Open Ankle Arthrodesis Research Articles

Clinical outcomes comparing arthroscopic vs open ankle arthrodesis

BackgroundOver the last twenty years, minimally invasive ankle arthrodesis has evolved into a well-tolerated and safe procedure. It has grown in favor to open ankle arthrodesis due to shorter length of stay and fewer complications recorded. This paper aims to compare the clinical outcomes of arthroscopic vs open ankle arthrodesis at 24-months followup. MethodsFrom 2004 to 2015, we reviewed a prospectively collected database in a tertiary hospital foot and ankle registry. 28 feet that underwent arthroscopic ankle arthrodesis were matched to 56 feet that underwent open ankle arthrodesis for age, sex and body mass index (BMI). Visual analogue scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-hindfoot Scores and Short Form Health Survey (SF-36) were obtained to assess clinical outcomes. These parameters were collected before surgery, at 6months and 24months after surgery. ResultsThe arthroscopic group demonstrated significant less pain in the perioperative period (arthroscopic: 1.9±1.2, open: 3.8±1.1, p<0.001) and shorter length of hospitalization stay (arthroscopic: 2.1±0.7 open: 3.5±1.7, p<0.001). Patients who underwent arthroscopic ankle arthrodesis also reported a higher SF-36 score on physical functioning at 6months (arthroscopic: 58.4±27.1, open: 47.1±24.0, p<0.05) and higher AOFAS Ankle-hindfoot Scale score at 24-months (arthroscopic: 78.9±18.9, open: 68.9±24.7, p<0.05). There were no postoperative complications in the arthroscopic group but 11 in the open group, including 9 which required followup operations. There was no significant difference in length of operative procedure between both groups. ConclusionsWe conclude that the arthroscopic group displayed better clinical outcomes compared to the open group at the 24months followup. The advantages of arthroscopic ankle arthrodesis include significantly less perioperative pain, higher AOFAS Ankle-hindfoot scores at 24months, shorter length of stay, fewer postoperative complications and followup operations. Level of evidenceLevel III, retrospective comparative series.

Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?

Category: Ankle Introduction/Purpose: Tibiotalar arthrodesis is generally a successful treatment option for patients with end stage ankle arthritis. However, there is a 9% risk of nonunion in patients undergoing primary tibiotalar arthrodesis. To date, it is unclear whether concurrent distal tibio-fibular joint arthrodesis affects this nonunion rate as there have been no studies directly comparing patients with and without arthrodesis of the distal tibio-fibular joint. The purpose of this clinical study is to compare the rate of nonunion in patients with a distal tibio-fibular fusion to those without a distal tibio-fibular fusion in the setting of a primary, open ankle arthrodesis. The hypothesis of this study was that the addition of a distal tibio-fibular fusion would decrease the nonunion rate in patients undergoing open ankle arthrodesis. Methods: This is a retrospective review of 521 consecutive patients from October 2002 to April 2016. 366 ankles from 354 unique patients met inclusion criteria. All patients underwent primary, open tibiotalar arthrodesis. 250 patients underwent open tibiotalar arthrodesis with a distal tibio-fibular fusion and 116 patients underwent open tibiotalar arthrodesis without a distal tibio-fibular fusion. Age, gender, body mass index, smoking, and preoperative radiographic deformity were controlled. The primary outcome measure was nonunion rate of tibiotalar arthrodesis. Secondary outcome measures were time to union, rate of wound complications, and rate of development of post-operative deep vein thrombosis (DVT)/Pulmonary embolism (PE). Results: Average age of the patients was 56.2 +/- 14.2 years. Mean follow-up time was 33.8 months. Unions were assessed on routine post-operative radiographs and by clinical examination. If there was a concern for nonunion, computerized tomography scan was utilized for further assessment. Nonunion rate of patients who had the distal tibio-fibular joint included was 19/250 (8%) and nonunion rate of those who did not have the distal tibio-fibular joint fused was 14/116 (12%) (p=0.16). There was no significant difference between those who had the distal tibio-fibular joint included versus who did not in wound complication rate (27% vs 31%, p=0.40), time to union (4.9 weeks versus 5 weeks, p =0.54), and DVT/PE rate (5% vs 3%, p=0.41), respectively [Table 1]. There were no major complications. Conclusion: To our knowledge, this is the first study directly comparing nonunion rates and complication rates in patients who underwent primary, open ankle arthrodesis with and without distal tibio-fibular joint arthrodesis. In this study, inclusion of the distal tibio-fibular joint in tibiotalar arthrodesis does not affect nonunion rate in patients undergoing primary, open ankle arthrodesis. Additionally, inclusion of the distal tibio-fibular joint does not affect rate of wound complication, time to union, and DVT/PE rate.

