Treatment Of Ankle Osteoarthritis Research Articles

Extraarticular Supramalleolar Osteotomy in Asymmetric Varus Ankle Osteoarthritis.

In recent years, supramalleolar osteotomy has become a valuable alternative for treatment of ankle osteoarthritis. The aim of this study was to investigate whether the preoperative stage of ankle osteoarthritis or tilt of the talus in the ankle mortise impacts radiologic and clinical outcomes following a supramalleolar osteotomy. Forty-four patients who underwent a supramalleolar osteotomy for posttraumatic asymmetric varus ankle osteoarthritis were included. Subgroups were formed according to the preoperative stage of ankle osteoarthritis and the tilt of the talus in the ankle mortise. The radiographic and clinical outcomes of each subgroup were compared, and survival rates calculated. Ankles with a preoperative Takakura stage of 2 and 3a showed a significant higher survival rate at 5 years (88% [95% CI, 67-100] and 93% [95% CI, 80-100]) compared with ankles with a preoperative Takakura stage of 3b (47% [95% CI, 26-86]; P = .044). The 5-year survival rate for patients with a preoperative tilt of the talus in the ankle mortise of 4-10 degrees was 85% (95% CI, 68-100), while patients with a preoperative tilt of >10 degrees showed a 5-year survival rate of 65% (95% CI, 46-93; P = .117). Supramalleolar osteotomy was a valuable treatment option for early to mid-stage posttraumatic asymmetric varus ankle osteoarthritis. Level IV, retrospective cohort study.

Microfracture of subchondral bone leads to persistent subchondral sclerosis and poorer functional outcomes following distraction arthroplasty of the ankle joint while biologic augment may improve recovery times

Category: Ankle Arthritis Introduction/Purpose: Treatment of ankle osteoarthritis (OA) continues to remain a challenge. Previous reports have demonstrated the short-term benefits of using joint distraction for the treatment of ankle (OA), however, its efficacy in long term clinical outcomes and its role in preserving the joint space remains controversial. The purpose of this study is to establish whether microfracture or biologics improve the outcomes of ankle distraction. Methods: Records of patients that underwent an ankle distraction procedure between January 2009-December 2013 were retrospectively reviewed. Four groups were identified: Group 1: distraction with no additional treatment, Group 2: distraction with microfracture, Group 3: distraction with microfracture and BMAC/PRP, Group 4: distraction with BMAC/PRP. Demographic data was recorded. Pre-and-postoperative range of motion, Foot and Ankle Outcome Scores (FAOS), complication rate, and return to activity were evaluated. Radiographic images were used to assess the joint space changes pre-operatively and post-operatively. Global comparisons were performed using chi square testing, while individual between-group comparisons were made using robust, resistant regression and Wald tests. Results: Eighty-one patients with a mean age of 47 (range, 37-69) underwent ankle distraction with a mean follow up of 5 years (range, 3-6). All treatment strategies resulted in statistically significant improvements in FAOS (<0.001). Groups that underwent microfracture had a statistically significant decrease in post-operative plantarflexion, dorsiflexion, subtalar inversion and subtalar eversion (p=0.003) as well as an overall decrease in joint space (0.002) with persistence of subchondral bone sclerosis. Patients who underwent distraction with no microfracture treatment resulted in a significant increase in post-operative joint space (p=0.001) and decreased sclerosis in the subchondral bone. Average return to activity was 6 months in patients who received BMAC/PRP with ankle distraction compared to 12 months in patients who were treated with ankle distraction and microfracture (p<0.01). Conclusion: Distraction arthroplasty results in good functional outcomes at medium term follow up. The addition of microfracture seems to create functional outcome deterioration, whereas the addition of a biologic agent either BMAC or PRP appears to benefit earlier return to function. Longer-term studies will be required to see if these effects are sustained.

