Treatment Of Ankle Arthritis Research Articles

Treatment of ankle osteoarthritis : Analysis of aGerman nationwide survey

In most cases osteoarthritis of the ankle is of posttraumatic origin. Younger people are more frequently affected, which makes treatment aparticular challenge. In addition to conservative treatment numerous surgical procedures are available for the treatment of advanced arthrosis. The aim of this nationwide survey was to document the current status of the diagnostics and treatment of ankle arthritis in Germany. Members of the German Society for Orthopedics and Trauma Surgery (DGOU) were invited to participate in an anonymous online survey on the treatment of ankle joint osteoarthritis. The survey included 69questions on the person, on the diagnostic and treatment approaches as well as 3 clinical and radiological patient cases. The evaluation of the results of the survey included differences in the subgroups of participants based on the discipline, the location of activity, position and certification. From November 2019 to February2020 a total of 343members participated in the survey. For the diagnostics 96% requested conventional radiographs in a standing position and in 2 levels. Other native radiographs were considered necessary by less than half of respondents. Less than one third of participants sometimes (n = 87) or always (n = 18) use an outcome score. The therapeutic repertoire included supramalleolar osteotomy (n = 106), ankle arthroplasty (n = 100) and arthrodesis (n = 248). Open arthrodesis using screws through an anterior approach was the most frequently used surgical procedure. Diagnostic standards were regularly used in the treatment of ankle arthrosis. With respect to the surgical treatment there was a wide heterogeneity due to the pathological anatomy and preferences of the participants. Open arthrodesis was the most frequently selected procedure.

Early Clinical Outcomes and Complications of Transfibular Total Ankle Arthroplasty: The Australian Experience

Category: Ankle Arthritis; Ankle Introduction/Purpose: We report the short-term outcomes of a retrospective cohort of Trabecular Metal total ankle arthroplasties (TAAs) via a transfibular approach from a single, nondesigner surgeon in Australia. Methods: This was a retrospective cohort study. Demographic, clinical, and patient-reported outcome measures (PROMs) were collected. The primary outcome was the Foot and Ankle Outcome Score (FAOS), and secondary outcomes included patient satisfaction, the EuroQol-5 Dimension (EQ5D), and complications including revision rates. Results: Between 2016 and 2019, 84 trabecular metal prostheses were implanted in 84 patients. Mean age (SD) at time of surgery was 68 (7.8) years, and 46 (55%) were male. Mean follow-up (SD) was 26.1 (13) months. There were significant improvements in the FAOS (Pain (47.9 to 79.1), activities of daily living (59.5 to 83.7), and quality of life (25.5 to 60.2)) and EQ-5D (0.55 to 0.75) (P < .001), and overall satisfaction was 69.6%. Complications included wound infection/breakdown (11.9%), fibular nonunion (3.5%), plate irritation (3.5%), and tibial nerve neuropathy (3.5%). There were no thromboembolic complications. Implant survivorship was 100%, with Trabecular Metal components retained in all patients. Two patients developed deep infection, with 1 requiring debridement and polyethylene exchange. No patients experienced implant loosening. Conclusion: Our results demonstrate that the trabecular metal survival rates are comparable with other total ankle implants in the Australian Orthopaedic Association National Joint Replacement Registry and as published in other international literature. Overall patient satisfaction was high, as were PROMs. However, the data highlight potential complications uniquely associated with this implant. The authors believe that these figures support TAA via a transfibular approach as a viable option in the treatment of ankle arthritis.

