Functional analysis of distraction arthroplasty in the treatment of ankle osteoarthritis

Low annual revision rate in ankle distraction for ankle osteoarthritis: A systematic review and meta-analysis

PURPOSE

Ankle osteoarthritis severely impacts patients' mental and physical quality of life. Besides total ankle replacement and ankle arthrodesis, ankle distraction has been shown to be a promising alternative. The primary aim of the present study was to determine the annual revision rates (ARRs) after ankle distraction. The secondary aim was to obtain an overview of patient-reported outcome measures and functional outcomes.

METHODS

A literature search until November 2023 was performed. Methodological quality was assessed using the methodological index for non-randomised studies criteria. Primary outcome was the ARR which was log-transformed and pooled using a random effects model. Secondary outcomes were pooled using a simplified pooling technique and included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), range of motion (ROM) and post-operative complications.

RESULTS

The literature search resulted in 287 articles, of which 10 studies, comprising 602 patients, were included. The patients had a pooled mean age of 47 years (range of means: 40-68) and a mean follow-up of 35 months (range of means: 24-48). The overall methodological quality was moderate to fair. The pooled ARR after ankle distraction was 4% (95% confidence interval [CI], 3%-7%). Pooling of AOFAS showed mean 26-point improvement (from 54 to 80). Additionally, ROM dorsiflexion improved at 5°, and the plantarflexion remained at 31°. The overall complication rate was 41% (95% CI, 35%-48%), of which 77% (95% CI, 67%-85%) were pin-tract infections.

CONCLUSION

Ankle distraction results in an ARR of 4% (95% CI, 3%-7%) with clinically relevant improved AOFAS scores. The overall complication rate is 41% and is mainly attributable to treatable pin-tract infections (77% of recorded complications).

LEVEL OF EVIDENCE

Level IV, Systematic Review and Meta-Analysis.

Harnessing joint distraction for the treatment of osteoarthritis: a bibliometric and visualized analysis

Osteoarthritis (OA) stands as a prevalent degenerative joint ailment, demanding immediate attention towards the development of efficacious therapeutic interventions. Presently, a definitive cure for OA remains elusive, and when conservative treatment modalities prove ineffective, resorting to a joint prosthesis becomes imperative. Temporary distraction emerges as a pivotal joint-preserving intervention in human OA patients, conferring both clinical amelioration and structural enhancements. Although extant clinical investigations exist, they are characterized by relatively modest sample sizes. Nonetheless, these studies furnish compelling evidence affirming that joint distraction engenders sustained clinical amelioration and structural refinement. Despite substantial strides in the last decade, a bibliometric analysis of joint distraction within the realm of osteoarthritis treatment research has been conspicuously absent. In this context, we have undertaken a comparative investigation utilizing bibliometric methodologies to scrutinize the landscape of joint distraction within osteoarthritis treatment. Our comprehensive analysis encompassed 469 scholarly articles. Our findings evince a consistent escalation in global research interest and publication output pertaining to this subject. The United States emerged as the frontrunner in international collaboration, publication count, and citation frequency, underscoring its preeminence in this domain. The journal "Osteoarthritis and Cartilage" emerged as the principal platform for disseminating research output on this subject. Notably, Mastbergen SC emerged as the most prolific contributor in terms of authorship. The identified keywords predominantly revolved around non-surgical interventions and joint arthroscopy procedures. This bibliometric analysis, augmented by visual representations, furnishes invaluable insights into the evolutionary trajectory of joint distraction as an osteoarthritis treatment modality spanning from 2003 to 2023. These insights will serve as a compass for the scientific community, facilitating further exploration in this promising domain.

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.

[Mid- and long-term effectiveness analysis of distraction arthroplasty in treatment of moderate to severe ankle arthritis]

OBJECTIVE

To investigate the mid- and long-term effectiveness of external fixator distraction arthroplasty in the treatment of moderate to severe ankle arthritis.