Syndesmotic Instability After Total Ankle Replacement

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) evolved over the last decades and has been shown to be an effective concept in the treatment of ankle osteoarthritis (OA). In three-component designs, the second interface between polyethylene insert (PI) and tibial component allows the PI to find its position according the individual physiological properties. This was believed to decrease shear forces within the ankle joint. However, it is not clarified to which extent such an additional degree of freedom may overload the ligamentous structures of the ankle joint over time. This may in particular be the case for the syndesmotic ligaments. Therefore, the purpose of this study was to analyze all ankles after TAR that showed a symptomatic overload of the syndesmotic ligaments and to determine the potential consequences. Methods: Between 2003 and 2017, 31 ankles (females, 17; males 14; mean age 60 [40-79] years) were treated with a tibio-fibular fusion for a symptomatic instability of the syndesmosis. The indication for TAR was posttraumatic OA in 27 (87%), primary OA in 3 (10%), and hemochromatosis in one ankle (3%). The 31 ankles included 23 primary TAR (74%), 6 revision TAR (19%), and two take-down of a fusion and conversion to TAR (7%). Criteria for fusion were the presence of at least two of the followings: (1) tenderness over the syndesmosis, (2) pain while compressing the fibula against the tibia (squeeze test), (3) pain while rotating the foot externally (external rotation test), (4) widening of the syndesmosis on an anteroposterior view. Alignment of TAR (tibial articular surface [TAS] angle) and hindfoot alignment were measured on standard radiographs. Intraoperatively, the syndesmotic instability was confirmed before fusion. The wear of PI was documented. Results: After a mean of 63 (range, 4 – 152) months after TAR, all patients evidenced pain at the level of the syndesmosis of at least 3 months. 25 ankles (81%; 24 after posttraumatic OA) showed a widening of the syndesmotic space and 22 ankles (71%) of the medial clear space with lateral translation of the talus. The PI was seen to overlap the tibial component in 15 ankles (48%). Nine ankles (29%) evidenced cyst formation, and eight ankles (26%) showed a decrease in height of the PI; whereas, in 3 ankles (10%) a fracture of the PI was found. A valgus misalignment of the heel was found in 25 ankles (81%), a valgus TAS in 16 (52%) and a varus TAS in 11 ankles (36%). Conclusion: A syndesmotic instability after a three-component TAR apparently occurred mostly after posttraumatic OA, in particular if the heel was left in valgus. If the talus starts to move lateralward, the PI seems to be at risk for increased wear and finally mechanical failure (Figure 1). Therefore, a valgus misaligned heel should always be corrected during TAR implantation. If there is any sign of syndesmotic instability, a fusion should be considered. Further studies must proof whether in cases with a syndesmotic instability the use of a two-component design will be superior, as it stabilizes the talus in the coronal plane.

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach.

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.

Current situation of the treatment of ankle osteoarthritis

Current situation of the treatment of ankle osteoarthritis

Arthroplasty versus arthrodesis in the treatment of ankle osteoarthritis – Medium term results

Considering the applications of cellular materials in the sacrificial claddings for impact/blast alleviation, this study presents a method for the design of cellular foam claddings with temperature gradient under high initial velocity impacts. A one-dimensional model for the compaction of cellular foam claddings with temperature gradient is developed for the striker-rod impact scenario based on the R-P-P-L idealization. The predictions of the proposed model are compared with FE simulations with the realistic R-PLH material model based on the actual experimentally derived stress-strain curves. The predictions of the dependency of critical length, critical impact velocity and impact force of the cellular foam rod with temperature gradient on the temperature distribution and the relation of critical impact velocity of an aluminum foam rod with a given length to the temperature contrast at its two ends are compared well with the numerical simulations results.

A National Comparison of Total Ankle Replacement Versus Arthrodesis. Is There a Paradigm Shift?

Category: Ankle, Ankle Arthritis, Diabetes Introduction/Purpose: Total ankle replacement (TAR) and tibiotalar arthrodesis (TTA) are both utilized in the surgical management of ankle osteoarthritis. Over the past decade, foot and ankle surgeons have broadened the indications for TAR, and subsequently have performed less TTA. Currently, no studies exist evaluating the epidemiological, pre-operative, and temporal trends between TTA and TAR. The purpose of this study was to compare nationwide trends of TAR and TTA in the treatment of ankle osteoarthritis. Methods: The Nationwide Inpatient Sample (NIS) from 2007 to 2013 was used to extract data on patients over 50 years of age who underwent either primary TAR or TTA. Patients who underwent both procedures or revision procedures were excluded. Univariate and multivariate analysis were performed to assess for differences in temporal, demographic, and primary diagnosis trends between TAR and TTA. Results: 15,060 patients underwent TAR and 35,096 underwent TTA between 2007 and 2013. Patients undergoing TTA had significantly more comorbidities (2.17 vs 1.55, P<0.001). Temporal analysis demonstrated a significant 15% increase every 3 years in TAR performed from 2007 (14%) to 2013 (45%) (Figure 1) (P<0.001). Multivariate analysis comparing TAR and TTA demonstrated that in patients with a primary diagnosis of post-traumatic osteoarthritis, the odds of having a TAR in 2013 was 12 times higher than in 2007 (P<0.05). Similar increases in TAR utilization was demonstrated in patients with primary osteoarthritis (4.93 times) and rheumatoid arthritis (3.12 times) (P<0.001). Analysis of comorbid diagnoses revealed that patients with diabetes, hypertension, or CAD were 4.66 times more likely to have a TAR in 2013 compared to 2007 (P<0.001). Conclusion: Over the past decade the indications for TAR have increased, and foot and ankle surgeons are performing TAR with greater frequency. This has been most evident in patients undergoing TAR for post-traumatic arthritis and rheumatoid arthritis. Foot and ankle surgeons still prefer to perform TAR in patients with fewer comorbidities compared to TTA. However, as technology has advanced and surgeons have become more facile with the technique, patients with specific comorbidities are undergoing TAR at a significantly higher annual incidence.