Resource Utilization After Surgery for End-Stage Ankle Arthritis: Comparison Between Ankle Replacement, Open and Arthroscopic Ankle Fusion

Resource utilization is lower for arthroscopic ankle fusion versus open ankle fusion or total ankle arthroplasty. Arthroscopic techniques for ankle arthrodesis have more recently been developed, although there has been limited research exploring the cost of arthroscopic (AAA) versus open ankle arthrodesis (OAA), and comparing ankle fusions to replacement (TAA). We hypothesize that resource use after AAA will be lower than that after OAA, and both will be lower than TAA. We performed a retrospective review of a prospectively collected database. Patients with >2 years of follow up who had undergone AAA, OAA or Hintegra TAA at a single institution between 2003-2010. Ninety patients with TAA, 52 with AAA and 56 with OAA met our inclusion criteria. For resource utilization we measured number of post-operative clinic visits, initial OR time and OR time for re-operations, initial length of stay (LOS) and length of stay for additional hospital admissions. To compare the resource utilization outcomes among the groups, we performed multivariable gamma regression model and negative binomial regression model with a random intercept to accounting for clustering by surgeon. Models were adjusted for preselected confounding variables. When taking into account of both initial surgery and post procedure, AAA had the lowest number of clinical visits among the three groups, [AAA vs. TAA (ratio of event rate = 0.39; 95%CI of 0.29, 0.51 p<0.0001); AAA vs. OAA (ratio of event rate = 0.66; 95%CI of 0.49, 0.89 p=0.01)]. OAA was ranked at the second lowest position [OAA vs. TAA (ratio of event rate = 0.58; 95%CI of 0.44, 0.78 p=0.0003)]. Similar results were found for total LOS. AAA had significantly shorter LOS than TAA (ratio of event rate = 0.35; 95%CI of 0.24, 0.49 p<0.0001) and OAA (ratio of event rate = 0.60; 95%CI of 0.42, 0.86, p=0.01). Again, OAA had less LOS than TAA (ratio of event rate = 0.58; 95%CI of 0.42, 0.80 p=0.001). In term of OR time, while AAA required less time among the three groups [AAA vs. TAA (ratio of event rate = 0.62; 95%CI of 0.45, 0.86 p=0.004); AAA vs. OAA (ratio of event rate = 0.66; 95%CI of 0.47, 0.94 p=0.02)], no statistical significant difference was found between OAA and TAA (ratio of event rate = 0.93; 95%CI of 0.67, 1.29 p=0.67). When examining OR for only the post-procedure, no significant different was found among the three groups. For the post-procedure LOS, comparing with TAA, the other two groups required shorter hospital stay [AAA vs. TAA (ratio of event rate = 0.01; 95%CI of 0.002, 0.09; p<0.0001); OAA vs. TAA (ratio of event rate = 0.01; 95%CI of 0.001, 0.12; p=0.0003)], whereas no difference was found between AAA and OAA (ratio of event rate = 1.21; 95%CI of 14.04, 0.89 p=0.88). Using several measures of resource use, we find that arthroscopic ankle fusions compare favourably to both ankle replacements and open ankle fusions. We also show that resource use measurements can be a useful surrogate for complications, and that resource use can demonstrate the practical implications of complications of patients, surgeons and health care resources.

Comparison of fusion and complication rates in patients with primary open ankle arthrodesis

Comparison of fusion and complication rates in patients with primary open ankle arthrodesis

