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SICOT e-Newsletter

Issue No. 47 - August 2012

Scientific Debate

Ankle Arthrodesis versus Ankle Replacement

The treatment for patients with end stage ankle arthritis between the ages of 45 to 60 years is controversial. Where ankle arthritis is secondary to post traumatic without evidence of infection, neuropathy, diabetes, peripheral vascular disease or rheumatological condition, either option is possible.

Ankle Arthrodesis

Syah Bahari & Johnny McKenna
Foot and Ankle Unit, Sport Surgery Clinic & St James’ Hospital, Dublin, Ireland

When comparing ankle arthrodesis to ankle replacement, one needs to understand that ankle arthrodesis is a pain relieving salvage procedure. It does not allow ankle range of motion where ankle replacement does. Thus, the comparison for these two treatment modalities needs to be based on surgical technique, complications, level of pain relief and level of activities achievable after the procedure.

Ankle arthrodesis is still considered as the gold standard for end stage ankle arthritis. Main complications are wound infection and failure to fusion. Introduction of arthroscopic ankle arthrodesis technique has significantly improved the incidence of these complications and also decreased the time to union [1]. However, risk of developing hindfoot arthritis has been the main concern for ankle arthrodesis. Long-term follow-up of ankle arthrodesis patients did show a development of hindfoot arthritis mostly in the subtalar joint. Interestingly, their clinical and functional outcome remains unclear as subjectively 91% of the patients were satisfied with the results [2]. This complication may be avoided by ankle replacement but aseptic loosening associated with ankle replacement is also a concern.

For a young patient, ankle arthrodesis can be viewed as an intermediate procedure where, when symptomatic hindfoot arthritis has developed, triple arthrodesis can be performed and the ankle arthrodesis can be converted to a replacement [3]. However, preservation of ankle anatomy is essential to allow ankle arthrodesis to be converted to ankle replacement [4]. With ankle replacement, significant bone loss may occur with osteolysis preventing any revision procedure or ankle arthrodesis and may end up with tibiotalar-calcaneal arthrodesis or pantalar arthrodesis.

Ankle arthrodesis is a reliable pain relieving procedure. Failure to fusion or pre-existing subtalar or talonavicular arthritis would explain persistent pain after surgery. MRI scan of the ankle and hindfoot is advisable to detect any degenerative changes in subtalar or talonavicular joint prior to surgery. SPECT scan has been advocated as a more sensitive modality than MRI in assessment of subtalar or talonavicular arthritis [5].

Patient level of activity is not limited after ankle fusion, even high impact activity. Activity that requires ankle movement such as standing on tip toe, jumping, squatting or lunging may not be possible but subtalar joint and medial column movement will increase to compensate thus allowing some sporting activities such as cycling, hiking, swimming, skiing and rowing [6]. Ankle replacement may allow more physiological ROM of ankle but there is no consensus on activity allowed after surgery. Expert opinions suggest avoiding high impact activity thus limiting the activity of patients with an ankle replacement.

For patients aged 45 to 60 years old with expectation to continue with high impact activity and workload, ankle arthrodesis is recommended as it will provide pain relief and allow returning to their expected level of function.

  
References:

  1. Cottino U, Collo G, Morino L et al. Arthroscopic ankle arthrodesis: a review. Curr Rev Musculoskelet Med. 2012 Jun;5(2):151-5
  2. Hendrickx RP, Stufkens SA, de Bruijn EE et al. Medium- to long-term outcome of ankle arthrodesis. Foot Ankle Int. 2011 Oct;32(10):940-7
  3. Kim BS, Knupp M, Zwicky L, Lee JW et al. Total ankle replacement in association with hindfoot fusion: Outcome and complications. J Bone Joint Surg Br. 2010 Nov;92(11):1540-7
  4. Greisberg J, Assal M, Flueckiger G et al. Takedown of ankle fusion and conversion to total ankle replacement. Clin Orthop Relat Res. 2004 Jul;(424):80-8
  5. Pagenstert GI, Barg A, Leumann AG et al. SPECT-CT imaging in degenerative joint disease of the foot and ankle. J Bone Joint Surg Br. 2009 Sep;91(9):1191-6
  6. Schuh R, Hofstaetter J, Krismer M et al. Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome. Int Orthop. 2012 Jun;36(6):1207-14

