Abstract
Ankle joint distraction (AJD) has been described to be a valuable joint-sparing alternative to arthrodesis or arthroplasty; however, clinical endpoints associated to this surgical intervention are lacking. The current case report describes clinical and biomechanical outcome measures of ankle joint distraction in a 14-year-old patient with severe haemophilia A. Because of persistent and incapacitating pain and the poor response to conservative and invasive treatment options, ankle joint distraction was performed in this 14-year-old patient using an external fixator encompassing two Ilizarov full rings in the tibia and a foot ring fixed to the foot by four K-wires. State-of-the-art medical imaging and non-invasive skin marker-based 3D multi-segment foot modelling were performed in a pre- and post-operative stage. From a structural viewpoint, this AJD was a success since it improved and stabilised the osteo-cartilaginous lesions of the ankle. Biomechanical outcome measures associated with the 18-month follow-up were found to be suboptimal, showing an early plantarflexion pattern at the ankle joint during midstance and a tendency towards increased power absorption at the midfoot with peak power absorption being almost two times higher when compared to boys of the same age. From a functional viewpoint, we observed a clear reduction in the patients’ physical activities until one year after AJD. Despite these functional and structural improvements, recurrent painful phenomena, including the development of a complex regional pain syndrome (CRPS) and a stress fracture of the third metatarsal bone, were observed which are probably related with the development of recurrent subchondral oedema.
Highlights
Regular factor replacement can reduce the incidence of joint bleeds and slow down the development of haemophilic arthropathy, the ankle joint remains vulnerable even in children with haemophilia on primary or secondary prophylaxis and is the primary joint affected [1,2,3]
Foot core strengthening exercises together with rocker-bottom footwear and custom-made foot orthotics are recommended as conservative treatment strategies in presence of ankle haemarthropathy
Together with radiosynoviorthesis, provide unsatisfactory results for the patient doctors are left with three surgical treatment options: fusion, total ankle replacement or joint distraction
Summary
Regular factor replacement can reduce the incidence of joint bleeds and slow down the development of haemophilic arthropathy, the ankle joint remains vulnerable even in children with haemophilia on primary or secondary prophylaxis and is the primary joint affected [1,2,3]. In an attempt to preserve motion and spare adjacent joint disease, ankle joint arthroplasties are marketed and often compared to arthrodesis in terms of patient-reported and functional outcomes [5]. Both of these common procedures are ablative to the native joint, an option which may not be desirable as a long-term solution in a young patient with ankle osteoarthritis. Current knowledge about both the clinical effects and complications of AJD in young patients with haemophilia is limited, while this is of utmost importance when striving for value-based healthcare The objective of this case report was to report state-of-the art clinical, structural and biomechanical outcome measures associated to AJD in a young patient with advanced degeneration of the ankle joint
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