Resource Utilization After Ankle Arthritis Surgery

Category: Ankle Arthritis Introduction/Purpose: As an alternative to ankle replacement, ankle arthrodesis remains a mainstay in the treatment of end- stage arthritis. Arthroscopic techniques for ankle arthrodesis have more recently been developed, although there has been limited research exploring the cost of arthroscopic (AAA) versus open ankle arthrodesis (OAA), and comparing ankle fusions to replacement (TAA). We hypothesize that resource use after AAA will be lower than that after OAA, and both will be lower than TAA. Methods: We performed a retrospective review of a prospectively collected database. The COFAS database was used to identify patients with &gt;2 years of follow up who have undergone AAA, OAA or Hintegra TAA at St Paul’s Hospital between 2003-2010. Ninety patients with TAA, 52 with AAA and 56 with OAA met our inclusion criteria. The following data were documented: patient demographics (age, gender, presence of diabetes, inflammatory arthritis or any smoking history), factors related to the index surgery (type of surgery, OR time, length of stay) and factors relating to the post-operative course (number of unplanned post-operative clinic visits, OR time for re-operations, length of stay for additional hospital admissions). For all significant comparisons, p &lt; 0.05. Results: AAA required less primary surgery OR time and shorter primary hospital stay vs. TAA and OAA. Patients required more additional follow-up visits for TAA and OAA vs. AAA. TAA required more additional days in hospital compared to OAA or AAA. For each primary TAA, on average an additional seven clinic visits, 60 minutes of revision surgery, three days in hospital were required on top of the cost assigned for the primary arthroplasty. For each primary AAA, an additional four clinic visits, 23 minutes of revision surgery and one day in hospital were required. For each primary OAA, an average additional five clinic visits, three minutes of revision OR time, and 0.2 days of additional hospital stay were required. Conclusion: Using several measures of resource use, we find that arthroscopic ankle fusions compare favourably to both ankle replacements and open ankle fusions. We also show that resource utilization measurements can be a useful surrogate for complications, and that resource utilization can demonstrate the practical implications of complications for patients, surgeons and health care providers or payers.

Swelling Results in Poor Outcome After Ankle Arthritis Surgery

Category: Ankle Arthritis Introduction/Purpose: Patients often comment on swelling after foot and ankle surgery. However the relationship between swelling and outcome has not been defined. Pinsker and Daniels demonstrated that swelling was an important aspect of outcome. The purpose of this paper was to determine the relationship between swelling score and outcome after ankle fusion and replacement. A secondary purpose was to determine how this relationship changed in time, how swelling score changed before and after surgery, and determine differences in swelling score between total ankle replacement (TAR), open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA). Methods: The MODEMS outcomes package from AAOS was used, with the validated ankle osteoarthritis score (AOS) score being used to assess outcomes in the pain and disability domains. The swelling score was indexed from 1 to 5, 1 being no swelling and five being severe swelling. Outcomes were recorded pre-operatively and annually up to 2010. Statistical analysis was performed using 95% confidence intervals and correlations being determined using Pearson’s correlation and r 2 values. Results: The swelling score was correlated with AOS score preoperatively. Postoperatively patients with a swelling score of 1 had an average AOS score of 15.1 (CI 13.3 to 16.9), a swelling score of 2 had an AOS score of 23 (CI 21.7 to 24.9), 3 an AOS of 31 (CI 29.6 to 33.1), 4 an AOS of 33.6 (CI 34.9 to 38.8), and 5 an AOS of 39 (CI 35.3 to 43.0). There was therefore a difference in outcome score for all groups of swelling score (i.e. 1 scored better than 2, 2 better than 3, 3 better than 4 and 4 better than 5). Swelling scores were the same for TAR, OAA and AAA preoperatively. Postoperatively swelling scores were lower for AAA (2.1, CI 1.9 to 2.2) compared to TAA (2.5, CI 2.4 to 2.6) and OAA (2.5, CI 2.4 t0 2.6). Conclusion: Swelling has a relationship with outcome. Swelling after surgery may result in poorer outcomes. Strategies to reduce swelling such as patient education about elevation, surgical technique and the use of compression stockings may improve outcomes. Arthroscopic surgery may have better outcomes because of the reduction in postoperative swelling.

