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Modern Management of Ankle Arthritis Including Primary Ankle Replacement
Abstract
About 1% of the world’s population is affected by ankle osteoarthritis (OA). It is nine times less prevalent than hip and knee OA. Around 80% of cases are secondary to previous trauma, with 12% due to inflammatory diseases and only 7% occurring primarily. Various radiological classifications exist and these will be discussed in the chapter. Nonoperative treatment options include analgesia, braces/orthotics, footwear modifications, and walking aids. Nonoperative interventions with injections involve corticosteroids, hyaluronic acid, and other biological injection therapies.
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Category
Ankle Arthritis, Arthroscopy
Introduction/Purpose
Ankle trauma is highly implicated in the etiology of osteoarthritis (OA) of the ankle, and posttraumatic ankle OA is often observed in younger patients. In advanced stages, ankle arthrodesis has been considered as a gold standard treatment, and total ankle arthroplasty is also developed over the past decade for older patients. However, the surgical treatment of severe ankle OA for younger, active patients remains challenging. Ankle distraction arthroplasty is an alternative option for treatment of severe ankle OA in younger patients. The distraction device enables joint distraction with ankle motion that induces cartilage repair of the ankle. This study aimed to clarify the clinical outcome of the ankle distraction arthroplasty with arthroscopic microfracture for ankle OA in younger patients.
Methods
This retrospective analysis included 7 ankle OA patients who underwent distraction arthroplasty with arthroscopic microfracture, in 5 men and 2 women, with a mean age of 45.9 years (range, 39-62). Range of motion (ROM) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score were evaluated as the clinical outcomes. The talotibial joint space was identified as anterior, center and posterior segment on lateral view. The width of joint space in each segment was measured on pre- and post-operative weight-bearing radiographs. The distraction device was removed at 3 months after initial surgery, and second look arthroscopy was also performed at the same time. The arthroscopic findings were assessed retrospectively.
Results
All 7 patients were followed with a mean follow-up period of 4.2 years. One patient who had the worst preoperative AOFAS score of 19 converted to arthroscopic ankle arthrodesis at 2 years after the initial surgery. The mean total ROM and AOFAS score improved from 29.3 to 37.1 (p = 0.028), from 41.7 to 76.1 (p = 0.018), respectively. Weight-bearing radiographs showed a width of ankle joint space with anterior, center and posterior of 1.9 mm, 1.8 mm, 2.0 mm at preoperative status and 2.9 mm, 2.8 mm, 2.9 mm at final follow-up status. Second look arthroscopy revealed that the fibrous cartilage like tissue covered the cartilage defect area at the talotibial joint in all patients.
Conclusion
Our findings suggest that the distraction arthroplasty with arthroscopic microfracture could be a useful option for active patients with advanced stage of ankle OA. Good clinical status and the width of joint space had been preserved for a maximum of seven years. Further follow-up was required to elucidate the long-term clinical results.
Purpose
To evaluate and compare complication rates and postoperative outcomes in patients with ankle debridement alone vs. debridement and hinged ankle distraction arthroplasty.
Methods
A total of 50 patients with posttraumatic ankle osteoarthritis (OA) with a mean age of 40.0 ± 8.5 years were included into this prospective randomized study: 25 patients in ankle debridement alone group and 25 patients in debridement and hinged ankle distraction group. The mean follow-up was 46 ± 12 months (range 36–78 months). The clinical and radiographic outcomes were evaluated at the 6-month and 3-year follow-up using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, SF-36 quality of life score, and van Dijk OA classification. A Kaplan–Meier survival analysis was performed to calculate the 3-year and 5-year survival rates.
Results
Both patient groups experienced significant pain relief, functional improvement, and improvement in quality of life postoperatively. In total, 26 major secondary procedures were performed. The overall survival rates in the debridement and ankle distraction group were 19 of 25 (74%) and 15 of 25 (59%) at 3 years and 5 years, respectively. The overall survival rates in the ankle debridement alone group were 12 of 25 (49%) and 9 of 25 (34%) at 3 years and 5 years, respectively.
Conclusions
The study demonstrated comparable postoperative functional outcome and quality of life. However, rate of postoperative revision surgery was substantially higher in ankle debridement alone group.
Level of evidence
Randomized controlled study, Level I.
Objectives:
There is a discrepancy between evidence in support of the widespread use of intra-articular hyaluronic acid (IAHA) to treat knee osteoarthritis (OA) in clinical practice, and the often discordant recommendations from multiple international guideline committees, which requires further investigation.
Methods:
We conducted a literature review to determine the strength of evidence in support of the efficacy and safety of IAHA, from randomized controlled trials and meta-analyses.
Results:
Our analysis shows that IAHA provides a moderate symptomatic benefit to knee OA patients and without major safety concerns. In fact, IAHA may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement.
Conclusions:
We advocate for the consideration of recommending IAHA injection as a treatment option in the management of knee OA, tailored by disease stage and patient phenotype. Future research efforts should focus on identification of OA patient subgroups that demonstrate a more robust response to IAHA, determination of long-term effects of repeat IAHA injections on patient-reported outcomes and total knee replacement-sparing effect, further elucidation of disease-modifying effects, and the potential for combination therapy with other pharmacologic and non-pharmacologic therapies to optimize the management of knee OA.
Background:
Intra-articular (IA) injections are commonly used to treat knee arthritis pain; however, whether their efficacy generalizes to ankle arthritis remains debatable. We aimed to evaluate the evidence for IA therapies in the management of this patient population.
Methods:
We performed a literature search for observational and randomized controlled trials (RCTs). Treatments included corticosteroids (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and mesenchymal stem cells (MSC). We extracted study details, patient demographics, treatment characteristics, efficacy outcomes, and safety. When feasible, data from RCTs were meta-analyzed using a random-effects model and 95% confidence intervals (CIs) were calculated. A P value <.05 was considered statistically significant.
Results:
We identified 27 studies (1085 patients). Ankle OA, rheumatoid arthritis (RA), and hemophilic arthropathy populations were examined. The majority of studies were observational (20 studies); the only RCTs were those evaluating HA. Case series demonstrated favorable results in terms of symptomatic relief with CS, HA, PRP, and MSC injections; however, the effects of CS may only be short term and the evidence on MSCs was limited to 1 study with 6 ankle OA patients. Pooled results (3 RCTs, 109 patients) suggested significantly improved Ankle Osteoarthritis Scale scores with HA over saline at 6 months, with a mean difference of 12.47 points (95% CI 1.18-23.77, P = .03).
Conclusion:
Evidence from small trials favors HA and PRP injections for the treatment of pain associated with ankle osteoarthritis. However, the relative efficacy of all injectable therapies is far from definitive and warrants further high-quality comparative trials.
Level of evidence:
Level III, systematic review.
Aims:
This study presents the first report of clinical and radiographic outcomes of the Infinity Total Ankle System (Wright Medical, Memphis, TN) with minimum 2-year follow-up.
Patients and methods:
The first 67 consecutive patients who underwent primary total ankle arthroplasty (TAA) with the Infinity system at 2 North American sites between August 2013 and May 2015 were reviewed in a prospective, observational study. Demographic, radiographic, and functional outcome data were collected preoperatively, at 6 to 12 months postoperatively, and annually thereafter.
Results:
The overall implant survival rate was 97% (65 of 67 implants) at a mean follow-up of 35.4 months (27 to 47 months). Two cases underwent talar component revision for aseptic loosening. Six of the 67 cases (9%) required a nonrevision reoperation. Mean Foot Function Index and Ankle Osteoarthritis Scale scores at latest follow-up improved from preoperative by 21.6 ( P < .0001) and 34.0 ( P < .0001), respectively. No radiographic loosening of any talar or tibial components was identified in the 65 nonrevised cases.
Conclusion:
Early clinical and radiographic outcomes with the Infinity TAA are promising and compare favorably to those reported for both fixed- and mobile-bearing third-generation TAA designs, even when used in cases with deformity and increased case complexity.
