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Our goal was to compare the health status of patients with primary and secondary arthrosis of the ankle before and after arthrodesis or total substitution arthroplasty, and to determine the improvement in quality of life and whether there is any difference between these techniques. A prospective comparative study of clinical-functional evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) scale and quality of life with the short form (SF)-36 questionnaire in patients who underwent arthrodesis (16 cases) or total substitution arthroplasty of the ankle (14 cases) after 2 years (mean, 25.2 months) of follow-up after surgery, in comparison with the baseline preoperative status. In this series of comparable patients, both techniques showed a statistically significant improvement with regard to the clinical evaluation and quality of life after 2 years of follow-up; the arthrodesis group increased from mean AOFAS values of 37.12 to 45.62 (P = .055) and mean SF-36 values of 32.96 to 46.25 (P = .008), whereas in the arthroplasty group the mean values of AOFAS increased from 33 to 62 (P = .024) and SF-36 from 33.62 to 59.84 (P = .001). Nevertheless, in all cases the improvement was statistically greater in patients who underwent arthroplasty than in those who underwent arthrodesis (P = .048 for AOFAS, and P = .026 for SF-36). In conclusion, arthrodesis and arthroplasty represent good options in the surgical treatment of ankle arthrosis, providing both a significant improvement in function and in the health perception and quality of life of the patient. New-generation total ankle substitution arthroplasty provides an improvement in the quality of life and perception of general health of the patient with arthrosis of this joint, when this technique is compared with surgical fusion.
The purpose of this study was to compare the brake reaction time of patients with successful right ankle fusion to normal volunteers without an ankle fusion.
Ten patients who underwent successful right ankle arthrodesis were evaluated using a driving simulator as well as an in-shoe pedobarographic measuring system. Brake reaction time, braking force, peak pressure, contact area, and the center of force between the foot and the brake pedal were recorded. SF-12 scores were obtained from all study patients. A control group of ten age-matched individuals without ankle fusion was included for comparison.
Mean brake reaction time for the ankle fusion group (0.42+/-0.14 seconds) was significantly slower than for the control group (0.33+/-0.06 seconds) (p=0.03). The center of force was consistently isolated to the forefoot in the ankle fusion group compared to controls who distributed the center of force over both the forefoot and midfoot. There was no significant difference between the ankle fusion and control groups with respect to braking force, peak pressure, or contact area.
The mean brake reaction time following successful right ankle arthrodesis was significantly slower than that of normal controls. However, the fusion group time was still below the threshold for what is defined as a safe brake reaction time by the United States Federal Highway Administration.
Re: Ankle arthrodesis vs athroplasty and quality of life
Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome.
Schuh R, Hofstaetter J, Krismer M, Bevoni R, Windhager R, Trnka HJ. Int Orthop. 2011 Dec 16. [Epub ahead of print]
Ankle arthrodesis (AAD) and total ankle replacement (TAR) are the major surgical treatment options for severe ankle arthritis. There is an ongoing discussion in the orthopaedic community whether ankle arthrodesis or ankle fusion should be the treatment of choice for end stage osteoarthritis. The purpose of this study was to compare the participation in sports and recreational activities in patients who underwent either AAD or TAR for end-stage osteoarthritis of the ankle.
A total of 41 patients (21 ankle arthrodesis /20 TAR) were examined at 34.5 (SD18.0) months after surgery. At follow-up, pre- and postoperative participation in sports and recreational activities has been assessed. Activity levels were determined using the ankle activity score according to Halasi et al. and the University of California at Los Angeles (UCLA) activity scale. Clinical and functional outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. The percentage of patients participating in sports and recreational activities, UCLA score and AOFAS score were compared between both treatment groups.
In the AAD group 86% were active in sports preoperatively and in the TAR group this number was 76%. Postoperatively in both groups 76% were active in sports (AAD, p = 0.08). The UCLA score was 7.0 (± 1.9) in the AAD group and 6.8 (± 1.8) in the TAR group (p = 0.78). The AOFAS score reached 75.6 (± 14) in the AAD group and 75.6 (± 16) in the TAR group (p = 0.97). The ankle activity score decrease was statistically significant for both groups (p = 0.047).
Our study revealed no significant difference between the groups concerning activity levels, participation in sports activities, UCLA and AOFAS score. After AAD the number of patients participating in sports decreased. However, this change was not statistically significant.
Despite improvement in outcome after ankle arthroplasty, fusion of the ankle joint is still considered the gold standard. A matter of concern is deterioration of clinical outcome as a result of loss of motion and advancing degeneration of adjacent joints. We performed a long-term study to address these topics.
Between 1990 and 2005 a total of 121 ankle arthrodeses were performed at our institute. Thirty-five cases were excluded because of simultaneous subtalar arthrodesis. Ten had died and ten were lost to followup. Six had a bilateral ankle arthrodeses, leaving 60 patients (66 ankles) eligible for followup. There were 40 males and 26 females with a mean age at surgery of 47 years. In 60 ankles, fusion was obtained using a two-incision, three-screw technique. All patients were assessed using validated questionnaires and clinical rating systems: Short Form 36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale, Foot and Ankle Ability Measure (FAAM) and a subjective satisfaction rating. Radiological progression of osteoarthritis of the adjacent joints was assessed.
