Ankle joint distraction arthroplasty for severe ankle arthritis

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.

Distraction Arthroplasty Combined with Autologous Bone Grafting for Diffuse-type Tenosynovial Giant Cell Tumour with Articular Cartilage Defect and Subchondral Bone Cysts: A Case Report

Tenosynovial giant cell tumour encompasses a group of lesions that present with synovial differentiation and most commonly occur in the joint synovium, bursae, and tendon sheaths. Diffuse-type tenosynovial giant cell tumour, previously known as pigmented villonodular synovitis, is one of the most common benign soft tissue tumours of the foot and ankle and usually affects young adults. The differential diagnosis of diffuse-type tenosynovial giant cell tumours remains a clinical problem because its clinical symptoms are similar to those of inflammatory arthritis, including rheumatoid arthritis. Moreover, persistent diffuse-type tenosynovial giant cell tumours can lead to articular deterioration, including osseous erosions and subchondral bone cysts. Joint-preserving procedures are considered optimal for treating younger patients with ankle osteoarthritis because the indication of ankle arthrodesis and total ankle arthroplasty is limited. Thus, ankle distraction arthroplasty could be an alternative for treating diffuse-type tenosynovial giant cell tumour with articular deterioration in young patients. Here, we report about a woman in her early 30s who presented with ankle pain owing to a diffuse-type tenosynovial giant cell tumour with an articular cartilage defect and subchondral bone cysts. We performed ankle distraction arthroplasty combined with an autologous bone graft. A follow-up examination at 2 years revealed preservation of physical function and pain alleviation. These findings suggest that distraction arthroplasty is a viable treatment option for remedying the destruction of the articular cartilage and subchondral bone owing to diffuse-type tenosynovial giant cell tumours in young adults.

Distraction arthroplasty in the management of osteoarthritis of the ankle: A systematic review

BACKGROUND

This study aimed to evaluate the use of distraction arthroplasty for ankle osteoarthritis, with respect to patient reported outcome measures (PROMs), complications, range of motion and radiographic outcomes.

METHODS

A computer-based search was performed in PubMed, Cinahl, Embase, Scopus and ISI Web of Science. Two reviewers independently performed title/abstract and full-text screening. Quality assessment was performed using The Methodological Index for Non-Randomised Studies (MINORS) and Joanna Briggs Institute criteria.

RESULTS

Whilst all studies evaluating PROMs reported significant (P < 0.05) improvement, these were either below or only slightly above the minimally clinically important difference. The rate of conversion to arthrodesis or total ankle arthroplasty was high, with failure rates of up to 52% reported.

CONCLUSION

Due to the inconsistent improvements in PROMs, which are likely overestimated due to substantial bias, and the high failure rate, this review suggests that distraction arthroplasty is not currently an effective treatment option for ankle arthritis.

LEVEL OF EVIDENCE

Level IV, systematic review of level I to IV studies.

Effect of Ankle Proprioception Training on Preventing Ankle Injury of Martial Arts Athletes

Martial arts routines originated in China and are a traditional sport of the Chinese nation. They are one of the outstanding sports culture representatives in China since ancient times. Excessively difficult movements in some martial arts routines during competitions or training can cause athlete injuries. The purpose of this article is to study the effect of proprioceptive training of ankle joints on preventing ankle injuries in martial arts athletes. Can ankle strength training and ankle proprioceptive training combined with strength training improve the dynamic and static balance of football players? This article analyzes the mechanism and causes of martial arts athletes' injuries and proposes treatment methods for ankle injuries. In the experimental part of this article, 16 martial arts athletes (8 males and 8 females) were selected as research objects, and they were randomly divided into 4 male and female experimental groups and 4 control groups. The experimental group received ankle muscle strength training for 6 weeks, and the control group received ankle muscle strength training and ankle proprioception training. The experimental results prove that ankle proprioceptive training can improve the dynamic and static balance of martial arts athletes and can effectively prevent the occurrence of ankle injury. In this paper, the dynamic balance ability in the biped standing state with eyes closed was tested, and the reductions of the stability index in the front and back directions of the control group and the experimental group were 0.03 and 0.2, respectively. It can be seen that the stability training effect of the experimental group was obvious.

