Clinical outcomes comparing arthroscopic vs open ankle arthrodesis

Arthroscopic Tibiotalar Arthrodesis Using an Arthroscopic Autologous Tissue Collector: A Technique Guide

Tibiotalar arthrodesis is a common procedure performed in patients with ankle arthritis to relieve pain, restore function, and improve the quality of life. Obtaining proper bone-to-bone apposition is crucial to obtaining a solid fusion. Therefore, adequate joint preparation is critical. Open-joint preparation is the standard of care, but arthroscopic arthrodesis is becoming increasingly popular, as it can decrease tissue trauma, postoperative pain, hospital stay, and complications. The addition of bone matrix allograft and autograft also improves healing rates. Use of an arthroscopic autologous tissue collector through standard arthroscopic portals allows harvesting of bone matrix autograft without having to perform additional invasive bone harvesting outside of the affected joint. We present our technique for tibiotalar arthrodesis using an arthroscopic approach with an arthroscopic autologous tissue collector.

Tibiotalocalcaneal ankle arthrodesis with posterior approach arthroscopic-assisted hindfoot nailing

PURPOSE

End-stage ankle arthrosis causes severe pain and limited movement. Tibiotalocalcaneal arthrodesis with arthroscopy-assisted hindfoot nailing can be used to achieve a high union rate and low complication rate. We aimed to examine the early- and mid-term results of patients treated with this technique from various perspectives and to evaluate them by comparing them with the current literature.

METHODS

Data were collected from 25 patients who met the established criteria and underwent TTCA with arthroscopic-assisted hindfoot nailing. In addition to the demographic data of the patients, their clinical and pain scores were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS). Additionally, the union time and complication data during the follow-up period were examined.

RESULTS

When the AOFAS and VAS scores of the 25 patients were examined, a significant improvement was observed in the preoperative period and early postoperative period comparisons (p < .001). No significant change was observed between the comparison of the postoperative 12th month and last postoperative control clinical scores. While the union rate of the patients was observed to be 92%, the average union time was 13.1 ± 3.5 weeks. During follow-up, peri-implant fracture, deep infection, and non-union were observed in one patient each (12%).

CONCLUSION

The early- and mid-term postoperative results of patients treated with TTCA surgery with posterior approach arthroscopic-assisted hindfoot nailing show that this technique may be an option with low complication and high union rates for the appropriate group of patients planned for ankle arthrodesis.

Effect of a compression staple on correction of varus deformity during arthroscopic ankle arthrodesis

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) has become popular because of its higher rate of bone union, lower invasiveness, and shorter hospital stays compared to those of open arthrodesis. However, postoperative malalignment is often observed for severe varus deformity, which can cause nonunion, pain, and adjacent joint arthrosis. A compression staple can provide a persistent, strong compressive force on the bone surface. This study aimed to clarify the difference in alignment correction in AAA by comparing a compression staple and screws fixation with screws-only fixation pre- and postoperatively.

METHODS

Seventy ankles in 67 patients undergoing AAA were retrospectively reviewed. AAA with three screws through the distal tibia was performed in 53 ankles, and 17 ankles underwent AAA with a compression staple and two screws. After the preparation of the joint surface arthroscopically, patients in the S group had three canulated cancellous screws inserted through the medial tibia. Patients in the CS group had a compression staple placed at the lateral aspect of the tibiotalar joint and two screws inserted through the medial side. Clinical scores and pre-and postoperative alignment on plain radiographs were compared between the two procedures.

RESULTS

There were no significant differences in the pre-and postoperative Japanese Society for Surgery of the Foot scale. One ankle in the S group exhibited nonunion. There were no significant differences in talar tilt and tibiotalar angles between the groups. The tibial plafond angle in the CS group was significantly lower than that in the S group (p < 0.05). Postoperatively, talar tilt and tibiotalar angles on the coronal image, and the lateral tibiotalar angle in the CS group were significantly lower than those in the S group (p < 0.05).

CONCLUSION

AAA with a compression staple and two-screw fixations could obtain more optimal alignments than AAA with screw-only fixation, even in cases with severe varus deformity.

Comparison of different internal fixation models in ankle arthrodesis using 3D finite-element analysis

BACKGROUND

The purpose of this study is to use three-dimensional finite-element analysis to better understand the biomechanical features of various internal fixators for ankle arthrodesis.

