Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BackgroundThe aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.MethodsSix patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4 ± 1.9 years (range 1.0–6.5).ResultsOne patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.ConclusionIn the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.     

Supramalleolar osteotomies for degenerative joint disease of the ankle joint: indication, technique and results

Patients with varus or valgus hindfoot deformities usually present with asymmetric ankle osteoarthritis. In-vitro biomechanical studies have shown that varus or valgus hindfoot deformity may lead to altered load distribution in the tibiotalar joint which may result in medial (varus) or lateral (valgus) tibiotalar joint degeneration in the short or medium term. The treatment of asymmetric ankle osteoarthritis remains challenging, because more than half of the tibiotalar joint surface is usually preserved. Therefore, joint-sacrificing procedures like total ankle replacement or ankle arthrodesis may not be the most appropriate treatment options. The short- and midterm results following realignment surgery, are very promising with substantial pain relief and functional improvement observed post-operatively. In this review article we describe the indications, surgical techniques, and results from of realignment surgery of the ankle joint in the current literature.     

Safety and efficacy of total ankle arthroplasty versus ankle arthrodesis for ankle osteoarthritis: A systematic review and meta-analysis

Osteoarthritis is the most common joint disease-causing pain and disability, and its management keeps creating a debate. So, we aimed to compare the safety and efficacy of total ankle arthroplasty and ankle arthrodesis for ankle osteoarthritis. We searched PubMed, Cochrane, Scopus, and Web of Science till August 2021. The outcomes were pooled as Mean difference (MD) or Risk Ratio (RR), and 95% confidence interval. We included 36 studies. The results showed a significantly lower risk of infections in total ankle arthroplasty (TAA) than ankle arthrodesis (AA) (RR= 0.63, 95% CI [0.57, 0.70], p < 0.00001), amputations (RR= 0.40, 95% CI [0.22, 0.72], p = 0.002), postoperative non-union (RR= 0.11, 95% CI [0.03, 0.34], p = 0.0002), and a significant increase of overall range of motion in TAA than AA. Our results preferred total ankle arthroplasty over ankle arthrodesis in terms of lowering the rates of infections, amputations, and postoperative non-union, with better change in the overall range of motion.     

Post-operative management after total ankle arthroplasty: A systematic review of the literature

BackgroundCurrently, there is no consensus on the most appropriate post-operative management for patients undergoing total ankle arthroplasty. The aim of this study is therefore to offer a systematic review of the pertaining literature to identify current post-operative protocols and describe possible differences.MethodsA systematic review to identify recent studies concerning the post-operative management after total ankle arthroplasty was conducted. Five topics were analyzed: length of hospital stay, type and duration of immobilization, weight-bearing management, post-operative pharmacological therapies, adopted rehabilitation scheme.ResultsEighty-four studies met the inclusion criteria and were included in the review process. Most of the papers appear to have conflicting opinions with no consensus and homogeneous protocols.ConclusionDue to various methodological limitations, it is not possible to provide sufficiently supported evidence-based recommendations, and it is therefore difficult to determine the superiority of one post-operative protocol over the others after total ankle arthroplasty.     

Use of intramedullary carbon fiber nail in hindfoot fusion: A small cohort study

Background

Current literature on carbon fiber implant use in foot and ankle surgery is scant. The purpose of this paper is to report medium-term outcomes of hindfoot fusion using a carbon fiber intramedullary nail.

Complications following total ankle arthroplasty: A systematic literature review and meta-analysis

BackgroundTotal ankle arthroplasty (TAA) is increasingly used as a treatment for end-stage ankle arthropathy. However, TAA may be more sensitive to complications, failure and subsequent re-operations compared to ankle arthrodesis. The aim of this systematic review and meta-analysis is to generate an overview of complications of TAA surgery.MethodsPubMed, EMBASE and the Cochrane library were searched between 2000 and 2020 to identify all papers reporting on complications in TAA surgery. Meta-analysis was conducted based on type of complication in TAA surgery. Pooled estimates of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates was rated and described according to the recommendations of the GRADE working group.ResultsOne hundred twenty-seven studies were included in this systematic review. All combined, they reported on 16.964 TAAs with an average follow-up of 47.99 ± 29.18 months. Complications with highest reported pooled incidence were intra-operative fracture 0.06 (95 %CI 0.04–0.08) (GRADE Very low) and impingement 0.06 (95 %CI 0.04–0.08) (GRADE low) respectively.ConclusionReported complication incidence of TAA surgery is still high and remains a significant clinical problem that can be severely hampering long-term clinical survival of the prosthesis. The results of this systematic review and meta-analysis can help guide surgeons in informing their patient about complication risks. Implementation of more stringent patient selection criteria might contribute to diminishing TAA complication rates.     

