Clinical benefit of joint distraction in the treatment of ankle osteoarthritis

Ankle Distraction Arthroplasty: A Survivorship Review and Meta-Analysis

Multiple treatments exist for ankle osteoarthritis. Ankle arthrodesis is the gold standard in late-stage osteoarthritis, but sacrifices range of motion and risks nonunion. Total ankle arthroplasty is typically reserved for low-demand patients as the long-term outcomes are poor. Ankle distraction arthroplasty is a joint sparing procedure which utilizes external fixator frame to unload the joint. This promotes chondral repair and improves function. This study aimed to organize clinical data and survivorship in published papers and direct further research efforts. Thirty-one publications were evaluated and 16 were included in the meta-analysis. The Modified Coleman Methodology Score was used to assess quality of the individual publications. Random effects models were used to estimate the failure risk after ankle distraction arthroplasty. Ankle Osteoarthritis Score (AOS), American Orthopedic Foot and Ankle Score (AOFAS), Van Valburg, and Visual Analog Scores (VAS) all improved postoperatively. Random effects model analysis revealed an overall failure ratio of 11% (95% CI: 7%-15%; p value ≤ .001; I2 = 87.01%) after 46.68 ± 7.17 months follow up, 9% (95% CI: 5%-12%; p value≤0.001 I2=81.59%) with less than 5 years follow-up and 28% (95% CI: 16%-41%; p value≤0.001 I2=69.03%) for patients with more than 5 years follow-up. Ankle Distraction Arthroplasty has promising short to intermediate term outcomes which makes this a reasonable treatment option to delay joint sacrificing surgery. The selection of the optimal candidates and consistent technique would improve research and subsequently outcomes. Based on our meta-analysis, negative prognostic factors include female sex, obesity, ROM < 20°, leg muscle weakness, high activity level, low preoperative pain levels, higher preoperative clinical scores, inflammatory arthritis, septic arthritis, and deformity.

Ankle joint distraction is a promising alternative treatment for patients with severe haemophilic ankle arthropathy

INTRODUCTION

Haemophilic ankle arthropathy (HAA) causes major morbidity. When conservative treatment fails, major surgical interventions are indicated. An alternative treatment to maintain joint mobility and postpone these interventions is desired.

AIM

To gather prospective data on clinical/structural changes after ankle joint distraction (AJD) in HAA.

METHODS

This study includes patients with severe HAA insufficiently responding to conservative treatment. AJD was performed during 8-10 weeks by use of an external frame. Questionnaires, physical examination and radiology were used to evaluate pain, function and structural changes before and 6, 12, 24 and 36 months after distraction. Mixed effect models were used for analysis.

RESULTS

This study includes eight cases (21-53 years). The fixed effects estimates of the visual analogue score (0-10) improved from 7.5 at baseline to 3.4 (p = .023) 3 years after distraction. The Haemophilia Activities List (HAL, 0-100) for basic/complex lower extremities functions improved from respectively 29.6 and 31.5 to 54.3 (p = .015) and 50.7 (p = .031). Joint mobility was maintained. Magnetic resonance imaging (MRI) showed thickened cartilage and reduced bone marrow oedema and subchondral cysts. Pin tract infections (n = 6) were effectively treated and no adverse bleeding events occurred. At 3-year follow-up, in none of the patients the originally indicated arthrodesis was performed.

CONCLUSION

This first prospective study showed that AJD in HAA results in decreased pain, improved function and decreased arthropathy-related MRI findings in the majority of patients for prolonged time. Although the study population is small and follow-up is relatively short, AJD may be promising to postpone invalidating interventions and might be a breakthrough treatment.

Distraction Arthroplasty as Acute and Definitive Treatment for Open Ankle Fracture Dislocation

A 73-year-old woman with significant medical comorbidities presented with a grade I open left ankle fracture dislocation. Distraction arthroplasty was used as a definitive treatment for this injury. The patient tolerated the procedure and had no postoperative complications. The external fixator was removed at 6 months. The patient maintained good ankle function at the 1-year postoperative visit. Distraction arthroplasty is a viable acute and definitive treatment option for ankle fracture in patients with significant medical comorbidities. [Orthopedics. 2021;44(1):e148-e150.].

