Clinical effectiveness of arthroscopic vs open ankle arthrodesis for advanced ankle arthritis: A systematic review and meta-analysis

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.

The Ankle Joint: Updates on Ankle Fusion Approaches and Fixation

Ankle fusion is a well-studied, classical procedure for conditions affecting the ankle joint, and has a long history with predictable results. Although there are many different approaches available, a few options are commonly used. The two main focuses of modern literature are on anterior plating versus traditional screw fixation, and on arthroscopic versus open techniques for fusion. This article discusses recent literature and then presents cases and techniques that are commonly used today. This includes arthroscopic ankle arthrodesis, traditional transfibular approach, anterior plating, and the indications and application of external fixation. Standard recovery and complications are discussed.

Association of Preexisting Triple Fusion and Arthroscopic Ankle Arthrodesis nonunion

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) is a successful treatment for end-stage ankle arthritis. A significant early complication of AAA is symptomatic nonunion. Published nonunion rates range from 8% to 13%. Longer term, there is concern that it predisposes to subtalar joint (STJ) fusion. To better understand these risks, we undertook a retrospective investigation of primary AAA.

METHODS

All adult AAA cases conducted at our institution over a 10-year period were reviewed. A total of 284 eligible AAA cases in 271 patients were analyzed. The primary outcome measure was radiographic union. Secondary outcome measures included reoperative rate, postoperative complications and subsequent STJ fusion. Univariate and multivariate logistic regression analysis was performed to identify nonunion risk factors.

RESULTS

The overall nonunion rate was 7.7%. Smoking (odds ratio [OR] 4.76 [1.67, 13.6], P = .004) and previous triple fusion (OR 40.29 [9.46, 171.62], P < .001) were independent risk factors on univariate analysis. Only prior triple fusion persisted as a major risk factor associated with nonunion on multivariate analysis (OR 18.3 [3.4, 99.7], P < .001). Seventy percent of patients with a previous triple fusion went on to develop nonunion compared to 5.5% of those without. Increasing age, obesity, surgical grade, diabetes, postoperative weightbearing plan, steroid use, and inflammatory arthropathy were not significant risk factors. The leading cause of reoperation was hardware removal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Eleven (4.2%) required subsequent STJ fusion. The "survivorship" of STJ post AAA was 98%, 85%, and 74% at 2, 5, and 9 years, respectively.

CONCLUSION

As the largest study of AAA in the literature, our findings suggest prior triple fusion is a major independent risk factor for AAA nonunion. These patients should be counseled of this high risk and may benefit from alternative surgical options.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

A network meta-analysis of the efficacy of arthrodesis with various fixation methods in the treatment of advanced ankle osteoarthritis

This study aimed to compare the efficacy of arthrodesis with various fixation methods in the treatment of advanced ankle osteoarthritis. Thirty-two patients with osteoarthritis of the ankle (mean age 59.91±6.16 years) took part in the study. The patients were divided into 2 groups - Ilizarov apparatus (21 patients) and screw fixation (11 patients). Each group was also divided into subgroups based on etiology - posttraumatic and nontraumatic. The AOFAS and VAS scales were compared in the preoperative and postoperative periods. It was found that screw fixation was more effective in the treatment of late stages of osteoarthritis (OA) of the ankle during the postoperative period. Comparison of the AOFAS and VAS scales showed no significant differences between the groups in the preoperative period (p = 0.838; p = 0.937). After 6 months, the results were better in the screw fixation group (p = 0.042; p = 0.047). Complications were observed for a third of the patients (10 patients). 6 patients had pain in the operated limb (4 patients in the Ilizarov apparatus group). Three patients in the Ilizarov apparatus group developed a superficial infection, and one developed a deep infection. Different etiology did not affect the postoperative efficacy of arthrodesis. The choice of the type of should be related to a clear protocol for the presence of complications. When choosing the type of fixation for arthrodesis, a patient's condition as well as a surgeon's preferences should be taken into account.

Perspectives and trends for minimally invasive surgery for hallux valgus deformity in the Asia Pacific region

BACKGROUND

Evolving evidence and improved instrumentation have led to increasing importance of minimally invasive surgery (MIS) surgery in the treatment of hallux valgus deformity. This study aims to investigate the current trends of the practice of MIS hallux valgus surgery in the Asia Pacific region.

