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     

Total ankle replacements: an overview

One of the most widely debated topics amongst foot and ankle surgeons is the treatment of end stage arthritis. With the advent of the newer generation of total ankle replacement (TAR), a viable option over an arthrodesis is now available for patients with end-stage ankle arthritis. When compared with an ankle arthroplasty, recent reports suggest the ankle arthrodesis has poor long-term outcomes (20 years+) and can experience short- and long-term complications. Proper training, strict patient selection, and proper implant contribute to a successful outcome. As advances continue to be made in both implant design and surgical technique, the benefits of a TAR appears to provide the foot and ankle surgeon a good alternative for the appropriate patient.     

Applications of the transfibular approach to the hindfoot: A systematic review and description of a preferred technique

BackgroundThe indications and technique for the transfibular approach to the tibiotalar joint have evolved since its initial popularization in 1942. The purpose of this systematic review is to assess the indications, techniques, and postoperative outcomes among procedures performed with the transfibular approach.MethodsA comprehensive search of PubMed, Medline, and Embase databases from 1942 to 2018 was performed in accordance with PRISMA guidelines. After an initial broad search of transfibular approach indications, articles were stratified into 4 major surgical categories for assessment: (1) tibiotalar arthrodesis (2) tibiotalocalcaneal arthrodesis (3) total ankle replacement and (4) distal tibial tumor excision. Data was analyzed according to these 4 categories.ResultsA total of 32 studies (874 ankles) were included. Fibular non-union rates were 0.7 % (5 of 672) across all studies, 0.6% (2 of 329) for tibiotalar arthrodesis, 0.0% (0 of 12) for tibiotalocalcaneal arthrodesis, 1.0 % (3 of 296) for total ankle arthroplasty and 0.0% (0 of 15) for other procedures. Rates of deep infection were 2.5% (23 of 903) across all studies, 3.2% (15 of 466) for tibiotalar arthrodesis, 3.7% (4 of 106) for tibiotalocalcaneal arthrodesis, 1.3% (4 of 296) for total ankle arthroplasty, and 0.0% (0 of 15) for other procedures.ConclusionsThe transfibular approach is useful for cases requiring extensile exposure of the tibiotalar joint. This study provides evidence that the transfibular approach yields satisfactory results, with low complication and infection rates.Level of evidenceIV     

Arthrodesis of the ankle joint with lag screws

Surgical Principles In patients with painful limitation of mobility or malposition of the ankle joint, arthrodesis will improve the function of the limb. The loss of movements in the ankle joint will largely be compensated by other joints of the foot. Compression arthrodesis between talus and tibia with lag screws results in stability which, together with a below knee cast, allows early full weight bearing. In general, neutral position of the ankle for men and women is the best position for a fused ankle [1, 13, 15]. Revised Version from: Operat. Orthop. Traumatol. 2 (1990), 131–138 (German Edition).     

Effect of total ankle replacement on the 3-dimensional subtalar joint alignment in varus ankle osteoarthritis

BackgroundVarus ankle osteoarthritis (OA) is typically associated with peritalar instability, which may result in altered subtalar joint position. This study aimed to determine the extent to which total ankle replacement (TAR) in varus ankle OA can restore the subtalar alignment.MethodsFourteen patients (15 ankles, mean age 61 ± 6 years) who underwent TAR for varus ankle OA were analyzed using semi-automated measurements based on weight-bearing computed tomography. Twenty healthy individuals served as a control group.ResultsAll angles improved between preoperative and a minimum of 1 year (mean 2.1 years) postoperative and were statistically significant in 6 out of 8 angles (P < 0.05).ConclusionsOur findings indicate that talus repositioning after TAR restores the subtalar joint alignment which may improve hindfoot biomechanics. Future studies are required to implement these findings for TAR in presence of hindfoot deformity.Level of evidenceIV.     

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.     