Arthrofibrosis of the Ankle

Arthrofibrosis is a common, but often overlooked, condition that imparts significant morbidity following injuries and surgery to the foot and ankle. The most common etiologies are related to soft tissue trauma with subsequent fibrotic and contractile scar tissue formation within the ligaments and capsule of the ankle. This leads to pain, alterations in gait, and ankle dysfunction. Initial treatment often includes extensive physical therapy, however, if severe enough surgical options exist. Although the literature regarding ankle arthrofibrosis is scarce, this review article provides a greater understanding of the pathogenesis of arthrofibrosis and describes the current and future therapeutic options to treat fibrotic joints. Level of Evidence: Level V, expert opinion.

Ankle distraction arthroplasty for the treatment of severe ankle arthritis: Case report, technical note, and literature review

RATIONALE

Widely applied in the treatment of severe ankle arthritis (AA), ankle distraction arthroplasty (ADA) can avoid not only the ankle range of motion loss but also ankle fusion. However, the clinical outcomes of ADA for severe AA are poorly understood. This study aims to present our clinical outcomes of severe AA treated by ADA.

PATIENT CONCERNS

A 53-year-old man suffered right ankle sprain 10 years ago, endured right ankle pain and limited movement for 6 years.

DIAGNOSIS

The patient was diagnosed as severe AA.

INTERVENTIONS

He received ankle distraction arthroplasty. No adjuvant procedures were performed. The visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) score, the short-form (SF)-36 physical component summary (PCS) score and ankle activity score (AAS) were recorded to access the clinical outcomes pre- and postoperatively. Moreover, ankle joint space distance was evaluated on weight-bearing radiographs.

OUTCOMES

The patient derived effective pain relief and restored a satisfactory range of movement. There was a 13-month follow-up period after frame removal. The AOFAS score improved from 56 preoperatively to 71 postoperatively. The VAS score decreased from 6 prior to surgery to 1 after surgery. The SF-36 PCS was 47.2 and 71.8 pre- and postoperative, respectively. The AAS scores were improved from 3.4 preoperatively to 7.3 postoperatively.

LESSONS

ADA is reliable to achieve pain relief, functional recovery, and serve AA resolution. Besides, it is an alternative to ankle arthrodesis or total ankle arthroplasty in selected patients with severe AA.

Matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach- 5-year-follow-up in 100 patients

BACKGROUND

The aim of the study was to assess the 5-year-follow-up after matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to May 31, 2012 were included. Size and location of the chondral lesions, method-associated problems and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested from the ipsilateral pelvic bone marrow and centrifuged (10min, 1500RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and twenty patients with 124 chondral lesions were included in the study. Age at the time of surgery was 35 years on average (range, 12-65 years), 74 (62%) were male. VAS FA before surgery was 45.2 on average (range, 16.4-73.5). Lesions were located at medial talar shoulder, n=55; lateral talar shoulder, n=58 (medial and lateral, n=4); tibia, n=11. Lesion size was 1.7cm² on average (range, .8-6cm²). One hundred patients (83%) completed 5-year-follow-up after. VAS FA improved to 84.4 (range, 54.1-100; t-test, p<0.01).

CONCLUSIONS

MAST as part of a complex surgical approach led to improved and high validated outcome scores in the mid-term-follow-up. No method related complications were registered. Even though a control group is missing, we conclude that MAST as part of a complex surgical approach is an effective method for the treatment of chondral lesions of the ankle for at least five years.

Distraction arthroplasty compared to other cartilage preservation procedures in patients with post-traumatic arthritis: a systematic review

Post-traumatic arthritis (PTA) is characterized by the deterioration of articular cartilage temporally associated with an articular injury. With a paucity of literature comparing joint preservation techniques, we performed a systematic review of the literature intending to describe and summarize the results of ankle distraction arthroplasty as it compares with studies on tibio-talar microfracture, allograft, and autograft for ankle joint preservation in the post-traumatic population under 50 years of age. Research databases were searched and abstracts screened for relevance on our topic of interest. Abstracts meeting screening criteria with high interobserver reliability underwent full-manuscript review and coding for pertinent citation, study level, treatment, and outcome variables. Outcome variables for patient-reported pain scales, validated outcome measurement tools, radiographic progression, reoperation/re-treatment rates, and complication rates were recorded. Out of 105 unique citations, 10 publications were included. The distraction arthroplasty studies had 36 out of 181 patients requiring reoperation for complications (19.9%), while other joint-preserving procedures studies had 40 out of 177 patients requiring reoperations for complications (22.6%). Clinical outcome scores at mean follow-up time ranging from 2 to 10 years between studies were similar. Reported results for a variety of cartilage preservation procedures, including distraction arthroplasty, are satisfactory and reoperation rates for complication are similar. Limitations in available data and underlying study quality affect synthesis of the results therein. While distraction arthroplasty is an option for cartilage preservation in patients with PTA of the ankle, the technique is highly specialized which may affect the external validity.