Primary Open vs. Arthroscopic Ankle Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis is the gold-standard treatment option for patients with end-stage ankle osteoarthritis resulting in measurable improvements in postoperative pain relief. Arthroscopic ankle arthrodesis has gained increasing popularity, however there remains a lack of comparative data with open ankle arthrodesis. The objectives of this retrospective study were to compare (1) demographics, (2) surgical technique, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary open vs. arthroscopic tibiotalar arthrodesis. Methods: Between March 2002 and November 2014, 385 primary ankle arthrodeses were performed at our institution. There were 212 male and 173 female patients with a mean age of 56 ± 14.7 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 89.4 ± 19.7 kg (46-168), 172.9 ± 11.1 cm (147-208), and 29.9 ± 5.8 kg/m2 (18.9-54.9), respectively. There were 322, and 63 patients with primary open and arthroscopic arthrodesis, respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique was analyzed in both groups including approach, main fixation type, and allograft/autograft use. Finally, fusion rates and time to complete union were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 37.9 ± 27.0 months (12.0-150.4). Results: Demographics and comorbidities were comparable in both groups. All but one arthroscopy were performed using anterior portals. All arthroscopic ankle arthrodeses were performed using screw fixation, while fixation types varied in open arthrodesis (P &lt; 0.001). Autograft use was higher in open arthrodesis at 84.2% vs. 6.3% (P &lt; 0.001), while allograft was favored for arthroscopic arthrodesis at 66.7% vs. 20.2% (P = 0.101).Osseous union was with 92.2% and 90.5% in patients with open and arthroscopic arthrodesis, respectively (P = 0.529). However, the time to complete osseous fusion was significantly shorter in patients with arthroscopic ankle fusion, at 4.3 vs. 5.1 months (P = 0.034). Wound and thrombembolic complications occurred significantly more often in patients with open ankle arthrodesis. Conclusion: Osseous union rates were comparable in both patient groups,however union time was significantly shorter in the arthroscopic group. Wound healing problems and thrombembolic complications were more common in patients who underwent open ankle arthrodesis.

Arthroscopic Ankle Fusion

Category: Ankle Arthritis Introduction/Purpose: Arthroscopic ankle arthrodesis (AAA) has been shown to result in reduced postoperative stay and better short-term outcome than open ankle arthrodesis. Coronal ankle joint deformity often is considered a contraindication for AAA. The aim of this study was to examine whether a preoperative coronal deformity influenced the midterm outcome after AAA for end-stage ankle arthritis. Methods: The Canadian Orthopaedic Foot and Ankle Society (COFAS) database prospectively collects data about the outcome of patients after surgical treatment of end-stage ankle arthritis. The database yielded 98 patients who had isolated ankle arthrodesis at the University of British Columbia between 2005 and 2013. The cohort consisted of 66 men and 32 women who had 62 arthroscopic and 38 open arthrodesis. The preoperative coronal deformity was measured using the tibiotalar angle (between a line perpendicular to the anatomical axis of the tibia and the proximal talar surface) and the tibial plafond angle (between a line perpendicular to the tibial axis and the distal tibial surface) on weight-bearing x-rays. Primary outcome measure was the COFAS Ankle Arthritis Scale (COFAS-AAS) at final follow-up. Secondary outcome measures were the reduction of the COFAS-AAS (ΔCOFAS-AAS) and the medial tibiotalar surface angle (between the anatomical axis and the proximal talar surface) at final follow-up. Results: The tibiotalar angle was lower in the arthroscopic than in the open group (8.2°±7.0 vs. 12.3°±8.2, p=.014) with similar range in both groups (0-25° vs. 0-27°). However, the tibial plafond angle (3.6°±11.4 vs. 11.4°±12.3, p&lt; .005) and its range (0-19° vs. 0-43°) were markedly different. (Figure) The arthroscopic group scored slightly better regarding COFAS-AAS (26.0±19.8 vs. 28.8±23.6, p=.529) and ΔCOFAS-AAS (- 28.1±19.6 vs. -25.9±20.8, p= .603). Concerning patients with tibial plafond angles ≤19°, again the arthroscopic group had slightly better COFAS-AAS (26.0±19.8 vs. 28.9±12.4, p=.588) and ΔCOFAS-AAS (-28.1°±19.6 vs. -26.0°±18.5, p=.627). Regression analyses revealed no effect of tibiotalar or tibial plafond angle onto COFAS-AAS (p=.267 and p= .965) and ΔCOFAS- AAS (p=.741 and p=.392). Radiographic outcome was similar in both groups (medial tibiotalar angle 89.3°±2.2 vs. 88.1°±4.4, p=.135). Conclusion: Both, arthroscopic and open arthrodesis were associated with significant improvements in the COFAS-AAS and acceptable radiographic alignment. Former studies used the tibiotalar angle to describe preoperative coronal ankle joint deformity. In the presented study the range of the preoperative tibiotalar angle was similar in both groups, whereas all patients with tibial plafond angles ≥20° had an open arthrodesis. Therefore, the tibial plafond angle seems to better assist when deciding between arthroscopic or open arthrodesis in patients with a coronal ankle joint deformity. Within these limits preoperative coronal deformity had no influence on the outcome of arthroscopic ankle arthrodesis.

