The mini-arthrotomy ankle arthrodesis: a review of nine cases

Does a fibula-sparing approach improve outcomes in tibiotalocalcaneal arthrodesis?

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis is considered a salvage procedure for either complex deformity or arthritis about the hindfoot, and can be performed via fibula-resection (FR) or fibula-sparing (FS) approaches. The primary aim of this study was to investigate differences in outcomes in FR versus FS TTC arthrodeses.

METHODS

This was a retrospective cohort study reviewing outcomes of TTC arthrodesis at a single institution. Patients who underwent a TTC arthrodesis from 2005 to 2017 and had minimum two-year follow-up were included. Preoperative diagnosis, pre- and post-operative radiographic coronal alignment, fixation methods, and complications were compared between groups.

RESULTS

107 patients (110 ankles) underwent TTC arthrodesis, with a mean age of 57.0 years (sd, 14.0 years). The mean clinical follow-up was 50.7 months (range, 24-146) and mean radiographic follow-up was 45.8 months (range, 6-146 months). Pre-operative diagnoses included arthritis (N = 40), prior non-union (N = 21), Charcot neuro-arthropathy (N = 15), failed total ankle arthroplasty (N = 15) and avascular necrosis of the talus (N = 19). Sixty-nine ankles comprised the FS group and 41 comprised the FR group. There was no significant difference in the non-union rate between groups (29% FR vs 38% FS, p = 0.37), complication rate (59% FR vs 64% FS, p = 0.59), or post-operative coronal standing radiographic alignment (89.6 degrees FR, 90.5 degrees FS, p = 0.26). Logistic regression analyses demonstrated a pre-operative diagnosis of failed TAA was associated with post-operative nonunion (OR:3.41,CI:1.13-11.04,p = 0.03). Pre-operative indication for TTC arthrodesis of arthritis alone was associated with a decreased risk of non-union (OR:0.27,CI:0.11-0.62,p = 0.002).

CONCLUSION

TTC arthrodesis is a successful surgical option for complex hindfoot deformity, arthritis, and limb salvage regardless of surgical approach. We did not detect a difference in the union rate, incidence of complications, or coronal plane radiographic alignment in fibula-sparing versus fibula-resection constructs. Patients with a pre-operative indication for surgery of arthritis may be at decreased risk of developing non-union.

LEVEL OF EVIDENCE

III - Retrospective cohort study.

Mini-open vs. Transfibular Approach for Ankle Arthrodesis, Which Approach is Superior in Joint Preparation: A Cadaver Study

BACKGROUND

Arthrodesis is considered the gold standard for end-stage ankle arthritis in patients who fail conservative management. Achieving union is paramount while minimizing complications. An essential item for successful union is preparation of the articular surface. Our study aims to evaluate the difference in joint preparation between direct lateral and dual mini-open approaches.

MATERIALS AND METHODS

Ten below knee fresh-frozen specimens were used for this study. Five were prepared through lateral approach, and five using dual mini-incisions. After preparation, all ankles were dissected and images of tibial plafond and talar articular surfaces were taken. Surface areas of articulating facets and unprepared cartilage of talus, distal tibia, and distal fibula were measured and analyzed.

RESULTS

A greater amount of total surface area was prepared with the mini-open approach in comparison to the transfibular approach. Percentage of prepared surface area of total articulating surface (including talus and tibia/fibula), talus, tibia, and fibula with the transfibular approach were 76.9%, 77.7%, and 75%, respectively. Percentages were 90.9%, 92.9%, and 88.6% with the mini-open approach. When excluding medial gutter, there was no significant difference between techniques (83.94% vs. 90.85%, p = 0.1412).

CONCLUSION

Joint preparation with the mini-open approach is equally efficacious as the transfibular approach for the tibiotalar joint. The mini-open approach does provide superior preparation of the medial gutter and inferior tibial surface which may help to increase union rates and decreased complications.

LEVEL OF EVIDENCE

V.

Current Concepts in the Management of Ankle Osteoarthritis: A Systematic Review

Ankle osteoarthritis is less common than hip or knee osteoarthritis; however, it is a relatively common presentation and is predominantly related to previous trauma. Treatments have traditionally consisted of temporizing measures such as analgesia, physiotherapy, and injections until operative treatment in the form of arthrodesis is required. More recently, interest has been increasing in both nonoperative and alternative operative options, including joint-sparing surgery, minimal access arthrodesis, and new arthroplasty designs. The present systematic instructional review has summarized the current evidence for the treatment options available for ankle osteoarthritis.