METHODS

The clinical data of 23 patients with moderate to severe ankle arthritis treated with external fixation distraction arthroplasty who met the selection criteria between January 2007 and November 2019 were retrospectively analyzed. There were 20 males and 3 females; the age ranged from 21 to 65 years, with an average age of 43.7 years. Etiology included 8 cases of primary ankle arthritis, in which 5 cases combined with varus deformity; 15 cases of traumatic ankle arthritis, the cause of injury was 5 cases after ankle fracture surgery, 3 cases after Pilon fracture surgery, 5 cases of chronic ankle instability and repeated sprain, and 2 cases of other causes. According to Takakura staging system, there were 4 cases of stage ⅢA, 12 cases of stage ⅢB, and 7 cases of stage Ⅳ; according to Giannini staging system, there were 5 cases of stage Ⅱ and 18 cases of stage Ⅲ; according to Cheng staging system, 16 cases were in stage Ⅲ, and 7 cases stage Ⅳ. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) score were used to evaluate the improvement of ankle pain and function before operation and at last follow-up, and the data were analyzed according to different etiological groups. At last follow-up, the surgical results were evaluated subjectively and objectively. The changes of ankle joint space before operation and at last follow-up were compared. The patients were divided into two groups according to their age: ≤45 years old group [young group, 10 cases, aged (35.62±7.41) years old] and >45 years old group [middle-aged and elderly group, 13 cases, aged (54.20±6.20) years old]. The AOFAS ankle-hindfoot score and VAS score were compared before and after operation between the two groups, and the influence of age on distraction arthroplasty was analyzed.

RESULTS

The external fixator was removed after 3 months of continuous distraction,12 patients got infection around the wire tunnels. All the 23 patients were followed up 13-143 months, with an average of 56.9 months; the follow-up time was (43.46±32.77) months and (69.80±37.79) months in the young group and middle-aged and elderly group, respectively. At last follow-up, the AOFAS ankle-hindfoot score and VAS score significantly improved when compared with those before operation ( P<0.05). According to etiological analysis, there was no significant difference in AOFAS ankle-hindfoot score and VAS score before and after operation ( P>0.05) in Pilon fracture patients, while the significant difference was found in remaining patients ( P<0.05). There was significant difference in AOFAS ankle-hindfoot score before operation between the young group and the middle-aged and elderly group ( t=2.110, P=0.040), but no significant difference in preoperative VAS score and the differences in VAS score and AOFAS ankle-hindfoot score before and after operation between the two groups ( P>0.05). The subjective and objective results of pain evaluation at last follow-up showed that 4 patients had no pain, 12 patients had moderate pain relief, 5 patients had mild pain relief, and 2 patients had no significant pain relief; among the 10 patients who were followed up more than 5 years, there were 2, 5, 2, and 1 patient, respectively; 2 patients who were followed up more than 10 years had moderate pain relief. At last follow-up, the ankle joint space was (3.7±0.4) mm, which significantly increased when compared with before operation [(1.5±0.2) mm] ( t=1.791, P=0.002). The ankle joint space was (2.9±0.5) mm in 10 patients who were followed up more than 5 years, and 3.3 mm and 3.0 mm in 2 patients who were followed up more than 10 years.

CONCLUSION

Distraction arthroplasty of the ankle joint can achieve satisfactory results in patients with moderate to severe ankle arthritis (except for arthritis caused by Pilon fracture), and age has no significant effect on distraction arthroplasty.

Comparisons between ankle distraction arthroplasty and supramalleolar osteotomy for treatment of post-traumatic varus ankle osteoarthritis

BACKGROUND

Ankle distraction arthroplasty and supramalleolar osteotomy were both options for post-traumatic varus ankle arthritis (VAA), but their comparative effectiveness was scarcely reported. This study aimed to compare the outcomes of two operative methods for treatment of Takakura-Tanaka stage 3 post-traumatic VAA.