Incidence of ankle arthrodesis and total ankle replacement between 1997 and 2018: A nationwide registry study in Finland

BackgroundSurgical treatment options for end-stage ankle osteoarthritis (OA) include ankle arthrodesis (AA) and total ankle replacement (TAR). We investigated the national incidence of AA and TAR and assessed trends in the surgical management of ankle OA in Finland between 1997 and 2018.MethodsThe Finnish Care Register for Health Care was used to calculate the incidence of AA and TAR based on sex and different age groups.ResultsThe mean age (SD) of patients was similar, 57.8 (14.3) years for AA and 58.1 (14.0) for TAR. TAR showed a 3-fold increase from 0.3 per 100 000 person-years in 1997 to 0.9 per 100 000 person-years in 2018. The incidence of AA operations decreased during the study period from 4.4 per 100 000 person-years in 1997 to 3.8 per 100 000 person-years in 2018. TAR utilization increased notably at the expense of AA between 2001 and 2004.ConclusionTAR and AA are both widely used procedures in the treatment of ankle OA, with AA being the favored option for most patients. The incidence of TAR has remained constant for the past 10 years, indicating appropriate treatment indications and utilization.     

Clinical outcome results of total ankle replacement and ankle arthrodesis: a pilot randomised controlled trial

BackgroundAnkle arthrodesis (AA) and replacement (TAA) are widely accepted options in managing end-stage ankle arthritis (ESAA). We hypothesize that clinical outcomes would be similar for both interventions.MethodsWe conducted a multicenter randomized controlled trial that collected data on patient demographics, complication rates, Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. We evaluated pre and postoperative scores within and between cohorts.ResultsThe thirty-nine ankles enrolled had a mean follow-up of 5.1 ± 2.8 years. Total AOS scores improved significantly in both groups; 59.4 ± 15.9 to 38 ± 20 (p-value = 0.002) for TAA and 64.6 ± 19.7 to 31.8 ± 16.5 (p-value < 0.001) for AA at last follow-up. Complication rate was higher in the AA cohort with four major complications (20%).ConclusionWe observed a statistically significant benefit with TAA and AA. As a pilot trial, this study is meant to inform on design and feasibility of future RCTs.Level of evidenceII     

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

ObjectiveEvaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures.DesignRetrospective case series.SettingUniversity hospital.PatientsFrom January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation.InterventionTransfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau.Main outcome measurementsComplications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function.ResultsTwo patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60–100, S.D:11).ConclusionThe transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction.Level of evidenceTherapeutic level IV.     

踝关节融合术与全踝关节置换术治疗终末期踝关节炎临床疗效的Meta分析

目的:系统评价全踝关节置换术(total ankle arthroplasty,TAA)和踝关节融合术(ankle arthrodesis,AA)在治疗终末期踝关节炎的临床疗效。方法:文献检索PubMed、EMBASE和Cochrane图书馆数据库发表的TAA或AA治疗终末期踝关节炎的文献,检索日期从建库至2021年6月。采用偏倚风险工具进行文献质量评价。采用RevMan 5.3软件美国足对两组踝外科协会踝与后足评分(American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale,AOFAS)、视觉模拟评分(visual analog scale,VAS)、踝关节骨关节炎评分(ankle osteoarthritis scale,AOS),步态分析(步速、步频、步幅)、活动范围(range of motion,ROM),满意度、并发症和再次手术率进行Meta分析。结果:共纳入12篇文献,其中AA组1 050例,TAA组3 760例,共计4 810例患者。Meta分析结果显示两组的AOFAS总分[MD=-3.12,95%C...     

Ankle arthrodesis:A systematic approach and review of the literature

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.     

Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials

BackgroundWhat level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures.MethodsA systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union.ResultsThe primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12–0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates.ConclusionThis systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations.Level of EvidenceSystematic review and meta-analysis of level I evidence     

Peri-prosthetic bone cysts after total ankle replacement. A systematic review and meta-analysis

Background

Periprosthetic cystic osteolysis is a well-known complication of total ankle replacement. Several theories have been proposed for its aetiology, based on individual biomechanical, radiological, histopathology and outcome studies.

Total ankle arthroplasty and ankle arthrodesis in rheumatic disease patients: An analysis of outcomes and complications using the National Inpatient Sample (NIS) database

IntroductionRheumatoid arthritis (RA), can manifest as an inflammatory arthropathy in the ankle. As a result, this study sought to examine the role of RA with respect to complications in patients undergoing either total ankle arthroplasty or ankle arthrodesis by utilizing the National Inpatient Sample to assess for correlations.MethodsAdmissions for TAA and AA were extracted from the National Inpatient Sample using primary ICD-9-CM diagnosis codes. Patients aged 18–65 years with a duration of hospital stay of >3 days and isolated complications were included. Multivariable regression was then performed within matched groups to determine differences.ResultsThere was decreased risk of myocardial infarction, pulmonary embolism, surgical site infection, and urinary tract infection in patients with RA. Postoperative development of pneumonia was seen at a higher rate in patients with RA.ConclusionRA is not associated with a markedly increased complication burden in the appropriately chosen surgical candidate for ankle arthrodesis and ankle arthroplasty.     