METHODS

We used finite-element analysis to compare four different types of internal fixations in ankle arthrodesis: Group A had three crossed screws (Ø6.5 mm); Group B had two crossed screws (Ø6.5 mm) and an anterior plate (Ø2.7 mm); Group C only had an anterior anatomical plate (Ø3.5 mm); Group D had one anterior anatomical plate (Ø3.5 mm) and one posterior-lateral screw (Ø6.5 mm). We adopted Ansys 21.0 software to analyze and compare the four types in terms of the displacement of the arthrodesis surface and the stress peak and stress distribution of these models under intorsion, extorsion, dorsiflexion torque, and neutral vertical load.

RESULTS

① Displacement of the arthrodesis surface: In Group A, the maximum displacement was larger than Group D under neutral vertical load and dorsiflexion torque but less than it under intorsion and extorsion torque. In Group B, the maximum displacement against dorsiflexion, neutral vertical load, intorsion, and extorsion was less than that in the other three fixation models. In Group C, the maximum displacement against the above four loading patterns were significantly higher than that in another three fixation models. ② Stress peak and stress distribution: based on the stress distribution of the four models, the peak von Mises stress was concentrated in the central sections of the compression screws, plate joints, and bending parts of the plates.

CONCLUSIONS

The fixation model consisting of two crossed screws and an anterior outperformed the other three fixation models in terms of biomedical advantages; thus, this model can be deemed a safe and reliable internal fixation approach for ankle arthrodesis.

Arthroscopic vs. Open-Ankle Arthrodesis on Fusion Rate in Ankle Osteoarthritis Patients: A Systematic Review and Meta-Analysis

Although open surgery is the conventional option for ankle arthritis, there are some reports in the literature regarding the use of the arthroscopy procedure with outstanding results. The primary purpose of this systematic review and meta-analysis was to analyze the effect of the surgery technique (open-ankle arthrodesis vs. arthroscopy) in patients with ankle osteoarthritis. Three electronic databases (PubMed, Web of Science, and Scopus) were searched until 10 April 2023. The Cochrane Collaboration's risk-of-bias tool was used to assess the risk of bias and grading of the recommendations assessment, development, and evaluation system for each outcome. The between-study variance was estimated using a random-effects model. A total of 13 studies (including n = 994 participants) met the inclusion criteria. The meta-analysis results revealed a nom-significant (p = 0.072) odds ratio (OR) of 0.54 (0.28-1.07) for the fusion rate. Regarding operation time, a non-significant difference (p = 0.573) among both surgical techniques was found (mean differences (MD) = 3.40 min [-11.08 to 17.88]). However, hospital length stay and overall complications revealed significant differences (MD = 2.29 days [0.63 to 3.95], p = 0.017 and OR = 0.47 [0.26 to 0.83], p = 0.016), respectively. Our findings showed a non-statistically significant fusion rate. On the other hand, operation time was similar among both surgical techniques, without significant differences. Nevertheless, lower hospital stay was found in patients that were operated on with arthroscopy. Finally, for the outcome of overall complications, the ankle arthroscopy technique was a protective factor in comparison with open surgery.

Clinical Outcomes Following Percutaneous Ankle Fusion With Bone Graft Substitute

Background

Percutaneous ankle fusion is an emerging technique with minimal published outcome data. The goal of the present study is to retrospectively review clinical and radiographic outcomes following percutaneous ankle fusion and provide technique tips to perform percutaneous ankle fusion.

Methods

Patients >18 years of age, treated by a single surgeon, from February 2018 to June 2021, who underwent primary isolated percutaneous ankle fusion supplemented with platelet-derived growth factor B (rhPDGF-BB) and beta-tricalcium phosphate, with at least 1-year follow-up were included. Surgical technique consisted of percutaneous ankle preparation followed by fixation with 3 headless compression screws. Pre- and postoperative visual analog scale (VAS) and Foot Function Index (FFI) were compared using paired t tests. Fusion was assessed radiographically by the surgeon on postoperative radiographs and computed tomography (CT) at 3 months postoperatively.