Comparison of Fusion and Complication Rates in Patients with Primary Open Ankle Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: In the last decades, different surgical techniques with various approaches and fixation methods have been described for ankle arthrodesis. Tibiotalar arthrodesis can be performed with or without distal tibiofibular fusion. The objectives of this retrospective study were to compare (1) demographics, (2) surgical techniques, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary open tibiotalar arthrodesis with vs. without distal tibiofibular fusion. Methods: Between March 2002 and November 2014, 322 primary open ankle arthrodeses were performed at our institution. There were 183 male and 139 female patients with a mean age of 56.0 ± 14.0 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 90.0 ± 20.4 kg (46-168), 172.9 ± 11.4 cm (147-208), and 30.0 ± 5.7 kg/m2 (18.9-54.9), respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique has been analyzed in both groups including surgical approach, main fixation type, and allograft/autograft use. Finally, fusion rate and time to complete osseous fusion were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 36.7 ± 26.7 months (12.0-150.4). Results: 214 had a combined distal tibiofibular fusion, while 108 did not. The most common surgical approach was lateral and anterior in patients with and without distal tibiofibular fusion, respectively (P &lt; 0.001). The main fixation type was different between groups, with the most common technique being screws for patients with tibiofibular fusion, and plates in those without (P &lt; 0.001). Autograft and allograft were used significantly less frequently in patients without distal tibiofibular fusion. The rate of osseous union was comparable in both groups with 92.2% and 93.0% in patients with and without distal tibiofibular fusion, respectively (P = 0.675). The incidence of wound and thrombembolic complications was similar in both groups. Conclusion: The osseous union rates and complication rates were comparable in both patient groups, with and without distal tibiofibular fusion.

Open Versus Arthroscopic Ankle Arthrodesis: A Comparison of Subsequent Procedures in a Large Database

Arthroscopic and open ankle arthrodesis have been compared in very few studies, and no consensus has been reached regarding the incidence of postoperative revision surgery associated with each technique. The purpose of the present study was to compare these 2 approaches for the incidence of postsurgical operations. Patients who had undergone either arthroscopic or open ankle arthrodesis were identified between January 2005 to December 2011 in the PearlDiver™ database using a predetermined algorithm and searched for the following postsurgical operations: revision ankle arthrodesis, midfoot arthrodesis, and hindfoot arthrodesis. In the current database, 7322 cases were performed with an open technique and 1152 arthroscopically. The incidence of revision arthrodesis was not significantly different statistically between the 2 techniques. However, the incidence of subsequent adjacent joint arthrodesis was greater for the open cohort (5.6% versus 2.6%; odds ratio 2.17, 95% confidence interval 1.49 to 3.16). In the open cohort, the incidence of hindfoot arthrodesis was greater than the incidence of midfoot arthrodesis (3.9% versus 1.6%, odds ratio 2.43, 95% confidence interval 1.95 to 3.01). The results showed that although open ankle arthrodesis is more commonly performed, it is associated with a greater incidence of subsequent adjacent joint arthrodesis specifically in the hindfoot.

Factors Affecting the Outcomes of Uncomplicated Primary Open Ankle Arthrodesis.

The objective of this study was to identify factors influencing operative outcomes in straightforward, uncomplicated open ankle fusions. We reviewed all primary open ankle fusions conducted at 1 institution over an 11-year period to identify straightforward, uncomplicated open ankle fusions. Inclusion required a minimum of 6 months follow-up. Patients were excluded for neuropathic arthropathy, insensate limb, failed total ankle replacement, simultaneous arthrodesis of the subtalar joint, or fusions performed within 1 year of injury to salvage failed fixation and painful function due to (1) open fractures, (2) segmental bone loss greater than 1 cm, (3) infection, or (4) talar body fractures. The primary outcome variable was radiographic union at 6 months. Other operative complications were analyzed as secondary outcomes. Five hundred twenty-eight ankle fusion surgeries were performed on 440 patients at 1 institution during the study period. Two hundred fifteen surgeries met inclusion/exclusion eligibility criteria for uncomplicated open ankle fusions. The overall union rate was 91%. In this cohort of uncomplicated open ankle fusions, bivariate analysis over a broad range of potential factors and further focused multivariate analysis found that nonunion was more than 3 times more likely to occur after previous subtalar fusion, and 2 times more likely to occur in patients with preoperative varus ankle alignment. The rate of reoperation was 19%, with nonunion revision as the leading reason, followed by hardware removal and incision and drainage for presumed infection. Diabetes was not a significant risk factor of either deep or superficial infection. Open ankle fusion failed in 9% of uncomplicated ankles with arthritis. Patients who had an open ankle fusion done after previous subtalar joint fusion, as well as those who had preoperative varus ankle alignment, had a significantly higher rate of nonunion. Level III, retrospective comparative study.