Association of Diabetes Mellitus and Immediate Postoperative Complications after Total Ankle Replacement: A Large Database Analysis

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total Ankle Replacement (TAR) has rapidly grown in popularity over the last fifteen years as a treatment for ankle arthritis. With this growth, it is imperative to understand risk factors that may predispose patients to complications following the procedure. This information can be valuable in generating treatment plans and facilitating conversation regarding risks and benefits of those plans. Current literature on TAR-related outcomes is limited in timeframe and scope and does not investigate the association of diabetes with common post operative complications. The objective of this study was to perform a retrospective database analysis to quantify the risk of 90-day complications in patients with diabetes undergoing TAR when compared to patients without diabetes undergoing TAR. Methods: The TriNetX database was utilized for this study. Patients who underwent TAR were identified and stratified by those with a history of diabetes mellitus and those without a history of diabetes mellitus of any type. The cohorts were 1:1 propensity matched based on demographic information and medical history. The 90-day complication rates for readmission, inpatient service use, opioid use, anesthesia use, periprosthetic fracture, deep vein thrombosis, and wound dehiscence were calculated using chi-square analysis. Results: n=5,984 TAR patients were identified. 52% were male and 48% female with mean age of 73±10 years. There was a n=1,331 patients in each the patients with diabetes and without diabetes groups after cohort analysis and propensity matching. TAR patients with diabetes had a significantly higher 90-day odds ratio of inpatient service use (OR: 1.675, 95% CI 1.3082-2.144; p< 0.001). There was no significant difference between groups in opioid use (OR: 1.13, 95% CI 0.941-1.357; p=0.1908), anesthesia use (OR: 1.335, 95% CI 0.906-1.965; p=0.1424), and wound dehiscence (OR: 1.313, 95% CI 0.829-2.08; p=0.2445); Table 1. There was insufficient data to determine the role of diabetes on critical care services, periprosthetic fracture, and DVT within 90 days of TAR. Conclusion: TAR is a developing operation for ankle arthritis and little data exists on diabetes related perioperative complications. The results of this study show that although diabetes is significantly associated with a higher rate of inpatient service use, it may not have as large a role in opioid use, anesthesia use, and wound dehiscence in the immediate postoperative period. More information is still needed to address long term outcomes and the role diabetes plays in other postoperative complications.

Outcomes of ankle arthrodesis in adult patients with ankle osteoarthritis in Kashin-Beck disease.

We retrospectively evaluated the characteristics of these patients and the effectiveness of ankle arthrodesis in the treatment of ankle arthritis caused by Kashin-Beck disease (KBD). A retrospective study of KBD patients with ankle osteoarthritis who underwent ankle arthrodesis between December 2012 and January 2022 was performed. A total of 46 patients were included. The general characteristics, clinical manifestations and imaging features of the patients were recorded and summarized. measured using the VAS score, and ankle function was assessed by the AOFAS ankle-hindfoot score. Multiple subchondral cystic changes were found in 42(91.3%) patients. The VAS scores for both resting and weight-bearing conditions were 6.28 ± 1.30 vs. 2.09 ± 1.12 (P < .001) and 6.87 ± 1.01 vs. 2.17 ± 0.98 (P < .001), respectively. The AOFAS scores were 59.17 ± 5.50 and 88.39 ± 1.42, respectively (P < .001). The subchondral multiple cystic transformation of the ankle KBD has a certain suggestive role.Arthrodesis is an effective method to reduce ankle pain and improve ankle function in KBD patients with ankle osteoarthritis.

Application of three dimensional printed personalized guide plate assisted arthroscopic ankle arthrodesis in the treatment of ankle arthritis