Level of evidence: III.

Matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle is safe and effective - 2-year-followup in 130 patients

BACKGROUND

The aim of the study was to assess the 2-year-follow-up of matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from October 1, 2011 to July 31, 2013 were analyzed. Size and location of the chondral defects, method-associated problems and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analyzed. Stem cell-rich blood was harvested from the ipsilateral pelvic bone marrow and centrifuged (10min, 1500rpm). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide). The matrix was fixed into the chondral defect with fibrin glue.

RESULTS

One hundred and forty-four patients with 150 chondral defects were included in the study. The age of the patients was 35 years on average (range, 12-68 years), 85 (59%) were male. The VAS FA before surgery was 48.5 on average (range, 16.5-78.8). The defects were located as follows, medial talar shoulder, n=62; lateral talar shoulder, n=66 (medial and lateral talar shoulder, n=6), tibia, n=22. The defect size was 1.6cm² on average (range, .6-6cm²). 130 patients (90%) completed 2-year-follow-up. The VAS FA improved to an average of 87.5 (range, 62.1-100; t-test (comparison with preoperative scores), p=.01).

CONCLUSIONS

MAST led to improved and high validated outcome scores. No method related complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects of the ankle.

Ankle joint distraction arthroplasty for severe ankle arthritis

BACKGROUND

Ankle distraction arthroplasty is one option for the treatment of severe ankle arthritis in young patients. The outcomes and factors predicting success in distraction arthroplasty are poorly understood.

METHODS

From January 2011 to May 2015, 16 patients who had undergone ankle distraction arthroplasty for ankle arthritis were operated, including six males and ten females. All patients were available for analysis. The main outcome measurements included joint space on weight bearing radiographs, AOFAS-AH scores (American Orthopaedic Foot & Ankle Society ankle-hindfoot score), VAS scores and SF-36 scores.

RESULTS

All 16 patients were followed for a mean follow-up of 40.9 ± 14.7 months (range, 17-67 months). Fourteen of the 16 patients still had their native ankle joints. One patient had undergone ankle arthrodesis 1 year after the operation and one patient had converted to spontaneous ankle fusion at the 3 years follow-up postoperative. The VAS score improved from 5.9 ± 0.8 to 3.7 ± 2.2 (p = 0.0028). The mean AOFAS-AH score improved from 41.9 ± 7.2 preoperatively to 68.1 ± 20.0 postoperatively (p = 0.001). The mean SF-36 score improved from 43.1 ± 7.6 preoperatively to 62.7 ± 18.8 postoperatively (p = 0.002). A weight-bearing ankle space larger than 3 mm at 1 year following distraction is a positive predictive factor.

CONCLUSIONS

In this study, the treatment of ankle motion distraction for end stage ankle arthritis showed benefit in 9/16 (56.25%) patients at 41 months. It is a promising method for young patients with severe ankle arthritis.

Functional analysis of distraction arthroplasty in the treatment of ankle osteoarthritis

Background

Ankle joint distraction arthroplasty (AJDA) is an alternative surgical procedure for the management of moderate to severe ankle osteoarthritis. However, the benefit of this procedure and failure relative factors are still in debate. The purpose of the current study was to evaluate the functional outcomes of AJDA in treatment of moderate to severe ankle OA and to evaluate the relative factors correlated with treatment failure.

Methods

Forty-six van Dijk stages II and III ankle osteoarthritis patients were included. Fifteen males and 31 females with a mean age of 54.8 (range, 42–71) years were followed with a mean of 42.8 (range, 24–68) months. The Ankle Osteoarthritis Scale (AOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used for functional outcome evaluation. The talar tilt (TT) angle and ankle joint space distance (AJSD) were evaluated. The risk ratio (RR) was calculated for each potential failure relative factor.

Results

The AOS and AOFAS scores were significantly improved at the last follow-up time (P < 0.01). The AJSD was improved in 61% of patients and with a significant improvement compared with the preoperative conditions (P < 0.01). The TT angle and range of motion reached no significant difference. The failure rate was 21.7%. Patients with large TT (≥5°) angle (RR = 3.81, 95% CI 1.28–11.33, P = 0.02) and obesity (RR = 3.58, 95% CI 1.30–9.89, P = 0.01) were found to have positive correlation with failure. No correlation was found between failure and gender, or overweight, or side, or age, or type and stage of OA, or pin infection.

