quality of life.

PATIENTS AND METHODS

We retrospectively reviewed all 16 prospectively followed patients (21 implants) with HH who underwent ankle arthroplasty. They had an average age of 59.5 years at the time of surgery. We obtained a visual analog scale for pain, the SF-36, and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Component stability was assessed using weightbearing radiographs. The minimum followup was 3.1 years (average, 5.3 years; range, 3.1-8.6 years).

RESULTS

Postoperatively, one patient had débridement of a painful cyst on the tibial side and one patient had a subfibular débridement with a lateral ligament reconstruction. The tibial and talar components were stable in all ankles. The average pain score decreased from 6.7 (range, 3-10) to 1.9 (range, 0-4). All eight categories of SF-36 score showed improvement. The hindfoot score increased from 46 (range, 22-67) to 84 (range, 74-94).

CONCLUSIONS

Our data suggest TAA in patients with ankle osteoarthritis secondary to HH is associated with a low risk of postoperative complications and produces pain relief and good function.

Total ankle replacement in patients with gouty arthritis

BACKGROUND

Gout is the most common cause of inflammatory arthritis in men and older women. The purpose of this review was to assess prosthetic component stability, postoperative pain relief, functional outcome, and quality of life of patients with gouty ankle arthritis who were treated with total ankle replacement.

METHODS

Sixteen patients (nineteen ankles) with chronic gout and a mean age (and standard deviation) of 65.2 ± 5.5 years were treated with a non-constrained three-component total ankle arthroplasty because of painful ankle arthritis. The average duration of follow-up was 5.1 ± 2.5 years. Component stability was assessed with use of weight-bearing radiographs. Clinical outcomes were analyzed with use of a visual analogue scale (VAS) for pain, a 36-item short-form health survey (SF-36), and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score.

RESULTS

There were no intraoperative complications. In one patient, both arthroplasties were revised 4.7 years postoperatively because of painful prosthetic loosening. The average VAS score for pain decreased significantly from 7.5 ± 1.8 (range, 5 to 10) to 1.2 ± 1.3 (range, 0 to 3) (p < 0.001). All eight categories of the SF-36 score showed significant improvement (all p < 0.001). The average AOFAS hindfoot score increased significantly from 38 ± 15 (range, 15 to 77) preoperatively to 75 ± 13 (range, 54 to 92) postoperatively (p < 0.001).

CONCLUSIONS

Total ankle replacement in patients with painful gouty ankle arthritis is associated with a low risk of intraoperative and postoperative complications and leads to significant pain relief, high patient satisfaction, and good functional results.

Arthrodesis with internal fixation of the infected ankle

Arthrodesis may be necessary to avoid amputation when treating an infected tibiotalar joint. In such cases, external or hybrid fixation is usually used. In this retrospective study, we report our experience in treating tibiotalar joint infection by arthrodesis with internal fixation. From March 1992 to October 2005 (13 years, 7 months), 20 patients underwent septic ankle arthrodesis with internal fixation. The mean duration of infection before fusion was 2.5 ± 6.7 years. Arthrodesis was performed with the Méary technique in 9 (45%) cases and with the Crawford-Adams technique in 11 (55%) cases. Internal fixation consisted of screw fixation, staple fixation, or a combination of both. The mean duration of antibiotic treatment was 97.5 ± 37.5 days, and the mean follow-up was 64 ± 36 months, with no patient lost to follow-up. Patients were considered cured if no clinical, biological, or radiologic signs of infection were present at a minimum of 2 years follow-up. The incidence of cure was 85.0% (91.0% with Crawford-Adams and 77.8% with Méary techniques). Radiographic fusion was identified in 89.5% of the cases (91.0% with Crawford-Adams and 87.5% with Méary techniques) at a mean of 4.8 ± 2.4 (range 3 to 11) months postoperative. Tibiotalar arthrodesis in the presence of sepsis can be performed with internal osteosynthesis only under certain conditions. In our experience, this treatment produced satisfactory fusion in 89.5% of patients and eradicated infection in 85.0% of cases.

Treatment of ankle osteoarthritis: arthrodesis versus total ankle replacement

While ankle arthrodesis has remained the gold standard treatment for symptomatic primary, secondary, and posttraumatic ankle arthritis, more recently, total ankle replacement (TAR) has seen considerable improvement in terms of biomechanics, function, and complication rates. However, while in the long-term degeneration of the adjacent joints is almost always found on radiographs after ankle arthrodesis, the longevity of TAR is still insufficient and does not match that of total knee and hip joints. The current review article focuses on the treatment of ankle arthritis by means of arthrodesis and TAR.

High union rates and function scores at midterm followup with ankle arthrodesis using a four screw technique

When evaluating the role of ankle arthrodesis in the treatment of severe ankle arthritis, postoperative infection, nonunion, and the development of arthritis at the adjacent joints are major issues when considering treatment alternatives. We evaluated the rate of complications, the functional outcome, and compensatory range of motion at the midtarsal joint at medium-term followup after ankle arthrodesis with four cancellous screws. We performed 94 ankle fusions in 92 patients; 12 patients were lost to followup and eight declined to participate, leaving 72 patients (76%) for evaluation. The minimum followup was 4.8 years (mean, 5.9; range, 4.8-7.8 years). No patient developed a deep infection; three patients developed postoperative hematoma which we operatively drained. Union occurred in 93 of the 94 patients (99%). The sagittal motion at the midtarsal joint averaged 24 degrees . Secondary arthritis of the subtalar and talonavicular joints developed during the followup period in 17% and 11%, respectively. Progression of preexisting arthritis occurred in 13 of 43 patients (30%) at the subtalar joint and five of 26 patients (19%) at the talonavicular joint. None of these patients had fusion of an adjacent joint. The average American Orthopaedic Foot and Ankle Society score increased from 36 preoperatively to 85 at followup. Ankle arthrodesis with screws provides high rates of union, reliable pain relief, and favorable functional medium-term results.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Use of bone morphogenetic proteins in arthrodesis: clinical results

Bone grafting is not routinely required in primary arthrodesis in the absence of infection, avascular necrosis, bone defect or previous non-union; when any of the above factors is present, autograft is the gold-standard method. However, donor site morbidity and the quantitative and qualitative limitations of autograft have led to the development of alternatives. This study documents the use of the bone morphogenetic protein BMP-7 in a total of 19 joint fusions (ankle, subtalar, talonavicular, pubic and sacroiliac). Healing rates of 90% and satisfactory subjective functional outcome in 70% of cases were recorded over a minimum follow-up of 15 months. These data should provide a sound foundation for future clinical trials evaluating the application of BMP-7 in the fusion of joints.