Levels of evidence:
Level IV.
Osteoarthritis (OA) is a chronic condition characterized by a loss of joint cartilage and is a major cause of disability in Canada, with an estimated CN$195 billion annual cost. Knee OA leads to persistent pain and loss of function, and treatment goals primarily focus on symptom relief and retention of function. Intra-articular hyaluronic acid (IAHA) has therapeutic benefits, and numerous recently published meta-analyses (MAs) and commentaries have highlighted new evidence on the role of IAHA therapy for knee OA. A diverse, multidisciplinary group of specialists met independently in closed sessions to review findings from eight MAs with literature search end dates no earlier than 2012 to address controversies surrounding IAHA therapy for mild-to-moderate knee OA within the Canadian treatment context. Outcomes from a total of eight MAs were reviewed, and consistent and statistically significant improvements in pain, function and stiffness up to 26 weeks were found with IAHA therapy compared with IA placebo or controls, regardless of MA size or trial quality. These findings are in line with those of a Cochrane review, another recent systematic review and patient satisfaction survey. Overall, three MAs reported outcomes based on molecular weight (MW), with the two reporting effect sizes showing significantly improved pain outcomes for higher compared with lower MW HAs. Recent evidence suggests that HA therapy is well tolerated with no increased risk of serious adverse events compared with placebo and the full therapeutic effect of IAHA therapy appears to have considerable clinical importance, consisting of the combined IA placebo and HA therapeutic effects. IAHA therapy is a well-tolerated and effective option for patients with mild-to-moderate knee OA failing first-line pharmacological therapy.
Background:
A major complication of foot and ankle arthrodesis is nonunion, which occurs in approximately 12% of cases. Various factors influence a patient's risk for nonunion following foot and ankle arthrodesis. We surveyed international foot and ankle surgeons to determine (1) risk factors perceived most important for nonunion, (2) factors considered absolute contraindications for arthrodesis, and (3) differences among expert groups regarding perceived risk factors and their stratification.
Methods:
A questionnaire was e-mailed to members of a major foot and ankle journal editorial board and four foot and ankle society executive committees. The relative risk of 18 potential nonunion risk factors was rated from 1 to 10, using smoking 1 pack/day as a benchmark score of 5.00.
Results:
The response rate was 72% (100/139); 81% declared foot and ankle surgery encompasses >90% of their practice. The highest perceived risk factors ( p < 0.001) were smoking 2 packs/day (mean score 8.69), lack of fusion site stability (8.66), and poor local vascularity (7.66). The least important risk factors ( p < 0.001) were perceived to be age >60 years (mean score 2.54), rheumatoid arthritis (3.05), and osteoporosis (3.56). The most frequently cited absolute contraindications to arthrodesis surgery were local infection (46%), poor local vascularity (41%), and smoking (32%).
Conclusion:
To improve arthrodesis outcomes, resource allocation and patient and surgeon education should focus on smoking, construct stability, and local vascularity. Development of an objective nonunion risk assessment tool to identify patients at risk for nonunion using these results could help maximize the efficiency of available resources.
Background:
Talar osteochondral lesions are more common than has been previously recognized. Optimal treatment remains unclear and the subject of much debate in the literature. Although reparative techniques such as microfracture have produced initial good results and remain the gold standard in the management of these lesions, the literature is deficient in long-term data. Recently, techniques focused on enhancing the local biological environment have been developed which have demonstrated promising outcomes.
Methods:
We reviewed the available evidence concerning scaffold-based techniques and biological adjuncts in the management of talar osteochondral lesions published in the English language on PubMed.
Results:
An update is provided on the current evidence concerning the role of biological adjuncts in the management of osteochondral lesions of the talus.
Conclusions:
There has been an explosion of interest among the orthopaedic community in the role of biologics in the management of complex talar osteochondral lesions. A number of exciting new techniques have been developed which show promise. Robust randomized control trials are required to identify the optimal surgical strategy.
Ankle arthrodesis is a common treatment used for patients with end-stage ankle arthritis (ESAA). The surgical goal of ankle arthrodesis is to obtain bony union between the tibia and talus with adequate alignment [slight valgus (0°-5°)], neutral dorsiflexion, and slight external rotation positions) in order to provide a pain-free plantigrade foot for weightbearing activities. There are many variations in operative technique including deferring approaches (open or arthroscopic) and differing fixation methods (internal or external fixation). Each technique has its advantage and disadvantages. Success of ankle arthrodesis can be dependent on several factors, including patient selection, surgeons’ skills, patient comorbidities, operative care, etc. However, from our experience, the majority of ESAA patients obtain successful clinical outcomes. This review aims to outline the indications and goals of arthrodesis for treatment of ESAA and discuss both open and arthroscopic ankle arthrodesis. A systematic step by step operative technique guide is presented for both the arthroscopic and open approaches including a postoperative protocol. We review the current evidence supporting each approach. The review finishes with a report of the most recent evidence of outcomes after both approaches and concerns regarding the development of hindfoot arthritis.
Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with end-stage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis.
A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted, including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis radiographs and medical records were available for analysis.
The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints and patient symptoms was not established in a number of the clinical studies reviewed.
There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings and clinical presentation in this cohort of patients has not been conclusively demonstrated.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
Knee osteoarthritis (OA) is the most common articular disease. Different methods are used to alleviate the symptoms of patients with knee OA, including analgesics, physical therapy, exercise prescription, and intra-articular injections (glucocorticoids, hyaluronic acid [HA], etc). New studies have focused on modern therapeutic methods that stimulate cartilage healing process and improve the damage, including the use of platelet-rich plasma (PRP) as a complex of growth factors. Due to the high incidence of OA and its consequences, we decided to study the long-term effect of intraarticular injection of PRP and HA on clinical outcome and quality of life of patients with knee OA.
This non-placebo-controlled randomized clinical trial involved 160 patients affected by knee OA, grade 1-4 of Kellgren-Lawrence scale. In the PRP group (n = 87), two intra-articular injections at 4-week interval were applied, and in the HA group (n = 73), three doses of intra-articular injection at 1-week interval were applied. All patients were prospectively evaluated before and at 12 months after the treatment by Western Ontario and McMaster Universities Arthritis Index (WOMAC) and SF-36 questionnaires. The results were analyzed using SPSS 16.1 software (RCT code: IRCT2014012113442N5).
At the 12-month follow-up, WOMAC pain score and bodily pain significantly improved in both groups; however, better results were determined in the PRP group compared to the HA group (P < 0.001). Other WOMAC and SF-36 parameters improved only in the PRP group. More improvement (but not statistically significant) was achieved in patients with grade 2 OA in both the groups.
This study suggests that PRP injection is more efficacious than HA injection in reducing symptoms and improving quality of life and is a therapeutic option in select patients with knee OA who have not responded to conventional treatment.
Purpose
The purposes of this study were to evaluate regeneration of the articular cartilage after medial opening-wedge high tibial osteotomy for knees with medial-compartment osteoarthritis and to assess the clinical outcome and cartilage regeneration according to the postoperative limb alignment at 2 years postoperatively.
Methods
The study involved 159 knees in 159 patients. For evaluation of cartilage degeneration, the International Cartilage Repair Society grading system was used for arthroscopic grading on initial arthroscopy during high tibial osteotomy. The patients underwent a second-look arthroscopic evaluation of the articular cartilage at the time of removal of the plate, an average of 2 years after the initial osteotomy. For evaluation of cartilage regeneration, the articular cartilage was classified into 2 stages as no regenerative change (grade 1) or white scattering with fibrocartilage, partial coverage with fibrocartilage, or even coverage with fibrocartilage (grade 2) on second-look arthroscopy. Maturation of the cartilage regeneration was defined as even coverage with fibrocartilage. “Immaturation” of the cartilage regeneration was defined as white scattering with fibrocartilage or partial coverage with fibrocartilage. Clinical evaluations were performed by use of Knee Society scores preoperatively and at 2 years postoperatively. We divided the knees into 3 groups according to the postoperative limb alignment. Group A comprised knees with a mechanical tibiofemoral angle of 0° or less. Group B comprised knees with a mechanical tibiofemoral angle greater than 0° and less than 6°. Group C comprised knees with a mechanical tibiofemoral angle of 6° or greater.