Objective: To compare the efficacy of conventional open ankle fusion and three dimensional(3D) printed guide plate assisted arthroscopic ankle fusion. Methods: A retrospective cohort study was performed on 256 patients with advanced traumatic ankle arthritis, who were admitted to the Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from May 2018 to February 2023 and underwent ankle fusion procedures. The study cohort comprised 119 males and 137 females, with an age of (59.6±9.5) years (range: 37 to 83 years). Among them, 175 cases underwent internal fixation with plates and screws (58 cases through the combined medial and lateral approach, and 117 cases through the simple lateral approach), 48 cases underwent internal fixation with screws through the anterior approach (conventional open group), and 33 cases underwent minimally invasive arthroscopic ankle fusion assisted by 3D printed guide plate (3D printed guide plate arthroscopy group). Propensity score matching was employed to achieve a 1∶1 match(caliper value=0.02) between the baseline characteristics of patients in the 3D printed guide plate arthroscopy group and the conventional open group. Perioperative and follow-up data between the two groups were compared using the t-test, Mann-Whitney U test, Wilcoxon signed rank test,χ² test, or Fisher's exact probability method, as appropriate. Results: Matching was successfully achieved with 20 cases in both the 3D printed guide plate arthroscopy group and the conventional open group, and there were no statistically significant differences in baseline characteristics between the two groups (all P>0.05). The operation time in the 3D printed guide plate arthroscopy group was significantly longer than that in the conventional open group ((88.9±5.6) minutes vs. (77.9±11.7) minutes;t=-2.392, P=0.022), while the frequency of intraoperative fluoroscopies ((1.7±0.8) times vs. (5.2±1.2) times; t=10.604, P<0.01) and length of hospitalization ((5.5±0.9) days vs. (6.4±1.5) days;t=2.480, P=0.018) were significantly lower in the 3D printed guide plate arthroscopy group compared to the conventional open group. The fusion rate was 95.0% (19/20) in the 3D printed guide plate arthroscopy group and 85.0% (17/20) in the conventional open group, with no statistically significant difference between the two groups (χ²=1.111,P=0.605). The fusion time was (12.1±2.0) weeks in the conventional open group and (11.1±1.7) weeks in the 3D printed guide plate arthroscopy group, with no statistically significant difference between the two groups (t=1.607, P=0.116). At the final follow-up, the American Orthopedic Foot and Ankle Society ankle hindfoot scale was (72.6±5.5)points in the 3D printed guide plate arthroscopy group and (70.5±5.8)points in the conventional open group, with no statistically significant difference between the two groups (t=-1.003, P=0.322). The VAS score of the 3D printed guide plate arthroscopy group was (M(IQR)) 1.50 (1.00) points, lower than that of the conventional open group by 3.00 (1.00) points, with statistically significant differences (Z=-3.937, P<0.01). The complication rate was significantly higher in the conventional open group (25.0%(5/20) vs. 5.0%(1/20), P=0.182). Conclusion: 3D printed guide plate assisted arthroscopic ankle fusion exhibited several advantages, including reduced frequency of fluoroscopies, alleviation of postoperative pain, and decreased complications and length of hospitalization.

Early Clinical Outcomes and Complications of Transfibular Total Ankle Arthroplasty: The Australian Experience

We report the short-term outcomes of a retrospective cohort of Trabecular Metal total ankle arthroplasties (TAAs) via a transfibular approach from a single, nondesigner surgeon in Australia. This was a retrospective cohort study. Demographic, clinical, and patient-reported outcome measures (PROMs) were collected. The primary outcome was the Foot and Ankle Outcome Score (FAOS), and secondary outcomes included patient satisfaction, the EuroQol-5 Dimension (EQ5D), and complications including revision rates. Between 2016 and 2019, 84 trabecular metal prostheses were implanted in 84 patients. Mean age (SD) at time of surgery was 68 (7.8) years, and 46 (55%) were male. Mean follow-up (SD) was 26.1 (13) months. There were significant (P < .001) improvements in the FAOS in the subscales of pain (47.9 to 79.1), activities of daily living (59.5 to 83.7), and quality of life (25.5 to 60.2) and EQ-5D (0.55 to 0.75) (P < .001), and overall satisfaction was 69.6%. The commonest complications were wound infection or breakdown (11.9%, n=10), fibular nonunion (3.5%), plate irritation (3.5%), and tibial nerve neuropathy (3.5%). There were no thromboembolic complications. Implant survivorship was 100%, with Trabecular Metal components retained in all patients. Two patients developed deep infection, with 1 requiring debridement and polyethylene exchange. No patients experienced implant loosening. Our results demonstrate that the trabecular metal survival rates are comparable with other total ankle implants in the Australian Orthopaedic Association National Joint Replacement Registry and as published in other international literature. Overall patient satisfaction was high, as were PROMs. However, the data highlight potential complications uniquely associated with this implant. The authors believe that these figures support TAA via a transfibular approach as a viable option in the treatment of ankle arthritis. Level IV, retrospective cohort study.

The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty

The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.