Simultaneous Total Ankle Replacement and Contralateral Ankle Arthrodesis for Bilateral Ankle Osteoarthritis: A Retrospective Study Focused on Clinical Outcomes and Cost‐effectiveness

ObjectiveTotal ankle replacement (TAR) and ankle arthrodesis (AA) are two common surgical treatment options for end‐stage ankle osteoarthritis. However, few reports compare the outcomes of simultaneous TAR and contralateral AA for bilateral ankle osteoarthritis. The aim of this study was to assess changes in pain, joint range of movement (ROM), functional outcomes, patient satisfaction, and cost‐effectiveness following simultaneous TAR and contralateral AA.MethodsA retrospective study was conducted on 12 patients with bilateral end‐stage ankle osteoarthritis who underwent simultaneous TAR and contralateral AA in our institution between May 2016 and August 2018, and who had a minimum of two‐year follow‐up data. Clinical and radiological follow‐up data for all patients were collected after 4 months, 1 year and 2 years. The results were assessed clinically on a visual analogue scale (VAS) and included ROM, American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score, and satisfaction questionnaire. The total hospital costs of patients were also recorded. Independent sample t tests were conducted to compare continuous variables between groups. Paired sample t‐tests were conducted to compare changes from the preoperative to postoperative evaluations within each group.ResultsBoth surgical groups presented with pain reduction (P < 0.001) at the one‐year postoperative session, which was generally consistent until the two‐year follow‐up. There was a significant increase (P < 0.001) in the mean AOFAS score postoperatively in both ankles. The functional outcomes at the one‐ and two‐year follow‐up were significantly better in patients in the TAR group than in those in the AA group (P < 0.001). Joint ROM differences were observed between the two groups after surgery (decreased ankle ROM in arthrodesis, P < 0.001; increased ankle ROM in arthroplasty, P < 0.001). The mean satisfaction score was 2 (range, 1–4) for the TAR group and 3 (range, 1–5) for the AA group. A significant difference in the satisfaction score was observed between the two groups (P = 0.036). Simultaneous TAR and contralateral AA was 34.1% less expensive than simultaneous bilateral TAR. No intraoperative complications were noted in either group. Wound healing occurred without problems within 2 weeks after surgery. No symptomatic deep venous thrombosis was found during follow‐up.ConclusionTAR had better patient‐perceived post‐operative function and preserves more anatomic sagittal plane motion compared to ankles undergoing AA. In addition, simultaneous TAR and contralateral AA are more cost‐effective than simultaneous bilateral TAR, with lower costs for the average patient.     

Efficacy of total ankle replacement with meniscal-bearing devices: a systematic review and meta-analysis

Introduction The reputation of total ankle arthroplasty for treating end-stage ankle arthritis of different origin is dubious. Newer generation meniscal-bearing prostheses may have overcome the known problems with earlier implants. There is, however, no systematic approach to the available scientific evidence allowing for a critical appraisal of their benefits and risks.Materials and methods We conducted a systematic review meta-analysis of studies exploring the efficacy of three-component total ankle prostheses. We demanded a minimum sample size of 20 subjects, at least 1 year of follow-up, and a clinically relevant study endpoint (for example, results of ankle scoring, ranges of motion [ROM], complications, and survival rates). We identified citations by electronic medical databases and a manual search. We made no restrictions for language. We used an eight-point quality scale to appraise methodological standards, and modeled outcomes by random-effects meta-regression analysis.Results Eighteen of 1830 citations including 1086 patients fulfilled our eligibility criteria. Studies met a median of four quality items (interquartile range 2–5). Outcome estimates did not depend on methodological quality. There was no evidence of strong heterogeneity or publication bias. With standardized 100-point ankle and hindfoot scores, formal data pooling was possible for 10 trials ( n =497), showing a mean improvement of 45.2 points (95% confidence interval [CI] 39.3–51.1). Overall ROM improved slightly (6.3°, 95%CI 2.2–10.5°). Weighted complication rates ranged from 1.6% (deep infections) to 14.7% (impingement). Secondary surgery had to be performed in 12.5%, whereas secondary arthrodesis was necessary in 6.3%. The weighted 5-year prosthesis survival rate averaged 90.6%.Conclusions Ankle arthroplasty improves pain and joint mobility in end-stage ankle arthritis. Its performance in comparison to the current reference standard (that is, ankle fusion) remains to be defined in a properly designed randomized trial.