Long-term results of ankle arthrodesis in children and adolescents with haemophilia

Outcomes of ankle joint distraction in a paediatric and young adult cohort presenting with symptomatic ankle arthritis

Ankle arthritis in paediatric and young adult patients causes significant morbidity; therefore, joint-preserving procedures are preferable. Ankle joint distraction (AJD) is a technique that preserves the native joint. However, only short-term outcomes are reported in paediatric patients. Therefore, this study reports on intermediate-term outcomes in a paediatric cohort. Demographics for all patients who underwent AJD at two centres were prospectively collected. Case records were reviewed retrospectively for complications and further intervention. Mean joint space at baseline and follow-up radiographs were evaluated by two independent observers. All patients were contacted for completion of a Foot and Ankle Outcome Score (FAOS). Seven patients received AJD between February 2016 and June 2019. Median age at surgery was 15 years (9.0-24.6 years). Complications included one superficial pin-site infection and one patient death due to complications from juvenile idiopathic arthritis 6.2 years post-operatively. Two patients were converted to fusion, at 12.6 months and 26.2 months following frame removal; one patient underwent spontaneous fusion at 9 months following frame removal. The four patients who continued without further intervention achieved 2.59 mm mean joint space at last follow-up (0.65-5.08 mm) and FAOS of 35-79%. Mean follow-up length was 4.3 years (2.9-6.3 years) with final radiographs at mean 2.6 years. While recognising the limitations of this retrospective review, several patients had significant, sustained improvements in joint space with good clinical outcome. Complications for this procedure are minimal, and it is a potential joint-preserving option for managing end-stage ankle arthritis in young patients.

Ankle arthrodesis and total ankle replacement in patients with congenital bleeding disorders suffering from severe ankle arthropathy

INTRODUCTION

In patients with congenital bleeding disorders suffering from severe ankle arthropathy, when conservative treatment and joint-preserving surgical techniques fail, there are two possible non-joint-preserving options: ankle arthrodesis (AA) and total ankle replacement (TAR).

AREAS COVERED

The scope and aim of this article was to analyze the current role of AA and TAR in patients with congenital bleeding disorders suffering from severe ankle arthropathy.

EXPERT OPINION

In patients with congenital bleeding disorders, both TAR and AA provide good results, mainly in terms of pain relief, although they are not exempt from complications (between 0% and 33% in TAR and between 5% and 23.5% in AA). The current controversy about which of the two surgical techniques, TAR or AA, gives better results, the current literature is not able to resolve it in patients with congenital bleeding disorders. While this question is being answered, my opinion regarding patients with congenital bleeding disorders is that the age of the patient must be taken into account. Given known prosthetic survival rates, the older the patient, the more we might be inclined to indicate TAR. Conversely, AA may be more appropriate for relatively young patients.

Mid-to long-term postoperative outcomes of ankle joint fusion in patients with haemophilia: A systematic review

INTRODUCTION AND AIM

The ankle joint is the most common site for haemophilic arthropathy. The aim of this study was to review the outcomes of ankle joint fusion in patients with haemophilia A or B. The primary outcome measures were union rates, time to union, perioperative blood loss/transfusion, postoperative complications and length of hospital stay (LOS). Secondary outcome measures were hind foot functional outcome scores and the visual analogue pain scale (VAS).

MATERIALS AND METHODS

A search of PubMed, Medline, Embase, Journals@Ovid and the Cochrane register was performed conforming to the PRISMA guidelines. Only human studies with a minimum follow-up of 1-year were included. The MINORS and ROBINS-1 tools were used for quality appraisal.

RESULTS

A total of 952 articles were identified and only 17 studies met the eligibility criteria after the screening. The mean age of the patients was 37.6 (SD 10.2). A total of 271 ankle fusions were performed with the open crossed-screw fixation being the most common technique. Union rates were 71.5%-100% at 2-6 months. The pooled postoperative complication and revision rates were 13.7% and 6.5%, respectively. The range of LOS was 1.8-10.6 days. The mean preoperative American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score was 35 (SD 13.1) whereas the mean postoperative AOFAS score was 79.4 (SD 5.3). The mean preoperative VAS was 6.3 (SD 1.6) while the mean postoperative VAS score was .9 (SD .4) across 38 ankle fusions.