Fusion was achieved in 91% after primary surgery. In six patients rearthrodesis was needed to obtain fusion. The mean SF-36 score was 63 (SD, 22) for the physical component scale and 81 (SD, 15) for the mental component scale. The mean FAAM score was 69 (SD, 17) and the mean AOFAS Ankle Hindfoot score was 67 (SD, 12). Ninety-one percent were satisfied with their clinical result. Infection occurred once. No other serious adverse events were encountered. In all contiguous joints significant progression of arthritis was appreciated.
Ankle arthrodesis using a two-incision, three-screw technique was a reliable and safe technique for the treatment of end-stage osteoarthritis of the ankle. It resulted in a good functional outcome at a mean followup of 9 years. Progressive osteoarthritis of the contiguous joints was clearly appreciated but the functional and clinical importance of these findings remains unclear.
Total ankle replacement (TAR) continues to grow as an alternative to arthrodesis for patients who suffer from end-stage ankle arthritis. We examined changes in pre-operative gait mechanics at one-year and two-year post surgery in patients who received a fixed-bearing TAR.
Fifty-one patients who received a primary fixed-bearing TAR and had no complications requiring further surgery were identified from a larger database of TAR patients. A motion capture system and four force plates were used to collect three-dimensional joint mechanics and ground reaction forces (GRF) during level walking at self-selected speed before surgery and at one-year and two-year post surgery. The Four Square Step Test, Timed Up and Go, visual analog scale (VAS), and the AOFAS-Hindfoot score were also assessed for each subject.
Timed Up and Go, VAS score and AOFAS-Hindfoot score along with all measured kinetic and kinematic parameters significantly improved at each post-operative assessment (p<0.05). Four Square Step Test time showed significant improvement between the pre-operative and two-year post-operative time points but not between the pre-operative and one-year post-operative time points (p<0.05). There were no differences in the measured ankle dorsiflexion angles between any time points.
DISCUSSION AND CONCLUSION
All of the observed changes suggest improved or maintained gait function in patients who have received a TAR. The greatest improvement occurred between the pre-operative and one-year follow up.
End-stage ankle arthritis (ESAA) is a debilitating condition associated with severe pain, dysfunction, and reduced quality of life. Many patients with ESAA have difficulty walking for even 100 feet or up a single flight of stairs. Patients seeking surgery for ESAA have two primary treatment options: ankle arthrodesis (i.e., ankle fusion) and ankle arthroplasty (i.e., ankle replacement). Few studies have directly compared the effectiveness of these two procedures, and no randomized controlled trials (RCTs) have been performed.
The investigators will conduct a multi-site RCT comparing the effectiveness of ankle arthrodesis and ankle arthroplasty over a 2-year follow-up period. The investigators will compare overall physical function and ankle specific function; ankle pain intensity and interference with activities; activity levels; and general health between subjects undergoing ankle arthrodesis and ankle arthroplasty before surgery and at 3, 6, 12, and 24 months after surgery. The investigators will also compare post-surgical complication rates, and the investigators will identify prognostic factors that are predictive of higher physical function, ankle specific function, reduced pain, improved general health, and overall patient satisfaction.
Ankle arthrodesis is still a gold standard salvage procedure for the management of ankle arthritis. There are several functional and mechanical benefits of ankle arthrodesis, which make it a viable surgical procedure in the management of ankle arthritis. The functional outcomes following ankle arthrodesis are not very well known. The purpose of this study was to perform a clinical and radiographic evaluation of ankle arthrodesis in posttraumatic arthritis performed using Charnley's compression device.
MATERIALS AND METHODS:
Between January 2006 and December 2009 a functional assessment of 15 patients (10 males and 5 females) who had undergone ankle arthrodesis for posttraumatic arthritis and/or avascular necrosis (AVN) talus (n=6), malunited bimalleolar fracture (n=4), distal tibial plafond fractures (n=3), medial malleoli nonunion (n=2). All the patients were assessed clinically and radiologically after an average followup of 2 years 8 months (range 1-5.7 years).
All patients had sound ankylosis and no complications related to the surgery. Scoring the patients with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, we found that 11 of the 15 had excellent results, two had good, and two showed fair results. They were all returned to their preinjury activities.
We conclude that, the ankle arthrodesis can still be considered as a standard procedure in ankle arthritis. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function. Still, one should keep in mind that it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of subtalar arthritis.
Total ankle replacement (TAR) continues to grow as an alternative to
arthrodesis for patients who suffer from end-stage ankle arthritis. The
purpose of this study was to examine changes in gait mechanics from
before surgery to 1 and 2 years after surgery in patients who received
a fixed-bearing TAR.
Methods: Fifty-one patients with a primary
fixed-bearing TAR and no complications requiring further surgery were
identified from a database and enrolled in this non-randomized study.
Subjects were examined preoperatively, and at 1 and 2 years
postoperatively. Three-dimensional joint mechanics and ground reaction
forces (GRF) were collected during level walking. The Four Square Step
Test, Timed Up and Go (TUG), VAS, and the AOFAS-Hindfoot score were
assessed for each subject at each time point.
Results: TUG, VAS and
AOFASHindfoot score along with all measured kinetic parameters
demonstrated significant improvements across all of the time points (p
< 0.05). Four Square Step Test time was significantly improved between
the preoperative and 2-year postoperative time point (p < 0.05).
Measured ankle dorsiflexion angles did not demonstrate significant
change between any time points.
Conclusions: All of the observed
changes suggest improved or maintained functioning in patients who
received a TAR with the greatest improvement occurring within the first
year. Sagittal plane ankle range of motion and dorsiflexion angle at
heel strike were unchanged across all of the time points. The results
of this study indicate that patients with end-stage osteoarthritis
demonstrate improvements in pain and gait up to 2 years following
surgery while maintaining ankle range of motion.