METHODS

This was a retrospective study, comprising 73 consecutive patients who presented with Takakura-Tanaka stage 3 post-traumatic VAA treated by either ankle distraction arthroplasty (n = 32) or supramalleolar osteotomy (n = 41) from January 2016 to December 2019. All patients had a minimum 24-month follow-up assessments. The outcome measures were visual analog scale (VAS), the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores, complications, patient-rated overall satisfaction and ankle function.

RESULTS

At an average of 32 months (range, 24-52 months) follow-up, significant improvement was observed for VAS, AOFAS, range of motion (ROM) and most radiographic parameters (except for TAS and TLS for ankle distraction arthroplasty group) compared to preoperative baselines (p < 0.05) for both groups. However, both groups did not differ significantly in terms of VAS or AOFAS, excellent and good rate (78.1% versus 85.4%, p = 0.422), overall rate of postoperative complications (28.1% vs. 17.1%, p = 0.257), or various radiographic parameters (e.g. tibial anterior surface angle, talar tilt angle and tibial lateral surface angle) (all p > 0.05). The ankle distraction arthroplasty group had a better postoperative ankle motion than did the supramalleolar osteotomy group, in terms of plantarflexion (37.8 ± 4.2 vs. 30.4 ± 3.6, p = 0.006), dorsiflexion (36.5 ± 6.4 vs. 28.3 ± 5.5, p = 0.004), varus (32.1 ± 4.5 vs. 27.1 ± 3.1, p = 0.017) and valgus (28.4 ± 3.7 vs. 25.2 ± 2.8, p = 0.046).

CONCLUSIONS

Both operative treatments are effective for Takakura-Tanaka stage 3 post-traumatic VAA. In practice, individualized treatment option tailored to the ankle condition and patients' specific need should be considered.

LEVEL OF EVIDENCE

 III, retrospective comparative series.

Effect analysis of iliac bone autografting for Hepple V osteochondral lesions of the talus

Background

Talar cartilage injury is a kind of disease that causes long-term and chronic pain of ankle joint. Autologous osteochondral transplantation has been viewed as an alternative choice for treating these lesions, but donor-site morbidity has limited its application. This study aimed to analyze the efficacy of iliac bone autografting for Hepple V osteochondral lesions of the talus.

Methods

This retrospective study included 32 patients surgically treated for Hepple V osteochondral lesions of the talus from January 2015 to January 2020. All patients underwent open surgery. Ipsilateral iliac bone grafts were taken and filled with talar cartilage injury area. The improvement of postoperative ankle pain was evaluated by Visual Analogue Scale (VAS), and the improvement of ankle function was evaluated by the American Orthopaedic Foot & Ankle Society (AOFAS). During the postoperative follow-up, X-ray examination of the front and side of the ankle joint and CT of the ankle joint were performed to evaluate the bone cartilage healing in the graft area.

Results

Thirty-two patients (32 ankles) (100%) returned for clinical and radiologic follow-up at an average of 28 (range 24–36) months postoperatively. At 3 months postoperatively and at the last follow-up, the AOFAS scores were (80.4 ± 3.6) and (89.2 ± 6.4), respectively, which were significantly improved compared with the preoperative score (49.7 ± 8.1), and the difference was statistically significant (P < 0.05). The VAS scores were (2.1 ± 0.9) and (1.5 ± 0.8), respectively, which were significantly better than the preoperative score (6.2 ± 1.7), and the difference was statistically significant (P < 0.05). Re-examination of the front and side of the ankle joint X-rays and CT showed that the bone healing at the osteotomy of medial malleolus and osteochondral transplantation area. All patients had no pain at the donor site. No complications occurred in 32 patients at the last follow-up.

Conclusions

With iliac bone autografting for Hepple V osteochondral lesions of the talus can effectively relieve ankle joint pain and significantly improved ankle function.

Level of evidence

Level III, Retrospective series.

