Revision tibiotalar arthrodesis with posterior iliac autograft after failed arthroplasty: A matched comparative study with primary ankle arthrodeses

Dedicated locking plate reduces non-union risk in open ankle fusion in obese patients

INTRODUCTION

Obesity is a growing public health concern. In ankle osteoarthritis, non-conservative treatment in advanced stages consists in ankle fusion, or else total ankle replacement, for which obesity is a relative contraindication. One of main complications of ankle fusion is non-union. Devascularization, obesity and fixation material are all factors involved in postoperative non-union, and have to be taken into account in surgical strategy for reliable results. The objective of this study was to compare the rate of ankle non-union in obese patients using quadruple screwing or a dedicated locking plate. The hypothesis was that the locking plate limits the risk of non-union in this population.

METHODS

All patients were obese (BMI>30kg/m2) and presented ankle osteoarthritis with>10° intra-articular deformity. The approach and joint preparation were performed via an anteromedial approach. Group S was composed of 32 patients, operated on by quadruple screwing; group P comprised 10 patients operated on using a dedicated locking plate. The main endpoint was a significant difference in the rate of non-union between the 2 groups. The secondary endpoint was improvement in pre- and 6-month postoperative AOFAS score.

RESULTS

Group S presented 31% non-union (10/32) and group P 0% (0/10) (p<0.05). Postoperative AOFAS score was significantly higher in group P: 67.8±10.4 [range, 40-92] vs. 83.1±8.0 [range, 64-92] (p<0.05).

CONCLUSION

The dedicated anterior locking plate is a technique of choice for ankle fusion in obese patients with intra-articular deformity>10°, to limit the risk of non-union.

LEVEL OF EVIDENCE

IV; retrospective study.

Combined anterior and posterior vs isolated posterior facet fixation for subtalar arthrodesis: A proportional meta-analysis and systematic review of the literature

INTRODUCTION

Subtalar arthrodesis (SA) is a common procedure to treat end-stage subtalar osteoarthritis. We set out in order to determine whether a combined direct fixation of both anterior and posterior facets during SA might influence union and complications compared to isolated fixation of the posterior facet. Our hypothesis was that a combined fixation increases the union rate and reduces the complication rate.

METHODS

In this PRISMA-compliant PROSPERO-registered systematic review, we included studies reporting data after SA stabilized with screws in adults. The characteristics of the cohort, study design, surgical details, nonunion and complication rate at the longest follow-up were recorded. The modified Coleman Methodology Score (mCMS) was applied to appraise the quality of studies. Two groups were compared: an ANT/POST group (screws positioned both in the anterior and posterior facet) and an ONLY POST group (isolated posterior facet fixation).

RESULTS

Eighteen series (685 feet: ANT/POST = 96, ONLY POST = 589) were selected. The median follow-up was 28 months (IQR, 12-42). The pooled proportion showed a similar nonunion rate (6% vs 10%; p = 0.46) and complication rate (14% vs 19%, p = 0.47) in the ANT/POST group as compared to the ONLY POST group. The pooled proportion of reoperation was not different either (ANT/POST: 7% vs ONLY POST: 10%, p = 0.37). Kernel regression suggested a correlation between the proportion of open/arthroscopic procedures and the nonunion rate (p = 0.025) with a median nonunion rate at 10.9% and 5.9% for open and arthroscopic procedures, respectively. Mean CMS was 40.4 points (poor quality).

CONCLUSION

This proportional meta-analysis suggested that a combined direct fixation of anterior and posterior facets during subtalar arthrodesis does not significantly influence the risk of nonunion nor affects the risk of complication and reoperation as compared to isolated posterior facet fixation.

LEVEL OF EVIDENCE

IV; review of Level I-IV studies.

Female sex as a negative predictor of outcomes of ankle arthrodesis: a retrospective comparative monocentric study

BACKGROUND

End-stage post-traumatic osteoarthritis of the ankle joint may require arthrodesis if conservative treatment fails and a decision against total ankle replacement is made. We aimed to compare the sex-specific differences in outcomes and objectify them using validated specific scores.

METHODS

Between 2010 and 2021, 221 patients underwent ankle arthrodesis at our institution, including 143 men (MAA) and 78 women (FAA). In addition to demographic data, the aetiology of osteoarthritis, the Foot Function Index (FFI-D), the Olerud-Molander Score (OMAS), and the Short Form-12 questionnaire (SF-12) were collected in this monocentric study. The mean follow-up time was 5.8 years. End-stage osteoarthritis was mostly due to ankle fractures as a result of sprains, falls, and road traffic accidents.

RESULTS

Post-operatively, the mean FFI-D for pain was 17.3 (MAA: 14.7; FAA 22.2) and 43.9 for function (MAA: 41.1; FAA 49.5); the mean OMAS was 58.2; and the mean SF-12 physical component score was 42.5. Women achieved significantly worse results in all scores; only the mental component summary of the SF-12 did not differ between the sexes (p > 0.05). Approximately 34% of women stated that the result in terms of gait pattern was worse than expected (MAA 16.1%; p < 0.05). Again, significantly more men stated that the result was better than expected (MAA: 48.3%; FAA: 31.5%, p < 0.05).

CONCLUSIONS

The fact that the clinical results were significantly worse in women after ankle arthrodesis should be considered when determining the indication. However, the expectations of men and women also need to be individually adjusted.

Results of Total Ankle Arthroplasty Versus Ankle Arthrodesis

No differences have been found between total ankle arthroplasty (TAA) and ankle arthrodesis (AA) with respect to patient-reported outcome measures (PROMs), although both interventions were shown to improve PROMs with respect to the preoperative situation. That is, both interventions (AA and TAA) were effective in improving preoperative symptoms. On the other hand, 2-year complication rates were higher after AA (27%) than after TAA (16%); however, infection rates were similar (4%). The published revision rate after AA is 16% versus 11% after TAA. In short, TAA and AA appear to offer the same PROMs, but TAA has a lower rate of complications (except for infection) and revisions.

Ankle surgery in 2022: What do the scientific articles say, and what do the patients?

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