Ankle arthritis is a cause of major disability; however reports in the literature on the incidence of ankle osteoarthritis are rare.
To explore the methodological challenges in obtaining an incidence of ankle osteoarthritis and to estimate the incidence of symptomatic osteoarthritis presenting to Foot & Ankle specialists in the UK.
We searched available national diagnosis databases and also sent out a questionnaire-based survey to all Consultant members of the British Orthopaedic Foot & Ankle Society (n=180).
123 completed survey questionnaires were returned (68%) with each surgeon seeing on average 160 cases of symptomatic ankle arthritis and performing on average 20 definitive procedures for end-stage ankle osteoarthritis per year. There are no internationally agreed diagnostic or treatment codes specific for ankle osteoarthritis.
There are an estimated 29,000 cases of symptomatic ankle osteoarthritis being referred to specialists in the UK, representing a demand incidence of 47.7 per 100,000. 3000 definitive operations to treat end stage ankle osteoarthritis take place in the UK annually. We recommend that specific codes pertaining to ankle arthritis and its treatment be included in any future revisions of the WHO International Classification of Diseases (ICD) and operative procedure coding systems.
A large number of parameters are registered by pedobarography, usually requiring a research setting for interpretation. The purpose of this study was to evaluate which pedobarographic parameters (adjusted for walking speed and body weight) discriminate between healthy volunteers and patients after ankle or tibiotalocalcaneal arthrodesis. Furthermore, we evaluated which parameters are associated with the American Orthopaedic Foot and Ankle Society (AOFAS) score.
Thirty-five healthy volunteers, 57 patients with ankle and 42 with tibiotalocalcaneal arthrodesis were assessed by AOFAS scores and dynamic pedobarography. The arthrodesis patients were further investigated with radiographs. Median follow up was 4years. Eighteen basic parameters were measured each in the hind-, mid-, and forefoot. For dimension reduction, we represented a pre-selected set of 9 parameters by two indices (load, rollover). We used ordinal logistic and multiple linear regression to address the questions.
The midfoot index of load was the most important pedobarographic predictor (interquartile range odds ratio 100; 95% confidence interval 13, 771) for belonging to the healthy volunteers rather than the ankle or tibiotalocalcaneal arthrodesis groups. Similarly, it was an independent predictor for the AOFAS score (interquartile range effect 5 points; 95% confidence interval 1, 9). Healthy volunteers had a deeper midfoot depression in the force/pressure time graphs compared to patients after arthrodesis.
When evaluating foot function after ankle or tibiotalocalcaneal arthrodesis, the interpretation of a large number of pedobarographic parameters can be reduced to the interpretation of the midfoot index of load and the evaluation of the force/pressure time graphs.
Re: Ankle arthrodesis vs athroplasty and quality of life
Functional disabilities and issues of concern for Asian patients before total ankle arthroplasty.
Lee KT, Choi JH, Lee YK, Young KW, Kim JB, Kim JS, Kim WJ, Kim JH, Lee JY. Orthopedics. 2012 May;35(5)
Total ankle arthroplasty is a commonly performed invasive procedure that can be distressing to patients. Therefore, surgeons should consider patients' issues of greatest interest and concerns at the time of surgery and the function that patients hope to recover. Many studies have reported surgeon concerns before total knee arthroplasty and total hip arthroplasty, but few have focused on patients. The purpose of this study was to evaluate patients' functional disabilities and issues of concern regarding total ankle arthroplasty.Between May 2008 and June 2010, eighty-five patients (52 men and 33 women; mean age, 60 years) were recruited for the study. All patients were asked to complete a questionnaire divided into 3 parts: sociodemographic data, current functional disabilities and their perceived importance, and issues concerning patients before total ankle arthroplasty. Regarding functional disability based on severity, the top 5 issues were limping, difficulty squatting, daytime pain, difficulty kneeling, and difficulty climbing stairs. Regarding functional disability based on perceived importance, the top 5 issues were daytime pain, limping, difficulty walking, difficulty kneeling, and difficulty working. Regarding issues of concern, the top 5 issues were pain intraoperatively, ability to walk as much as desired, ability to climb stairs, pain after discharge from the hospital, and pain immediately postoperatively. The most important issue before total ankle arthroplasty was pain. Patients had a strong interest in high ankle extension and increased range of motion due to the lifestyle and religious activities of Eastern populations.
Ankle arthrodesis has been the gold standard operative treatment for
ankle arthritis refractory to nonoperative treatment. Although multiple
studies have evaluated the outcomes after ankle fusion, none has
focused on outcomes in elderly patients. The purpose of this study was
to evaluate outcomes of ankle fusion in patients over the age of 70.
Methods: Thirty patients (30 ankles) over the age of 70 who underwent
ankle fusion were identified. Average age at the time of surgery was
74.5 years (±3.7). The Foot and Ankle Ability Measure (FAAM) was
obtained postoperatively in 22 of the 23 patients still living.
Radiographs were followed until union with an average followup of 2.2
years. Results Union was achieved in 27 of 30 ankles (90%).
Postoperative radiographs showed 11 (36.6%) patients had progression of
subtalar arthritis. The average postoperative FAAM score was 81.5
(±18.3) with an average followup of 8.5 years (±1.7). Subjectively,
when asked to compare present function with their prearthritic state,
the average response was 75.1% (±19.6). The average American
Orthopaedic Foot and Ankle Society hindfoot score was 73.0 (±11.5).