Minimum 5-Year Outcomes of the Lateral Trabecular Metal Ankle Arthroplasty

Category:Ankle; Ankle ArthritisIntroduction/Purpose:The treatment of ankle arthritis has changed significantly with the recent advances in total ankle arthroplasty (TAR). Many different designs of TAR have been used around the world as the biomechanical technology advances and our understanding increases. Most implant system are anterior-based and have a flat cut on the tibial prosthesis. Only one implant, the Trabecular Metal (Zimmer-Biomet, Warsaw, IN), utilizes a lateral approach with a fibular osteotomy to gain access to the tibiotalar joint and a sagittally curved tibial component. Recent publications have described a higher reoperation rate with this implant system. This study aimed to report the 5-year clinical and radiographic outcome as well as the survivorship of the implant.Methods:Over a three-year period, two fellowship-trained foot and ankle surgeons used this implant system for patients indicated for TAR. A total of 38 patients were reviewed with an average age of 63.4+-8.6 years-old, BMI of 28.9+-4.6 and the majority (78%) had post-traumatic arthritis. Reoperations and revisions were collected prospectively as part of the local database. Patients participated in surveys preoperatively and at every annual follow-up which included the Foot and Ankle Outcome Score (FAOS). Patients were also evaluated with weightbearing radiographs preoperatively, at the 3 months postoperative and at the 5 year-mark. Those were analyzed by looking at the implant position with validated angles and comparing those over time. Further statistical analysis used paired t-test and Mann-Whitney U test.Results:The survivorship for our cohort was 92% at the 5-year mark. Three patients had the implant extracted at 12 and 15 months postoperative. Two of those patients had revisions to stemmed TARs and one had a below-knee amputation.Reoperations otherwise included 4 fibular hardware removal and 5 medial gutter debridement. As seen in Table 1, the FAOS improved significantly for all domains at 5-year compared to preoperative status. The Pain and Symptoms domains improved above than the MCID. The implant positioning both tibial coronal and sagittal as well as talar sagittal did not significantly change between 3 months and 5 years postoperative.Conclusion:This study describes the use of a laterally based Trabecular Metal TAR with great survivorship (92%) and clinically significant improvement in patient-reported outcomes. The rate of reoperation is higher due to prominent lateral hardware or poorly visualized medial gutters and revisions had to be performed through an anterior approach. Few other studies report 5-year outcomes from this prosthesis. There is a growing need to present more data from different centers to guide its ongoing clinical use.

Midterm Survivorship of the INBONE II Total Ankle Arthroplasty

The use of total ankle arthroplasty (TAA) in the treatment of ankle arthritis has grown substantially as advancements are made in design and surgical technique. Among the criteria guiding the choice between arthroplasty and arthrodesis, the long-term survival and postoperative outcomes are of crucial importance. Although outcomes of the INBONE I have been published, there is limited midterm survival data for the INBONE II. The purpose of this study was to determine the radiographic and patient-reported outcomes, and survivorship of this prosthesis in patients with a minimum 5-year follow-up. We retrospectively identified 51 ankles (46 patients) from 2010 to 2015 who underwent TAA with the INBONE II prosthesis at our institution. Of these, 44 cases had minimum clinical follow-up of 5 years (mean, 6.4; range 5-9). Median age was 66 years (range 42-81) and median BMI was 27.5 (range 20.1-33.0). A chart review was performed to record the incidence of revision and reoperation. Preoperative and postoperative radiographs were analyzed to assess the coronal tibiotalar alignment (TTA), the talar inclination angle, and the presence of periprosthetic lucencies and cyst formation. Preoperative and minimum 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscales were compared. Survivorship was determined by incidence of revision, defined as removal of a metallic component. The survivorship at 5 years was 98% and the rate of reoperation was 7.8% (n = 4); 2 patients underwent irrigation and debridement for infection, 1 patient underwent a medializing calcaneal osteotomy, and 1 patient underwent open gutter debridement, 1 patient underwent a revision of a subsided talar component at 3.2 years after index surgery. Average postoperative TTA was 88.6 degrees, with 42 rated as neutral (85-95 degrees), 2 varus (<85 degrees), and no valgus (>95 degrees) ankles. At final follow-up, asymptomatic periprosthetic cysts were observed in 8 patients. All FAOS domain scores improved between preoperative and final follow-up. At midterm follow-up, we observed significant improvement in radiographic alignment and patient-reported outcome scores for the INBONE II total ankle prosthesis. In addition, this cohort has had a relatively low reoperation rate and high survivorship. Level IV, case series.