Fashioning autologous bone graft from the fibula in the transfibular approach to open ankle arthrodesis.

Open ankle arthrodesis is one of the primary operations for disabling ankle arthrosis. The transfibular lateral approach to ankle fusion is a common approach for open ankle arthrodesis. Autologous bone graft can be harvested from the osteotomised fibula. We describe a safe technique of taking graduated slices of fibula bone graft, which allows optimal fibula length excision and are suitable in shape to pack into defects at the fusion site.

Comparison of Practice Patterns in Total Ankle Replacement and Ankle Fusion in the United States

Although tibiotalar fusion has historically been considered the gold standard treatment for end-stage arthritis of the ankle, the performance of total ankle replacement appears to be gaining favor as improved outcomes have been observed with new implant designs and surgical techniques. The purpose of this study was to compare trends and demographics in the performance of ankle fusion and total ankle replacement in the United States. The Current Procedural Terminology (CPT) codes of patients undergoing ankle fusion and total ankle replacement were searched using the PearlDiver Patient Record Database, a national database of orthopaedic patients. The CPT codes for open ankle arthrodesis (27870), arthroscopic ankle arthrodesis (29899), and total ankle replacement (27700, 27702) were searched for the years 2004 to 2009 to identify relative changes in the performance of ankle fusion and replacement over time. The performance of ankle fusion was unchanged during the 6-year study period. In contrast, an increase in total ankle replacement was observed, from 0.63 cases per 10 000 patients searched in 2004 to 0.99 cases per 10 000 patients in 2009 (P < .05). Both ankle fusion and total ankle replacement were performed most commonly in patients aged 60 to 69 years (P < .05). Although an even gender distribution was observed in patients undergoing total ankle replacement, open and arthroscopic fusion were more commonly performed in males (P < .05). With regard to regional distribution, open and arthroscopic fusion were most commonly performed in the western region of the United States, whereas total ankle replacement was performed most frequently in the Midwest (P < .001). In the population studied, the performance of total ankle replacement increased 57% from 2004 to 2009 and was performed equally in male and female patients when compared to ankle fusion, which was more often performed in males and was unchanged with time. Level IV, cross-sectional study.

Open Ankle Arthrodesis With a Fibular-Sparing Technique

Many ankle arthrodesis techniques excise the fibula or require a fibular osteotomy. Advantages of fibular preservation include increased surface area for bony union, preservation of the peroneal groove, prevention of valgus drift in cases of delayed union, and facilitation of future ankle arthroplasty. The goal of this study was to evaluate fusion rate and clinical outcomes of a novel open fibular-sparing ankle arthrodesis technique. A total of 50 consecutive ankle arthrodeses using this technique were included in this study. These consisted of 46 patients with an average age of 52 (range, 30 to 71) years. Outcomes assessed postoperatively included radiographs, complications, patient satisfaction, and functional scoring. At an average of 28 (range, 19 to 56) months postoperatively, 38 patients (42 ankles) were available for review. Of the 42 cases, 39 (93%) achieved union at an average of 12 weeks postoperatively. Of patients, 86% reported being "completely satisfied" with the outcome. Average AOFAS Ankle-Hindfoot Scale was 84 ± 12 and average Foot Function Index pain subscale was 1 ± 0.9. Two ankles (5%) were fused in excessive varus; no patient required revision surgery for malalignment. This method of open ankle arthrodesis preserved the fibula and had a high fusion rate with good patient outcome scores.