Complications included nonunion, deep infection, and adjacent joint
Conclusions: In this clinical cohort, ankle fusion was found
to be effective in the treatment of ankle arthritis. Functional outcome
was satisfactory and the rate of union was comparable with that
previously reported in the literature for younger patients. Although
total ankle arthroplasty is becoming increasingly popular, ankle
arthrodesis is an effective surgical treatment option in an elderly
This project highlights the red flags in postoperative rehabilitation of total ankle replacement (TAR) patients managed with two different postoperative rehab regimes.
20 TAR patients were recruited for a pilot RCT between 2008 and 2011; they were randomized to 2 groups (immobilisation in a below knee plaster cast for 6 weeks vs. early mobilisation following TAR); all patients underwent a graded outpatient Physiotherapy program until 12 weeks postoperatively. Assessments included questionnaires, complications, American Orthopaedic Foot and Ankle Score (AOFAS) done preoperatively, 3 and 6 months after surgery
Results 20 TARs for OA (13) and PTOA (7) took part in the trial. There were 10 patients in each arm of the study. Mean age 61.2 years; mean BMI was 29.4. Of the plaster group, there was 1 incidence of fracture medial malleolus (MM) at 6 weeks after removal of plaster cast, 1 fracture MM at 5 months following walking on the beach, 1 fracture (MM) after completion of outpatient physiotherapy session, and 1 fracture MM of unknown reason at 1 year. Of the early mobilisation group, there was 1 intraoperative fracture of tibia (treated conservatively); 1 fracture MM 6 weeks post-op; 2 fracture MM at 8 weeks post-op. All patients had good clinical outcomes at successive follow up assessments.
Conclusion These results highlights the need for considering a lighter exercise regime, and re-evaluating patient lifestyle, return to recreational activities and feedback on home exercise programs during planning and execution of each phase of postoperative rehabilitation programs to aid prevention of early fractures in patients following TAR.
Background Postoperative pain following (Mobility TM) ankle arthroplasty (AA) is recognised problem. This study aimed to determine pattern of postoperative pain following Ankle arthroplasty (AA).
Materials and Methods In prospective observational study 135 patients who had (AA) and follow-up of 12–36 months were included. AOFAS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. Patients with AOFAS of < 50 with postoperative ankle pain were examined in details.
Results From total of 135 of patients with follow-up of 12 months, (12.5%)17 patients have low AOFAS score and ankle pain, 11(12.5%) of 85 patients with 2 year follow-up and (10.6%),5 of 47 patients with 3 year follow-up. Most of patients with low AOFAS score during first year have improved but 3 patients. Different group patients developed ankle pain during the second and third year. 3 patients of 5, in year 3 follow-up have medial side ankle pain and 2 lateral; similarly there is more medial sided pain during year 2 review (7/11). There is more medial sided pain noticed during first postoperative year as well. Lateral pain seems to relate with subtalar joints problems. Medial side pain is less understandable, it might be due to tension in medial ankle ligaments. Our study showed improvement in AOFAS score and pain relief associated with medial ligaments release or medial malleolus fracture.
Conclusion There are 10–13 % of low AOFAS scores following Ankle Arthroplasty with ankle pain. There are emerging evidences explaining postoperative ankle pain. Further studies are required in this field.
Background The recommended indications for total ankle replacement (TAR) are limited, leaving fusion as the only definitive alternative. As longer-term clinical results become more promising, should we be broadening our indications for TAR?
Materials and Methods Our single-centre series has 133 Mobility TARs with 3–48 months' follow-up. 16 patients were excluded who were part of a separate RCT. The series was divided into two groups. ‘Ideal’ patients had all of the following criteria: age >60y, BMI <30, varus/valgus talar tilt <10°, not diabetic, not Charcot, not post-traumatic. The ‘Not ideal’ group contained those who did not fit any single criteria. We compared complications and outcome scores between both groups.
Results The ‘Ideal’ group contained 44 ankles vs. 80 in the ‘Not ideal’ group (124 ankles in 117 patients). Complications were (‘Ideal’ vs. ‘Not ideal’): infection: 1 (deep) vs. 3; DVT/PE: 0; periprostheticfracture: 4 vs. 7; CRPS: 2 vs. 2; revision: 0 vs. 2. AOFAS scores showed variable significance (mean values). Pre-op: 27.9 vs. 25.7 (p = 0.459); 3months: 79.4 vs. 73.2 (p = 0.041); 6 months: 79.9 vs. 75.4 (p = 0.053); 12 months: 79.7 vs. 75.8(p = 0.228), 36 months: 77.3 vs. 79.0 (p = 0.655). Further subgroup analysis has been performed.
Discussion Our results show that indications for TAR can be widened without further morbidity. Each case must be treated individually and accounted for other factors. Varus/valgus tilt can be corrected with appropriate calcaneal osteotomy +/- tendon transfers as a staged or combined procedure. TAR may be considered in younger patients based on functional and occupational demands. We may no longer be able to deter patients on BMI alone. Diabetic patients do not appear to have a higher complication rate.
Conclusion We have increasing evidence that we should now be considering TAR as the primary treatment for disabling ankle arthritis rather than fusion.