Ankle distraction arthroplasty (ADA): A brief review and technical pearls

Ankle distraction arthroplasty (ADA) is a procedure based on the concept that mechanical unloading of an arthritic joint will initiate a healing response in the subchondral bone and articular cartilage. ADA utilizes the patient's own healing response, preserves joint motion, and is a great option for patients with osteoarthritis who are not ready for prosthetic arthroplasty or fusion. The procedure is well described and technically simple and adjunctive biologic therapies are exciting for joint regeneration. Complications are minor, and more serious adverse events are avoidable. Supramalleolar osteotomy pairs well with ankle distraction but requires some analysis and planning.

Down-regulation of protease-activated receptor 2 ameliorated osteoarthritis in rats through regulation of MAPK/NF-κB signaling pathway in vivo and in vitro

Recently, protease-activated receptor 2 (PAR2) has been proved to be involved in the inflammatory response including osteoarthritis (OA). In the present study, we found that PAR2 antagonist could remarkably improve the pathological condition of OA rats in vivo. In addition, we also found that PAR2 antagonist could suppress the production of inflammatory factors (TNF-α and Cox-2), decrease the levels of MMP-1 and MMP-13, and restrain the levels of P62 proteins and aggravate the expression of LC3-II both in vivo and in vitro. Besides, in vitro, PAR2 antagonist could increase the proliferation and colony formation of chondrocytes induced with IL-1β. Moreover, PAR2 antagonist could decrease the expression of expressions of p-p38, p-IκBα and p-NF-κB in vitro. However, PAR2 agonist exhibited the opposite effects. Furthermore, SB203580, a p38 MAPK inhibitor, could remarkably promote the proliferation of chondrocytes induced with IL-1β, could alleviate the production of TNF-α and Cox-2, could down-regulate the protein expressions of MMP-1 and MMP-13, and could decrease the expression of P62 and increase the expressions of LC3-II of chondrocytes induced with IL-1β. Importantly, SB203580 could reverse the effects of PAR2 agonist on the functions of chondrocytes induced with IL-1β. Taken together, the present data suggest that down-regulation of PAR2 can ameliorate OA through inducing autophagy via regulation of MAPK/NF-κB signaling pathway in vivo and in vitro, and PAR2 can be considered as a potential candidate to treat OA.

Subtalar distraction arthroplasty with bone marrow aspirate concentrate (BMAC), preliminary results of a new joint preservation technique

INTRODUCTION

Isolated subtalar osteoarthritis (OA) is a debilitating condition usually occurring after trauma and particularly in the setting of an intraarticular calcaneal fracture. Currently, subtalar (talo-calcaneal joint) fusion surgery is the treatment of choice in managing subtalar OA after failure of conservative treatment. Unfortunately, subtalar fusion eliminates joint motion and increases the load over the adjacent midfoot and ankle joints, which affects the outcome of the surgery over time. Popular in the ankle, distraction arthroplasty offers another joint-preserving option, particularly important for active patients. In contrast to fusion as a salvage procedure, subtalar distraction arthroplasty allows the possibility of maintaining the function of the arthritic subtalar joint while reducing pain and improving the overall function of the foot and ankle.

METHODS

We performed subtalar distraction arthroplasty using a circular external fixator combined with BMAC on seven patients with symptomatic and refractory subtalar OA. All these patients were interested in an alternative to fusion. We obtained clinical and radiographic data before and after surgery. Ankle Osteoarthritis Score (AOS) and the Marijnissen Distraction Clinical Score (MDCS) were obtained before surgery, after one year, and at latest follow-up.

