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    Understanding 2 Surgical Options for Treating Ankle Arthritis

    “When a patient presents with arthritis of the ankle, how do you counsel that patient with regard to options, indications, contraindications, issues, and outcomes?” asked Daniel B. Ryssman, MD, at the recent ICJR/MAOA 1-day course, The Foot & Ankle – Current Concepts on Reconstruction, Sports and Trauma. “How do you choose between ankle arthrodesis and total ankle replacement?”

    Provided there are no contraindications, Dr. Rysmann, from Mayo Clinic in Rochester, Minnesota, said the following considerations should play a signficant role in the decision on which procedure to recommend:

    • Clinical outcomes
    • Adjacent joint arthritis
    • Complications
    • Survivorship
    • Deformity
    • Obesity

    Clinical Outcomes

    Reports in the literature on clinical outcomes are highly variable. The lack of objective, prospective, controlled data makes it impossible to directly compare the 2 treatment options with regard to pain relief, patient satisfaction, gait, and function.

    Ankle arthrodesis is known to cause an altered gait. Studies find that although highly satisfied, patients who undergo ankle arthrodesis continue to have functional limitations after surgery, including difficulty walking on uneven ground, difficulty with stairs, and aches after prolonged activity.

    Dr. Ryssman discussed the findings of the following studies on gait changes in total ankle replacement (TAR) and ankle arthrodesis:

    • Brodsky et al [1] included 50 patients who had undergone TAR with the Scandinavian Total Ankle Replacement (STAR) in their prospective study. They found increases in walking velocity (cadence and stride), range of motion (approximately 3°), and ankle power in patients who received the STAR implant.
    • Hahn et al [2] compared gait after ankle arthrodesis and TAR in 18 patients. After 12 months of follow-up, the authors found that pain had decreased and gait velocity and stride length had improved with both treatment options. In addition, range of motion improved in TAR patients, and peak plantar flexion moment increased in ankle arthrodesis patients.
    • Sinber et al [3] compared outcomes of ankle arthrodesis and TAR with normal controls. Patients who underwent TAR had greater motion in the sagittal plane. Patients in both treatment groups had decreased plantar flexion, ankle moment, and ankle power. The 2 groups also had similar improvements in patient-reported outcomes. Neither treatment group had a return to a normal gait.

    Dr. Ryssman concluded that patients who undergo either procedure will see improvements, but they will not regain normal motion or gait.

    Adjacent Joint Arthritis

    Several studies suggest that adjacent joint arthritis increases after ankle arthrodesis. This is believed to be due to altered biomechanics and increased motion and wear through the subtalar and tarsal joints as compensation for the loss of ankle motion.

    A meta-analysis by Ling et al [4] found altered biomechanics and an 18% to 100% prevalence of adjacent joint arthritis in studies of patients who had undergone ankle arthrodesis. Their analysis, however, was unable to show that ankle arthrodesis was the cause of the adjacent joint arthritis. Postoperative radiographic findings of arthritis did not conclusively correlate with clinical outcomes.

    Complications

    Great variability can be found in the reported complication rates for ankle arthrodesis and TAR:

    • For ankle arthrodesis, the complication rate ranges from 6% to 60%, with the non-union rate ranging from 0% to 41%.
    • For TAR, the overall complication rate ranges from 10% to more than 50%.
      Survivorship

    The union rate for ankle arthrodesis is around 90%. An advantage of this procedure is that once the arthrodesis heals, it will never fail.

    A meta-analysis of 49 studies by Haddad et al [5] examined outcomes of TAR and found a 5-year survival rate of 78% and a 10-year survival rate of 77%. A similar study by Zaidi et al [6] looked at 58 studies and found a 10-year survival rate of 89%.

    Dr. Ryssman tells his patients to expect a 10- to 15-year survival rate of about 80%.

    Preoperative Deformity

    Dr. Ryssman said reliable correction of the ankle deformity can usually be achieved with an ankle arthrodesis.

    It was historically thought that a coronal plane deformity of greater than 10° was a contraindication to TAR. This degree of deformity was believed to cause increased talar tilt and edge loading, leading to accelerated polyethylene wear, component loosening, and early failure.

    More recently, surgeons performing TAR have been able to correct preoperative deformities of up to 20° and achieve good outcomes.

    One study, [7] however, found no significant differences in severity of coronal plane deformity and clinical outcomes in TAR at 2 years after the procedure.

    Dr. Ryssman said deformities must be corrected if the surgeon is performing TAR.

    Obesity

    Mean BMI of overweight and obese patients does not decrease after successful ankle arthrodesis or TAR. [8]

    Multiple studies have shown that obesity is associated with increased rates of complications after ankle arthrodesis and TAR, and obese TAR patients have increased long-term risk of implant failure.

    Conclusion

    When comparing ankle arthrodesis and TAR, Dr. Ryssman finds that some indications are “hard and fast” and some are relative.

    So when discussing the options, Dr. Ryssman counsels his patients about the pros and cons of each procedure and together they make a decision based on patient factors such as history, health, expectations and desired activities.

    Click the image above to watch Dr. Ryssman’s presentation.

    References

    1. Brodsky JW, Polo FE, Coleman SC, Bruck N. Changes in gait following the Scandinavian total ankle replacement. J Bone Joint Surg Am. 2011;93:1890–6
    2. Hahn ME, Wright ES, Segal AD, et al. Comparative gait analysis of ankle arthrodesis and arthroplasty: initial findings of a prospective study. Foot Ankle Int. 2012;33(4):282-9
    3. Singer S, Klejman S, Pinsker E, Houck J, Daniels T. Ankle arthroplasty and ankle arthrodesis: gait analysis compared with normal controls. J Bone Joint Surg Am, 2013 Dec 18; 95 (24): e191
    4. Ling JS, Smyth NA, Fraser EJ, et al. Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot – a systematic review. J Bone Joint Surg Am, 2015 Mar 18; 97 (6): 513 -519
    5. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis – a systematic review of the literature. J Bone Joint Surg Am, 2007 Sep; 89 (9): 1899 -1905
    6. Zaidi R, Cro S, Gurusamy K, et al. The outcome of total ankle replacement – a systematic review and meta-analysis. Bone Joint J 2013;95-B:1500–7
    7. Queen RM, Adams Jr SB, Viens NA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am, 2013 Nov 06; 95 (21): 1927 -1934
    8. Penner MJ, Pakzad H, Younger A, Wing KJ. Mean BMI of overweight and obese patients does not decrease after successful ankle reconstruction. J Bone Joint Surg Am. 2012 May 2;94(9):e57