Current Trends in the Treatment of Ankle Arthritis: Analysis of the Korean Foot and Ankle Society (KFAS) Member Survey

Current Trends in the Treatment of Ankle Arthritis: Analysis of the Korean Foot and Ankle Society (KFAS) Member Survey

Total ankle arthroplasty.

We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre. Between December 2010 and May 2016, 118 consecutive Zenith prostheses were implanted in 114 patients. Demographic, clinical, and patient-reported outcome measures (PROMs) data were collected. The endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan-Meier survival curves were generated with 95% confidence intervals (CIs) and the rate of failure calculated for each year. Eight patients (ten ankles) died during follow-up, but none required revision. Of the surviving 106 patients (108 ankles: rheumatoid arthritis (RA), n = 15; osteoarthritis (OA), n = 93), 38 were women and 68 were men, with a mean age of 68.2 years (48 to 86) at the time of surgery. Mean follow-up was 5.1 years (2.1 to 9.0). A total of ten implants failed (8.5%), thus requiring revision. The implant survival at seven years, using revision as an endpoint, was 88.2% (95% CI 100% to 72.9%). There was a mean improvement in Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) from 85.0 to 32.8 and visual analogue scale (VAS) scores from 7.0 to 3.2, and overall satisfaction was 89%. The three commonest complications were malleolar fracture (14.4%, n = 17), wound healing (13.6%, n = 16), and superficial infection (12.7%, n = 15). The commonest reason for revision was aseptic loosening. No patients in our study were revised for deep infection. Our results show that Zenith survival rates are comparable with those in the literature for other implants and in the National Joint Registry (NJR). Overall patient satisfaction was high as were functional outcomes. However, the data highlight potential complications associated with this surgery. The authors believe that these figures support ankle arthroplasty as an option in the treatment of ankle arthritis. Cite this article: Bone Joint J2021;103-B(4):696-703.

Radiographic and Clinical Analysis of the INBONE II Total Ankle Arthroplasty

Category:Ankle Arthritis; AnkleIntroduction/Purpose:The use of total ankle arthroplasty (TAA) in the treatment of ankle arthritis has grown substantially as advancements are made in design and surgical technique. Among the criteria guiding the choice between arthroplasty versus arthrodesis, the long-term survival and postoperative outcomes are of crucial importance. First FDA approved in 2005, the INBONE I prosthesis was subsequently replaced by the INBONE II in 2010. While outcomes of the INBONE I have been published, there is limited long-term survivorship data for the INBONE II. The purpose of this study is to determine the minimum 5-year survivorship of the INBONE II prosthesis and causes of failure. In addition, we evaluate long-term radiographic and patient- reported outcomes.Methods:We retrospectively identified 46 prospectively followed patients from 2010 to 2015 who underwent TAA with the INBONE II prosthesis at our institution. Of these, 44 cases (41 patients) had minimum follow-up of 5 years (mean, 6; range, 5 to 9). Mean age was 65.6 years (range, 42 to 81) and mean BMI was 27.6 (range 20.1 to 33). Survivorship was determined by incidence of revision, defined as removal/exchange of a metal component. Chart review was performed to record incidences of revision and reoperation. Preoperative, immediate and minimum 5-year x-rays were reviewed; coronal tibiotalar alignment (TTA) was measured on standing AP radiographs to assess alignment of the prosthesis. A TTA of +-5° from 90° indicated neutral alignment, while <85° and >95° was considered varus and valgus alignment, respectively. Radiographic subsidence as well as presence and location of periprosthetic cysts were documented. Pre- and minimum 5-year FAOS domains were compared.Results:Survivorship was 97.7% with one revision of the talar component due to aseptic loosening and subsidence. The rate of other reoperations was 4.5% (2); one patient underwent medializing calcaneal osteotomy for valgus heel alignment, another patient underwent ostectomy and debridement for ankle impingement. Average preoperative TTA was 88.5 degrees with 15 neutral (average TTA of 89.7°), 14 varus (74°) and 12 valgus (104°) ankles. Average postoperative TTA was 88.6° with 35 neutral (89.3°), 6 varus (84.7°), and no valgus ankles. Radiographic subsidence was observed in one patient who underwent revision, and periprosthetic cysts were observed in 7 patients. There was significant improvement in all FAOS domains at final follow-up.Conclusion:This is the largest study to date dedicated to evaluating survivorship of the INBONE II prosthesis. Our data suggests a high survival rate and low reoperation rate with long-term follow-up of the INBONE II implant. We observed significant improvement in radiographic alignment as well as patient-reported clinical outcomes at minimum 5-year follow-up.

