Superiority of upper ankle arthrodesis over total ankle replacement in the treatment of end-stage posttraumatic ankle arthrosis

Ankle arthrodesis or total ankle arthroplasty surgery for end stage ankle arthritis, which is best? A review of the best available evidence

BACKGROUND

End Stage Ankle Arthritis (ESAA) causes pain and dysfunction. It is treated effectively with Total Ankle Arthroplasty (TAA) or Ankle Arthrodesis (AA). Currently there is no consensus on which surgical procedure is superior. This paper will provide a systematic review of all published high-quality studies directly comparing TAA and AA for the surgical treatment of ESAA to determine superiority.

METHODS

A comprehensive literature review of the highest quality studies published that directly compare clinical outcomes of TAA and AA for surgical treatment of ESAA was conducted. Each study was assigned a Level of Evidence (LOE) rating (I-III) and then summarized to assign a grade of recommendation (A-C, I). Superiority was determined for the clinical outcomes of pain, activity, Health Related Quality of Life (HRQL), readmission to hospital, revision surgery and general complications.

RESULTS

There is fair evidence (GOR B) that supports both TAA and AA for the surgical treatment of ESAA. However, TAA trended to be superior for pain relief (GOR B), activity (GOR B), health related quality of life (GOR B) and readmission rate (GOR B) while AA trended to be superior for revision rates (GOR B). Conflicting evidence was presented for general complications (GOR C) CONCLUSION: Due to the lack of level I papers and the findings from the papers reviewed not being consistent, no definitive conclusion on which procedure is better can be made. However, there is enough evidence to provide a basis for which procedure is more effective in each of the outcomes reviewed. This should be considered when deciding on which procedure is best suited for a patient on a case-by-case basis. To allow for a stronger recommendation, further studies-ideally, high-quality level I randomized control trials directly comparing Ankle Arthrodesis and Total Ankle Arthroplasty are needed.

LEVEL OF EVIDENCE

Level III, systematic review.

Efficacy of supramalleolar osteotomy in the treatment of traumatic ankle joint varus deformity in adolescents

BACKGROUND

Supramalleolar osteotomy (SMOT) has emerged as a valuable treatment for ankle varus deformity; however, there are fewer reports of treatment outcomes in adolescents. The purpose of this study was to investigate the radiologic and clinical outcomes of SMOT for the treatment of traumatic ankle joint varus deformity (TAVD) in adolescents.

METHODS

We reviewed 32 adolescent cases who underwent SMOT between February 2017 and February 2022 for TAVD. Radiologic assessment included tibial anterior surface angle (TAS), talar tilt angle (TT), and tibial lateral surface angle (TLS) preoperatively and at 3 months and 12 months postoperatively, and clinical assessment was performed using American Orthopaedic Foot and Ankle Society (AOFAS) scores, Visual Analogue Scale (VAS) scores, and ankle dorsiflexion-plantarflexion ROM including preoperative and 6 months postoperative and 12 months postoperative.

RESULTS

All 32 patients were followed up completely with a mean follow-up of (20.3 ± 3.2) months. From the radiologic outcomes, the mean preoperative TAS improved from 61.53 ± 3.74 to 88 ± 1.72 at 12 months postoperatively, the mean preoperative TT decreased from 2.25 ± 1.32 to 0.5 ± 0.57 at 12 months postoperatively, the mean preoperative TLS improved from 76.72 ± 0.21 to 79.34 ± 1.52 at 12 months postoperatively, the differences between the above preoperative and 12 months postoperative radiologic outcomes were statistically significant (p < 0.05), the mean preoperative AOFAS score improved from 65.5 ± 9.40 to 92.34 ± 4.00 at 12 months postoperatively, the mean preoperative VAS score decreased from 2.44 ± 1.24 to 0.78 ± 0.75 at 12 months postoperatively, and the mean preoperative range of motion (ROM) of ankle improved from 50.16 ± 7.46 to 55.78 ± 4.77 at 12 months postoperatively. The differences between the above preoperative and 12 months postoperative clinical results were statistically significant (p < 0.05).