Conclusions

The current study confirmed the early functional outcomes of ankle distraction arthroplasty. However, this procedure still has a relatively high failure rate, especially for those obese patients and patients with large TT angles.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-017-0519-x) contains supplementary material, which is available to authorized users.

Intermediate-term follow-up after ankle distraction for treatment of end-stage osteoarthritis

BACKGROUND

Treatment of end-stage ankle osteoarthritis remains challenging, especially in young patients. Initial reports have shown early benefits of joint distraction for the treatment of ankle osteoarthritis. We report the five to ten-year results of a previously described patient cohort following ankle distraction surgery.

METHODS

All thirty-six patients who had undergone ankle distraction surgery between December 2002 and October 2006 were contacted. Patients were evaluated by a clinical investigator and completed the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) surveys. Radiographs as well as computed tomography and magnetic resonance imaging scans of the ankles were obtained at the follow-up visits.

RESULTS

Twenty-nine patients (81%) were followed for a minimum of five years (mean and standard deviation, 8.3 ± 2.2 years). Sixteen (55%) of the twenty-nine patients still had the native ankle joint whereas thirteen patients (45%) had undergone either ankle arthrodesis or total ankle arthroplasty. Positive predictors of ankle survival included a better AOS score at two years (hazard ratio [HR] = 0.048, 95% confidence interval [CI] = 0.0028 to 0.84, p = 0.04), older age at surgery (HR = 0.91, 95% CI = 0.83 to 0.99, p = 0.04), and fixed distraction (HR = 0.094, 95% CI = 0.017 to 0.525, p < 0.01). Radiographs and advanced imaging revealed progression of ankle osteoarthritis at the time of final follow-up.

CONCLUSIONS

Ankle function following joint distraction declines over time. Patients should be well informed of the commitment that they must make during the treatment period as well as the long-term results after surgery.

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.

Sustained clinical and structural benefit after joint distraction in the treatment of severe knee osteoarthritis

BACKGROUND

Treatment of severe osteoarthritis (OA) in relatively young patients is challenging. Although successful, total knee prosthesis has a limited lifespan, with the risk of revision surgery, especially in active young patients. Knee joint distraction (KJD) provides clinical benefit and tissue structure modification at 1-year follow-up. The present study evaluates whether this benefit is preserved during the second year of follow-up.

METHODS

Patients included in this study presented with end-stage knee OA and an indication for total knee replacement (TKR); they were less than 60 years old with a VAS pain ≥60 mm (n = 20). KJD was applied for 2 months (range 54-64 days) and clinical parameters assessed using the WOMAC questionnaire and VAS pain score. Changes in cartilage structure were measured using quantitative MRI, radiography, and biochemical analyses of collagen type II turnover (ELISA).

RESULTS

Average follow-up was 24 (range 23-25) months. Clinical improvement compared with baseline (BL) was observed at 2-year follow-up: WOMAC improved by 74% (P < 0.001) and VAS pain decreased by 61% (P < 0.001). Cartilage thickness observed by MRI (2.35 mm (95%CI, 2.06-2.65) at BL) was significantly greater at 2-year follow-up (2.78 mm (2.50-3.09); P = 0.03). Radiographic minimum joint space width (JSW) (1.1 mm (0.5-1.7) at BL) was significantly increased at 2-year follow-up as well (1.7 mm (1.1-2.3); P = 0.03). The denuded area of subchondral bone visualized by MRI (22% (95%CI, 12.5-31.5) at BL) was significantly decreased at 2-year follow-up (8% (3.6-12.2); P = 0.004). The ratio of collagen type II synthesis over breakdown was increased at 2-year follow-up (P = 0.07).

CONCLUSION

Clinical improvement by KJD treatment is sustained for at least 2 years. Cartilage repair is still present after 2 years (MRI) and the newly formed tissue continues to be mechanically resilient as shown by an increased JSW under weight-bearing conditions.

[Results of arthrodiastasis in postraumatic ankle osteoarthritis in a young population: prospective comparative study]

INTRODUCTION

The most common cause of osteoarthritis of the ankle is post-traumatic, and although tibiotalar arthrodesis remains the surgical gold standard, a number of techniques have been described to preserve joint mobility, such as joint distraction arthroplasty or arthrodiastasis.