Results

Twenty-seven consecutive adult patients were included in the study. Mean follow-up was 21 months. Mean age was 59.8 years. Mean preoperative and postoperative VAS scores were 7.4 and 0.2, respectively (P < .01). Mean preoperative FFI pain domain, disability domain, activity restriction domain, and total score were 20.9, 16.7, 18.5, and 56.4, respectively. Mean postoperative FFI pain domain, disability domain, activity restriction domain, and total score were 4.3, 4.7, 6.7, and 15.8, respectively (P < .01). Fusion was achieved in 26 of 27 patients (96.3%) at 3 months. Four patients (14.8%) had complications.

Conclusion

We found in this cohort with surgery performed by a surgeon highly experienced in minimally invasive surgery that percutaneous ankle fusion augmented with a bone graft supplement achieved a high rate of fusion (96.3%) and a significant improvement in pain and function postoperatively while associated with minimal complications.

Level of Evidence

Level IV, case series.

Improvement in clinical outcome and quality of life after arthroscopic ankle arthrodesis in paralytic foot drop

BACKGROUND

Paralytic foot-drop is a disabling deformity that results from nerve or direct muscle injuries. Palliative surgeries such as tendon transfer and ankle arthrodesis are reserved for permanent deformity, with the arthroscopic technique had not been widely studied before. This study aims to evaluate the clinical outcome and quality of life after arthroscopic ankle fusion of paralytic foot-drop deformity.

MATERIALS AND METHODS

The patients who were retrospectively enrolled in this study underwent arthroscopic ankle fusion for paralytic foot-drop deformity between March 2017 and December 2021. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Cumberland Ankle Instability Tool (CAIT) were the measures used for clinical assessment. To judge the union, serial plain radiographs of the ankle were obtained. The preoperative and postoperative means were analyzed utilizing a two-tailed paired t-test, with a p value of less than 0.05 indicating statistical significance.

RESULTS

This study included 21 consecutive patients with a mean follow-up of 35.09 ± 4.5 months and a mean age of 41.5 ± 6.1 years. Highly significant improvements were observed between the preoperative and final follow-up means of the AOFAS score (from 57.6 ± 4.6 to 88.3 ± 2.7) and CAIT (from 12.1 ± 2.2 to 28.9 ± 1.01; p ˂ 0.00001 for both). All patients attained radiographic union and resumed their previous occupations without reporting serious adverse effects.

CONCLUSIONS

Arthroscopic ankle fusion is an effective, minimally invasive palliative surgery for patients suffering from permanent paralytic foot-drop deformity. This technique was shown to provide good functional and radiologic outcomes without significant complications.

LEVEL OF EVIDENCE

Retrospective cohort; level of evidence (IV).

Complications following ankle arthroscopy

This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur. A computer-based search was performed in PubMed, Embase, Emcare, and ISI Web of Science. Two-stage title/abstract and full-text screening was performed independently by two reviewers. English-language original research studies reporting perioperative complications in a cohort of at least ten patients undergoing ankle arthroscopy were included. Complications were pooled across included studies in order to derive an overall complication rate. Quality assessment was performed using the Oxford Centre for Evidence-Based Medicine levels of evidence classification. A total of 150 studies describing 7,942 cases of ankle arthroscopy in 7,777 patients were included. The overall pooled complication rate was 325/7,942 (4.09%). The most common complication was neurological injury, accounting for 180/325 (55.4%) of all complications. Of these, 59 (32.7%) affected the superficial peroneal nerve. Overall, 36/180 (20%) of all nerve injuries were permanent. The overall complication rate following anterior ankle arthroscopy was 205/4,709 (4.35%) compared to a rate of 35/528 (6.6%) following posterior arthroscopy. Neurological injury occurred in 52/1,998 (2.6%) of anterior cases using distraction, compared to 59/2,711 (2.2%) in cases with no distraction. The overall rate of major complications was 16/7,942 (0.2%), with the most common major complication - deep vein thrombosis - occurring in five cases. This comprehensive systematic review demonstrates that ankle arthroscopy is a safe procedure with a low overall complication rate. The majority of complications are minor, with potentially life-threatening complications reported in only 0.2% of patients.

Transfibular ankle arthrodesis with use of sagitally split fibula as a biological plate leads to excellent outcome: A retrospective analysis

Background

We studied ankle arthrodesis with a transfibular approach using sagitally spilitted fibula as a biological plate (onlay grafting) as well as other half of fibula as morcellised local interpositional graft (inlay grafting) to achieve bony union.