The purpose of our study was to describe and analyze the functional
outcomes of mid-term followup patients with ankle arthrodesis. Methods:
Twenty patients who had an isolated ankle arthrodesis were followed for
a mean of 3 years after surgery. We performed physical and functional
examination, radiographic examination and CT scan. Each completed
standardized, self-reported outcome questionnaires SF-36, AOFAS and
Mazur scores. All subjects were evaluated with a kinetic and kinematic
gait analysis and a plantar pressure study. Results: Only one patient
used a cane and seven patients required an insole to walk. We observed
no relation between the scores obtained. Most of the patients
showed good functional results and poor life quality scores. The joints
that were significantly more degenerated were the Chopart and the
subtalar joints, which were affected in 16 patients in the fused limb.
The kinematic parameters showed compensatory motion in the neighboring
joints and the kinetic parameters studied were similar in the
arthrodesis limb and the control limb. There was no significant
difference between the arthrodesis limb and the contralateral limb for
plantar pressures. Conclusion: Although ankle arthrodesis will help to
relieve pain and to improve overall function, it is considered to be a
salvage procedure that causes persistent alterations in gait, with the
possible development of symptomatic osteoarthritis in the other joints
of the foot. Patients and treating physicians should also expect
overall pain and functional limitations to increase over time.
The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence (LOE) available to support the operative technique of distraction ankle arthroplasty for the current generally accepted indications and make a grade of recommendation for each.
A comprehensive review of the literature was performed (November 2010 to January 2011) using the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of distraction ankle arthroplasty. All articles were reviewed and assigned a classification (I-V) of Level of Evidence. An analysis of the literature reviewed was used to assign a Grade of Recommendation for each current generally accepted indication for distraction ankle arthroplasty.
There is insufficient evidence based literature (Grade I) to support or refute the procedure for either: post-traumatic ankle arthritis, arthritis associated with ligamentous instability, primary degenerative joint disease, chondrolysis, deformity associated with arthritis, osteochondral defects and congenital ankle abnormalities.
Inadequate evidence based literature exists to support or refute all currently accepted indications for distraction ankle arthroplasty and further high quality, scientific studies are needed upgrade to these recommendations.
Background: Arthrodesis as well as total arthroplasty are well established but controversially discussed treatment options for end-stage osteoarthritis of the ankle joint. For guidance concerning the significance of both surgical procedures we have correlated our clinical, radiological and biomechanical data with an up-to-date literature review. Material and
Methods: 15 patients after arthrodesis because of an isolated end-stage osteoarthritis of the ankle joint were followed clinically and radiologically 4 (1.9-8.8) years after surgery. To evaluate the outcome, different scores (AOFAS, Kellgren and Lawrence) were used. In the second part of the study a dynamic foot model was implemented to simulate a foot strike in vitro utilising a cadaver foot. By controlling 6 extrinsic tendons via steel cables, a hydraulic force application and a moving ground plate, a foot strike was simulated. Intraarticular compression load was measured in the talonavicular and calcaneocuboid joints with pressure-sensitive foils.
Results: The mean AOFAS score for the subcategory pain was 28 ± 12 points. In the subcategory function the patients had a mean score of 38 ± 9 points summing up to a mean total AOFAS score of 66 ± 18 points. Six patients showed radiological evidence of degeneration of the talonavicular joint. For these patients the Kellgren and Lawrence score was 2.3 (1-4) points higher than for the opposite side. Concerning the subtalar joint in 6 patients the Kellgren and Lawrence score was 1.6 (1-3) points higher compared to the non-surgery side. In contrast we noted only one case with degeneration of the calcaneocuboid joint. The native trial utilising the foot model revealed a continuous rise of load transmission in both parts of the Chopart joint. After performing an arthrodesis, load transmission rose significantly in the second half of the foot strike concerning the talonavicular joint whereas the calcaneocuboid joint showed a decreased transmission of load.
Conclusion: Referring to published data complication rates after ankle arthrodesis are lower compared to total ankle arthroplasty whilst adjacent joint degeneration of the subtalar and talonavicular joints is more common
Ankle arthrodesis is a well-established procedure that has been successfully used for treatment of end stage arthritis of the ankle for well over a century. Internal fixation for ankle arthrodesis is adequate in most of the cases. However, surgeons and patients are occasionally confronted with cases in need for ankle arthrodesis but do not lend itself well to the ideal position and/or internal fixation. These cases may even contraindicate internal fixation. The aim of this study is to assess the results of ankle arthrodesis using different modalities of Ilizarov techniques and demonstrating its high versatility in treating such difficult cases.
PATIENTS AND METHODS:
This is a prospective study. Thirty cases of ankle fusion for end stage arthritis or instability were performed in the period between January 2002 and December 2007 at the Health Insurance Reference Hospitals, Alexandria, Egypt. Tibiotalar fusion was done in 22 cases and tibiocalcaneal fusion in 8 cases using different modalities of Ilizarov technique. The mean follow up period was 5.5 years (range 4-8, SD 1.9).
Sound and painless fusion was achieved in all the cases except one (97%). The difference between the mean preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) was found to be statistically highly significant (t=10.1, p=0.001). Many minor complications were encountered during the course of treatment in the form of: pin tract infections, wound dehiscence, cellulitis that was managed effectively with local wound care, oral antibiotics.
The versatility of the combinations of assemblies afforded by Ilizarov fixator was found to be endless. This makes the Ilizarov fixator to be an effective and versatile mean of treating difficult cases of ankle arthrodesis.
To determine the incidence of nonunion after isolated arthroscopic ankle arthrodesis.