Sport and physical activity after ankle arthrodesis with Ilizarov fixation and internal fixation.

Severe osteoarthritis (OA) of the ankle joint constitutes an important social problem. We used (1) the GRIMBY scale, (2) the LOWER LIMB Activity scale, (3) the UCLA (University of California Los Angeles) activity scale, (4) the VAS (visual analogue scale) ACTIVITY scale, and (5) the FAAM (foot and ankle ability measure) SPORT scale to verify whether the type of ankle joint arthrodesis stabilization affected sports and physical activity levels. We carried out a prospective clinical study of 47 patients who had undergone ankle arthrodesis with Ilizarov external fixator stabilization (Group 1, n = 21) or internal stabilization with screws (Group 2, n = 26) at Orthopaedic Clinic at the Wroclaw Medical University, Poland, from 2007 to 2015. Sports and physical activity levels were measured by (1) the GRIMBY scale, (2) the LOWER LIMB Activity scale, (3) the UCLA activity scale, (4) the VAS ACTIVITY scale, and (5) the FAAM SPORT scale. A comparison between the average results of Group 1 and Group 2 on the LOWER LIMB Activity scale and the GRIMBY scale before and after surgery revealed no significant differences. In Group 1, the mean scores on the VAS ACTIVITY scale and the UCLA activity scale after treatment were higher than in Group 2. In Group 1, the mean outcome in the SPORT FAAM scale after treatment was 40; in Group 2 it was 30.06. Ilizarov fixation of ankle arthrodesis is associated with better scores on the FAAM SPORT, UCLA activity and VAS ACTIVITY scales after treatment than internal fixation. The scores on the GRIMBY scale and the UCLA activity scale were significantly higher after treatment than before treatment in both groups. In this study, ankle fusion with Ilizarov fixation and internal fixation was found to be effective in the treatment of ankle arthritis. The levels of sport and physical activity were satisfactory in both groups, but the outcomes after fixation with the Ilizarov apparatus were better than after internal stabilization.

The Impact of Lower Back Pain on Functional Outcomes for Ankle Arthritis Treated with Arthroplasty and Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Methods: Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. Results: In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p &lt; 0.04), SF-36 PCS (32.5 vs 28.9 p &lt;0.01), and SF-36 MSC (51.8 vs 47.8 p &lt; 0.01). At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p &lt;0.02) and SF-36 MSC (54.1 vs 51.1 p &lt; 0.001). These results where repeated at the 5 year mark. There was no difference between TAA or AA (p &gt; 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. Conclusion: The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post-operatively, this was not the case for AAS scores.