RESULTS

The average age was 56 years (range 45-69). The mean duration of post-operative follow-up was 35.4 months (range 15.2-53.5). The inversion of the ankle joint changed from 16.9° (10°-25°) pre-operatively to 14.3° (10°-20°) post-operatively (P = 0.28), and the eversion from 5.6° (0°-10°) to 10.0° (0°-20°) (P = 0.17). We found an increase in subtalar joint space from 1.4 mm (0-3) to 2.6 mm (2-4) before and after surgery (P = 0.01), respectively. Finally, Pixel Density Ratio (PDR) increased from 0.87 (0.66-1.30) to 1.01 (0.89-1.18) (P = 0.19). Compared to pre-operative conditions, we observed a decrease in subchondral sclerosis on X-ray in all cases post-operatively. The AOS score for ankle pain improved from 58.8 (47-74) to 15.1 (0-31) (p < 0.01). The AOS score for ankle disability improved from 68.2 (57-81) to 16.1 (0-43.5) (p < 0.001). We found improvement in the MDCS over time for all measured parameters. The clinical condition improved from 1.4 (0-2) to 0.8 (0-2) after one year and to 0.3 (0-2) at the latest follow-up (p < 0.001). Mobility was measured as ROM in the treated ankle relative to each patient's contralateral ankle. This increased from 35% (0-100) to 66% (15-120) to 76% (15-100) (p = 0.059). Function improved from 2.3 (0-3) to 1.3 (0-3) to 0.6 (0-3) (p < 0.001). Pain decreased from 7.4 (2-10) to 4.4 (2-8) to 2.1 (0-7) (p < 0.01). Complications include one patient with sensory neuralgia.

CONCLUSIONS

Preliminarily, results of subtalar distraction arthroplasty as a new joint preservation technique are encouraging. Our research suggests the possibility of subtalar distraction arthroplasty as an effective treatment for symptomatic subtalar OA. Furthermore, this new operation does not eliminate the possibility of a future surgery like fusion. Subtalar distraction arthroplasty can be helpful in the management of subtalar OA in active patients who desire preservation of foot and ankle motion.

Multipotential stromal cells in the talus and distal tibia in ankle osteoarthritis - Presence, potency and relationships to subchondral bone changes

A large proportion of ankle osteoarthritis (OA) has an early onset and is post‐traumatic. Surgical interventions have low patient satisfaction and relatively poor clinical outcome, whereas joint‐preserving treatments, which rely on endogenous multipotential stromal cells (MSCs), result in suboptimal repair. This study investigates MSC presence and potency in OA‐affected talocrural osteochondral tissue. Bone volume fraction (BV/TV) changes for the loading region trabecular volume and subchondral bone plate (SBP) thickness in OA compared with healthy tissue were investigated using microcomputed tomography. CD271‐positive MSC topography was related to bone and cartilage damage in OA tissue, and in vitro MSC potency was compared with control healthy iliac crest (IC) MSCs. A 1.3‐ to 2.5‐fold SBP thickening was found in both OA talus and tibia, whereas BV/TV changes were depth‐dependent. MSCs were abundant in OA talus and tibia, with similar colony characteristics. Tibial and talar MSCs were tripotential, but talar MSCs had 10‐fold lower adipogenesis and twofold higher chondrogenesis than IC MSCs (P = .01 for both). Cartilage damage in both OA tibia and talus correlated with SBP thickening and CD271+ MSCs was 1.4‐ to twofold more concentrated near the SBP. This work shows multipotential MSCs are present in OA talocrural subchondral bone, with their topography suggesting ongoing involvement in SBP thickening. Potentially, biomechanical stimulation could augment the chondrogenic differentiation of MSCs for joint‐preserving treatments.

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.

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

Background

In highly active older individuals, end-stage ankle osteoarthritis has traditionally been treated using tibiotalar arthrodesis, which provides considerable pain relief. However, there is a loss of ankle joint movement and a risk of future arthrosis in the adjacent joints. Distraction arthroplasty is a simple method that allows joint cartilage repair; however, the results are currently mixed, with some reports showing improved pain scores and others showing no improvement. Distal tibial osteotomy (DTO) without fibular osteotomy is a type of joint preservation surgery that has garnered attention in recent years. However, to our knowledge, there are no reports on DTO with joint distraction using a circular external fixator. Therefore, the purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator for treating ankle osteoarthritis.