踝关节炎治疗研究进展

踝关节炎(ankle osteoarthritis)是临床常见疾病,疼痛为主要症状,对于处于不同阶段的患者,其临床表现不一样,治疗方式也有所不同,大体分为保守治疗和手术治疗。早期症状较轻,以保守治疗为主,中晚期患者,保守治疗难以缓解症状,大多选择手术治疗。目前,踝关节融合术依然是其治疗的标准方法,随着医学技术的不断进步,全踝关节置换术也正在被采用。文对踝关节炎的治疗进展进行综述。     

踝上截骨术治疗踝关节二期创伤性关节炎的疗效观察

目的 观察踝上截骨术治疗踝关节2期创伤性关节炎的疗效.方法 自2005年10月至2008年5月对47例踝火节2期创伤性关节炎行踝上截骨术治疗,31例获得完整随访.12例行开放性楔形截骨术,其中10例胫骨内侧开放件楔形截骨术即时矫正踝关节内翻,此间有3例在即时矫正内翻的同时行跗管松解术,2例因踝关节严重内翻畸形愈合,截骨同时在Ilizarov治疗器下缓慢牵张矫正原始畸形愈合;19例行腓骨退旋延长术.采用美国骨科足踝外科协会(AOFAS)踝关节功能评分系统进行评分.结果 31例获得12～43个月(平均27.3个月)随访.骨折全部愈合,临床愈合时间平均为13.3周(11～17周),完全负重时间平均为14.1周(12～19周).术后12个月踝火节AOFAS评分为63～92分,平均84.3分,其中优14例,良11例,一般6例,优良率80.6%.术后2例出现内侧切口裂开,1例发生内侧切口皮缘部分坏死,均经换药保守治疗痊愈.3例术后出现足外侧皮肤感觉麻木,2例患者在最近随访时X线片示关节炎有轻微进展,予以关节腔注射施沛特保守治疗后而无需手术即获得了满意的临床效果.无螺钉松动、断裂及内固定失效等其他并发症.结论 采用踝上截骨术治疗踝关节2期创伤性关节炎,近期可获得满意效果.     

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.     

全踝关节置换术治疗继发性踝关节炎的中期随访及疗效分析

目的评估全踝关节置换术（total ankle replacement,TAR）治疗继发性踝关节炎的治疗效果。方法回顾性分析1999年5月至2006年5月行TAR的18例患者,男2例,女16例;年龄52～66岁,平均61岁;病程9个月－18年。其中骨关节炎5例,创伤性关节炎9例,类风湿关节炎4例。患者均经保守治疗无效,且踝关节疼痛,活动障碍。术后患者定期随访,进行临床和影像学评估。结果患者均获随访,随访时间2～9年,平均5．4年;其中16例获得满意疗效。依据美国矫形足踝协会（American orthopaedic foot and ankle society,AOFAS）评分标准评分,由术前的27～53分,平均（41．5±6．8）分,提高至术后的60—91分,平均（74．6±9．7）分,视觉模拟评分（visual analogue scale,VAS）由术前的5～10分,平均（8．4±2．1）分改善至术后的1～4分,平均（2．3±0．9）分。无一例患者需行踝关节融合术或踩关节翻修术。影像学评估,16例假体位置稳定、无下沉迹象,2例在胫骨假体和骨质接触发生气球样骨溶解,但无任何症状。结论TAR可用于治疗踝关节炎。尽管TAR的中期随访效果比较满意,但TAR仍属较新技术,其远期临床效果有待进一步随访评估。     