Supra Malleolar Osteotomies for Neglected Tibial Deformity Affecting the Ankle and Foot

Ankle arthrosis continues to affect millions of people worldwide. Whereas it is not as common as hip and knee arthrosis in the aging population, it is more and more prevalent in the younger population. Also, it is not uncommon to see total destruction of the ankle joint in the neuropathic population. Whereas arthrosis of the knee and hip is mostly “wear and tear” type, the vast majority of ankle arthrosis is post traumatic. Because of this the likely hood of an underlying post traumatic deformity is high. Post Traumatic Deformity is often disabling particularly in the case of osteomyelitis treatment and open fractures with bone loss. This leads to a painful, non plantigrade, non functional limb. Consequently, the surgeon needs to perform complete and methodic pre-operative planning prior to performing any definitive reconstructive joint surgery. Ankle arthrodesis continues to be the standard of care for end stage ankle arthrosis. It is a tried and true procedure that provides the surgeon and patient, predictable union rates, low rate of complications and ultimately, gives acceptable AOFAS score, indicating a good post-surgical quality of life to the patient. However, arthrodesis is not without disadvantages. Over the last 10 years, however total ankle replacement (TAR), has become a growing and more widely accepted alternative to arthrodesis. New systems have improved instrumentation, shorter operating room time and fewer complications as well as improved functional outcomes. This procedure is also not without significant possible complications and disadvantages. Also, distraction ankle arthroplasty has shown to provide favorable short term and medium term favorable outcomes. However, regardless of the procedure selected by the surgeon and patient for the treatment of ankle arthritis, there is one principle that is ubiquitous but unfortunately often overlooked. This iatrogenic negligence leads to increased non-union rates, continued pain and ultimately loss of functionality of the limb. The authors of this paper have encountered several failed ankle arthrodeses and TAR’s because of this which required extensive revisional reconstructive surgery. Also, in the case of bony deformity, conservative measures such as braces, AFO’s will have disappointing results.

Lost in the wilderness: outcomes of total ankle arthroplasty: commentary on an article by Andrew R. Hsu, MD, and Steven L. Haddad, MD: "Early clinical and radiographic outcomes of intramedullary-fixation total ankle arthroplasty".

The treatment of ankle arthritis has seen a sea change over the past few decades, with surgeons becoming increasingly confident in offering total ankle arthroplasty to more patients with disability related to arthritis. Surgeons are emboldened by the expanding clinical literature; however, results that are generalizable to the greater foot and ankle community, sufficient numbers, long-term follow-up, and patient-reported outcomes (PROs) are lacking. The present study by Hsu and Haddad appears to be only the second clinical series to report survivorship and outcomes measures for the INBONE prosthesis, a fixed-bearing implant with intramedullary fixation of the tibial component. In this series of fifty-nine patients, implant survival was 97% at two years and AOFAS (American Orthopaedic Foot & Ankle Society) hindfoot scores and VAS (visual analog scale) pain intensity were significantly improved. However, the 44% complication rate, 24% reoperation rate, and nearly …

Ankle Arthrodesis Fusion Rates for Mesenchymal Stem Cell Bone Allograft Versus Proximal Tibia Autograft

Ankle arthrodesis is commonly used in the treatment of ankle arthritis. The present study compared mesenchymal stem cell (MSC) bone allografts and proximal tibia autografts as adjuncts in performing ankle arthrodesis. A total of 109 consecutive ankle fusions performed from 2002 to 2008 were evaluated retrospectively. Of the 109 fusions, 24 were excluded from the present study, leaving 85 patients who had undergone ankle arthrodesis. Of the 85 patients, 41 had received a proximal tibia autograft and 44, an MSC bone allograft. These 2 groups were reviewed and compared retrospectively at least 2 years postoperatively for the overall fusion rate, interval to radiographic fusion, and interval to clinical fusion. A modified and adjusted American College of Foot and Ankle Surgeons ankle scale was used to measure patient satisfaction. The overall fusion rate was 84.1% in the MSC bone allograft group and 95.1% in the proximal tibia autograft group (p = .158). The corresponding mean intervals to radiographic fusion were 13.0 ± 2.5 weeks and 11.3 ± 2.8 weeks (p ≤ .001). The interval to clinical fusion was 13.1 ± 2.1 weeks and 11.0 ± 1.5 weeks (p ≤ .001) in the MSC bone allograft and proximal tibia autograft group, respectively. No statistically significant difference was found in the fusion rates between the MSC bone allograft and proximal tibia autograft groups. Also, no statistically significant difference was found between the preoperative and postoperative scores using a modified and adjusted American College of Foot and Ankle Surgeons ankle scale between the 2 groups (p = .41 and p = .44, respectively). A statistically significant delay to radiographic and clinical fusion was present in the MSC bone allograft group compared with the proximal tibia autograft group; however, no difference was found in patient satisfaction.