Results
Grade 2 regeneration was achieved in the medial femoral condyle articular cartilage in 92% of knees and in the medial tibial plateau articular cartilage in 69% of knees. Maturation of the cartilage regeneration was found in the medial femoral condyle articular cartilage in 4% of knees and in the medial tibial plateau articular cartilage in 1% of knees. At follow-up, no significant differences were seen between clinical outcomes and initial cartilage degeneration (P = .338) or cartilage regeneration (P = .699). Regeneration of the medial femoral condyle articular cartilage was found in 75% of group A knees, 95% of group B knees, and 92% of group C knees. Significant differences were seen between cartilage regeneration and clinical outcomes (P = .001), as well as postoperative limb alignment (P = .018). Clinical and regeneration results were better in group B than in groups A and C.
Conclusions
The degenerated cartilage of the medial femoral condyle and medial tibial plateau could be partially or entirely covered by newly regenerated cartilage at 2 years after adequate correction of varus deformity by medial opening-wedge high tibial osteotomy without cartilage regeneration strategies.
Level of Evidence
Level IV, therapeutic case series.
The aim of this review was to analyze the available evidence on the clinical application of this biological approach for the injective treatment of cartilage lesions and joint degeneration, together with preclinical studies to support the rationale for the use of platelet concentrates, to shed some light and give indications on what to treat and what to expect from intra-articular injections of platelet-rich plasma (PRP).
All in vitro, in vivo preclinical and clinical studies on PRP injective treatment in the English language concerning the effect of PRP on cartilage, synovial tissue, menisci, and mesenchymal stem cells were considered. A systematic review on the PubMed database was performed using the following words: (platelet-rich plasma or PRP or platelet concentrate or platelet lysate or platelet supernatant) and (cartilage or chondrocytes or synoviocytes or menisci or mesenchymal stem cells).
Fifty-nine articles met the inclusion criteria: 26 were in vitro, 9 were in vivo, 2 were both in vivo and in vitro, and 22 were clinical studies. The analysis showed an increasing number of published studies over time. Preclinical evidence supports the use of PRP injections that might promote a favourable environment for joint tissues healing. Only a few high-quality clinical trials have been published, which showed a clinical improvement limited over time and mainly documented in younger patients not affected by advanced knee degeneration.
Besides the limits and sometimes controversial findings, the preclinical literature shows an overall support toward this PRP application. An intra-articular injection does not just target cartilage; instead, PRP might influence the entire joint environment, leading to a short-term clinical improvement. Many biological variables might influence the clinical outcome and have to be studied to optimize PRP injective treatment of cartilage degeneration and osteoarthritis. LEVEL OF EVIDENCE: IV.
Microfracture (MFX) is frequently used to treat deep cartilage defects in the ankle; however, the data on repair tissue (RT) quality after MFX are very limited at this time. T2-mapping at 3 T has been optimized for the ankle and can be used to noninvasively evaluate cartilage collagen and water content. The aim of this study was to determine if the RT after MFX in the ankle had T2 properties similar to the adjacent reference cartilage (RC).
Fourteen cases after MFX in the ankle were assessed with morphological MRI and T2-mapping at 3 T. The American Orthopaedic Foot and Ankle Society (AOFAS) score and a modified Cinicinnati Knee Rating System rating were used to evaluate the clinical outcome. The MRI protocol included a 3-dimensional sequence and a proton-density sequence for morphological evaluation and a multiecho spin echo sequence for T2-mapping. Region of interest analyses were carried out in accordance with the morphological images to ensure complete coverage of the defect site.
Both clinical scores demonstrated significant improvement at the time of the MR examination (P < 0.001). RT T2 was 49.3 ± 10.1 (range, 35.7-69.3) milliseconds, and RC T2 was 49.9 ± 8.2 (range, 38.4-63.7) milliseconds (P = 0.838). Relative T2 (rT2) was 1.00 ± 0.20 (range, 0.72-1.36).
MFX in the ankle can provide RT with T2 properties similar to adjacent cartilage.
The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence (LOE) available to support the operative technique of distraction ankle arthroplasty for the current generally accepted indications and make a grade of recommendation for each.
A comprehensive review of the literature was performed (November 2010 to January 2011) using the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of distraction ankle arthroplasty. All articles were reviewed and assigned a classification (I-V) of Level of Evidence. An analysis of the literature reviewed was used to assign a Grade of Recommendation for each current generally accepted indication for distraction ankle arthroplasty.
There is insufficient evidence based literature (Grade I) to support or refute the procedure for either: post-traumatic ankle arthritis, arthritis associated with ligamentous instability, primary degenerative joint disease, chondrolysis, deformity associated with arthritis, osteochondral defects and congenital ankle abnormalities.
Inadequate evidence based literature exists to support or refute all currently accepted indications for distraction ankle arthroplasty and further high quality, scientific studies are needed upgrade to these recommendations.
Total ankle arthroplasty (TAA) implantation is increasing, as the potential for pain relief and restoration of function and risks are compared with those for ankle fusion. A previous analysis with a simple decision tree suggested TAA was cost-effective compared with ankle fusion. However, reevaluation is warranted with the availability of newer, more costly implants and longer-term patient followup data.
Considering all direct medical costs regardless of the payer, we determined if TAA remains a cost-effective alternative to ankle fusion when updated evidence is considered.
Using a Markov model, we evaluated expected costs and quality-adjusted life years (QALY) for a 60-year-old hypothetical cohort with end-stage ankle arthritis treated with either TAA or ankle fusion. Costs were estimated from 2007 diagnosis-related group (DRG) and current procedural terminology (CPT) codes for each procedure. Rates were extracted from the literature. The incremental cost-effectiveness ratio (ICER), a measure of added cost divided by QALY gained for TAA relative to ankle fusion, was estimated. To identify factors affecting the value of TAA, sensitivity analyses were performed on all variables.
TAA costs 11,800/QALY gained. Few variables in the sensitivity analyses resulted in TAA no longer being cost-effective.
Despite more costly implants and longer followup, TAA remains a cost-effective alternative to ankle fusion in a 60-year-old cohort with end-stage ankle arthritis.
High tibial osteotomy (HTO) is a method used to treat medial compartmental osteoarthritis in the knee. The realignment of the knee changes the loading patterns within the joint and may allow for regeneration of articular cartilage. Magnetic resonance imaging methods can be used to assess the quality of the regenerated cartilage.
Altering mechanical alignment through HTO will have predictable effects on articular cartilage, allowing cartilage preservation and possible regeneration. Quality of regenerated cartilage will be inferior to normal articular cartilage.
Case series; Level of evidence, 4.
Ten patients undergoing medial opening wedge HTO were evaluated using dGEMRIC methods (ie, delayed gadolinium-enhanced magnetic resonance imaging of cartilage) preoperatively and at 6 months, 1 year, and 2 years after HTO. Magnetic resonance images were evaluated by hand segmentation, and T1(Gd) relaxation times reflective of glycosaminoglycan content were determined for these regions of interest using magnetic resonance imaging analysis software.
The lateral compartment displayed higher T1(Gd) values than the medial compartment at baseline. Initially, a decrease in T1(Gd) values on the medial side were observed for all patients at 6 months and remained reduced for all but 2 participants at 1 year and 2 years after HTO. However, on the medial side after 6 months, the rate of change for T1(Gd) values shifted from being negative (-9.6 milliseconds per month) to being positive (1.7 milliseconds per month). A positive change in the T1(Gd) of the medial tibial plateau was responsible for the positive overall change in the medial compartment. There was no significant difference in the rate of change on the lateral side (P = .141), with the average over the 2-year period being a decrease of 2.28 milliseconds per month.