OBJECTIVE

To evaluate the functional outcome and changes in Visual Analogue Scale (VAS) for pain after the application of the distraction arthroplasty for post-traumatic ankle osteoarthritis.

PATIENTS AND METHODS

A prospective comparative study of a group of 10 young patients with post-traumatic ankle osteoarthritis treated by synovectomy and arthrodiastasis, compared to a control group of 10 patients treated by isolated synovectomy. Results were calculated using the AOFAS scale and the VAS for pain before and after treatment.

RESULTS

As regards the pain measured by VAS, no difference was observed between the two groups before surgery (P=.99), but there was a difference at 3 months (P<.001), 6 months (P=.005), and 12 months (P=.006). No differences were observed in the AOFAS scale between the two groups before surgery (P=.99), or at 3 months (P<.99), but there was a difference at 6 months (P<.001).

CONCLUSIONS

Ankle arthrodiastasis is effective in reducing pain in post-traumatic ankle arthropathy, and is superior to isolated synovectomy.

Ankle joint distraction arthroplasty: why and how?

For select patients, distraction ankle arthroplasty may be a promising treatment approach for ankle osteoarthritis; however, there is still limited literature addressing its efficacy and clinical long-term results. In this article, the literature regarding the outcome after ankle distraction arthroscopy is reviewed, the indications and contraindication for this procedure are listed, our surgical technique is described, and our preliminary results with this procedure are presented.

Matrix-associated stem cell transplantation (MAST) in chondral defects of foot and ankle is effective

BACKGROUND

The aim of the study was to assess the feasibility and clinical results of matrix-associated stem cell transplantation (MAST) and 2-year-follow-up in chondral defects of foot and ankle.

METHODS

In a prospective, consecutive, non-controlled clinical follow-up study, all patients with chondral defects, that were treated with MAST from April 1st to November 30th, 2009 were analyzed. The size and location of the chondral defects, method-associated problems and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were registered and analyzed.

RESULTS

Twenty-six chondral defects in 25 patients were included in the study. The mean age of the patients was 33 years (range, 16-48 years), 18 (72%) were male. The VAS FA before surgery was 49.2 on average (range, 24.3-68.4). The defects were located as follows: medial talar shoulder, n=9; lateral talar shoulder, n=13 (medial and lateral talar shoulder, n=1); distal tibia, n=1; posterior calcaneal facet, n=1; head of 1st metatarsal, n=2. The defect size was 1.1cm(2) on average (range, .5-6 cm(2)). All patients completed 2-year-followup. No complications or consecutive surgeries were registered. The mean VAS FA at follow-up was 94.5 (range, 73.4-100; t-test, p<.01).

CONCLUSIONS

MAST led to good clinical scores. No complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects. The main advantage of MAST in comparison with ACI and MACI is the single procedure methodology. The advantage in comparison with AMIC is the potential higher concentration of stem cells.

Evidence-based indications for distraction ankle arthroplasty

BACKGROUND

The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence (LOE) available to support the operative technique of distraction ankle arthroplasty for the current generally accepted indications and make a grade of recommendation for each.

METHODS

A comprehensive review of the literature was performed (November 2010 to January 2011) using the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of distraction ankle arthroplasty. All articles were reviewed and assigned a classification (I-V) of Level of Evidence. An analysis of the literature reviewed was used to assign a Grade of Recommendation for each current generally accepted indication for distraction ankle arthroplasty.

RESULTS

There is insufficient evidence based literature (Grade I) to support or refute the procedure for either: post-traumatic ankle arthritis, arthritis associated with ligamentous instability, primary degenerative joint disease, chondrolysis, deformity associated with arthritis, osteochondral defects and congenital ankle abnormalities.

CONCLUSION

Inadequate evidence based literature exists to support or refute all currently accepted indications for distraction ankle arthroplasty and further high quality, scientific studies are needed upgrade to these recommendations.