Six year results of the Rebalance mobile bearing total ankle replacement

BackgroundWe report the outcomes of a prospective consecutive series of 267 total ankle replacements (TARs) using a new mobile bearing Rebalance® prosthesis.MethodsBetween April 2011 and December 2018, 267 consecutive Rebalance® prostheses were implanted in 255 patients at 3 different centers. Estimated survival curves with 95% confidence intervals were produced with the Kaplan–Meier method. 110 ankles were followed for at least 5 years and clinical and radiological outcomes were assessed in 92 of these ankles.ResultsTwenty-one ankles were revised at a mean of 34 (7–60) months. The estimated survival was 90% (95% CI 86–95) at 5 years and 88.3% (95% CI 83.–94 at 6 years. The ankles followed for at least 5 years demonstrated a median Likert score of 1 (1–4). Radiolucent zones were detected in 14% and osteolytic cysts in 3%.ConclusionThe survival rate of the Rebalance prosthesis conforms with other reports of similar designs. The satisfaction rate was high. Radiological zones and osteolytic cysts were found at a lower rate than usually reported for mobile bearing TARs. These results favour further use of this implant.     

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.     

Supramalleolar Osteotomy With Distraction Arthroplasty in Treatment of Varus Ankle Osteoarthritis With Large Talar Tilt Angle: A Case Report and Literature Review

We treated a 57-year-old female with modified Takakura stage 3B varus ankle osteoarthritis. Her preoperative talar tilt angle was 21.3°. The patient wished to avoid ankle joint arthrodesis or replacement. Therefore, medial opening wedge supramalleolar osteotomy with fibular osteotomy was used for her varus ankle osteoarthritis. Also, fixed medial distraction arthroplasty was performed to improve her talar tilt. After 3 months, the external device was removed, and the patient was allowed partial weightbearing and began full weightbearing 4 months postoperatively after the osteotomy site had reached bony union radiographically. At the 3-year follow-up visit, a radiograph showed the medial ankle joint space enlargement had been maintained. The talar tilt angle had decreased to 3.3°, and the modified Takakura stage had improved to stage 1. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score had improved from 26 points preoperatively to 85 points at 3 years postoperatively. Our findings suggested that good clinical and radiologic results can be achieved with supramalleolar osteotomy combined with distraction arthroplasty in the treatment of varus ankle osteoarthritis with a large talar tilt angle.     

Evans和Chrisman-Snook术式治疗踝关节外侧副韧带Ⅱ度损伤的生物力学比较

目的:测试Evans和Chrisman-Snook术式治疗踝关节外侧副韧带Ⅱ度损伤的术后稳定性,为临床治疗方法的选择及预后的判断提供依据。方法:2008年7月至2009年6月,采集18具冰冻下肢标本,男10例,女8例,平均年龄(39.3±11.2)岁,随机分为3组:正常对照组(A组),Evans术式组(B组)和Chrisman-Snook术式组(C组),每组6只标本。解冻后在B、C组中切断距腓前韧带和跟腓韧带,造成外侧副韧带Ⅱ度损伤,并采用Evans术式和Chrisman-Snook术式重建外侧副韧带,进行生物力学测试,观察胫距关节和距下关节侧方应力加载下的位移情况。结果:①胫距关节侧方应力试验显示B组对外侧副韧带损伤修复后位移大于A、C组(P<0.0001),A组与C组差异无统计学意义(P>0.05)。②距下关节侧方应力试验显示B组术后位移大于A、C组(P<0.0001),A组与C组差异无统计学意义(P>0.05)。结论:踝关节外侧副韧带损伤造成踝关节不稳,在其修复术式中Chrisman-Snook术式比Evans术式在重建踝关节术后初期稳定性上优于Evans术式,Chrisman-Snook术式更符合生物力学原理。     

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.     

踝关节创伤性关节炎的治疗现状及其相关进展

踝关节创伤性关节炎是一种常见的骨关节疾病,主要由创伤引起的踝关节损伤破坏其生物力学的平衡,导致踝关节发生退行性病变。常好发于青年人群,患者常易出现关节疼痛及僵硬等症状,不及时干预则发展为终末期踝关节创伤性关节炎。目前针对踝关节创伤性关节炎的治疗方法有很多种,但治疗方法的选择及应用国内并无相关文献进行报道,故我们对踝关节创伤性关节炎的病因、诊断、治疗方式等方面进行综述,为治疗踝关节创伤性关节炎提供相应参考。