Electronic databases and relevant peer-reviewed sources, including OvidSP/Medline (http://ovidsp.tx.ovid.com) and Google, were systematically searched for the terms "arthroscopic ankle arthrodesis" AND "nonunion". Additionally, we manually searched common American, British, and European orthopaedic and podiatric scientific literature for relevant articles. Studies were eligible for inclusion only if they included the following: isolated ankle arthrodesis, greater than 20 ankles, minimum mean follow-up of 12-months, a 2-portal anterior arthroscopic approach, fixation with 2 or 3 large-diameter cannulated cancellous screws, and the nonunion rate with no restriction on cause.
After considering all the potentially eligible articles, 7 (25.9%) met the inclusion criteria. A total of 244 patients (244 ankles)-148 (60.7%) male and 96 (39.3%) female patients, with a weighted mean age of 49.2 years-were included. For those studies that specified the exact follow-up, the weighted mean was 24.1 months. A total of 21 nonunions (8.6%) were reported, with 14 (66.7%) being symptomatic and requiring further intervention.
The results of this systematic review reveal an acceptable incidence of nonunion of 8.6%. However it is important to recognize that of these nonunions, 66.7% were symptomatic. This supports the belief that regardless of approach, nonunion of an ankle arthrodesis is problematic. In light of this finding, additional prospective studies are warranted to compare directly the incidence of nonunion between open, minimum incision, and arthroscopic approaches with a variety of fixation constructs.
Re: Ankle arthrodesis vs athroplasty and quality of life
Clinical and Radiographic Outcomes of the Mobility Total Ankle Arthroplasty System: Early Results From a Prospective Multicenter Study.
Sproule JA, Chin T, Amin A, Daniels T, Younger AS, Boyd G, Glazebrook MA. Foot Ankle Int. 2013 Feb 15
Background:The Mobility Total Ankle System is a third-generation design consisting of a 3-component, cementless, unconstrained, mobile-bearing prosthesis. This study reports the early results of a prospective multicenter study of the Mobility prosthesis.
Methods:Eighty-eight Mobility total ankle arthroplasties (TAAs) were implanted in 85 patients. The most common underlying diagnosis was posttraumatic arthritis (53%). Ankles were classified according to the Canadian Orthopedic Foot and Ankle Society (COFAS) end-stage ankle arthritis classification system. Coronal plane deformity was quantified preoperatively. Patients were reviewed at regular intervals postoperatively, with clinical and radiographic assessment. The mean follow-up time was 40 months (range, 30-60 months).
Results:Type 1 ankle arthritis was demonstrated in 44 ankles (50%). No patient had preoperative coronal plane angulation greater than 20 degrees. In 32 ankles (36%) the preoperative coronal alignment was neutral, and in 34 ankles (39%) the deformity was less than 10 degrees. The mean American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score improved from 38.2 (range, 12-59) preoperatively to 74.8 (range, 46-100) postoperatively. Bone-implant interface abnormalities were identified in 33 ankles with a retained prostheses (43%). Thirty (91%) of these involved zones around the tibial plate. In total, 8 TAAs required revision, 6 for aseptic loosening, 1 for talar migration, and 1 for deep infection. There was 1 conversion to arthrodesis for component malpositioning and 1 transtibial amputation for chronic regional pain syndrome. Six patients were being investigated for ongoing pain. The cumulative survival was 89.6% (95% confidence interval, 80.8-94.8) at 3 years and 88.4% (95% confidence interval, 79.3-93.9) at 4 years.
Conclusion:Early results of the Mobility TAA for independent researchers do not match those reported by other surgeons. Good pain relief and improved function were achieved postoperatively in 72 ankles (82%). High rates of bone-implant interface abnormalities around the tibial plate are concerning but require longer follow-up to determine their clinical significance
Re: Ankle arthrodesis vs athroplasty and quality of life
Ankle Arthrodesis vs TTC Arthrodesis: Patient Outcomes, Satisfaction, and Return to Activity. Ajis A, Tan KJ, Myerson MS. Foot Ankle Int. 2013 Mar
It is believed that patients with an ankle arthrodesis (AA) have better outcomes than after a tibiotalocalcaneal (TTC) arthrodesis due to preservation of subtalar motion. However, there are no studies comparing actual functional outcomes and patient satisfaction between AA and TTC arthrodesis.
We retrospectively analyzed patient satisfaction and functional outcomes of patients after an AA and TTC arthrodesis using a postal survey. A total of 173 patients who underwent TTC and 100 AA patients from 2002 to 2010 were identified with a minimum of 24 months follow-up. In all, 53 AA and 64 TTC arthrodesis patients were included in the study, with the remainder lost to follow-up. A return to activity questionnaire and SF-12 scores were used to compare functional outcomes. The mean follow-up time was 63 months.
Both groups showed good outcomes with a low visual analogue pain score (2.7 for AA and 2.8 for TTC), high satisfaction score (90.6% for AA and 87.5% for TTC), and return to work (77.4% for AA and 73.0% for TTC). In all, 84.6% of AA and 81.0% of TTC patients would have the surgery again. There were no significant differences between the 2 groups for these parameters. However, when asked if their desired activity level was met, fewer AA patients met their desired level (58.5% for AA and 66.5% for TTC, P = .02). AA patients were also more likely to feel their level was unmet due to the foot and ankle (85.6% for AA vs 25.7% for TTC, P < .001).
Both AA and TTC arthrodesis were associated with good functional outcomes and satisfaction. AA patients had higher postoperative activity expectations and were less likely to meet them. When they failed to meet these expectations, they were much more likely to attribute it to their operated ankle. We believe it is because of the different ways the 2 groups of patients are counseled preoperatively, which highlights the importance of managing patient expectations.