Ankle joint pressure change before and after subtalar joint arthrodesis in varus and valgus malalignment of the tibia

Purpose: The compensation mechanism of subtalar joint in ankle with varus or valgus deformity is controversial and not well established. This biomechanical study aims to investigate how subtalar joint arthrodesis will affect the ankle joint pressure in varus and valgus malalignment of the tibia. Methods: Eight fresh-frozen human cadaver legs were tested in this study. A custom-made fixture was utilized and a total of 600N was applied to simulate weight-bearing. Intra-articular sensors (TeckScan) were inserted in the ankle joint to demonstrate the ankle joint pressure. Conditions include: Neutral, 5°, 10°, 15° and 20° varus, 5°, 10°, 15° and 20° valgus. Results: After the fusion of the subtalar joint, when the tibia is gradually inverted, the inside pressure of the ankle joint gradually increases, and the pressure on the outside of the ankle joint gradually decreases. When the tibia is gradually eversion, the pressure on the outside of the ankle joint gradually increases, and the inside of the ankle joint gradually decreases. Conclusions: After the subtalar joint is fused, the compensatory activity of the subtalar joint disappears, and the regulation of the pressure in the ankle joint will be lost. We hypothesized that the inversion compensation of the subtalar joint is more likely to occur than the eversion compensation.

The Role of Distraction Arthroplasty in Managing Ankle Osteoarthritis

Ankle distraction arthroplasty (DA) is a joint-preserving option for the treatment of ankle osteoarthritis. The ideal patient is a young, active person who is compliant with follow-up and understands that clinical improvements may not be fully evident until 1 year after surgery. The procedure promotes cartilage healing and regeneration by removing mechanical stress at the joint surface through the application of a joint-spanning external fixator. There is an array of adjuvant procedures commonly performed to optimize healing potential-including microfracture, osteophyte removal, osteotomies, and soft tissue balancing procedures. Short- and intermediate-term studies have been promising, though there is a wide variance in reported failure and complication rates.

Large Osteochondral Defects of the Distal Tibia Plafond After Septic Arthritis of the Ankle Joint Treated by Arthrodiastasis and Iliac Bone Graft: A Case Report

Bone defects after septic arthritis of the ankle joint result in arthrodesis and severe loss of ankle motion. This must be prevented in young athletes. We report the case of a 17-year-old male patient with large osteochondral defects in the distal tibia plafond after septic arthritis, in whom iliac bone graft and arthrodiastasis were performed to preserve ankle motion. He was diagnosed with septic arthritis of the ankle joint postoperatively at the age of 16 years. After irrigation and hardware removal, C-reactive protein level was normal. However, he experienced continuous pain and could not walk; he was referred to our hospital. Computed tomography showed large osteochondral defects in the medial tibia plafond occupying ∼30% of the plafond articular surface. Simultaneous iliac bone block graft and arthrodiastasis with an external fixator were performed. We placed iliac bone graft into the defect in the medial tibia plafond using the anterior approach, and we placed an external fixator with hinge and tractioned and fixed the ankle joint. One week postoperatively, range of motion training of the ankle was started. We removed the foot ring at 3 months and the external fixator at 4 months postoperatively. The patient started jogging at 8 months and performing long jump at 1 year postoperatively. The Japanese Society for Surgery of the Foot ankle/hindfoot scale improved from 56 to 97 points at 2-year follow-up. Despite large osteochondral defects with septic arthritis, arthrodiastasis and iliac bone graft were beneficial for preserving the ankle joint and its function.

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.].

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.