Joint distraction arthroplasty as an alternative treatment for ankle osteoarthritis

Objective To analyze the feasibility of Ilizarov apparatus for ankle joint distraction to treat post-traumatic ankle osteoarthritis(OA). Methods From March 2012 to May 2014, 15 patients with moderate post-traumatic ankle OA treated with foot and ankle deformities, and combined with ankle distraction surgery simultaneously by Ilizarov apparatus. The average age of patients was (35.6±6.5) years (10 Males and 5 females). Selected cases were involved in unilateral ankle disease, including 9 cases with ankle fractures medical history and 6 cases with ankle sprain medical history. Distraction was carried out for 3 months during which full weight bearing was allowed. Results Joint mobility and radiographic joint space were preserved in all 15 cases. No patients had undergone either ankle arthrodesis or total ankle arthroplasty. Ankle osteoarthritis scale (AOS) score was (33.8 ± 7.95) points before operation, (55.4 ± 5.46) points in the first year follow-up, and increased to (71.4 ± 10.19) points in the second year after operation, medical outcomes study 36-item short-form health survey (SF-36) score was (37.2 ± 4.32) points before operation, and increased to (52.8 ± 3.42) and (59.2 ± 2.95) points at 1 year and 2 years after operation, respectively, the difference between the two groups was statistically significant. The results of ankle range of motion (ROM) indicated function improved which was similar at both 1 year and 2 year's follow-up. Radiology joint space width (JSW) assessment indicated that ankle gap was improved significantly in 11 patients (73.3%, 11/15) in the first year and maintain successfully in the second year. For the rest 4 patients (26.7%, 4/15), ankle joint gap did not improved significantly, AOS and SF-36 showed clinical symptoms improved. Conclusion Ilizarov apparatus for ankle joint distraction is a promising treatment for moderate post-traumatic ankle OA at early stage of treatment, at least delaying the need for a joint fusion or total ankle arthroplasty. Key words: Osteoarthritis; External fixators; Arthroplasty; Osteogenesis, distraction

Safety and Efficacy of Intra-articular Injection of Platelet-Rich Plasma in Patients With Ankle Osteoarthritis.

An intra-articular injection of platelet-rich plasma (PRP) may be an effective treatment for osteoarthritis (OA). However, its efficacy in ankle OA has not been investigated yet. The purpose of this study was to assess the safety and efficacy of an intra-articular injection of PRP in patients with ankle OA during a 24-week period. Twenty ankles of 20 patients with varus-type ankle OA who received intra-articular injections of PRP were evaluated. PRP was extracted from whole blood by using the double-spin technique. Three injections of 2-mL PRP were administered to the ankle at an interval of 2 weeks under ultrasonographic guidance. Adverse events and efficacy were assessed at 4, 12, and 24 weeks after the last injection. Clinical outcomes were assessed by using the visual analog scale (VAS) for pain, the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). No serious adverse effects were observed during the follow-up period. The VAS and JSSF scale scores significantly decreased from baseline to 4, 12, and 24 weeks after treatment ( P < .001). The mean score in the pain-related subscale of the SAFE-Q significantly improved from baseline to 12 weeks after treatment ( P = .04). Overall, the amount of pain reduction was maximal at 12 weeks after the last injection, and the effect was reduced at 24 weeks. The patients with late-stage OA had worse scores in all outcomes than those with early-stage OA. Intra-articular injections of PRP resulted in no serious adverse effects and significantly reduced pain in the patients with ankle OA. PRP treatment can be safe and effective and may be an option in the treatment of ankle OA. Level IV, case series.