CONCLUSION

Our study demonstrated that SMOT was effective in correcting TAVD and significantly improving ankle function in adolescents, and that it is an efficient and successful method for restoring ankle joint congruence and normal hindfoot alignment.

Septic History Limits the Outcome of Tibiotalocalcaneal Arthrodesis

Joint destruction necessitates tibiotalocalcaneal arthrodesis (TTCA) in cases of clinical deficits that cannot be controlled conservatively, possibly leading to sepsis. We aimed to compare the underlying etiology of posttraumatic joint destruction and the outcomes after TTCA in patients with a septic or aseptic history. Between 2010 and 2022, 216 patients with TTCA were retrospectively enrolled (septic TTCA (S-TTCA) = 129; aseptic TTCA (A-TTCA) = 87). Patient demographics, etiology, Olerud and Molander Ankle Scores (OMASs), Foot Function Index (FFI-D) scores, and Short Form-12 Questionnaire (SF-12) scores were recorded. The mean follow-up period was 6.5 years. Tibial plafond and ankle fractures were the most common causes of sepsis. The mean OMAS was 43.0; the mean FFI-D was 76.7; and the mean SF-12 physical component summary score was 35.5. All the scores differed significantly between the groups (p < 0.001). With an average of 11 operations until the arthrodesis was achieved, the S-TTCA patients underwent about three times as many operations as the A-TTCA patients (p < 0.001), and 41% of S-TTCA patients remained permanently unable to work (p < 0.001). The significantly worse results of S-TTCA compared to A-TTCA show the long and stressful ordeal that patients with a septic history suffer. Further attention must be paid to infection prophylaxis and, if necessary, early infection revision.

Preservation of the Subtalar Joint Determines Outcomes in a 10-Year Evaluation of Ankle Arthrodesis

Posttraumatic osteoarthritis may lead to surgical fusion of the ankle joint if non-surgical therapy fails. The indication for a fusion of the joint is based on the pain and disability of the patient, radiographic imaging, and surgeon experience, with no strict guidelines. We aimed to compare outcomes after tibiotalocalcaneal arthrodesis (TTCA) and tibiotalar arthrodesis (TTA) to highlight the functional importance of the subtalar joint. In total, 432 patients with ankle arthrodesis were retrospectively enrolled. Group A (n = 216) underwent TTCA; group B (n = 216) underwent TTA. Demographics, Olerud & Molander Ankle Score (OMAS), Foot Function Index (FFI-D), and Short Form-12 Questionnaire (SF-12) were recorded at a mean follow-up of 6.2 years. The mean OMAS was 50.7; the mean FFI-D was 68.9; the mean SF-12 physical component summary was 39.1. These scores differed significantly between the groups (p < 0.001). The overall revision rate was 18%, primarily for revision of non-union and infection (p < 0.001). Approximately 16% of group A and 26% of group B were able to return to previous work (p < 0.001). Based on significantly worse clinical scores of TTCA compared to TTA and the prolonged downtime and permanent incapacity, the indication for a generous subtalar joint arthrodesis with planned ankle arthrodesis should always be critically examined.

A comparative study of modern total ankle replacement and ankle arthrodesis for ankle osteoarthritis at different follow-up times: a systematic review and meta-analysis

PURPOSE

Total ankle replacement (TAR) or ankle arthrodesis (AA) is the main surgical treatment for end-stage ankle osteoarthritis. However, the therapeutic effect of the two surgical procedures at different follow-up times remains controversial. The purpose of this meta-analysis is to compare the short-term, medium-term, and long-term safety and efficiency of the two modern surgical treatments.

METHODS

We conducted a comprehensive search in PubMed, EMBASE, Cochrane library databases, Web of Science, and Scopus. The main results were the patient's reported outcome measure (PROM) score, satisfaction, complications, reoperation, and surgery success rate. Different follow-up times and implant designs were used to evaluate the source of heterogeneity. We used a fixed effects model for meta-analysis and I² statistic for evaluating heterogeneity.