Methods

A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed, followed by angled osteotomy and correction of the distal tibia; the ankle joint was then stabilized after its condition improved. An external fixator was used in all patients, and joint distraction of approximately 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery.

Results

The anteroposterior and lateral mortise angle during weight-bearing, talar tilt angle, and anterior translation of the talus on ankle stress radiography were improved significantly (P < 0.05). Signal changes on magnetic resonance imaging also improved in all patients. Visual analog scale and American Orthopedic Foot & Ankle Society scores improved significantly (P < 0.05), and no severe complications were observed.

Conclusion

DTO with joint distraction may be useful as a joint-preserving surgery for medial ankle osteoarthritis in older patients with high levels of physical activity.

Level of evidence

Level IV, retrospective 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.

Supramalleolar osteotomy with medial distraction arthroplasty for ankle osteoarthritis with talar tilt

BACKGROUND

An increased preoperative talar tilt (TT) angle was reported to be positively correlated with treatment failure after supramalleolar osteotomy (SMOT) for varus ankle osteoarthritis. Distraction arthroplasty was reported to have the ability to correct increased TT angles. The purpose of the current study was to compare the outcomes between SMOT with and without medial distraction arthroplasty (MDA) in the treatment of varus ankle osteoarthritis with increased TT angles.

METHODS

We retrospectively reviewed the functional outcomes and radiological findings of 34 patients who underwent SMOT with or without MDA for varus ankle osteoarthritis with increased TT angles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Ankle Osteoarthritis Scale (AOS) scores were used for functional evaluation. The tibial anterior surface (TAS) angle, talar tilt (TT) angle, tibial medial malleolar (TMM) angle, talocrural (TC) angle, tibial lateral surface (TLS) angle, and hindfoot alignment (HFA) angle were evaluated preoperatively and at the time of the last follow-up.

RESULTS

In the SMOT group, the AOFAS score and AOS pain and function scores were significantly improved (P < 0.01 for each) at a mean follow-up of 61 months. The TAS, TT, TC, TLS, and HFA angles were all significantly improved (P < 0.01 for each). Similarly, in the SMOT with MDA group, the AOFAS score, AOS pain and function scores, and the TAS, TT, TC, TLS, and HFA angles were all significantly improved postoperatively (P < 0.01 for each). When comparing the two groups, the postoperative TT angle was significantly smaller in the SMOT with MDA group (P = 0.023) than in the SMOT group. In addition, the failure rate of TT angle correction was significantly higher in the SMOT group (P = 0.016) than in the SMOT with MDA group.

CONCLUSION

SMOT is a promising procedure for functional improvement and malalignment correction for varus ankle osteoarthritis, even in patients with increased talar tilt. If SMOT is combined with MDA, there can be an improvement in the correction of the increased talar tilt.

LEVEL OF EVIDENCE

Level III, a retrospective comparative study.

Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis

Aim

The treatment algorithm for end-stage ankle arthritis is imperfect. Young or active patients are challenging to treat as fusion and replacement carry predictable consequences. Ankle distraction arthroplasty is a less commonly utilized surgical procedure for the treatment of osteoarthritis of the ankle. The purpose of this study was to report intermediate-term survival of ankle distraction and to identify factors associated with earlier time to failure.

Materials and methods

A single-centre, multi-surgeon cohort of 258 cases of ankle arthritis, treated with ankle distraction or ankle distraction with supramalleolar osteotomy (SMO), was identified. Patients were contacted by phone to determine the status of the ankle (natural vs fused/replaced). Data were collected through chart review. This included patient demographics, medical comorbidities, surgical procedure, and X-ray characteristics including pattern and severity. A Cox regression model was used to determine factors associated with failure during 10 years of follow-up. Risk factors were analysed as hazard ratios (HRs) and 95% confidence intervals (CIs). Time to failure was illustrated with Kaplan–Meier (KM) curves.