Material and methods

Retrospective clinico-radiological evaluation of 36 operated cases was done at 3, 6, 12 and 30 months follow-ups. Clinically union was considered once ankle became pain free on full weight bearing. Pain assessment was done by using VAS (visual analogue scale) score and functional evaluation was done by AOFAS (American Orthopaedic Foot & Ankle Society) hind foot score preoperatively and at different follow ups. Radiologically, sagittal plane ankle alignment and fusion status was determined at each follow up.

Results

Mean age of patients was 40.36 ± 10.56 years (range 18-55), who were evaluated for mean duration of 33.32 ± 11.25 months (range 24-65). Thirty-three (91.7%) ankles were fused adequately and mean duration to achieve bony union was 5.09 ± 1.3 months (range 4-9 months). Mean post-operative AOFAS score at final follow up was 76.65 ± 4.87 in comparison to 45.76 ± 3.38, preoperatively. VAS score improved significantly from 7.8 (pre-operative) to 2.3 (final follow-up). Non-union in three patients (8.3%) and ankle malalignment in one patient was observed.

Conclusion

Transfibular ankle arthrodesis achieves excellent bony unions and functional outcomes in severe ankle arthritis. Biologically incompetent fibula that to be judged individually by the operating surgeon to use it as a graft. Patients having inflammatory arthritis have more dissatisfaction than other aetiologies.

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.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

Do degree of coronal plane deformity and patient related factors affect union and outcome of Arthroscopic versus Open Ankle Arthrodesis?

BACKGROUND

This study aimed to analyse if union and outcome of Arthroscopic Ankle Arthrodesis (AAA) versus Open Ankle Arthrodesis (OAA) were influenced by the extent of coronal plane deformity and to report if patient related factors influence union.

METHODS

A total of 122 ankle arthrodesis procedures were included in the study. These were divided into two groups; Group A (n = 99) with deformity less than 15° and Group B (n = 23) with deformity greater than or equal to 15°. Data was collected on patient demographics, medical comorbidities (smoking, diabetes, obesity) and time to union. Patient reported outcome measures (PROMs) evaluated were Manchester Oxford Foot Questionnaire, EuroQol-5D and EuroQol visual analogue health thermometer (EQ-VAS).

RESULTS

The mean follow-up in Group A and B was 74.87 and 89.17 months respectively. The average deformity in Group A was 4.9° for AAA and 5.8° for OAA. In Group B it was 18.9° (maximum 28° varus) for AAA and 22.1° (maximum 41° valgus) for OAA. The overall union rate was 95% in Group A (AAA-94%; OAA-100%; [p = 0.20]) and 87% in Group B (AAA-100%; OAA-67%; [p = 0.02]). Mean time to union was 13.2 weeks in Group A (AAA-13.3 weeks; OAA-12.8 weeks; [p = 0.73]) compared to 12.4 weeks for Group B (AAA-12.9 weeks; OAA-11.8 weeks; [p = 0.56]). Irrespective of the extent of deformity and type of surgery, smokers had a 10 times higher likelihood of non-union (p = 0.03). In Group A, none of the PROMs showed significant difference between AAA and OAA. In Group B, EQ-VAS score reached statistical significance (p = 0.03) in favour of AAA whereas other PROMs showed no difference.

CONCLUSION

AAA is reproducible in achieving union in end stage ankle arthritis and good PROMs can be expected even in ankles with larger deformities. Regardless of the type of surgery and extent of deformity, smoking is a significant risk factor for non-union.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Larger sagittal inter-screw distance/tibial width ratio reduces delayed union or non-union after arthroscopic ankle arthrodesis

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) has risks of complications, such as delayed union and non-union. The number and direction of the inserted screws have been reported as important factors affecting the time to union of AAA. However, the ratio of inter-screw distance (ISD) to tibial width (TW) in different planes has not been investigated. Therefore, we aimed to explore the effect of this ratio on bone union following AAA.

METHODS

We retrospectively enrolled 63 patients (64 ankles) undergoing AAA from 2013 to 2019. Then, their age, body mass index (BMI), sex, diabetes mellitus (DM) status, Takakura-Tanaka classification, number of screws and radiographic parameters were analysed.

RESULTS

The patients had a mean age of 70.3 (range, 45-91) years. Bone fusion was achieved in 57 ankles (89%) in a mean period of 3.3 (range, 2-6) postoperative months. There were four cases of delayed union and three of non-union. No significant differences in age, BMI, sex, DM, Takakura-Tanaka classification, and number of screws could be detected between the groups. However, the sagittal ISD/TW ratio was significantly larger in the union group than in the delayed/non-union group with a cut-off value of 57.0%.