Background: It is still unknown how ankle range of motion changes following total ankle arthroplasty. This study was undertaken to more accurately address patient expectations, guide postoperative rehabilitation, and improve our understanding of how ankle range of motion changes with time.
Methods: 119 total ankle replacements of 3 different prosthetic designs from 1 surgeon were retrospectively examined and compared. Ankle dorsiflexion and plantar flexion ranges of motion were calculated and analyzed preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 year. The different ankle replacement systems were analyzed individually and together to determine whether trends were replicated.
Results: No significant increase in ankle range of motion was found 6 months postoperatively (P = .75). Mean combined postoperative range of motion did not change significantly from 24.3 degrees at 1 year versus a preoperative mean of 22.7 degrees (P = .75). Mean dorsiflexion improved significantly at the 6-week postoperative stage by 5.5 degrees (P < .001), whereas plantar flexion only improved by 2.9 degrees (P = .06). Mean dorsiflexion improved from preoperative levels by 5.4 degrees (P = .001), whereas mean plantar flexion decreased by 3.7 degrees (P = .004).
Conclusions: We found no notable improvement in ankle range of motion after 6 months following total ankle arthroplasty. We also found a disproportionately higher increase in dorsiflexion compared with plantar flexion following surgery and an overall reduction in mean plantar flexion range compared with preoperative values. Notwithstanding this discrepancy, total mean ankle range of motion 1 year postoperatively was similar to preoperative values. Reasons for the discrepancy between dorsiflexion and plantar flexion are unclear.
Re: Ankle arthrodesis vs athroplasty and quality of life
Management of Ankle Pain Following Ankle Arthroplasty
Rajeshkumar Kakwani, FRCS, Newcastle-Upon-Tyne, United Kingdom
MOHAMMED A. AL-MAIYAH, MIDDLESBROUGH, United Kingdom
Jayasree Ramaskandhan, MSc, Newcastle Upon Tyne, United Kingdom
Malik S. Siddique, MD, Newcastle-upon-Tyne, United Kingdom AAOS Annual Conference 2013
BACKGROUND: Postoperative pain following (Mobility TM) ankle arthroplasty (AA) is recognized problem. This study aimed to determine pattern of postoperative pain following ankle arthroplasty and its management options.
MATERIALS AND METHODS: In prospective observational study, 167 patients who had AA and minimum follow up of 24 months were included. FAOS ankle score, patients’ satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at three months, six months and annually. Twenty patients (12%) had moderate to severe postoperative ankle pain following the ankle arthroplasty.
RESULTS: Most of patients with mild pain and low AOFAS score during first year improved by the two-year review. The pain was localized to the medial aspect of the ankle in 10 patients, lateral side in eight patients, and both medial and lateral side in one patient and global in one patient with complex regional pain syndrome. Eight patients with medial or lateral pain needed re-operation. Five patients with medial pain were treated by complete release of deltoid ligament along with bony decompression of the medial compartment, two AA with lateral pain needed subtalar arthrodesis, one patient needed removal of metalwork from the calcaneum for relief of symptoms. A significant improvement of pain and AOFAS scores was observed in three out of the five patients who underwent medial compartment decompression and both patients who underwent subtalar arthrodesis.
CONCLUSION: There are 10-13% of low AOFAS scores following ankle arthroplasty due to pain. Our treatment protocol of mapping of pain and re-do surgery could improve the long-term outcome.
Re: Ankle arthrodesis vs athroplasty and quality of life
Does Modified Footwear Improve Gait after Ankle Arthrodesis?
Daniel A. Jones, MD, Saint Louis, Missouri
Berton R. Moed, MD, Saint Louis, Missouri
David Karges, DO, Saint Louis, Missouri AAOS Annual Conference 2013
PURPOSE: The purpose of this investigation is to determine if the rocker bottom sole modification to shoes can improve the mechanical gait in patients after ankle fusion. We hypothesize that the use of rocker bottom shoes will aid in allowing a more physiologic gait in patients who have previously undergone an ankle fusion.
METHODS: Two groups of participants were identified consisting of a study group (SG) and a control group (CG). The SG consisted of patients who previously underwent ankle arthrodesis. Thirty-six patients were identified from an orthopaedic trauma registry at a level I trauma center and were contacted to solicit interest in participation. Nine patients were available for participation. The CG of nine normal individuals was created using hospital personnel volunteers. All participants completed the Short Musculoskeletal Function Assessment (SMFA) and the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire. Markers were then placed on the lower extremities of all participants at the same anatomic locations. All participants were then video recorded while walking barefoot (BF) and while wearing rocker bottom shoes (RBS). These data were then analyzed using a computer based gait analysis software. Using the anatomic markers, the angles of heel strike (HS), foot flat (FF) and toe off (TO) of both groups while BF and while wearing RBS were measured. Multiple HS, FF and TO angles were measured for each subject and then averaged. Total motion (TM) was averaged on each subject (TO-HS). Statistical analysis was carried out to compare each group (CG/BF, CG/RBS, SG/BF and SG/RBS). Gait velocity was measured on each group and compared. Mann-Whitney U analysis was carried out on the SMFA and AOFAS questionnaires comparing the CG and SG.