CONCLUSION

Ankle arthrodesis offers improved pain and function in haemophilic ankle arthropathy with lower revision and complication rates than that reported in the literature for total ankle replacement.

Open Ankle Arthrodesis: A Retrospective Analysis Comparing Different Fixation Methods

A wide variation of surgical options, complications, and union rates are reported in the treatment of end-stage ankle arthritis. However, open ankle arthrodesis remains the golden standard for ankle arthritis. The purpose of this study was to evaluate the union rate and complication rate as well as identify potential risk factors for different methods of fixation in patients with end-stage ankle arthritis of different etiology. In total, 42 ankles of 41 patients with ankle osteoarthritis were included for this single-center retrospective study. The mean age was 50 years (range 22-75 years). Twenty patients were treated with screw-fixation, 14 with plate(s) and 8 with intramedullary nail. The results of this study showed an overall union rate of 97.6% (41 of the 42 operated ankles) and an overall complication rate of 21.4% (9 events). The mean follow-up time was 16 months (range 2.5-83.0 months). Complications consisted of 1 nonunion, 4 deep infections, 2 cases of wound dehiscence, 1 delayed union and 1 malalignment of the ankle joint. The plate-fixation group demonstrated significantly higher infections when compared with screw and intramedullary nail fixation (p = .017). There were no other significant variables for incidence of complications between patients in the uncomplicated and complicated group. This study achieved good clinical results for different methods of fixation in open ankle arthrodesis. In specific, the use of intramedullary nail provides excellent results for end-stage ankle arthritis with high union rate and a low complication rate.

A Foot to Last a Lifetime-Is Hindfoot Fusion Ever Appropriate for Pediatric Orthopaedic Conditions?

INTRODUCTION

Hindfoot deformities in the pediatric population can be painful and result in severe limitations. Although arthrodesis is known to relieve pain, there are concerns over its use because of the risk that adjacent joint degenerative disease could result, leading to a new source of pain, dysfunction, and additional surgical procedures later in life.

METHODS

A literature review of hindfoot fusions in children focused on articles with the highest levels of evidence and those of particular historical significance. Case examples were obtained by querying the billing records of the local clinic system for Current Procedural Terminology (CPT) codes of hindfoot arthrodeses. Surgery procedures were performed by both fellowship-trained pediatric orthopaedists and fellowship-trained foot and ankle orthopaedic surgeons.

RESULTS

The medical literature for this topic generally is divided into 2 main types of articles: those that describe hindfoot fusion procedures for a specific type of deformity or disease process and those that provide the indications and results of a single type of arthrodesis. Long-term follow-up studies are limited.

DISCUSSION

The long-term risk of degeneration to adjacent joints has been studied, with mixed results. Other problems, such as recurrent deformity, overcorrection, pseudarthrosis, osteonecrosis, and foot shortening also may be encountered over intermediate-term follow-up. Nevertheless, in properly chosen patients, hindfoot fusion can offer a great improvement over the damaging and destructive deformities of the feet caused by a variety of diseases and traumatic injuries. Hindfoot fusions have been used for the treatment of foot deformities secondary to severe trauma, hemophilia, tarsal coalition, clubfoot, and neurological disease such as polio, static encephalopathy, hereditary motor and sensory neuropathies, and myelodysplasia.

CONCLUSIONS

Hindfoot fusion in a child or adolescent should be considered only for the most extreme cases when all other options, short of amputation, have been considered or exhausted. While these procedures can offer improvement in the challenging cases, the surgeon should be aware of their long-term implications, including adjacent joint degeneration.