Functional Outcomes after Ankle Arthrodesis in Elderly Patients

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. 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. 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 arthritis. 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 patient population.

Periarticular osteotomy in the treatment of ankle arthritis

Objective To evaluate effect of periarticular osteotomy in the treatment of asymmetrical ankle arthritis.Methods Sixty-five patients with asymmetrical ankle arthritis were treated with periarticular osteotomy between February 2005 and May 2011,including 43 females and 22 males,aged from 35 to 74 years (mean,55.5 years).According to the Takakura classification of ankle arthritis,there were 29 patients in grade 2,32 in grade 3 and 4 in grade 4.Supramalleolar tibial osteotomy were performed in 20 patients,supramalleolar tibial and fibular osteotomy in 12,supramalleolar osteotomy combined with calcaneal osteotomy in 30 patients,and supramalleolar tibial and fibular osteotomy combined with calcaneal osteotomy in 3patients.Forty three patients underwent ligament reconstruction procedures.Based on radiographs,the tibial anterior surface angle (TAS) and tibial lateral surface angle (TLS) were compared before and after operation.AOFAS-AH score was used to evaluate the function of the ankle.Results Fifty-nine patients were followed up for an average of 35.7 months (range,7 to 94 months).Bone healing was observed in all patients,and the average healing time was 7 to 8 weeks.The average AOFAS-AH score was improved from 49.7 points preoperatively to 78.6 points 12 months postoperatively.Tbe average TAS and TLS was improved from 86.1° and 70.0° preoperatively to 93.9° and 81.5° 6 months postoperatively,respectively.Delayed wound healing occurred in 5 patients,which was resovled after nursing care.Forty-two patients felt excellent about results,15 felt good and 2 fell fair.Conclusion Perarticular osteotomy is a sound method in the treatment of asymmetrical ankle arthritis,based on chosing proper patients.The procedure can decrease the contact pressures on the degenerated cartilage and prolong the life span of the ankle. Key words: Ankle; Arthritis; Osteotomy

The Effect of Three Weekly Intra-Articular Injections of Hyaluronate on Pain, Function, and Balance in Patients with Unilateral Ankle Arthritis

Ankle arthritis can cause substantial pain and functional limitation. Previous studies have indicated that five weekly intra-articular injections of hyaluronate were safe and effective in the treatment of ankle osteoarthritis. The purpose of this study was to evaluate the effect and safety of three weekly injections of hyaluronate in patients with unilateral ankle arthritis. Fifty patients who had had unilateral ankle pain for at least six months and were classified radiographically as having Kellgren-Lawrence grade-2 or 3 ankle arthritis were recruited for a prospective study. Patients received three weekly intra-articular injections of hyaluronate. The primary outcome was the change in the Ankle Osteoarthritis Scale score at six months after the third injection. Secondary outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, four clinical tests of balance, consumption of rescue analgesics, and global patient satisfaction. Forty-six participants completed the study. A significant reduction in the mean Ankle Osteoarthritis Scale score was noted at one, three, and six months after the third injection (p < 0.05 for each follow-up visit compared with baseline). The mean AOFAS Ankle-Hindfoot Score improved from 60.5 points at baseline to 73.5, 75.5, and 76.7 points at one, three, and six months of follow-up, respectively (p < 0.05). The patients demonstrated significant improvement on all four balance tests at each follow-up visit (p < 0.05 for each test compared with baseline). Acetaminophen consumption dropped significantly following treatment (p < 0.05). The patients' satisfaction rate was high, and no serious adverse events were reported. This study suggests that three weekly injections of hyaluronate are well-tolerated and can provide pain relief and improve function and balance in patients with unilateral ankle arthritis. Larger controlled trials with longer follow-up are necessary to verify the effects of hyaluronate in the treatment of ankle arthritis.