Effect analysis of surgical treatment for ankle osteoarthritis under arthroscopy

Objective To discuss the clinical effect of surgical treatment for ankle osteoarthritis under arthroscopy. Methods Forty-eight cases with ankle osteoarthritis patients admitted at the Orthopaedic Hospital of Zhengzhou from January 2012 to June 2014 were selected and all of them were given the treatment of focal cleaning under arthroscopy.The clinical effect of surgical treatment were judged by modified McGuire ankle rating system, the United States after ankle surgery AOFAS ankle-full score and Mazur ankle rating system respectively. Results At the time of the last follow-up, modified McGuire ankle rating system((85.64±16.52) points vs.(52.46±10.25) points, t=-8.465), the United States after ankle surgery AOFAS ankle-full score [(85.24±11.46) points vs.(53.68±9.48) points, t=-7.548) and Mazur ankle rating system((86.45±12.57) points vs.(58.49±8.64) points, t=-6.596) all increased than that of pre-operation, the differences were statistically significant(P 0.05). Conclusion The clinical effect of surgical treatment for ankle osteoarthritis under arthroscopy is remarkable and it causes light damage to the body.It is especially suitable for patients with low-grade lesions and is worth popularization and application. Key words: Ankle; Osteoarthritis; Arthroscopy; Effect

Functional analysis of distraction arthroplasty in the treatment of ankle osteoarthritis

BackgroundAnkle joint distraction arthroplasty (AJDA) is an alternative surgical procedure for the management of moderate to severe ankle osteoarthritis. However, the benefit of this procedure and failure relative factors are still in debate. The purpose of the current study was to evaluate the functional outcomes of AJDA in treatment of moderate to severe ankle OA and to evaluate the relative factors correlated with treatment failure.MethodsForty-six van Dijk stages II and III ankle osteoarthritis patients were included. Fifteen males and 31 females with a mean age of 54.8 (range, 42–71) years were followed with a mean of 42.8 (range, 24–68) months. The Ankle Osteoarthritis Scale (AOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used for functional outcome evaluation. The talar tilt (TT) angle and ankle joint space distance (AJSD) were evaluated. The risk ratio (RR) was calculated for each potential failure relative factor.ResultsThe AOS and AOFAS scores were significantly improved at the last follow-up time (P < 0.01). The AJSD was improved in 61% of patients and with a significant improvement compared with the preoperative conditions (P < 0.01). The TT angle and range of motion reached no significant difference. The failure rate was 21.7%. Patients with large TT (≥5°) angle (RR = 3.81, 95% CI 1.28–11.33, P = 0.02) and obesity (RR = 3.58, 95% CI 1.30–9.89, P = 0.01) were found to have positive correlation with failure. No correlation was found between failure and gender, or overweight, or side, or age, or type and stage of OA, or pin infection.ConclusionsThe current study confirmed the early functional outcomes of ankle distraction arthroplasty. However, this procedure still has a relatively high failure rate, especially for those obese patients and patients with large TT angles.

Intermediate-term follow-up after ankle distraction for treatment of end-stage osteoarthritis.

Treatment of end-stage ankle osteoarthritis remains challenging, especially in young patients. Initial reports have shown early benefits of joint distraction for the treatment of ankle osteoarthritis. We report the five to ten-year results of a previously described patient cohort following ankle distraction surgery. All thirty-six patients who had undergone ankle distraction surgery between December 2002 and October 2006 were contacted. Patients were evaluated by a clinical investigator and completed the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) surveys. Radiographs as well as computed tomography and magnetic resonance imaging scans of the ankles were obtained at the follow-up visits. Twenty-nine patients (81%) were followed for a minimum of five years (mean and standard deviation, 8.3 ± 2.2 years). Sixteen (55%) of the twenty-nine patients still had the native ankle joint whereas thirteen patients (45%) had undergone either ankle arthrodesis or total ankle arthroplasty. Positive predictors of ankle survival included a better AOS score at two years (hazard ratio [HR] = 0.048, 95% confidence interval [CI] = 0.0028 to 0.84, p = 0.04), older age at surgery (HR = 0.91, 95% CI = 0.83 to 0.99, p = 0.04), and fixed distraction (HR = 0.094, 95% CI = 0.017 to 0.525, p < 0.01). Radiographs and advanced imaging revealed progression of ankle osteoarthritis at the time of final follow-up. Ankle function following joint distraction declines over time. Patients should be well informed of the commitment that they must make during the treatment period as well as the long-term results after surgery.