Effectiveness of ankle fusion in patients with hemophilia, advanced ankle degeneration, and unbearable pain for whom nonsurgical and surgical treatments have been ineffective

Introduction: In underdeveloped countries, patients with hemophilia often experience repetitive ankle joint hemorrhages due to a shortage of coagulation factors (factor VIII [FVIII] and factor IX [FIX] for hemophilia A and B, respectively).Areas covered: This is a narrative literature review in which we searched the Cochrane Library and PubMed for articles related to ankle arthrodesis in patients with hemophilia. The searches covered the period from the databases´ inception to 28 February 2021. In the event of unsuccessful hematologic prophylaxis and conservative measures (e.g. analgesics, cyclooxygenase-2 inhibitors, taping, intra-articular injections of hyaluronic acid and corticosteroids, physical and rehabilitation medicine, orthoses, radiosynovectomy, and joint-preserving surgery (e.g. removal of the distal tibia by open surgery or by arthroscopic surgery, joint debridement by arthroscopic surgery), the classical surgical solution is ankle arthrodesis, which does not preserve the ankle joint.Expert opinion: Ankle pain is reduced after ankle arthrodesis (75% of patients experience no pain). Approximately 5% of patients require reoperation due to lack of fusion, and deep infection occurs in 2.5%. After tibiotalar fusion, a self-reported activity scale shows that approximately 12% of patients improve, 9% worsen, and 79% show no improvement. The results of ankle arthrodesis therefore appear to be poor.Therefore, although 75% of the patients stopped having ankle pain after arthrodesis, according to a self-reported activity scale 88% of them did not improve or worsened.

Open Ankle Arthrodesis: a Systematic Review of Approaches and Fixation Methods

BACKGROUND

Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA.

METHODS

A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation.

RESULTS

We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95-0.99) for the anterior, 96% (95% CI 0.92-0.98) for the lateral and 96% (95% CI 0.68-1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93-0.98) and plate-fixation 99% (95% CI 0.96-0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance.

CONCLUSION

This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA.

LEVEL OF EVIDENCE

Level IIa.

Results and Outcomes of Combined Cross Screw and Ilizarov External Fixator Frame in Ankle Fusion

Ankle fusion is a treatment option for end-stage ankle arthritis. Fusion site stability and optimal foot positioning are crucial parameters. We present the results of our double fixation technique, combining both cross-screw fixation and Ilizarov external fixator frame via transmalleolar approach. We reviewed the files from 52 patients operated for ankle fusion in our center. In our technique, we use a transmalleolar approach, initial stabilization with 2 cannulated, half-threaded cross screws, and final stabilization with an Ilizarov external fixator frame. Fusion stability, weightbearing time, complication rates, and final functional scores were recorded and evaluated. Mean frame removal time was 11.2 ± 2.1 weeks, and 71.6% of patients were fully weightbearing at that time. Absolute fusion stability was reported in 88.46% of patients at that time, while no pseudarthrosis was noted in final follow-up at 12 months. According to the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot-ankle score evaluation at 12 months, 90.4% of patients reported excellent and 9.6% good results. None of the patients was referred for symptomatic forefoot arthritis, and there were no cases of deep infection or deep vein thrombosis. Material-related complications were reported in 1 patient who was treated with implant removal after 1 year. Ankle fusion is a salvage procedure that offers optimal results in end-stage ankle arthritis. Our technique offers absolute fusion site stability with excellent functional results, minor complications, and the advantages of early protected weightbearing. Careful patient selection in addition to fine foot positioning should be regarded as crucial for the final outcome.

Current practices in haemophilic patients undergoing orthopedic surgery - a systematic review

Haemophilia is an inherited disease that requires a different approach in order to evaluate, monitor and treat patients. Despite the great advances in therapeutic agents that have emerged, reports on the impact of monitoring outcomes on treatment decisions are rarely presented. Haemophilia A and haemophilia B are inherited bleeding disorders caused by deficiencies in blood clotting factor proteins. A systematic review was performed to identify literature reports on the current practices in haemophilic patients undergoing orthopedic surgery. The best therapy for haemophilic patients consists in performing primary prophylaxis to prevent joint bleeding and other complications. Besides the primary prophylaxis, thromboprophylaxis is used to prevent venous thrombosis in patients with hemophilia who undergo surgical orthopedic procedures. Further research is needed to better manage the pharmacologic approaches in haemophilic patients undergoing orthopedic surgery. Although patients with haemophilia present low risk for thromboembolic complications, such events have been reported in surgical procedures. The recommendations in patients with haemophilia are considerably variable in the current guidelines and clinical practice. The best therapy for haemophilic patients consists in performing primary prophylaxis to prevent joint bleeding and other complications.