Total ankle replacement in patients with gouty arthritis

BACKGROUND

Gout is the most common cause of inflammatory arthritis in men and older women. The purpose of this review was to assess prosthetic component stability, postoperative pain relief, functional outcome, and quality of life of patients with gouty ankle arthritis who were treated with total ankle replacement.

METHODS

Sixteen patients (nineteen ankles) with chronic gout and a mean age (and standard deviation) of 65.2 ± 5.5 years were treated with a non-constrained three-component total ankle arthroplasty because of painful ankle arthritis. The average duration of follow-up was 5.1 ± 2.5 years. Component stability was assessed with use of weight-bearing radiographs. Clinical outcomes were analyzed with use of a visual analogue scale (VAS) for pain, a 36-item short-form health survey (SF-36), and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score.

RESULTS

There were no intraoperative complications. In one patient, both arthroplasties were revised 4.7 years postoperatively because of painful prosthetic loosening. The average VAS score for pain decreased significantly from 7.5 ± 1.8 (range, 5 to 10) to 1.2 ± 1.3 (range, 0 to 3) (p < 0.001). All eight categories of the SF-36 score showed significant improvement (all p < 0.001). The average AOFAS hindfoot score increased significantly from 38 ± 15 (range, 15 to 77) preoperatively to 75 ± 13 (range, 54 to 92) postoperatively (p < 0.001).

CONCLUSIONS

Total ankle replacement in patients with painful gouty ankle arthritis is associated with a low risk of intraoperative and postoperative complications and leads to significant pain relief, high patient satisfaction, and good functional results.

Revisional total ankle arthroplasty because of a large tibial bone cyst

Osteoarthritis of the ankle can occur secondary to alteration of the articular surfaces, such as in the posttraumatic setting, or because of gradual degeneration as a result of biomechanical dysfunction. Although primary inflammatory ankle arthritis rarely occurs, the majority of cases of ankle osteoarthritis occur after bony trauma, ligamentous injury, congenital deformity, or previous surgical intervention. Although ankle arthrodesis was shown to be successful and reliable, and although it remains the gold standard for surgical intervention after nonsurgical care of the arthritic ankle has been exhausted, a reasonable return to a dynamic lifestyle can be limited by fusion of the ankle. With the ever-increasing prevalence of favorable objective outcomes after implantation of late-model ankle endoprostheses, total ankle arthroplasty has become a popular alternative to arthrodesis. As the number of total ankle replacements increases in the population, particularly in cases involving younger and more active patients, surgeons will encounter more cases that require revisional total ankle replacement. We describe a patient who underwent the exchange of one total ankle endoprosthesis for another, in the presence of a large cyst about the tibial component of the implant.

LEVEL OF CLINICAL EVIDENCE

4.

Outcome of Ilizarov ankle arthrodesis

BACKGROUND

Many operative techniques have been described for ankle arthrodesis, with varying fusion rates. In revisions, the fusion rate is lower than in primary arthrodesis. Recent reports have described good results after Ilizarov ankle arthrodesis. However, descriptions were qualitative, with none using an accepted score. We describe our experience with this technique and functional outcomes in our patients.

METHODS

Seventeen patients (average age 48 years) had primary or revision unilateral ankle arthrodesis using the Ilizarov technique at two centers. Diagnoses included post-traumatic arthritis and Charcot arthropathy. Three patients had talar osteonecrosis. Time in the frame averaged 15 weeks and in a cast 4 weeks. Followup averaged 6 years. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale.

RESULTS

All ankles achieved solid fusion. The average AOFAS score was 65 out of 86 possible. Based on this, results were defined as excellent in three patients, good in eight, fair in four, and poor in two. Minor complications were common, all resolving with local treatment. No deep infection developed. One fusion malunited in 8 degrees of varus.

CONCLUSIONS

The Ilizarov external fixator has numerous advantages applicable to ankle fusion, including: stable fixation, respect for soft tissues, and the possibility of postoperative alignment 'fine-tuning'. Additionally, the ability to direct forces through or around skeletal elements allows varying of the load through the skeletal elements, allowing early weightbearing. The Ilizarov technique, with its high union rate, may be considered for any ankle arthrodesis but is especially useful in complex cases such as revisions, talar osteonecrosis, soft-tissue compromise, and infection. Early weightbearing is an added benefit.