Hinged external fixation distraction for treatment of first metatarsophalangeal joint arthritis

Treatment for hallux rigidus varies from joint preservation to joint destructive procedures. The objective of the present study was to report an alternative method of treatment of hallux rigidus using hinged external fixation distraction of the first metatarsophalangeal joint and to present our surgical technique. Ten distractions were performed in 9 patients (9 female feet [90%] and 1 male foot [10%]). The mean age at surgery was 41.0 (range 20 to 64) years. All patients had stage II or III hallux rigidus on the Regnauld classification system for hallux rigidus. The patients were evaluated clinically and radiographically before and after the distraction treatment. The mean period of fixation was 16.40 (range 7 to 21) weeks. Six of the patients (60%) with distraction experienced pin tract infections that were treated with oral antibiotics. The reported mean preoperative categorical pain score in 7 patients (7 feet) was 8.2 (range 5 to 10), and the postoperative score was 0.83 (range 0 to 2; p = .001). Of the 6 patients (6 feet) who responded to the remaining portion of the survey, 4 (66.67%) were very satisfied with their results, and 2 (33.33%) were satisfied with their surgical result. None of the patients required additional surgical treatment during the mean 2.2 (range 1.2 to 3.3) years of follow-up. Hinged first metatarsophalangeal joint distraction with external fixation has been shown to be a viable treatment option for joint preservation for stage II and III hallux rigidus in the short term.

Arthrodiatasis for management of knee osteoarthritis

Osteoarthritic disease is the result of mechanical and biological events that destabilize the normal processes of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix, and subchondral bone. Osteoarthritis of the knee can cause symptoms ranging from mild to disabling. Initial management of most patients should be nonoperative, but because of the progressive nature of the disease, many patients with osteoarthritis of the knee eventually benefit from operative treatment. Various procedures have been described for treatment of the osteoarthritic knee, ranging from arthroscopic lavage and debridement to total knee arthroplasty. The aim of this study was to evaluate the clinical results of distraction arthroplasty combined with arthroscopic lavage and drilling of cartilage defects for treatment of osteoarthritis of the knee. Nineteen patients (15 women and 4 men; age range, 39-65 years) were operated on. Pre- and postoperative findings were compared. A control group comprising 42 patients treated with only arthroscopic procedures was evaluated for comparison. Follow-up ranged from 3 to 5 years. Results were evaluated both clinically and radiologically postoperatively and throughout the follow-up period. Clinically, pain and walking capacity improved in most patients. Radiologically, joint space widening and improvement of the tibiofemoral angle was noted in nearly all patients.

Combined medial displacement calcaneal osteotomy, subtalar joint arthrodesis, and ankle arthrodiastasis for end-stage posterior tibial tendon dysfunction

Combining an ankle arthrodiastasis with a medial displacement calcaneal osteotomy and a subtalar joint arthrodesis offers surgeons a joint-sparing procedure for young and active patients who have end-stage posterior tibial tendon dysfunction and ankle joint involvement. An isolated subtalar joint arthrodesis or triple arthrodesis combined with an ankle arthrodiastasis is an option that can be used in certain case scenarios. Delaying the need for a joint destructive procedure through an ankle arthrodiastasis, however, may have a great impact in the near future, as advancements are underway to improve the use of ankle endoprosthesis.

MRI evaluation of ankle distraction: a preliminary report

Ankle joint distraction has been shown to be a viable alternative to ankle arthrodesis or ankle replacement. The authors' approach to ankle joint preservation includes articulated ankle joint distraction, resection of blocking osteophytes, release of muscle and joint contractures, and realignment osseous ankle procedures. In a previous study that used this technique, 78% of patients maintained their ankle range of motion and had none to occasional moderate pain that could be managed generally with nonsteroid anti-inflammatory drugs alone. The rationale as to why joint distraction is successful is largely unknown. Therefore, the purpose of this study was to evaluate pre- and postoperative ankle MRI scans of patients who underwent hinged ankle joint distraction with external fixation.

Joint preservation of the osteoarthritic ankle using distraction arthroplasty

BACKGROUND

In recent years ankle distraction arthroplasty has gained popularity in the treatment of ankle arthritis as a means of both maintaining range of motion and avoiding fusion. We present a retrospective review of 25 patients who have undergone ankle distraction from 1999 to 2006.

MATERIALS AND METHODS

The mean age was 43 years; 16 were male, and 7 were female. Followup was 30 months after frame removal (range, 12 to 60 months). We were able to obtain followup on 23 of 25 patients. Adjuvant procedures were performed in some cases including Achilles tendon lengthening (5), ankle arthroscopy (4), open arthrotomy (1), and supramalleolar tibial and distal fibular osteotomy to correct distal tibial deformity (6).