RESULTS

Thirty-seven comparative studies were included. In the short term, TAR significantly improved clinical scores (AOFAS score: WMD = 7.07, 95% Cl: 0.41-13.74, I² = 0.0%; SF-36 PCS score: WMD = 2.40, 95% Cl: 2.22-2.58, I² = 0.0%; SF-36 MCS score: WMD = 0.40, 95% Cl: 0.22-0.57, I² = 0.0%; VAS for pain: WMD =  - 0.50, 95% Cl: - 0.56-0.44, I² = 44.3%) and had the lower incidence of revision (RR = 0.43, 95% CI: 0.23-0.81, I² = 0.0%) and complications (RR = 0.67, 95% Cl: 0.50-0.90, I² = 0.0%). In the medium term, there were still higher improvements in both the clinical scores (SF-36 PCS score: WMD = 1.57, 95% Cl: 1.36-1.78, I² = 20.9%; SF-36 MCS score: WMD = 0.81, 95% Cl: 0.63-0.99, I² = 48.8%) and the patient satisfaction (RR = 1.24, 95% Cl: 1.08-1.41, I² = 12.1%) in the TAR group, but its total complications rate (RR = 1.84, 95% Cl: 1.26-2.68, I² = 14.9%) and revision rate (RR = 1.58, 95% CI: 1.17-2.14, I² = 84.6%) were significantly higher than that of the AA group. In the long term, there was no significant difference in clinical score and satisfaction, and a higher incidence of revision (RR = 2.32, 95% Cl: 1.70-3.16, I² = 0.0%) and complications (RR = 3.18, 95% Cl: 1.69-5.99, I² = 0.0%) was observed in TAR than in AA. The result of the third-generation design subgroup was consistent with that of the above pooled results.

CONCLUSION

TAR had advantages over AA in the short term due to better performance in terms of PROMs, complications, and reoperation rates, but its complications become a disadvantage in the medium term. In the long term, AA seems to be favored because of lower complications and revision rates, although there is no difference in clinical scores.

Irritation from metalwork after ankle arthrodesis fixed using screws: a proportional meta-analysis and systematic review

OBJECTIVE

Ankle arthrodesis (AA) is often fixed using cannulated screws. The irritation from metalwork is a relatively common complication, but there is no consensus regarding the need to remove the screws on a systematic basis. The aim of this study was to determine (1) the proportion of screws removed after AA and (2) whether predictors of screw removal could be identified.

METHODS

This PRISMA-compliant systematic review was part of a larger previous protocol registered on the PROSPERO platform. Multiple databases were searched including studies in which patients undergone AA using screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS).

RESULTS

Forty-four series of patients from thirty-eight studies (1990 ankles, 1934 patients) were selected. The average follow-up was 40.8 months (range 12-110). In all studies, hardware was removed due to symptoms reported by patients and related to the screws. The pooled proportion of removal of metalwork was 3% (95% CI 2-4). The pooled proportion of fusion was 96% (95%CI 95-98), while the pooled proportion of complications and reoperations (excluding the removal of metalwork) stood at 15% (95% CI 11-18) and 3% (95% CI 2-4), respectively. The mean mCMS (50.8 ± 8.1, range 35-66) revealed only an overall fair quality of studies. The univariate analysis and the multivariate model showed that the year of publication (R = - 0.004; p = 0.01) and the number of screws (R = 0.08; p = 0.01) were associated with the screw removal rate. Specifically, we found that over time the removal rate decreased by 0.4% per year and that the use of three screws instead of two reduced the risk of removal of metalwork by 8%.

CONCLUSIONS

In this review, removal of metalwork after ankle arthrodesis using cannulated screws was needed in 3% of cases at an average follow-up of 40.8 months. It was indicated only in case of symptoms related to soft tissue irritation from screws. The use of three screws was paradoxically related to a reduced risk of removal of screws as compared to two-screw constructs.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV.