CONCLUSION

Larger sagittal ISD/TW ratios result in reduced post-AAA delayed union or non-union. The surgeon should be aware that the anterior and posterior screw widths should be approximately 60% or more of the anteroposterior width of the tibia.

Comparisons between ankle distraction arthroplasty and supramalleolar osteotomy for treatment of post-traumatic varus ankle osteoarthritis

BACKGROUND

Ankle distraction arthroplasty and supramalleolar osteotomy were both options for post-traumatic varus ankle arthritis (VAA), but their comparative effectiveness was scarcely reported. This study aimed to compare the outcomes of two operative methods for treatment of Takakura-Tanaka stage 3 post-traumatic VAA.

METHODS

This was a retrospective study, comprising 73 consecutive patients who presented with Takakura-Tanaka stage 3 post-traumatic VAA treated by either ankle distraction arthroplasty (n = 32) or supramalleolar osteotomy (n = 41) from January 2016 to December 2019. All patients had a minimum 24-month follow-up assessments. The outcome measures were visual analog scale (VAS), the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores, complications, patient-rated overall satisfaction and ankle function.

RESULTS

At an average of 32 months (range, 24-52 months) follow-up, significant improvement was observed for VAS, AOFAS, range of motion (ROM) and most radiographic parameters (except for TAS and TLS for ankle distraction arthroplasty group) compared to preoperative baselines (p < 0.05) for both groups. However, both groups did not differ significantly in terms of VAS or AOFAS, excellent and good rate (78.1% versus 85.4%, p = 0.422), overall rate of postoperative complications (28.1% vs. 17.1%, p = 0.257), or various radiographic parameters (e.g. tibial anterior surface angle, talar tilt angle and tibial lateral surface angle) (all p > 0.05). The ankle distraction arthroplasty group had a better postoperative ankle motion than did the supramalleolar osteotomy group, in terms of plantarflexion (37.8 ± 4.2 vs. 30.4 ± 3.6, p = 0.006), dorsiflexion (36.5 ± 6.4 vs. 28.3 ± 5.5, p = 0.004), varus (32.1 ± 4.5 vs. 27.1 ± 3.1, p = 0.017) and valgus (28.4 ± 3.7 vs. 25.2 ± 2.8, p = 0.046).

CONCLUSIONS

Both operative treatments are effective for Takakura-Tanaka stage 3 post-traumatic VAA. In practice, individualized treatment option tailored to the ankle condition and patients' specific need should be considered.

LEVEL OF EVIDENCE

 III, retrospective comparative series.

Technique Tip: Correcting Malalignment of the Talus Using a Pin-Based Distracter During Arthroscopic Ankle Arthrodesis

It is technical demanding work to perform arthroscopic ankle arthrodesis to treat end-stage ankle osteoarthritis with excessive talar tilt. This article aimed to provide an effective technique tip for the treatment of Takakura stage 3b ankle osteoarthritis with a talar tilt angle more than 15 degrees under arthroscopy. A conventional anterior arthroscopic approach is used. After arthroscopic examination and debridement, one pin which is parallel to the distal tibial surface is inserted into the tibial side of the ankle, the other pin which is parallel to the talar dome surface is inserted into the talar side of the ankle, both at the coronal plane. Then a distracter is used in the medial side to open the interspace of the tibiotalar joint and correct the talar tilt through the 2 pins, under which circumstance the tibiotalar joint surface can be well prepared. Next an anti-distracter is used in the lateral side to close the tibiotalar interspace and correct the talar tilt through the 2 pins, in which condition 3 fully threaded cannulated lag screws can be inserted through guide pins in a cross pattern to fix the ankle joint. We used the pin-based distracter to open and close tibiotalar interspace, correct the talar tilt and maintain a good mechanical axis for fusion, and the outcomes were good.

Open Ankle Arthrodesis for Deformity Correction

Open ankle arthrodesis remains a reliable solution for ankle arthritis, especially in the setting of deformity. Careful preoperative evaluation needs to be performed, both clinically and radiographically. The specific deformity present helps determine the approach used and the fixation choices. Deformity is most commonly seen intraarticularly, though deformity can also be present anywhere along the lower extremity, including compensatory deformity in the foot. Multiple different techniques can be used to address both the deformity and achieve a successful ankle arthrodesis. Patient outcomes reported in the literature are generally good, with high union rates and improved functional outcomes.