Medial opening wedge HTO provides subjective improvements in pain and quality of life, but the potential benefit of allowing articular cartilage preservation and possible regeneration is not well established. Results showed that after a nonweightbearing period, the rate of change in the medial compartment changes from negative to positive, indicating the potential for articular cartilage recovery secondary to an improved mechanical environment.
Despite advances in managing degenerative arthritis of the ankle joint, there are few optimal treatment options for young patients with symptomatic, end-stage degenerative disease. Popular surgical options consist of traditional arthrodesis and, more recently, arthroplasty. Additional techniques, including arthroscopic debridement and joint distraction, have gained little traction. An alternative option is bipolar fresh osteochondral allograft (OCA) transplantation of the tibiotalar joint. We previously reported on a cohort of 86 ankles that had undergone bipolar OCA of the tibiotalar joint and now present the results after longer, mid-term follow-up (mean, 9.2 years) of the same cohort. OCA survivorship was 74.8% at 5 years and 56% at 10 years. Of the patients with a surviving graft, 74% were satisfied with the results. At the latest follow-up, 86% reported better function and 79% reported less pain compared with preoperatively. Bipolar OCA transplantation of the tibiotalar joint is an effective alternative treatment for selected young patients with end-stage ankle arthritis who wish to avoid arthrodesis or prosthetic arthroplasty.
Level of Evidence
Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
Background:
Osteochondral allograft (OCA) transplantation is a useful treatment for posttraumatic ankle arthritis in young patients, but failure rates are high and reoperations are not uncommon. The aim of this study was to evaluate the outcomes of failed ankle OCA transplantation converted to ankle arthrodesis (AA) or total ankle arthroplasty (TAA).
Methods:
We evaluated 24 patients who underwent salvage procedures (13 AA and 11 TAA) after primary failed ankle OCA transplantation. Reoperations were assessed. Failure of the salvage procedure was defined as an additional surgery that required a revision AA/TAA or amputation. Evaluation among nonfailing ankles included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), pain, and satisfaction.
Results:
In the salvage AA cohort, 3 patients were classified as failures (2 revision AA and 1 amputation). The 10 nonfailing patients had a mean follow-up of 7.4 years. Eighty-eight percent were satisfied with the procedure, but 63% reported continued problems with their ankle (eg, pain, swelling, stiffness). Mean pain level was 1.9 and AAOS-FAM core score was 83±13. In the salvage TAA cohort, 2 patients were classified as failures (both revision TAA). The 9 nonfailing patients had a mean follow-up of 3.8 years. Fifty percent were satisfied with the procedure, but 40% reported continued problems with their ankle. The mean pain level was 1.3, and the median AAOS-FAM core score was 82±26.
Conclusion:
Revision and reoperation rates for salvage procedures following failed OCA transplantation of the ankle are higher compared to published data for primary AA and TAA procedures. However, we believe OCA transplantation can serve as an interim procedure for younger patients with advanced ankle joint disease who may not be ideal candidates for primary AA or TAA at the time of initial presentation.
Level of evidence:
Level IV, case series.
Aims:
We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.
Patients and methods:
Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal 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 and the rate of failure calculated for each year.
Results:
A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up.
Conclusion:
STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.
Background:
A number of new 2-component total ankle arthroplasty systems that emphasize minimal bone resection have been introduced for which few clinical outcomes reports are available. Our aim was to identify the rate of early revision among patients receiving the 2-component INFINITY prosthesis.
Methods:
Patients from 2 prospectively collected databases at the authors' institution were screened for inclusion in the present study. All patients who underwent a primary total ankle arthroplasty (TAA) with the INFINITY prosthesis and who were at least 1 year postoperative were included. A total of 159 ankles with a mean 20 months of follow up (range, 12-37) met these criteria. All surgeries were performed by 1 of 2 orthopaedic foot and ankle surgeons with extensive experience in TAA. The primary outcome was the need for revision surgery, defined as removal of 1 or both metal components. Peri-implant lucency at most recent follow-up was a secondary outcome. Weightbearing radiographs at most recent follow-up were graded for lucency independently by 2 reviewers.
Results:
Sixteen ankles (10%) underwent revision at a mean 13 months postoperatively. The most common reasons for revision were symptomatic tibial component loosening and deep infection (6 patients each, 3.8%). Of the 108 ankles with retained components and at least 1 year of radiographic follow-up, 8 (7.4%) had global lucency around the tibial component suggestive of loosening at most recent follow-up.
Conclusions:
Our initial review of patients undergoing TAA with this new 2-component prosthesis demonstrates an elevated early revision rate due to tibial component loosening compared to other implant systems.
Level of evidence:
Level IV, case series.
We report a retrospective study of 62 total ankle arthroplasties performed between 1972 and 1981. Forty-one of these have been reviewed clinically after an average follow-up of five and a half years; only 13 can be described as satisfactory. The complications encountered in all 62 arthroplasties are detailed, the most significant being superficial wound healing problems, talar collapse, and loosening of the components; 13 prosthetic joints have already been removed and arthrodesis attempted. The management of the complications is discussed. In view of the high complication rate and the generally poor long-term clinical results, we recommend arthrodesis as the treatment of choice for the painful stiff arthritic ankle, regardless of the underlying pathological process.
Background:
Over the past decade, total ankle arthroplasty (TAA) has become a mainstay in the treatment of end-stage ankle arthritis. Currently in its fourth generation, the Scandanavian Total Ankle Replacement (STAR) is the only 3-piece mobile bearing ankle prosthesis available in the United States. Our current study reports implant survivorship at 15 years and patient outcomes for a subset of these survivors available for study.
Methods:
Eighty-four TAAs were performed between 1998 and 2000. Metal component survivorship at 15 years was calculated with a Kaplan-Meier curve. Twenty-four (29%) of 84 patients were available for participation with a minimum 15-year follow-up. Any radiographic changes were documented. All additional procedures and complications were recorded. Clinical findings, self-reported performance and pain evaluations, and AOFAS ankle/hindfoot scores were noted.
Results:
Metal implant survival was 73% at 15 years. Of the 24 patients available for clinical evaluation, 18 of 24 patients (70.7%) had no change in prosthetic alignment from the immediate postoperative radiograph. Only 1 subtalar fusion was required for symptomatic adjacent joint arthritis. Three patients sustained a broken polyethylene component. AOFAS scores improved from an average of 39.6 points preoperatively, to an average of 71.6. More than half (52.4%) of patients with retained implants required an additional surgical procedure; 3 required 2 additional procedures. The average time to subsequent procedure was 10.2 years.
Conclusion:
Our small cohort demonstrated STAR ankles with retention at 9 years were highly likely to survive to 15 years, and patients continued to have significant improvement in pain relief and minimal decrease in function. At 15 years from TAA, metal survivorship was 73%. As with all ankle replacements, supplementary procedures were common.
Level of evidence:
Level IV, case series.
Autologous chondrocyte implantation (ACI) is an established surgical procedure that has provided satisfactory results. The aim of the present study was to correlate the clinical outcomes of a series of 20 patients treated by ACI at a 7-year follow-up examination with the magnetic resonance imaging (MRI) T2-mapping 5-year follow-up findings. We evaluated 20 patients using the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and the established follow-up protocol until 87.2 ± 14.5 months. MRI T2-mapping sequences were acquired at the 5-year follow-up examination. At the MRI examination (60 ± 12 months), the mean AOFAS score improved from 58.7 ± 15.7 to 83.9 ± 18.4. At the final follow-up examination at 87.2 ± 14.5 months, the AOFAS score was 90.9 ± 12.7 (p = .0005). Those patients who experienced an improvement between 5 and 7 years after surgery had a significant greater percentage of T2-map value of 35 to 45 ms (hyaline cartilage) compared with those patients who did not improve (p = .038). MRI T2 mapping was shown to be a valuable tool capable of predicting reproducible clinical outcomes after ACI even 7 years after surgery. The quality of the regenerated tissue and the degree of defect filling became statistically significant to the clinical results at the final follow-up examination.