Challenging the Anxiety Over Coronal Plane Deformity

The treatment of ankle osteoarthritis with total ankle arthroplasty has experienced a resurgence over the past three decades. The introduction of the Agility total ankle implant in the early 1980s was the genesis of the contemporary efforts at ankle arthroplasty1. The early success of that fixed-bearing implant, as well as the less-favorable longer-term outcomes, spurred the development and introduction of a number of newer fixed and mobile-bearing designs, including the two implants highlighted in this study, the two-component Salto-Talaris and INBONE total ankle prostheses. Recent reports have demonstrated that the results of total ankle arthroplasty are on par with, and possibly superior to, those of arthrodesis with respect to pain and function2,3. In addition, the survivorship of total ankle implants, while not yet demonstrated to be equivalent to that of total hips and knee implants, has been shown to be quite favorable at intermediate-term follow-up. Mann et …

Total Ankle Arthroplasty With Combined Calcaneal and Metatarsal Osteotomies for Treatment of Ankle Osteoarthritis With Accompanying Cavovarus Deformities

Our study evaluated the short-term clinical and radiographic results of total ankle arthroplasty (TAA) with combined bony reconstructions for treatment of end-stage ankle osteoarthritis with accompanying cavovarus/hindfoot varus deformities. This study included 8 patients (10 ankles) with ankle osteoarthritis (OA) who were treated by TAA with combined calcaneal and metatarsal osteotomies between September 2004 and June 2010 and were followed an average of 17.9 months (12-43 months). Visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographic measurements, and patient satisfaction were evaluated. The average patient age was 66.2 years (range, 55-76 years). Eighteen bony reconstruction procedures such as lateral sliding calcaneal osteotomy (n = 9) and first metatarsal dorsiflexion osteotomy (n = 4) were performed in addition to TAA. VAS pain score improved from an average of 8.8 (range, 6-10) preoperatively to an average of 2.4 (range, 0-7) (P < .05), and the AOFAS score improved from 36.9 (range, 14-71) preoperatively to 89.3 (range, 68-100) (P < .05). Ninety percent of the patients were satisfied with the results. Radiographically, the tibiocalcaneal angle (TCA) improved from a preoperative average of 19.0 degrees (range, 13-23 degrees) to 0.2 degrees (range, -5.4 to 2.8 degrees), the tibial axis-talar dome angle (TA-TDA) improved from a preoperative average of 15.6 degrees (range, 11.1-18.0 degrees) to 3.3 degrees (range, 1.7-5.6 degrees), and the talar dome-ground surface angle (TD-GSA) improved from a preoperative average of 21.2 degrees (range, 15.4-27.5 degrees) to 5.1 degrees (range, 1.8-10.2 degrees) (P < .05). We found that it was occasionally necessary to perform combined calcaneal and metatarsal osteotomies with TAA in order to successfully treat ankle OA with an accompanying cavovarus/varus deformity. The TD-GSA and TCA were also found to be important radiographic parameters in assessing varus ankles. IV, retrospective case series.

Foot &amp; ankle

The December 2012 Foot &amp; ankle Roundup360 looks at: correcting the overcorrected club foot; syndesmotic surgery; autograft for osteochondral defects; sesamoidectomy after fracture in athletes; complications in ankle replacement; the arthroscope as a treatment for ankle osteoarthritis; whether da Vinci was a modern foot surgeon; and a popliteal block in ankle fixation.

Effects of Intraarticular Botulinum Toxin A in the Treatment of Ankle Osteoarthritis