Intermediate to long-term clinical outcomes and survival analysis of the Salto Mobile Bearing total ankle prothesis

INTRODUCTION

Osteoarthritis of the ankle is a major burden to affected patients. While tibio-talar arthrodesis has been the gold-standard regarding the treatment of osteoarthritis of the ankle joint for many years, at present total ankle arthroplasty (TAA) provides appealing clinical outcomes and is continually gaining popularity. The aim of this study was to evaluate the intermediate- to long-term clinical outcome including the survival rate of Salto Mobile Bearing TAA (Tonier SA, Saint Ismier, France).

MATERIAL AND METHODS

In this retrospective study intermediate- to long-term outcomes measures [Ankle Range of Motion (ROM), American Orthopaedic Foot and Ankle Score (AOFAS score) and survival rate] of 171 consecutive TAA were analysed and compared before and after surgery. Revision was defined as secondary surgery with prothesis component removal, while reoperation was defined as a non-revisional secondary surgery involving the ankle.

RESULTS

At a mean follow-up (FU) period of 7.2 ± 2.7 years (range 2.0 to 14.1 years) there was a significant improvement in ankle ROM (total ROM improved from 25.0° ± 15.0° to 28.7° ± 11.3°, p = 0.015; plantarflexion improved from 18.4° ± 11.7° to 20.6° ± 8.2°, p = 0.044; dorsiflexion improved from 6.6° ± 5.7° to 8.1° ± 4.9°, p = 0.011). AOFAS score increased significantly by 41 ± 15 points after surgery (43.3 ± 11.1 before and 84.3 ± 12.0 after surgery, p < 0.001). Overall survival rate within the FU was 81.3% (95% CI 75.3% to 87.3%) with any secondary surgery, 89.9% (95% CI 84.1% to 93.6%) with revision and 93.6% (95% CI 89.8% to 97.3%) with reoperation as endpoint.

CONCLUSION

This study endorses the previously reported appealing intermediate- to long-term outcomes of the Salto Mobile Bearing TAA. There was a significant increase in ROM and AOFAS score as well as decent implant survival at final FU.

Arthrodesis and Defect Bridging of the Upper Ankle Joint with Allograft Bone Chips and Allograft Cortical Bone Screws (Shark Screw®) after Removal of the Salto-Prosthesis in a Multimorbidity Patient: A Case Report

The case describes the revision of an upper ankle prosthesis because of loosening. When ankle replacement is the first choice and actual bone quality does not allow a replacement of the prosthesis, arthrodesis is the only way of reducing pain and gaining stability. The amount of missing bone due to the removed prosthesis was severe. Shark Screws®, made of human allograft cortical bone, were used to fix an allograft femoral head and tibia as well as fibula and talus to each other for stabilization. This was performed without any autologous bone graft and without metal screws. The human matrix of the cortical allograft allows the creation of new vessels followed by osteoblastic activity and production of new bone. The revascularization of the allografts reduces the risk of infection and wound problems. Over time, the patient's bone metabolism allows the allografts to be remodeled into the patient's bone. The case reported here had severe multimorbidity. The loosening of the prosthesis mainly affected the ability to perform housework, mobility, enjoying leisure, and it had a great impact on the emotion and well-being of the patient. One year after surgery, the patient is very satisfied to be able to walk without pain and scratches for about 90 min.

Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?