Purpose:
To perform a systematic review comparing the clinical scores, union rate, complications, reoperations, hospital stay, and operation time between open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA).
Methods:
We conducted a comprehensive search in the MEDLINE, Embase, and Cochrane Library databases. Only comparative studies were included in this meta-analysis. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The outcomes analyzed included clinical scores, union rate, complications, reoperations, hospital stay, operation time, and intraoperative blood loss.
Results:
A total of 7 retrospective comparative studies were included in this systematic review. Clinical scores were noted in 3 studies. The American Orthopaedic Foot & Ankle Society ankle-hindfoot score and the Ankle Osteoarthritis Scale score were better in the AAA group than in the OAA group. The union rate was similar between the OAA (70%-100%) and AAA (76.2%-100%) groups. The complication rate was higher in the OAA group (6.7%-47.1%) than in the AAA group (0%-23.8%) in 6 studies. The reoperation rate was similar between the OAA (0%-26.5%) and AAA (0%-27.6%) groups. The hospital stay was shorter in the AAA group in 6 studies. Among the 5 studies that reported operation time, 4 reported no significant difference. Two studies showed that intraoperative blood loss was significantly less in the AAA group.
Conclusions:
AAA was shown to offer the advantages of better clinical scores, fewer complications, a shorter hospital stay, and less blood loss compared with OAA. However, the union rate, reoperation rate, and operation time were similar overall between the 2 groups.
Level of evidence:
Level III, systematic review of Level III studies.
Background:
The aim of this study was to evaluate the clinical and radiologic outcomes of medial compartment ankle osteoarthritis after supramalleolar osteotomy (SMO) without the bone marrow stimulation procedure and confirm cartilage recovery by second-look arthroscopy.
Methods:
Twenty-two ankles that were followed for more than 1 year after SMO were retrospectively reviewed. Visual analog scale pain scores and American Orthopaedic Foot & Ankle Society ankle-hindfoot scores were used for functional evaluations. The tibial anterior surface angle and tibial lateral surface angle were measured on radiographs, and ankle osteoarthritis was classified by Takakura stage. Among the 22 patients, 21 underwent ankle arthroscopy prior to SMO, and second-look arthroscopy was performed in 16 patients 1 year postoperatively. Tibiotalar cartilage regeneration was evaluated according to the modified Outerbridge classification for the 14 patients who had undergone SMO without the bone marrow stimulation procedure.
Results:
The mean visual analog scale and American Orthopaedic Foot & Ankle Society scores significantly improved from 6.5 preoperatively to 1.1 postoperatively and from 60.7 preoperatively to 87.1 postoperatively, respectively ( P < .05). The mean tibial anterior surface and tibial lateral surface angles significantly improved from 83.5° and 76.9° preoperatively to 93.8° and 80.2° postoperatively, respectively ( P < .05). All preoperative Takakura stage IIIa cases and IIIb case improved to postoperative stage II. On second-look arthroscopy, cartilage regeneration of the medial compartment of the tibiotalar joint was observed in 12 of 14 patients (85%), whereas cartilage deterioration was not observed in any patient.
Conclusions:
SMO without the bone marrow stimulation procedure for medial ankle osteoarthritis demonstrated cartilage regeneration in the medial tibiotalar joint in most patients by second-look arthroscopy, as well as satisfactory clinical and radiologic outcomes.
Level of evidence:
Level IV, case series.
Introduction:
Severe post-traumatic ankle arthritis poses a reconstructive challenge in young and active patients. Although technically demanding and despite unsolved immunological issues, bipolar fresh total osteochondral allograft (BFTOA) represent an intriguing option to arthrodesis and prosthetic replacement. The purpose of this paper is to evaluate the outcomes of a series of 48 ankle BFTOA at 10 years follow up and to investigate the rate of survival long term.
Methods:
58 patients underwent BFTOA, of these 48 were available for follow up. The allograft was prepared with the help of specifically designed jigs and the surgery was performed using either a lateral or a direct anterior approach. Patients were evaluated clinically and radiographically preoperatively, and at a mean 121±18months of follow-up.
Results:
The AOFAS score improved from 31±11 pre operatively, to 65±25 at the last (p<0.0005). Fourteen failures occurred, with 70.8% allograft rate of survival. All the surviving allografts showed a reduction of the ankle joint movement, still associated with a satisfactory clinical result.
Conclusion:
The use of BFTOA represents an intriguing option to arthrodesis or arthroplasty. A satisfactory clinical result associated to a good movement of the transplanted joint is to be expected up to short-mid-term, overtime. Long term, the range of motion (ROM) is progressively decreased up to spontaneous arthrodesis in some cases, still the joint results pain free and patient's perception is of a well functioning ankle. A deeper knowledge of the immunological behavior of transplanted cartilage is needed in order to improve the durability of this fascinating technique.
Osteoarthritis is the most common and disabling of the orthopedic diseases. Currently, the conservative treatment of osteoarthritis is limited to symptomatic treatment, whose goal is to improve function and pain control. Ankle osteoarthritis is relatively uncommon, in contrast to osteoarthritis of the hip and knee, and the therapeutic options (both pharmacologic and surgical) are limited, with surgery providing poorer and less predictable results. The effectiveness of platelet-rich plasma injections for osteoarthritis is still controversial, especially so for ankle arthritis, owing to the lack of evidence in the present data. We retrospectively evaluated the mid- to long-term clinical results (mean follow-up of 17.7 months) for platelet-rich plasma injections in 20 patients (20 ankles) with ankle osteoarthritis. We evaluated the presence of pain using the visual analog scale, function using the Foot and Ankle Disability Index, and subjective satisfaction. The pre- and post-treatment scores, obtained from the clinical records and from telephone interviews during the follow-up period, were compared using the Student t test. We found a strong positive effect for 4 platelet-rich plasma injections (injected once a week) on pain (p = .0001) and function (p = .001), with 80% of patients very satisfied and satisfied, and only 2 patients (10%) required surgery because of early treatment failure. These results suggest that the use of platelet-rich plasma injection is a valid and safe alternative to postpone the need for surgery.
Objective:
Because there are no epidemiologic data regarding the frequency of ankle osteoarthritis (OA) in a general population, we sought to analyze this disabling condition in a large, well-characterized, community-based cohort of older individuals.
Methods:
Cross-sectional data, including ankle radiographs, were from the most recent data collection (2013-2015) of the Johnston County OA Project. Radiographic ankle OA (rAOA) was defined as a Kellgren-Lawrence arthritis grading scale of ≥ 2 on weight-bearing lateral and mortise radiographs. The presence of pain, aching, or stiffness in the ankles as well as history of ankle injury (limiting ability to walk for at least 2 days) were assessed. Chi-square statistics (categorical variables) and Student t tests (continuous variables) were used to compare all participant characteristics by rAOA status. Joint-based logistic regression models with generalized estimating equations were used to examine associations of rAOA and covariates of interest [age, body mass index (BMI), sex, race, ankle symptoms, and injury history].
Results:
Of 864 participants with available data, 68% were women, 34% were African American, with a mean age of 72 years and BMI of 31 kg/m(2). Nearly 7% of this sample had rAOA. Increasing age, high BMI, history of ankle injury, and presence of ankle symptoms were all independently associated with greater odds of having rAOA; no significant differences were seen by sex or race.
Conclusion:
The frequency of rAOA was higher than estimates generally quoted in the literature. While injury was an important contributor, other factors such as age, BMI, and symptoms were also significantly associated with rAOA.