Open Ankle Arthrodeses via an Anterior Approach

In open ankle arthrodesis, debate remains as to which surgical approach and fixation devices should be used. The purpose of this study was to identify union, complication, and patient satisfaction rates of ankle fusions performed at our institution, using the plane between extensor hallucis longus and tibialis anterior with medial tibiotalar screw internal fixation. A retrospective review was performed of all isolated primary fusions between 2005 and 2009. Eighty-two ankles were identified in 73 patients. All patient records were reviewed, and 57 patients (65 ankles) attended for clinical evaluation and scoring. Age range at surgery was 18 to 75 years (mean, 56.1 years); 8 patients were smokers. Diagnoses were trauma in 52 patients (63%), osteoarthritis in 17, rheumatoid arthritis in 7, Charcot-Marie-Tooth disease in 3, congenital talipes equinovarus in 2, and talar avascular necrosis in 1. Follow-up range was 7 months to 8.3 years (mean, 4 years). Time to union ranged from 8 to 39 weeks (mean, 13.3) with a union rate of 100%. The AOFAS range was 12 to 93 (mean, 70). Eighty percent were "very satisfied" or "satisfied." Major complication rate was 14.6%: 7 malalignments; 3 wound problems; 2 complex regional pain syndrome; and 2 delayed unions, both smokers. An excellent union rate, high patient satisfaction, and low complication rate were achieved with this technique. Varus malalignment and persistent pain resulted in dissatisfaction. Many patients remained highly active, and bilaterally fused patients functioned as well as unilateral ones. Level IV, retrospective case series.

Prospective Comparison of Open and Arthroscopic Ankle Arthrodesis Using Validated Outcome Score with Two-Year Minimum Follow-Up (SS-55)

Introduction Ankle arthrodesis remains the gold standard treatment for isolated ankle arthritis. Despite improved techniques a 10% nonunion rate, 9% re-operation rate, 5% below knee amputation rate post ankle arthrodesis are reported. Arthroscopic ankle arthrodesis has been recommended by some as a solution to the relatively high rate of complications associated with the open technique. However, to date no other prospective comparative study has been reported to compare the two fusion techniques. Methods Prospective patient data was gathered from consenting patients at baseline, 6 months, one year and two years from two centers, one performing open ankle arthrodesis and one performing arthroscopic arthrodesis. The primary outcome Measures was the Ankle Osteoarthritis Score (AOS). Secondary outcome measures included tourniquet time, length of stay (LOS), non-union rate, and complication rates. A power analysis indicated that 30 patients were required in each group. There were 31 ankles in the open arthrodesis group and 30 ankles in the arthroscopic arthrodesis group. The groups were comparable for age (mean 59.2 vs. 56.0) and BMI (mean 27.9 vs. 29.4). Results The AOS score improved in the open group from 56.8 preoperatively to 33.5 at one year (p Conclusion This was a prospective comparative study of two very similar groups of isolated ankle arthritis using an arthroscopic and open technique of ankle fusion. Both groups showed a significant improvement in symptoms from baseline with a greater change in AOS score and shorter hospital stay in the arthroscopic group.

Radiographic Analysis of Wedge Allograft Correction of Angular Malalignment in Ankle Fusion

Patients undergoing ankle arthrodesis often have coronal or sagittal plane malalignment. Correction of this deformity can be technically challenging. This retrospective review examines the use of an augmented interposition wedge allograft for deformity correction in ankle arthrodesis. Nineteen patients underwent open ankle arthrodesis with interposition allograft at our institution since 2003. Sixteen patients had isolated ankle fusions and three patients had ankle fusions as part of a tibiotalocalcaneal fusion. A wedge of frozen tricortical iliac crest or femoral head allograft was cut to appropriate size and shape to correct angular deformity with an average maximum graft width of 9.5 mm. Fixation of the arthrodesis was with either a cannulated screw and plate construct or a lateral blade plate. Radiographs were reviewed to assess preoperative, initial postoperative and final alignment at the time of solid fusion. Fusion was assessed on plain radiographs by visualization of bridging bony trabeculae. Seventeen of 19 patients (89%) obtained fusion at an average of 14.9 wks. Eleven ankles had preoperative tibiotalar valgus deformity with an average coronal alignment of 98.8 degrees and sagittal alignment of 110.5 degrees. Final coronal alignment was 90.9 degrees and sagittal alignment was 107.7 degrees. Eight ankles had varus deformity with an average coronal alignment of 77.4 degrees and sagittal alignment of 101.9 degrees. Final coronal alignment was 89.4 degrees and sagittal alignment was 107.4 degrees. The tibiotalar joint fusion rate in this series compares favorably to historically published data for standard ankle fusion. Interposition allograft was an effective method for deformity correction in difficult ankle arthrodeses.