RESULTS

Twenty-one patients (91%) reported improved pain with those furthest post-op experiencing the best results. The average preoperative AOFAS score was 55 (range, 29 to 82), and the average postoperative score was 74 (range, 47 to 96). The difference between pre- and postoperative scores was significant (p = 0.005). SF-36 scores showed modest improvement in all components. Only two of the patients in the study underwent fusion after ankle distraction. Total ankle motion was maintained in all patients with improvement in the functional arc of motion in five patients who started with mild equinus contractures.

CONCLUSION

We feel that ankle distraction offers a promising solution for many people with ankle arthritis.

A case report of a simultaneous local osteochondral autografting and ankle arthrodiastasis for the treatment of a talar dome defect

Talar osteochondral defects (OCDs) are a challenge for treating physicians because they frequently are missed or diagnosed incorrectly, often resulting in severe degenerative arthritis of the ankle joint. Surgical intervention becomes a viable option in the presence of larger OCDs associated with loose bodies or osteochondral lesions that have failed conservative treatment. The successful use of autologous osteochondral autograft in the knee has promoted the applicability in the ankle. This report describes a unique technique for the treatment of large talar osteochondral lesions using a local osteochondral autograft combined with an ankle arthrodiastasis.

Use of circular external fixation for combined subtalar joint fusion and ankle distraction

The authors discuss a novel technique not previously published that incorporates a subtalar joint arthrodesis with an ankle joint arthrodiastasis as an alternative to a tibiotalocalcaneal arthrodesis. Young and active patients who experience refractory pain and stiffness to the rearfoot and ankle secondary to combined severe subtalar and ankle arthrosis are suitable candidates for this surgical procedure. This new approach is based on sound principles in the treatment of severe arthrosis affecting the ankle and subtalar joint. The authors are currently prospectively reviewing their surgical experience with this procedure and believe that it provides an alternative option for the patient, with potentially promising long-term results.

Distraction arthroplasty of the ankle--how far can you stretch the indications?

Ankle joint distraction has been shown to be a viable alternative to ankle arthrodesis or ankle replacement. The à la carte approach to ankle joint preservation (resection of blocking osteophytes, release of muscle/joint contractures, and realignment osseous ankle procedures) presented in this article as important for a successful outcome as is the hinged ankle joint distraction technique itself. The authors reviewed 32 patients who underwent this ankle joint distraction technique and found 78% of patients had maintained their ankle range of motion and have no pain to occasional moderate pain that can be managed generally with nonsteroidal anti-inflammatory drugs alone. Only one has required an ankle fusion, and only one has been converted to an ankle joint replacement. The longevity of these results and the higher percent of good or excellent results when compared with other studies suggest that combining adjunctive procedures and articulation with ankle distraction improves the results of this procedure.

Distraction arthroplasty

Few joint-preserving surgical options exist for the patient who has ankle arthritis refractory to conservative measures. Therefore, continuous effort is afforded to the development of additional treatment options for such patients. Distraction arthroplasty has been proposed as one of these options for the patient in whom fusion or joint replacement is not appropriate. Although the mechanism of action remains unknown, the reports of several researchers support the potential beneficial effects that can be obtained from joint distraction arthroplasty in the severely osteoarthritic ankle. Furthermore, the studies published to date suggest that these effects may not only persist for years but also improve as time progresses during the first several years after treatment. Although additional laboratory studies are needed to understand the biochemical and biomechanical effects of distraction, additional prospective clinical studies are also needed to further understand its efficacy and appropriate patient population. The data thus far suggests that joint distraction arthroplasty may be a viable alternative treatment to arthrodesis and replacement for the young patient who has a congruent, painful, mobile, arthritic ankle joint.

Alternatives to ankle implant arthroplasty for posttraumatic ankle arthrosis

Various surgical options beyond implant arthroplasty are available to treat posttraumatic ankle arthrosis. Conservative options are usually employed in combination and include the use of nonsteroidal anti-inflammatories, bracing, and orthoses, as well as injections of intra-articular corticosteroid and hyaluronic acid. If these conservative treatments fail, surgical intervention can be entertained. Alternatives to total ankle implant arthroplasty include (1) arthroscopic debridement, (2) arthrodiastasis, (3) peri-articular resurfacing using allograft or cartilage transplantation, and (4) peri-articular osteotomies to correct angular, rotational, or translational malalignment. However, ankle arthrodesis is the standard technique for end-stage ankle arthrosis. This article reviews the literature and presents an in-depth surgical technique for each procedure. The article also describes how to prevent and address the most common complications.