Ankle distraction is an alternative to ankle arthrodesis or total ankle arthroplasty in younger patients with arthritis. Ankle distraction involves the use of external fixation to mechanically unload the ankle joint, which allows for stable, congruent range of motion in the setting of decreased mechanical loading, potentially promoting cartilage repair. Adjunct surgical procedures are frequently done to address lower-extremity malalignment, ankle equinus contractures, and impinging tibiotalar osteophytes. Patients can bear full weight during the treatment course. The distraction frame frequently uses a hinge, and patients are encouraged to do daily range-of-motion exercises. Although the initial goal of the procedure is to delay arthrodesis, many patients achieve lasting clinical benefits, obviating the need for total ankle arthroplasty or fusion. Complications associated with external fixation are common, and patients should be counseled that clinical improvements occur slowly and often are not achieved until at least 1 year after frame removal.
Background:
Corticosteroid injections have been used for a variety of foot and ankle pathologies over the years, and our aim was to evaluate the efficacy and safety of them in our clinic.
Materials and methods:
We performed a retrospective review of notes and a telephone questionnaire on the clinical outcome of all patients who underwent a corticosteroid injection of the foot or ankle in a year. All procedures were performed in an outpatient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance and had a minimum of 2 years of follow-up.
Results:
Overall, 314 of 365 (86%) patients reported a significant improvement in symptoms, and 242 (66%) reported complete resolution of their pain, with 107 (29%) remaining asymptomatic at the 2-year follow-up. The mode time of recurrence of pain was 3 months. Fifty-one (14%) underwent a further injection and 88 (24%) underwent operative intervention within the follow-up period. Complication rates in our series were low. There were no reported infections. Complications occurred in 5 patients (1.3%), including steroid flare, pain, and plantar plate ruptures.
Conclusion:
Corticosteroid injections were a safe and effective option for treating a variety of foot and ankle conditions and reduced the need for surgery. They were particularly effective for the treatment of ankle soft tissue impingement. They appear ineffective in providing significant improvement in pain for longer than 3 months in conditions such as plantar fasciitis and hallux rigidus.
Level of evidence:
IV, case series.
Background:
Supramalleolar osteotomy (SMOT) is an alternative operative procedure for the management of early and midstage varus ankle arthritis. However, whether fibular osteotomy is needed is controversial. The purpose of the current study was to evaluate the functional and radiologic outcomes of pre- and postoperative SMOT, and to compare the outcomes between patients with and without fibular osteotomy.
Methods:
Forty-one Takakura stage 2 and 3 varus ankle osteoarthritis patients treated with SMOT were included. Fourteen males and 27 females with a mean age of 50.7 (range, 32-71) years were followed with a mean of 36.6 (range, 17-61) months. There were 22 cases with fibular osteotomy and 19 without. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Maryland foot score, and Ankle Osteoarthritis Score (AOS) were used for pre- and postoperative functional evaluation. The tibial articular surface angle (TAS), talar tilt (TT), tibiocrural angle (TC), and tibial lateral surface angle (TLS) were evaluated pre- and postoperatively.
Results:
At the last follow-up, the mean AOFAS score (from 50.8 to 83.1 points) and Maryland score (from 58.3 to 81.6 points) in overall were improved (P < .01); the mean AOS pain (from 42.6 to 26.1 points) and function (from 53.4 to 36.8 points) scores were decreased (P < .01). For radiologic evaluation, all the included parameters were improved (P < .05) except TLS. The mean Takakura stage was decreased (P < .01). No significant difference could be detected in comparing the functional outcomes between those with and without fibular osteotomy. However, in the fibular osteotomy group, TT was decreased (P < .05) and TC was improved (P < .01) significantly.
Conclusion:
SMOT was promising, with substantial functional improvement and malalignment correction for varus ankle arthritis. Fibular osteotomy may be necessary in cases with large TT and small TC angles.
Level of evidence:
Level III, retrospective comparative study.
Background:
In cases with total ankle replacement (TAR) failure, a decision between revision TAR and salvage arthrodesis (SA) must be made. In a previous study, we analyzed revision TAR and found low functional outcome and satisfaction. The aims of the current study were to analyze SA concerning failure rate and patient-related outcome measures (PROMs).
Methods:
Until September 2014, a total of 1110 primary TARs were recorded in the Swedish Ankle Registry. Of the 188 failures, 118 were revised with SA (and 70 with revision TAR). Patient- and implant-specific data for SA cases were analyzed as well as arthrodesis techniques. Failure of SA was defined as repeat arthrodesis or amputation. Generic and region-specific PROMs of 68 patients alive with a solid unilateral SA performed more than 1 year before were analyzed.
Results:
The first-attempt solid arthrodesis rate of SA was 90%. Overall, 25 of 53 (47%) patients were very satisfied or satisfied. Mean Self-reported Foot and Ankle Score (SEFAS) was 22 (95% confidence interval 20-24), Euro Qol-5 Dimensions 0.57 (0.49-0.65), Euro Qol-Visual Analogue Scale 59 (53-64), Short Form-36 physical 34 (31-37) and mental 50 (46-54). The scores and satisfaction were similar to those after revision TAR but the reoperation rate was significantly lower in SA (P < .05).
Conclusion:
Salvage arthrodesis after failed TAR had a solid arthrodesis rate of 90% at first attempt, but similar to revision TAR, less than 50% of the patients were satisfied and the functional scores were low. Until studies show true benefit of revision TAR over SA, we favor SA for failed TAR.
Level of evidence:
Level IV, retrospective case series.
Background:
The cause of ankle osteoarthritis (OA) is usually trauma. Patients are relatively young, since ankle trauma occurs at a relatively young age. Several conservative treatment options are available, evidence of the benefits and harms of these options are lacking.
Objectives:
To assess the benefits and harms of any conservative treatment for ankle OA in adults in order to provide a synthesis of the evidence as a base for future treatment guidelines.
Search methods:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, issue 9), MEDLINE (Ovid) (1946 up to 11 September 2014), EMBASE (1947 to September 2014), PsycINFO (1806 to September 2014), CINAHL (1985 to September 2014), PEDro (all years till September 2014), AMED until September 2014, ClinicalTrials.gov, Current Controlled Trials, The Dutch Register. To identify potentially relevant studies we screened reference lists in retrieved review articles and trials.
Selection criteria:
We considered randomised or controlled clinical trials investigating any non-surgical intervention for ankle OA for inclusion.
Data collection and analysis:
We used standard methodological procedures expected by Cochrane.