RESULTS: The SG scored statistically worse than the CG on the AOFAS questionnaire (p<0.05) and on every section of the SMFA (p<0.05). On average, the TM of the SG was 3.9 degrees while BF and was 8.7 degrees while wearing RBS. This increase of TM of 4.8 degrees was significant (p<0.05). The motion increase of the SG wearing RBS was closer to the averages of TM in the CG while BF (11.3 degrees) and while wearing RBS (11.0 degrees); however the differences were still statistically different from the normal (CG) values (p<0.05 for both). In the CG, the shoe wear had no effect on TM (p=0.59) and the velocity of gait did not statistically differ between the groups while BF (p=0.70) or while wearing RBS (p=0.145).
CONCLUSION: Patients who have had an ankle arthrodesis gain a statistically significant increase of total motion towards normal while wearing rocker bottom shoes. Further study is indicated to determine the potential positive effect of wearing rocker bottom shoes on overall patient function.
There are few records for total ankle replacement (TAR) in Asia. We aimed to report the cumulative intermediate-term outcomes in terms of clinical scores, survivorship and failure rates for patients managed with TAR in Asia.
We conducted a systematic search for relevant articles published in English and other languages between January 1990 and February 2012. The study published before 1990 and used outdated prosthesis designs implanted before the early 1980s was excluded. Eligible studies were evaluated using the Coleman Methodology Score and data collection was independently performed by three reviewers.
Seven studies qualified for analysis, describing 321 implants (112 HINTEGRA®, 104 TNK, 35 STAR, 13 ND-Bioceram, 57 un-reported implants). Overall studies showed the improvement of clinical scores following TAR. Pooled data for the survivorship analysis ranged from 100% at 3.2 years to 77% at 14.1 years. Pooled mean failure rate was 4.9 ± 3.2% over a mean follow-up of 5.2 ± 1.7 years.
TAR prostheses currently used in Asia achieved satisfactory intermediate-term outcomes in terms of clinical scores, survivorship and failure rates.
Re: Ankle arthrodesis vs athroplasty and quality of life
Hindfoot Motion Following STAR Total Ankle Arthroplasty: A Multisegment Foot Model Gait Study.
Brodsky JW, Coleman SC, Smith S, Polo FE, Tenenbaum S. Foot Ankle Int. 2013 Jun 17.
One of the rationales for total ankle arthroplasty (TAA) is that it may retard the changes of hypermobility and accelerated arthritis in the hindfoot after ankle arthrodesis. Until recently, it has not been possible to quantify or even objectively demonstrate biomechanical findings to substantiate the theory that postsurgical biomechanical changes in the ankle produce changes in the kinematics of the hindfoot. Standard gait analysis has treated the foot as a single biomechanical unit. This study was undertaken to describe the hindfoot motion following Scandinavian Total Ankle Replacement (STAR) TAA by using multisegment foot model gait analysis.
Forty-six patients with a mean age of 66 years underwent a 3D gait analysis following TAR. Mean interval between surgery and gait analysis was 4.9 years (range 2 to 9). The contralateral limb was used as control for each patient. Temporospatial variables and kinematic parameters were studied.
Temporospatial results showed statistically significant differences. Stance time on the affected side was 61.1% ± 2.2% of the gait cycle compared to 63.2% ± 2.1% for the unaffected side. Step length was 55.6 cm ± 10 on the affected side compared to 53.9 cm ± 10 for the unaffected side. Kinematics results were statistically significant: Ankle range of motion (ROM) on the arthroplasty side was 16.8 ± 4.5 degrees compared to 23.6 ± 5.0 on the unaffected side. Sagittal plane ROM was 12.7 ± 4.2 degrees on the arthroplasty side and 17.3 ± 3.5 degrees on the unaffected side. Coronal plane ROM was 4.7 ± 2.4 degrees on the arthroplasty side and 7.5 ± 2.4 degrees on the unaffected side. Transverse plane ROM on the arthroplasty side was 4.1 ± 1.5 degrees and 4.9 ± 1.6 on the unaffected side.
This study showed that, in addition to previously documented diminution in sagittal plane motion and gait velocity, some of the residual abnormalities of gait following TAR were comprised of differences in hindfoot function. These results relate to the growing recognition of the importance of understanding hindfoot mechanics apart from those of the tibiotalar joint.
Background. Renewed interest in total ankle arthroplasty (TAA) has developed globally as a result of recent literature supporting new-generation implants as a viable alternative to arthrodesis. The literature also demonstrates a learning curve among surgeons adopting TAA. The purpose of this study is to better define this learning curve for surgeons using third-generation implants.
Methods. Charts and radiographs were reviewed for the initial 26 TAA procedures performed by the senior author. Three third-generation implants were used: SBi (Small Bone Innovations) STAR, Salto Talaris, and Wright Medical INBONE. We report perioperative and early postoperative complications.
Results. Two perioperative fractures occurred in the first 9 cases, and the incidence subsequently dropped to 0 (P = .0431). Two cases of component malalignment occurred in the first 3 patients receiving the STAR implant, and the incidence then dropped to 0 (P = .0034). Five wound complications (4 minor and 1 major) occurred, all in the final 14 patients. No cases of nerve injury, tendon laceration, or deep vein thrombosis occurred. Two patients returned to the operating room as a result of complications, and the total perioperative and early postoperative complication rate was 27%.
Conclusion. The observed rate of perioperative and early postoperative complications in this case series was low relative to other similar-sized studies, suggesting that third-generation implants can reduce adverse events. Our results demonstrate that some common complications could be avoided altogether (nerve/tendon injuries), some decreased quickly with experience (intraoperative fractures and component malpositioning), and some persisted unchanged throughout this study (wound complications). These findings should influence surgical training, surgeon willingness to adopt this procedure, and patient counseling.