[Open or arthroscopic arthrodesis of the ankle joint : Which is better?]

Due to the change in the age structure in Germany and the steadily increasing number of fractures, arthrosis of the upper ankle joint, mainly caused by posttraumatic conditions, is becoming more and more relevant in routine trauma surgery and orthopedics. Patients suffer from reduced functionality and quality of life as well as immobilizing pain. In addition to an ankle joint prosthesis arthrodesis of the upper ankle joint offers an alternative for the treatment of advanced arthrosis. When performing an arthrodesis there is basically the option of both open and arthroscopic procedures to prepare the joint and remove the cartilage. In both procedures the upper ankle joint is usually fixed with 2-3 cannulated compression screws. Comparative studies to date have shown an advantage of the arthroscopic technique in terms of complication rate, length of hospitalization, proportion of ossification and functional outcome. The indications for arthroscopic fusion should be strictly considered, especially in the case of malalignment, as major axis corrections are difficult to perform. In such cases, open fusion of the upper ankle joint still seems superior to the arthroscopic method.

Arthroscopic vs open ankle arthrodesis: A prospective case series with seven years follow-up

BACKGROUND

The osteoarthritis of the ankle, although less common than other joints, is associated with severe functional limitation. Surgical options are ankle arthroscopic debridement, osteotomies, ankle arthrodesis and ankle arthroplasty. Ankle arthroplasty is increasingly used thanks to the new implants design, but ankle arthrodesis still represents the most used technique and it can be performed arthroscopically or with an open procedure.

AIM

To compare mid-term results of arthroscopic vs open ankle arthrodesis of patients affected by end-stage ankle arthritis.

METHODS

This study enrolled 23 patients, which underwent ankle arthrodesis. The patients were divided into 2 groups: group A (open procedure; n = 11) and group B (arthroscopic procedure, n = 12), the two groups were homogeneous with regard to age and body mass index (P = 0.347). The American Orthopaedic Foot and Ankle score (AOFAS), Freiburg Ankle score (FAS) and visual analogue scale for pain intensity were evaluated preoperatively, at six months and at final follow-up of 7.6 years in group A and 7.3 years in group B (P = 0.364).

RESULTS

Patients in the arthroscopic group showed better results at six-month follow-up compared to the open group at the AOFAS (group A, 62.2; group B, 78.5; P < 0.05) and the FAS (group A, 61.1; group B, 70.3; P = 0.015) scores. Pain relief was achieved in both groups at six-month follow-up (group A, 1.4; group B, 0.9; P = 0.162). Both open and arthroscopic groups showed improved clinical outcomes from baseline to final follow-up (P > 0.05). Hospital stay was shorter in group B than in group A (P = 0.001). More complications were reported in the open group than in the arthroscopic group (P = 0.459).

CONCLUSION

The arthroscopic and the open arthrodesis are valid and safe options for the treatment of ankle arthritis on the basis of clinical outcomes at 7 years follow-up. Moreover, the arthroscopic treatment shows faster improvement at six-month follow-up in comparison with the open group.

Treatment of Severe Rigid Posttraumatic Equinus Deformity With Gradual Deformity Correction and Arthroscopic Ankle Arthrodesis

BACKGROUND

Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications.

METHODS

We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period.

RESULTS

Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2.

CONCLUSION

Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Open versus arthroscopic ankle arthrodesis in high-risk patients: a comparative study

PURPOSE

Arthroscopic ankle arthrodesis is known to offer high fusion rates, improvements in pain and functional outcomes, low risks of complications, and reinterventions. The aim of this study is to compare open vs. arthroscopic ankle arthrodesis in patients at high risk of complications.

METHODS

A single-centre retrospective comparative analysis of ankle fusions was conducted. Patient records were screened for demographics, type of arthrodesis, follow-up length, pre-operative diagnosis, risk factors for non-union, operative time, radiographic union, time to union, complications, and reinterventions. The American Orthopedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Italian version of the Foot Function Index (FFI), and a visual analog scale (VAS) for pain scores collected pre-operatively and in the last follow-up were used to assess clinical outcomes.