Tibiotalar arthrodesis successfully treats ankle arthritis but carries risk of nonunion. It is unclear whether concurrent distal tibiofibular arthrodesis affects tibiotalar nonunion rate. The purpose of this study is to compare tibiotalar nonunion and complication rates in patients with versus without a distal tibiofibular arthrodesis. This is a retrospective review of 516 consecutive ankle arthrodesis performed between March 2002 and May 2016. A total of 319 ankles (312 patients) underwent primary, open tibiotalar arthrodesis (227 with distal tibiofibular arthrodesis, 92 without). Primary outcome measure was nonunion rate. Secondary outcome measures were time to tibiotalar union, rate of development of post-operative deep vein thrombosis (DVT)/pulmonary embolism (PE), rate of deep wound complications, and rate of return to operating room (OR). No differences in nonunion rates were observed in both cohorts of patients with versus without distal tibiofibular arthrodesis: 17/227 (7.5%) versus 11/92 (12%) (p = 0.2), respectively, odds ratio was 0.74, 95% CI: 0.29~2.08 (p = 0.55). There was no difference in deep wound complications (5.3% versus 10.9%, p = 0.42), time to union (3.7 months versus 4.1 months, p = 0.72), or rate of development of DVT/PE (5.2% versus 2.2%, p = 0.18) between patients with and without distal tibiofibular arthrodesis, respectively. This is the first study directly comparing nonunion and complication rates in primary, open ankle arthrodesis with and without distal tibiofibular arthrodesis. Inclusion of the distal fibular joint with the tibiotalar fusion was not associated with a change in tibiotalar nonunion rate, time to union, wound complications, or postoperative DVT/PE.

Comparison of patient demographics, utilization trends, and costs of total ankle arthroplasty and ankle fusion in the United States from 2010 to 2019

INTRODUCTION

Contemporary studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) for tibiotalar osteoarthritis are sparse. Therefore, the purpose of this study was to utilize a nationwide administrative claims database from 2010 to 2019 to compare: (1) baseline demographics; (2) utilization, (3) in-hospital length of stay (LOS), and (4) costs of care.

METHODS

Using the PearlDiver database, a retrospective query from January 1st, 2010 to December 31st, 2019 was performed for all patients who underwent TAA and AF for tibiotalar osteoarthritis. Baseline demographics, comorbidities, and geographic utilization were compared using Pearson Chi-square analyses. Linear regression was used to compare differences in procedure utilization and in-hospital LOS during the study interval. Reimbursements between the two cohorts during the study interval were compared. A p value less than 0.05 was statistically significant.

RESULTS

In total, 14,248 patients underwent primary TAA (n = 5544) or AF (n = 8704). Patients undergoing AF were generally younger (< 60) with greater comorbidity burden driven by hypertension, diabetes mellitus, obesity, and tobacco use compared to TAA patients (p < 0.0001). Over the study interval, TAA utilization remained constant (912 vs 909 procedures; p = 0.807), whereas AF utilization decreased by 42.5% (1737 vs 998 procedures; p = 0.0001). Mean in-hospital LOS for patients undergoing TAA decreased (2.5 days vs. 2.0 days, p = 0.0004), while AF LOS increased (2.6 days vs. 3.5 days, p = 0.0003). Reimbursements for both procedures significantly declined over the study interval (TAA: $4559-$2156, AF: $4729-$1721; p < 0.013).

CONCLUSION

TAA utilization remained constant, while AF utilization declined by 42.5% from 2010 to 2019. There was divergence in the LOS for TAA versus AF patients. Both procedures significantly declined by over 50% in reimbursements over the study interval.

Patient-specific instrumentation (PSI) in total ankle arthroplasty: a systematic review

BACKGROUND

Patient-specific instrument (PSI) may theoretically make total ankle arthroplasty (TAA) more accurate. Several studies have reported the outcomes of PSI TAA. The aim of this study is to systematically review the literature of PSI TAA.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library databases were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines for PSI TAA. The quality of the included studies was evaluated according to Methodological Index for Non-Randomized Studies (MINORS).

RESULT

Nine articles were ultimately included in the systematic review. The implant position and function outcome of TAA was similar between PSI and SI. Prediction accuracy of implant size remained great difference. PSI can shorten the operative time and fluoroscopy time. The quality of current studies on PSI TAA is insufficient to produce high-level evidence.

CONCLUSION

PSI can get similar implant position and clinical outcome in TAA compared to SI, but current evidence is not strong enough to evaluate PSI TAA.