Background: Preliminary evidence suggests that Botulinum toxin type A (BoNT-A) injected intraarticularly into painful joints has a significant nociceptive effect. The purpose of this study is to investigate the effects of intraarticular BoNT-A on the pain and physical function for patients with ankle osteoarthritis (OA).Method: A prospective study with 6 months follow-up done in a university-affiliated tertiary care medical center, patients with symptoms and radiographic evidence of ankle OA for at least 6 months were recruited. Patients received intraarticular injections of 100 units of BoNT-A in 2 cc of normal saline. The injections were performed by the same experienced doctor. The primary outcome were assessed with the ankle function using the Ankle Osteoarthritis Scale (AOS) score. Secondary outcomes were assessed with American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score, VAS, ankle sagittal range of motion (ROM), single leg stance test (SLS), Timed ”Up-and-Go” test (TUG) and consumption of rescue analgesics. These tests were conducted pre-injection and at 2 weeks, 1 month, 3 months, and 6 months post injection. Patients' global satisfaction was assessed at 2 weeks, 1 month, 3 months, and 6 months post injection. Adverse events during the study period were recorded also.Results: Fifteen patients were recruited and 13 patients completed the study. All patients showed significant improvements in their AOS, AOFAS, VAS, SLS and TUG scores. These improvement persisted for at least 6 months. Acetaminophen consumption dropped significantly following treatment (p＜0.001). Ankle sagittal ROM did not change significantly throughout the study period. Patients' global satisfaction rate was high and no serious adverse events were reported.Conclusions: Intraarticular BoNT-A injection to the ankle joint is well tolerated. It effectively reduces pain, disability as well as improves balance function in patients with ankle OA. These effects can last for 6 months. Future studies that include rigorously controlled designs and larger number of patients would be necessary to determine the efficacy for the treatment of ankle OA.

Motion Versus Fixed Distraction of the Joint in the Treatment of Ankle Osteoarthritis

Initial reports have shown the efficacy of fixed distraction for the treatment of ankle osteoarthritis. We hypothesized that allowing ankle motion during distraction would result in significant improvements in outcomes compared with distraction without ankle motion. We conducted a prospective randomized controlled trial comparing the outcomes for patients with advanced ankle osteoarthritis who were managed with anterior osteophyte removal and either (1) fixed ankle distraction or (2) ankle distraction permitting joint motion. Thirty-six patients were randomized to treatment with either fixed distraction or distraction with motion. The patients were followed for twenty-four months after frame removal. The Ankle Osteoarthritis Scale (AOS) was the main outcome variable. Two years after frame removal, subjects in both groups showed significant improvement compared with the status before treatment (p < 0.02 for both groups). The motion-distraction group had significantly better AOS scores than the fixed-distraction group at twenty-six, fifty-two, and 104 weeks after frame removal (p < 0.01 at each time point). At 104 weeks, the motion-distraction group had an overall mean improvement of 56.6% in the AOS score, whereas the fixed-distraction group had a mean improvement of 22.9% (p < 0.01). Distraction improved the patient-reported outcomes of treatment of ankle osteoarthritis. Adding ankle motion to distraction showed an early and sustained beneficial effect on outcome.

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.

Indications for Supramalleolar Osteotomy in Patients with Ankle Osteoarthritis and Varus Deformity

Osteotomies are reported to be effective for the treatment of most cases of primary and traumatic moderate osteoarthritis of the ankle joint. Because of unsatisfactory results following supramalleolar tibial osteotomy in several of our patients, we investigated the cause of the unsatisfactory results and the indications for this surgical procedure. Supramalleolar tibial osteotomy combined with fibular osteotomy was performed in sixteen ankles (sixteen patients) to treat moderate medial ankle osteoarthritis. The median duration of follow-up was 2.3 years (range, one to 6.5 years). Clinical assessment was performed with use of the American Orthopaedic Foot & Ankle Society (AOFAS) scale, and the osteoarthritis stage was determined radiographically with use of the modified Takakura classification system. Clinical and radiographic results were compared among groups defined by high (≥9.5°) or low (≤4°) postoperative talar tilt and by the presence or absence of postoperative lateral subfibular pain. The optimal threshold of preoperative talar tilt for predicting high postoperative talar tilt was determined with use of receiver operating characteristic curve analysis. The mean AOFAS score, mean Takakura stage, and mean values of all radiographic parameters were improved significantly after surgery. The preoperative talar tilt was correlated with the postoperative talar tilt (Spearman rho = 0.75, p < 0.01). The mean AOFAS score was higher (p = 0.02) and the mean radiographic stage was lower (p = 0.03) in the group with low postoperative talar tilt than in the group with high talar tilt. The optimal threshold for predicting high postoperative talar tilt was 7.3° of preoperative talar tilt, with a sensitivity of 100% and a specificity of 91.7%. The patients with lateral subfibular pain had a lower mean AOFAS score, a greater angle between the tibia and the ankle surface postoperatively, and greater postoperative heel valgus than those without lateral subfibular pain. Supramalleolar osteotomy is indicated for the treatment of ankle osteoarthritis in patients with minimal talar tilt and neutral or varus heel alignment.