Results

In total, 144 cases were successfully contacted with median follow-up of 4.57 years. In total, 16.7% of ankles failed (24/144). The 5-year survival was 84% (95% CI: 78–91%). In adjusted Cox regression, female sex (HR = 2.68, p = 0.049) and avascular necrosis (AVN) of the talus (HR = 3.77, p = 0.041) were significantly associated with failure risk.

Conclusion

Avascular necrosis of the talus and male/female gender differences in survival were found to be significant. Our experience shows that ankle distraction is a valid and effective operation for the treatment of end-stage ankle arthritis.

Clinical significance

This work is clinically significant in that it demonstrates excellent intermediate-term survival data for hinged ankle distraction for treatment of osteoarthritis of the ankle. Additionally, it evaluated patient and disease characteristics allowing improved patient counselling with regard to survival longevity.

Level of evidence

IV cohort study.

How to cite this article

Greenfield S, Matta KM, McCoy TH, et al. Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis. Strategies Trauma Limb Reconstr 2019;14(2):65–71.

Early and mid-term results of transarticular external fixation in the treatment of supination-external rotation type IV equivalent ankle fractures

PURPOSE

To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice.

METHODS

This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded.

RESULTS

All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases).

CONCLUSION

In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials.

Supramalleolar Osteotomy With Distraction Arthroplasty in Treatment of Varus Ankle Osteoarthritis With Large Talar Tilt Angle: A Case Report and Literature Review

We treated a 57-year-old female with modified Takakura stage 3B varus ankle osteoarthritis. Her preoperative talar tilt angle was 21.3°. The patient wished to avoid ankle joint arthrodesis or replacement. Therefore, medial opening wedge supramalleolar osteotomy with fibular osteotomy was used for her varus ankle osteoarthritis. Also, fixed medial distraction arthroplasty was performed to improve her talar tilt. After 3 months, the external device was removed, and the patient was allowed partial weightbearing and began full weightbearing 4 months postoperatively after the osteotomy site had reached bony union radiographically. At the 3-year follow-up visit, a radiograph showed the medial ankle joint space enlargement had been maintained. The talar tilt angle had decreased to 3.3°, and the modified Takakura stage had improved to stage 1. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score had improved from 26 points preoperatively to 85 points at 3 years postoperatively. Our findings suggested that good clinical and radiologic results can be achieved with supramalleolar osteotomy combined with distraction arthroplasty in the treatment of varus ankle osteoarthritis with a large talar tilt angle.

Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status

INTRODUCTION

In advanced stages of ankle osteoarthritis (OA), ankle arthrodesis (AA) or total ankle arthroplasty (TAR) may be necessary. Our purpose is to compare AA and total ankle replacement for the surgical management of end stage ankle OA.

SOURCES OF DATA

We conducted a literature search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the terms 'ankle' in combination with 'OA', 'arthrodesis', 'arthroplasty', 'joint fusion', 'joint replacement'. Studies where treatment was exclusively total ankle replacement or AA were excluded. Treatment characteristics and outcome parameters (overall postoperative outcome and complication rate) were reviewed.

AREAS OF AGREEMENT

When counseling patients who are considering their options with regard to ankle arthritis treatment, surgeons should determine on an individual basis which procedure is more suitable.

AREAS OF CONTROVERSY

TAR has become an accepted treatment for end-stage OA, but revision rates for TAR are significant higher than for AA (odds ratio 2.28 95% confidence interval [CI], 1.63-3.19; P < 0.0001).

GROWING POINTS

The results of TAA are gradually improving, but the procedure cannot yet be recommended for the routine management of ankle OA.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although there is some evidence to support TAR to conserve ankle motion and offer improved function and decreased pain with high satisfaction rates, revision rates for TAR are significantly higher than revision rates for AA. Proper patient selection should be better addressed in future studies for successful treatment of end-stage ankle OA.

LEVEL OF EVIDENCE

Systematic review, level III.