METHOD

A survey was sent via email to 30 fellowship-trained foot and ankle surgeons in 11 Asia Pacific countries, all registered with their respective national orthopaedic societies. The survey consisted of 8 questions and was designed to assess surgeon experience with MIS hallux valgus surgery, including common contraindications, satisfaction levels, learning curves and post-operative rehabilitation after MIS hallux valgus surgery.

RESULTS

The vast majority of surgeons (63%) performed MIS hallux valgus surgery. However, only 18% of surgeons performed MIS surgery in more than half of their hallux valgus cases. A severe deformity was the most common contraindication (81%), followed by the instability of the first tarsometatarsal joint (50%), and abnormal DMAA (Distal Metatarsal Articular Angle) (38%). There was no statistically significant difference between the satisfaction score of MIS versus open surgery (p-value 0.1). The median number of cases the surgeons needed to perform before they considered themselves comfortable performing the surgery was 10 cases (range 1-100). Most surgeons allowed full weight bearing at 4-6 weeks after surgery.

CONCLUSIONS

MIS hallux valgus surgery is gaining popularity in the Asia Pacific region, with the majority of surgeons adopting this practice. The fact that severe deformity is seen as the most frequent contraindication and that MIS surgery is still not the most popular alternative demonstrates that surgeons are still circumspect when it comes to MIS surgery. Surgeons can use the findings of this study to guide their adoption of MIS practices in hallux valgus surgery and gauge well they perform in comparison to their counterparts in the Asia Pacific region.

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.

Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction

BACKGROUND

Circular frames for ankle fusion are reserved for complex clinical scenarios. The literature is heterogenous and conflicting. We aim to present the indications and outcomes of this procedure.

METHODS

A retrospective cohort study based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow-up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiologic and clinical outcomes, and adverse events. Factors influencing radiologic and clinical outcomes were analyzed.

RESULTS

47 patients were included, with a median follow-up of 30 months (interquartile range [IQR] 20-40). The median age at time of surgery was 63.5 years (IQR 58-71). Patients had a median of 2 previous surgeries (IQR 1-3). The median LOS was 8.5 days, and median EFT was 237 days (IQR 166-280). Simultaneous limb lengthening (median 3.3 cm, IQR 1.9-3.5) was performed in 11 patients, increasing the EFT by a mean of 4 months. Primary and final union rates were 91.5% and 95.7%, respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. In addition, 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and reoperations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT.

CONCLUSION

Complex ankle fusion using circular frames can achieve good outcomes, however time in frame may be prolonged with a high rate of adverse events. Identified risk factors for poorer outcomes should be considered in patient counselling and prognostication.

LEVEL OF EVIDENCE

Level III, prognostic.

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.

Ankle Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents

Purpose

To evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020.

Methods

The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents was assessed. Arthroscopy procedures of the leg/ankle were categorized. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results

There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 (6.2 ± 5 [range 0-35] vs 6.1 ± 6 [range 0-76] P = .732), despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 ± 47 [range 55-414] in 2016; 200.8 ± 57 in 2020 [range 67-601], P < .001). There was wide variability in ankle arthroscopy case volume among residents. The 90th percentile of residents performed 13 cases in 2020, compared with 5 in 50th percentile, and 1 in the 10th percentile.

Conclusions

Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed.

Clinical Relevance

Understanding ankle arthroscopy in case volume and variability is important for programs to ensure that orthopaedic residents are gaining adequate exposure to increasingly popular procedures. Orthopaedic surgery residency programs should explore methods to increase resident exposure to ankle arthroscopy.

[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.

Two-Year Revision Rates in Total Ankle Replacement Versus Ankle Arthrodesis

The aim of this study was to compare outcomes between total ankle replacement (TAR) and ankle arthrodesis (AA) for ankle osteoarthritis using real-world data.

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

Introduction

There are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy.

Presentation of case

The patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws.

Discussion

The patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain.

Conclusion

We reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach.

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Ankle osteoarthritis and malalignment can be followed by osteotomy.

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One-stage ankle arthrodesis and deformity correction should be considered.

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Anterolateral plate was useful for arthrodesis and correction.