Main results:
No other RCT concerning any other conservative treatment besides the use of hyaluronic acid (HA) for ankle OA was identified. Six randomised controlled trials (RCTs) were included.A total of 240 participants diagnosed with ankle OA were included in this review. The primary analysis included three RCTs (109 participants) which compared HA to placebo. One study compared HA to exercise therapy, one compared HA combined with exercise therapy to an intra-articular injection of botulinum toxin and one compared four different dosages of HA.Primary analysis: a pooled analysis of two trials (45 participants) found that the Ankle Osteoarthritis Scale (AOS) total score (measuring pain and physical function) was reduced by 12% (95% CI -24% to -1%) at six months (mean difference (MD) -12.53 (95% CI -23.84 to -1.22) on a scale of 0 to 100; number needed to treat for an additional beneficial outcome (NNTB) = 4 (95% CI 2 to 205); this evidence was graded as low quality, due to limitations in study design (unclear risk of selection bias for two studies and unclear risk for attrition bias for one study) and imprecision of results: a small population size (45 participants). It is not known if a mean difference of 12.53 points on a 100 point scale is clinically relevant. No minimal important clinical difference is known for this score. Pain and function outcomes were not reported separately. Radiographic joint structure changes were not investigated. For the mean quality of life at six months (two trials; 45 participants) no meta-analysis could be performed due to missing data. No serious adverse events (SAEs) were noted and no participants withdrew because of an adverse event. There were a few adverse events (AEs) 5/63 (8%) in the HA group and 2/46 (4%) in the placebo group. The Peto odds ratio (Peto OR) to have an adverse event was 2.34 higher compared to the control group (95% CI 0.45 to 12.11). This evidence is inconclusive because of a wide CI and a small number of events.For comparing HA to exercise therapy (30 participants) the results for pain on a Visual Analogue Scale (VAS 0 to 10) at 12 months are inconclusive (MD 0.70, 95% CI -2.54 to 1.14). The American Orthopedic Foot and Ankle Society score (AOFAS score) was 13.10 points (MD) higher in favour of HA (95% CI 2.97 to 23.23) on a scale of 0 to 100. The evidence was graded as low. No adverse events were found. Radiographic structure changes were not measured; no participants withdrew due to AEs; no SAEs were found.For the comparison of HA injection combined with exercise therapy to an intra-articular injection of botulinum toxin A (BoNT-A) (75 participants), the outcome of the AOS pain score of the affected joint at six months is inconclusive (MD 0.10, 95% CI -0.42 to 0.62). The physical function (the AOS disability score) at six months is inconclusive (MD 0.20, 95% CI -0.34 to 0.74). The same number of AEs were found in both groups; HA 2/37 (5.9%), BoNT-A 2/38 (5.8%) (risk ratio (RR) 1.03, 95% CI 0.15 to 6.91). Radiographic changes were not examined, no SAEs were found and no participants withdrew because of an AE. The evidence was graded as low.The RCT comparing four different dosing schedules for HA (26 participants) showed the best median decrease in pain on walking VAS (on a scale of 0 to 100) for 3 x 1 ml at 27 weeks with a median decrease of 30. Physical function, radiographic changes and quality of life were not measured.Twenty-seven percent of all participants had AEs, most of them in the 2ml group (57% in this group). No participants withdrew due to an AE and no SAEs were noted.Overall the quality of the evidence showed some serious limitations. The evidence was graded low for the primary analysis comparing HA to placebo. This was based on a limitation in design and implementation: sample sizes were small (45 to 92 participants) and and imprecision in results: there was an unclear risk of bias for several items concerning the three studies used in the meta analysis.
Authors' conclusions:
Currently, there is insufficient data to create a synthesis of the evidence as a base for future guidelines for ankle OA. Since the aetiology of ankle OA is different, guidelines that are currently used for hip and knee OA may not be applicable for ankle OA. Simple analgesics as recommended for hip and knee OA seem however a reasonable first step to treat ankle OA. It is unclear if there is a benefit or harm for HA as treatment for ankle OA compared to placebo at six months based on a low quality of evidence. Inconclusive results were found comparing HA to other treatments. HA can be conditionally recommended if patients have an inadequate response to simple analgesics. It remains unclear which patients (age, grade of ankle OA) benefit the most from HA injections and which dosage schedule should be used.
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.
© The Author(s) 2015.
Background:
Both total ankle replacement (TAR) and ankle arthrodesis do show some problems in long-term studies. To choose either of these surgical options is a delicate task. There are no randomized studies reported in the literature and no previous studies in which patients constitute the own controls.
Methods:
Patients with a TAR and a contralateral ankle arthrodesis were identified in the Swedish Ankle Register. A self-reported foot and ankle specific questionnaire (SEFAS) was sent to these patients who also were asked to report their grade of satisfaction from 1 to 5.
Results:
The median SEFAS score was 32 (16-44) for the prostheses and 27 (14-47) for the arthrodeses. The median satisfaction score was 2 (1-4) for the prostheses and 2 (1-5) for the arthrodeses. There were no statistically significant difference between the prosthetic side and the fused side regarding these scores.
Conclusion:
Patients who had undergone ankle arthrodesis on one side and had the contralateral ankle replaced, were equally satisfied with both procedures.
Background:
The purpose of this study was to document outcomes following microfracture of articular cartilage lesions of the ankle. Our hypothesis was that patients who underwent ankle microfracture would have good to excellent outcomes.
Methods:
This study was institutional review board approved. Patients older than 18 years who underwent ankle microfracture surgery for Outerbridge grade 3 or 4 articular cartilage lesions, by a single surgeon, were included. Detailed intraoperative findings were documented at surgery. Patients completed a questionnaire with Foot and Ankle Disability Index (FADI), Lysholm, Tegner, and patient satisfaction with outcome. All data were collected prospectively and stored in a data registry and retrospectively reviewed. Forty patients (21 males, 19 females, mean age = 42 years [range, 19-65 years]) were included in this study. Thirteen (33%) had previous ankle surgery. Follow-up was obtained for 94% of patients (n = 34). Mean follow-up time was 26 months (range, 12-48 months).
Results:
Mean talar defect size was 70 mm(2) (range, 4-300 mm(2)). Mean tibia defect size was 31 mm(2) (range, 8-54 mm(2)). Four patients (10.5%) required subsequent surgery following microfracture surgery. Mean time to second surgery was 17 months (range, 4-32 months). Mean Lysholm score was 74 (range, 31-96). Mean FADI Activities of Daily Living (ADL) was 81 (range, 33-99), FADI Sport was 62 (range, 13-100), and FADI total score was 77 (range, 28-98). Median Tegner was 4 (range, 0-10). Median patient satisfaction was 8 (range, 3-10). Patients who had previous ankle surgery had significantly lower outcome scores versus patients who did not have previous ankle surgery for FADI ADL (70 vs 81, P = .029) and FADI Total (51 vs 77, P = .028). Days from injury to surgery were correlated with age at surgery (r = .323, P = .042) and negatively correlated with FADI ADL (r = -.431, P = .014), FADI Sport (r = -.490, P = .004), FADI Total (r = -.429, P = .014), and Tegner (r = -.402, P = .023).
Conclusion:
Patients who underwent microfracture for grade 3 or 4 ankle articular cartilage lesions had high patient satisfaction. Patients who had previous ankle surgery had lower postoperative ankle function; however, patient satisfaction remained high. This study supports microfracture for treatment of grade 3 and 4 ankle articular cartilage lesions.
Level of evidence:
Level IV, case series.
Surgical treatments for end-stage ankle arthritis include total ankle replacement and ankle arthrodesis. Although arthrodesis is a reliable procedure, ankle replacement is often preferred by patients. This prospective study evaluated intermediate-term outcomes of ankle replacement and arthrodesis in a large cohort at multiple centers, with variability in ankle arthritis type, prosthesis type, surgeon, and surgical technique. We hypothesized that patient-reported clinical outcomes would be similar for both procedures.
Patients in the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database were treated with total ankle replacement (involving Agility, STAR, Mobility, or HINTEGRA prostheses) or ankle arthrodesis by six subspecialty-trained orthopaedic surgeons at four centers between 2001 and 2007. Data collection included demographics, comorbidities, and the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. The preoperative and latest follow-up scores for patients with at least four years of follow-up were analyzed. Sensitivity analyses excluded ankles that had undergone revision. A linear mixed-effects regression model compared scores between the groups, adjusting for age, sex, side, smoking status, body mass index, inflammatory arthritis diagnosis, baseline score, and surgeon.
Of the 388 ankles (281 in the ankle replacement group and 107 in the arthrodesis group), 321 (83%; 232 ankle replacements and eighty-nine arthrodeses) were reviewed at a mean follow-up of 5.5 ± 1.2 years. Patients treated with arthrodesis were younger, more likely to be diabetic, less likely to have inflammatory arthritis, and more likely to be smokers. Seven (7%) of the arthrodeses and forty-eight (17%) of the ankle replacements underwent revision. The major complications rate was 7% for arthrodesis and 19% for ankle replacement. The AOS total, pain, and disability scores and SF-36 physical component summary score improved between the preoperative and final follow-up time points in both groups. The mean AOS total score improved from 53.4 points preoperatively to 33.6 points at the time of follow-up in the arthrodesis group and from 51.9 to 26.4 points in the ankle replacement group. Differences in AOS and SF-36 scores between the arthrodesis and ankle replacement groups at follow-up were minimal after adjustment for baseline characteristics and surgeon.
Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation; rates of reoperation and major complications were higher after ankle replacement.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. PEER REVIEW This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Total ankle replacement is increasingly recommended for patients with end-stage ankle osteoarthritis. We analyzed the survivorship of 722 arthroplasties performed with one type of three-component total ankle prosthesis.
Seven hundred and seventy-nine primary total ankle arthroplasties (741 patients) were performed between May 2000 and July 2010 with use of the HINTEGRA three-component prosthesis. A logistic multiple regression model was used to identify independent risk factors for prosthesis failure in 684 patients (722 ankles). The mean time to final follow-up (and standard deviation) was 6.3 ± 2.9 years.
Seven hundred and twenty-two ankles (684 patients) were available for survivorship analysis at the latest follow-up. The overall survival rates were 94% and 84% after five and ten years, respectively. Sixty-one ankles had a revision arthroplasty (twenty-seven both components, thirteen the tibial component only, and fourteen the talar component only) or were converted to a fusion (seven ankles).There were no polyethylene failures. There were no amputations. The generation category of the prosthesis, the cause of ankle osteoarthritis, and the age of the patient were identified as independent risk factors for prosthesis failure.
The midterm survivorship of the HINTEGRA implant was comparable with that of other third-generation total ankle replacements.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
Ankle arthrodesis results in measurable improvements in terms of pain and function in patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity, with reports of shorter hospital stays, shorter time to solid fusion, and equivalent union rates when compared with open arthrodesis. However, there remains a lack of high-quality prospective data.
Methods:
We evaluated the results of open and arthroscopic ankle arthrodesis in a comparative case series of patients who were managed at two institutions and followed for two years. The primary outcome was the Ankle Osteoarthritis Scale score, and secondary outcomes included the Short Form-36 physical and mental component scores, the length of hospital stay, and radiographic alignment. There were thirty patients in each group.
Results:
Both groups showed significant improvement in the Ankle Osteoarthritis Scale score and the Short Form-36 physical component score at one and two years. There was significantly greater improvement in the Ankle Osteoarthritis Scale score at one year and two years and shorter hospital stay in the arthroscopic arthrodesis group. Complications, surgical time, and radiographic alignment were similar between the two groups.
Conclusions:
Open and arthroscopic ankle arthrodesis were associated with significant improvement in terms of pain and function as measured with the Ankle Osteoarthritis Scale score. Arthroscopic arthrodesis resulted in a shorter hospital stay and showed better outcomes at one and two years.
OBJECTIVE: s: To explore the effectiveness and safety of hyaluronic acid (HA) administration for ankle osteoarthritis (OA) and to investigate the effects of variations in HA regimens on treatment responses. DATA SOURCES: Electronic databases including PubMed and Scopus were searched from January 1995 to June 2012. STUDY SELECTION: We included randomized controlled trials or prospective cohort studies that employed intra-articular HA to treat ankle OA. Four randomized controlled trials, one comparative and four single arm prospective studies were identified, comprising 354 PARTICIPANTS: Data extraction: We determined effect sizes for selected studies by extracting pain scores from ankle OA or visual analogue scales before and after HA or reference treatments. Meta-regression was implemented to determine whether outcomes were modified by variations in HA regimens. DATA SYNTHESIS: The pooled effect size of improvement scores from baseline was 2.01 (95% CI, 1.27-2.75), whereas the values of comparisons with reference treatments including saline, exercise and arthroscopy reduced to 0.85 (95% CI, -0.13 to 1.83). The placebo effect of the injection procedure accounted for 87% of the observed efficacy of HA treatment. The meta-regression indicated that the molecular weight was not associated with the magnitude of pain relief, but increases in total doses and 39 active ingredients administered might result in better outcome. Conversely, increases in injection volumes might cause a reduction of effect sizes. Regarding the side effects, the use of extremely high molecular weight HA frequently caused early post-injection pain. CONCLUSION: Intra-articular HA administration can significantly reduce pain in ankle OA compared with the condition before treatment, and is likely superior to reference therapy. We recommend using multiple doses with an appropriate injection volume to achieve maximum effectiveness.
Posttraumatic osteoarthritis affects approximately 5.6 million Americans annually. Those affected are typically younger and more active than persons with primary osteoarthritis. Arthrodesis is the typical management option for persons with end-stage ankle and subtalar posttraumatic arthritis. Arthroplasty is typically reserved for elderly persons. The functional limitations resulting from any of these strategies make treatment of this young population challenging. Combat wounds frequently lead to severe lower extremity injuries. We present a series of patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint after combat trauma. They were treated at our institution with an integrated orthotic and rehabilitation initiative called the Return To Run clinical pathway. This clinical pathway may serve as an alternative or adjunct to arthrodesis and arthroplasty for young patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint.
Purpose:
This study was designed to review the outcomes of patients who have undergone arthroscopic treatment for mild to moderate ankle osteoarthritis and to determine the factors associated with unsuccessful outcomes.
Methods:
A total of 63 patients (mean age, 53.7 ± 16 years) with mild to moderate ankle osteoarthritis who underwent arthroscopic treatment were analysed. We investigated the possible correlations between the clinicopathologic features and clinical outcomes using the visual analogue scale for pain and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score and analysed the data to clarify the effect of prognostic factors on clinical outcome.
Results:
Visual analogue scale and AOFAS scores were improved after surgery for up to 2 years (p < 0.0001). The largest improvements in clinical scores were observed after 6 months, and thereafter, they steadily declined. Body mass index (BMI) (p = 0.011) and presence of associated intra-articular lesions (p = 0.002) showed a significant correlation with the clinical outcome. There was no association between outcome and the patient's age, gender, duration of symptoms, type of osteoarthritis, treatment modality and coronal alignment (n.s.).
Conclusion:
Arthroscopic treatment for mild to moderate ankle osteoarthritis has a favourable outcome in selected patients. BMI and associated intra-articular lesion are significant risk factors for poor outcome.
The contact area of eight human talocrural joints was measured. After preparation, the talocrural joint was set into the compression machine. Under loading the casting was made by silicon rubber and the pressure distribution was measured by pressure sensor sheet. The contact area was localized at anterior and lateral parts. Under 1,500 N loading, the contact area was 522 mm2 and the maximum pressure was 9.9 MPa. Slight diastasis caused a decrease of the contact area and an increase of pressure.An acht menschlichen oberen Sprunggelenken wurde der Gelenkkontakt analysiert. Nach der Vorbereitung wurde das obere Sprunggelenk in eine Kompressionsmaschine eingespannt. Unter beibehaltener Belastung wurde eine Guform aus einer Giemasse hergestellt and auch die Verteilung des Druckes mit einem drucksensitiven Papier vermessen.Die Gelenkkontaktflche auf der Talusrolle liegt im ventrolateralen Bereich. Unter 1500 N Kompression ist der Maximumdruck 9.9 MPa and der Flcheninhalt 522 mm2. Eine kleine Diastase des oberen Sprunggelenks bewirkt eine Verringerung der Kontaktflche und eine Vermehrung des Druckes.
End-stage ankle arthritis should have an appropriate classification to assist surgeons in the management of end-stage ankle arthritis. Outcomes research also requires a classification system to stratify patients appropriately.
Six fellowship trained foot and ankle surgeons met on two occasions to derive a classification system for end-stage ankle arthritis. A four-part classification system was designed. Four surgeons reviewed blinded patient profiles and radiographs on two occasions to determine the inter- and intraobserver reliability.
Good interobserver reliability (kappa = 0.62) and intraobserver reproducibility (kappa = 0.72) was demonstrated for the classification system.
The COFAS classification system appears to be a valid tool for the management and research of end-stage ankle arthritis.