Unloading joints to treat osteoarthritis, including joint distraction

PURPOSE OF REVIEW

Patients are increasingly becoming interested in nonpharmacologic approaches to manage their osteoarthritis. This review examines the recent literature on the potential beneficial effects of unloading joints in the treatment of osteoarthritis, with a focus on joint distraction.

RECENT FINDINGS

Mechanical factors are involved in the development and progression of osteoarthritis. If "loading" is a major cause in development and progression of osteoarthritis, then "unloading" may be able to prevent progression. There is evidence that unloading may be effective in reducing pain and slowing down structural damage. This review describes unloading by footwear and bracing (nonsurgical), unloading by osteotomy (surgical), and has a focus on unloading by joint distraction. Excellent reviews in all these three fields have been published over the past few years. Recent studies argue for the usefulness of a biomechanical approach to improve function and possibly reduce disease progression in osteoarthritis.

SUMMARY

To improve patient function and possibly reduce disease progression, a biomechanical approach should be considered in treating patients with osteoarthritis. Further research (appropriate high-quality clinical trials) and analysis (clinical as well as preclinical and fundamental) are still necessary, however, to understand, validate, and refine the different approaches of unloading to treat osteoarthritis.

Ankle joint distraction

Ankle joint distraction is a viable alternative to ankle arthrodesis or ankle replacement. A congruent, painful, mobile, and arthritic ankle joint that is treated with this technique can achieve good to excellent results. Attention to the principles (anterior osteophyte resection, equinus contracture release, and ankle joint realignment procedures) is as important for a successful outcome as the accurate application of the hinged ankle joint distraction technique itself.

Effective repair of a fresh osteochondral defect in the rabbit knee joint by articulated joint distraction following subchondral drilling

PURPOSE

Joint distraction has been used to treat osteoarthritis and was found to delay the need for arthrodesis or joint replacement. However, there has been little basic research on articulated joint distraction for the repair of osteochondral defects. We investigated the effects of joint distraction with motion after drilling on a fresh osteochondral defect in the weight bearing area of the rabbit knee joint.

METHODS

A full thickness osteochondral defect was created in the weight bearing area of both medial femoral condyles of an adult Japanese white rabbit. After drilling of the defect, the experimental knee joint was distracted for 1.5 mm using a pair of external fixators to decrease compression force. The contralateral knee joint was used as a control with no apparatus. Gross findings and histological evaluation were assessed to study morphology of the repaired cartilage.

RESULTS

A partial repair with cartilage-like tissue was observed in the joints of the experimental group at 4 weeks. While cartilage-like tissue stained with Safranin O was found in the experimental group at 8 and 12 weeks, destructive changes were observed in the control joints. Morphological changes were evaluated using the histological grading scale [Wakitani S, Goto T, Pineda SJ, et al. Mesenchymal cell-based repair of large, full-thickness defect of articular cartilage. J Bone Joint Surg Am 1994;76(4):579-92]. There was no significant difference between experimental and control groups at 4 weeks (mean 11.2 and 13.8 points, respectively). However, the mean scores of the experimental groups at 8 and 12 weeks (mean 6.8 and 7.5, respectively) were significantly better than those of the control groups at the same time points (mean 14 points each). Between the experimental groups, the scores at 8 and 12 weeks were both significantly better than those at 4 weeks.

CONCLUSION

A combination of subchondral drilling, joint motion and distraction by an articulated external fixator promoted repair of a fresh osteochondral defect in the weight bearing area. Although distraction for 4 weeks was not a long enough period to repair the defect, distraction for 8 and 12 weeks resulted in a good outcome.

Joint distraction for the treatment of ankle osteoarthritis

Joint distraction has demonstrated substantial promise in the treatment of tibiotalar arthritis. Its minimally invasive nature, combined with the fact that it does not seem to "burn any bridges," lends considerable clinical appeal. Even if joint distraction provides only temporary relief and clinical results slowly deteriorate over time, more definitive and committed procedures potentially can be forestalled for a considerable period of time. Nevertheless, the current literature and clinical experience with this technique is limited. Further research and analysis is ongoing and will be necessary to understand, validate, and refine this novel approach to ankle arthritis.

Biomechanics of external fixation and limb lengthening

Surgeons who use external fixators for foot and ankle conditions need to understand the biomechanical principles to ensure good outcomes. Fixators can be used for fracture fixation, correction of contractures, distraction osteogenesis, and distraction arthroplasty. A two-ring fixator with wire fixation remains the gold standard with which all other frames are compared. Small changes in mechanical characteristics can have major implications on new bone or cartilage formation.