Distraction arthroplasty in osteoarthritis of the foot and ankle

Post-traumatic osteoarthritis (PTOA) is a complex and painful problem in the foot and ankle. Ninety percent of osteoarthritis cases in the foot and ankle can be classified as post-traumatic. PTOA can affect any of the 33 joints in the foot and the ankle. Distraction arthroplasty is a method for treatment of early arthritic joints without fusing or replacing them and its effectiveness has been well documented. The purpose of this case series is to present our successful experiences and positive results using distraction arthroplasty to treat PTOA in the ankle, subtalar, first metatarsophalangeal, and second tarsometatarsal joints, and to present distraction arthroplasty as a viable alternative to invasive joint sacrificing procedures such as arthrodesis or arthroplasty. Distraction Arthroplasty effectively and safely treats PTOA and improves the stability of joints in the Foot and Ankle. Additionally, the use of bone marrow aspirate concentrate as an adjuvant can improve the long-term functional and structural outcomes of the joint, and can prolong the need for further, more aggressive surgical interventions such as fusion or arthroplasty.

Autologous Osteochondral Graft for Early Posttraumatic Arthritis of Tibiotalar Joints After Comminuted Pilon Fractures in Young Patients

BACKGROUND

Posttraumatic arthritis of tibiotalar joints after AO/OTA type C3 pilon fractures, especially in young patients with a significant osteochondral defect in the tibial plafond joint surface, is a challenging situation. We report a joint-preserving technique using autologous osteochondral graft in combination with ankle distraction and supramalleolar osteotomy (SMOT), if necessary, to improve its outcome.

METHODS

Seventeen patients with an average age of 32.1 years with Takakura grade 1 to 3A posttraumatic arthritis of the tibiotalar joint after AO/OTA type C3 pilon fractures received osteochondral autograft transplantation, ankle distraction, and SMOT, when supramalleolar malalignment was present, between February 2010 and November 2015. The visual analog scale (VAS), Short-Form 36 (SF-36) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and ankle range of motion were used for outcome analysis. Radiographic assessment of any SMOT and the apparent joint space was performed. Fourteen patients were followed for an average of 18 months.

RESULTS

The VAS, SF-36, and AOFAS scores as well as the ankle range of motion all improved significantly at the last follow-up after the surgery (P < .01). No deep surgical site infection, donor site complication, nonunion, osteochondral block loosening, or resorption was noted. No secondary arthrodesis was needed at the end of follow-up.

CONCLUSION

Autologous osteochondral graft transplantation in combination with ankle distraction and SMOT was a promising joint-preserving technique for early posttraumatic arthritis of tibiotalar joint after severe pilon fractures in young patients.

LEVEL OF EVIDENCE

Level IV, case series.

Debridement and hinged motion distraction is superior to debridement alone in patients with ankle osteoarthritis: a prospective randomized controlled trial

PURPOSE

To evaluate and compare complication rates and postoperative outcomes in patients with ankle debridement alone vs. debridement and hinged ankle distraction arthroplasty.

METHODS

A total of 50 patients with posttraumatic ankle osteoarthritis (OA) with a mean age of 40.0 ± 8.5 years were included into this prospective randomized study: 25 patients in ankle debridement alone group and 25 patients in debridement and hinged ankle distraction group. The mean follow-up was 46 ± 12 months (range 36-78 months). The clinical and radiographic outcomes were evaluated at the 6-month and 3-year follow-up using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, SF-36 quality of life score, and van Dijk OA classification. A Kaplan-Meier survival analysis was performed to calculate the 3-year and 5-year survival rates.

RESULTS

Both patient groups experienced significant pain relief, functional improvement, and improvement in quality of life postoperatively. In total, 26 major secondary procedures were performed. The overall survival rates in the debridement and ankle distraction group were 19 of 25 (74%) and 15 of 25 (59%) at 3 years and 5 years, respectively. The overall survival rates in the ankle debridement alone group were 12 of 25 (49%) and 9 of 25 (34%) at 3 years and 5 years, respectively.

CONCLUSIONS

The study demonstrated comparable postoperative functional outcome and quality of life. However, rate of postoperative revision surgery was substantially higher in ankle debridement alone group.

LEVEL OF EVIDENCE

Randomized controlled study, Level I.