Arthroscopic versus Open Ankle Arthrodesis: A Retrospective Cost Analysis

Compared with traditional open arthrodesis, arthroscopic ankle arthrodesis has been associated with similar rates of fusion, decreased time to union, decreased pain, shorter hospital stay, earlier mobilization, reliable clinical results, and fewer complications. The aim of this case-control study was to analyze cost differences between outpatient arthroscopic and inpatient open ankle arthrodesis. To this end, the authors analyzed 20 ankle arthrodesis procedures: 10 performed by one surgeon on an inpatient basis using an open approach, and 10 performed by another surgeon on an outpatient basis arthroscopically. Patient age, body mass index, tourniquet time, length of stay, complications, days to clinical union, and insurance type, as well as charges and reimbursements for the surgeons and the hospital or surgery center were abstracted from the records. Statistically significant differences were observed between the outpatient arthroscopic and inpatient open arthrodesis groups for total site charges ($3898 ± 0.00 versus $32,683 ± $12,762, respectively, P < .0001), reimbursement to the surgeon ($1567 ± $320 versus $1107 ± $278, respectively, P = .003), and reimbursement to the hospital or ambulatory surgery center ($1110 ± $287 versus $8432 ± $2626, respectively); the ratio of hospital/surgery center charges to hospital/surgery center reimbursements was 28.48% for the inpatient arthroscopic group and 25.80% for the inpatient open arthrodesis group. Outpatient arthroscopic ankle arthrodesis, compared with inpatient open ankle arthrodesis, appears to be less expensive for third party payers, and surgeons are paid more, whereas hospitals and ambulatory surgical centers get paid a greater proportion of the charges that they bill.

Ankle arthrodesis using a tibio-calcaneal external fixator.

The results of open ankle arthrodesis in 23 patients with primary and secondary ankle-talar arthritis are presented. All patients were treated with open ankle arthrodesis using the Citieffe/CH-N external fixator with pins inserted in the tibia and the calcaneus. Union rate was 91% (21 patients) at an average of 13weeks (range, 12-16weeks). Mean follow-up was 6years. Most of the patients (91%) were satisfied with the end results of the operation.

Komplikationen und Revisionseingriffe nach OSG-Totalendoprothesen

Summary Total ankle arthroplasty has shown rapidly increasing acceptance in the last five years. Due to the increasing number of implantations, the experience and the learning curve are responsible for the success of these surgical procedure. Nevertheless, a higher rate of pitfalls and failures may be expected. The possible intra- and postoperative complications in total ankle arthroplasty, their sources of failure and the revision options are demonstrated. From 7/97 to 11/03, 147 S.T.A.R. prosthesis in 144 patients (69 f, 75 m) were implanted in our hospital. The mean age at primary surgery was 57.7 years (min. 24, max. 82 years). The necessary revision surgery was performed 1.2 years after primary implantation. Especially preexisting scars due to prior surgical procedures cause intra- and postoperatively complications (De' Orio 2003). Thus, troubles in wound healing (n: 31) are often described in patients, where intraoperatively the soft tissue suffered from an inadequate trauma. In our cohort, late complications included persisting intraarticular synovitis, especially in rheumatoid arthritis patients, an impingement (n: 4) and an above average apparent wear of the PE gliding core (n: 2) with early signs of lucency and a following osteolysis. Revision surgery (3 synovectomies/tenosynovectomies, 2 lengthenings of the Achilles tendon with a dorsal capsulotomy, subtalar arthrodesis, 4 revisions of the PE gliding core, 3 revisions of singular components, 2 complete revisions of the prosthesis, 2 ankle fusions) more than three months after primary implantation was indicated by persisting or acute pain and joint failures. A total of 23 revisions of the 147 patients were performed (15.6%). Only in 10 cases (6.8%) these complications and the following surgical procedures influenced the satisfaction of the patients. The existing midterm results and the review of the data verify that total ankle arthroplasty is more than an alternative to open ankle arthrodesis in the progressive phases of arthritic joint destruction, and as the last salvage procedure it can be followed by a secondary necessary arthrodesis.