RESULTS

There were 23 open and 21 arthroscopic ankle fusions. Union rate was higher (90.5% vs. 65.2%, p < 0.05) and complication rate was lower (14.3% vs. 47.8%, p < 0.05) in the arthroscopic group. In addition, patients who underwent arthroscopic arthrodesis reported better pain control, with higher improvements in VAS for pain scores. There was no significant difference in length of operative time, time to fusion, AOFAS, and FFI scores improvements between the two groups.

CONCLUSIONS

Arthroscopic ankle arthrodesis resulted in higher union rates, fewer complications, and lower reoperation rates in patients at high risk of complications.

Arthroscopic ankle fusion only has a limited advantage over the open operation if osseous operation type is the same: a retrospective comparative study

Background

A great deal of research suggests that arthroscopic ankle fusion (AAF) has advantages over open ankle fusion (OAF), but these outcomes would be imprecise because of a selection bias. The purpose of this study is to verify which is better for ankle fusion, AAF or OAF. We regrouped the OAF group into two subgroups according to whether the osseous operation type is the same as AAF group. The goal is to minimize the impact of disease severity, thereby reducing selection bias to some extent.

Methods

We retrospectively analyzed the data of ankle fusion in our hospital between July 2015 and October 2018. Forty-three patients were enrolled and divided into AAF group (n = 17) and OAF group (n = 26). In order to eliminate selection bias, we divided OAF group into complex osseous operation subgroup (COO subgroup) (n = 15) and simple osseous operation subgroup (SOO subgroup) (n = 11). The osseous operation type of SOO subgroup is the same as AAF group. Then, we compared the differences between these groups. All patients were followed up at least 1 year after operation. We analyzed data, including etiology composition, surgical time, intra-op blood loss, reduction of albumin, total hospital stays, union time, fusion situation, complications, radiological examination, functional score, and questionnaire survey. Then we performed statistical analyses.

Results

We found that the etiological components of AAF group and OAF group were different; the etiological components of AAF group and SOO subgroup were similar. We found that AAF group has advantages over OAF group and COO subgroup in general. However, except in terms of surgical trauma, hospital stays, and short-term complications occurred, the AAF group has not obvious advantages over SOO subgroup, including intra-op blood loss, fusion condition, postoperative function score, and postoperative patient satisfaction; and AAF group need more surgical time than the SOO subgroup.

Conclusions

The arthroscopic ankle fusion can bring a good curative effect; however, if the osseous operation type is the same, the arthroscopic ankle fusion only has a limited advantage over the traditional open operation in perioperative soft tissue protection and enhanced recovery after surgery.

A New Classification for Ankle Arthrodesis When Using an External Fixator

Background

We have classified ankle arthrodesis when using an external fixator into four types based on the deformity and defect. Each of the four types of technique have been evaluated retrospectively.

Materials and methods

Thirty-three lower limb segments in 30 patients (average age 49 years) were treated by ankle arthrodesis using an external fixator in our institution. We classified the pre-treatment problems into four types and adjusted the surgical treatment accordingly: type I—no bone defect, no or mild deformity; type II—no bone defect, severe deformity; type III—bone defect with the possibility to shorten acutely after resection of the pathological focus; and type IV—bone defect but without the ability to shorten acutely after resection of the pathological focus. Type I problems were treated with curettage of ankle cartilage and bone graft with external fixation. Type II problems were treated with mobilisation using an external fixation after performing a type I ankle arthrodesis. Type III problems were treated with ankle arthrodesis using acute shortening and distraction. Type IV problems were treated with ankle arthrodesis using bone transport.

Results

All patients had secure ankle fusion and were able to bear total weight in walking on completion of treatment. The mean external fixation period was 96 days in type I, 181 days in type II, 231 days with lengthening in type III and IV. The complications included re-fracture in three cases, deformity at the lengthening site in one, delayed union in one, and infection at fusion site in one.

Conclusion

We have strategized ankle arthrodesis procedures using an external fixator into four groups in order to align the surgical technique with the pre-treatment problem. Our classification can help decide the appropriate operative method when using an external fixator, especially for difficult cases.

How to cite this article

Matsubara H, Watanabe K, Takata M, et al. A New Classification for Ankle Arthrodesis When Using an External Fixator. Strategies Trauma Limb Reconstr 2019;14(3):148–154.