Ankle Replacement

Sudarshan Munigangaiah & Paula Kelly
Foot and Ankle Unit, Adelaide and Meath Hospital, Dublin, Ireland

Total ankle replacement has remarkably progressed as one of the treatment options for end stage arthritis of ankle. Total ankle replacement is technically demanding and generally performed by only experienced foot and ankle surgeons. Saltzman et al. [1] in their multicentre randomised control trial comparing total ankle replacement to ankle arthrodesis reported that ankle replacement was superior in post operative relief and functional outcome at twenty-four months follow-up. Recent studies have shown that ankle replacement could be attractive surgical alternative ankle arthrodesis for patients with advanced osteoarthritis of ankle in short and intermediate follow-up studies [2]. At this point of time long-term follow-up studies are not available to say that total ankle replacement has replaced the ankle arthrodesis as the surgical gold standard.

Most of the time ankle arthrodesis is successful in relieving pain in ankle arthritis patients. However, many reports have highlighted that there are short and long term problems following ankle arthrodesis in activities like getting out of chairs, climbing stairs, running and walking on uneven surfaces [3]. A young patient undergoing ankle arthrodesis has a high risk of developing osteoarthritis in hind foot in subsequent years to come. This might lead to additional subtalar or pantalar fusion procedure [4]. Although many studies have shown that ankle arthrodesis is successful in relieving pain in end stage osteoarthritis of ankle, this is associated with non-union and malunion. Now the question arises: how do we treat painful non-union and mal unions of ankle arthrodesis. Hintermann et al. [5] carried out a study in which thirty painful ankle arthrodesis in twenty-eight patients were revised to total ankle replacements. Average age of these patients was 58.2 years. Total ankle replacements were followed up to average 55.6 months with functional and radiological outcome. Authors in this study concluded that for patients with pain at the site of a failed ankle arthrodesis, conversion to total ankle arthroplasty with the use of a three-component ankle implant is a viable treatment option that provides reliable intermediate-term results. In this case series total ankle replacement has been used as a salvage procedure for failed ankle fusion.

Although total ankle replacement is becoming increasingly popular for treatment of end stage osteoarthritis of ankle it has a steep learning curve [6]. Correct positioning of the talar component is one of the most demanding steps in the ankle replacement. Sagittal mal position of the talar component is one of the most common complications of the total ankle replacement [6]. A systematic review carried out in 2009 by Gougoulias concluded that total ankle replacements that are available currently improve ankle function. Residual pain is common and wound complications can occur. Overall, failure rate is approximately 10% at 5 years with a wide range from different centres [7]. This systematic review also revealed that the improvement in ankle range of movement was relatively small from 0 to 14 degrees. Surgeons should inform the patients preoperatively that improvement in ankle range of movement is not one of the expected benefits [7]. So far only two studies have suggested participation in certain sports activities after total ankle replacement [8,9]. However, till date we don’t know whether sport activities are advisable after total ankle replacement. If participating in sport activities, would this affect the survival of the ankle replacement. Further long-term follow-up studies are needed to answer these questions.

   
References:

  1. Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009;30:579-96
  2. Deorio JK, Easley ME , Total ankle arthroplasty. Instr Course Lect. 2008; 57:383-413.
  3. Lance EM, Paval A, Fries I, Larsen I, Patterson RL Jr. Arthrodesis of the ankle joint. A follow-up study. Clin Orthop Relat Res. 1979;142:146-58.
  4. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001; 83: 219-28.
  5. Hintermann B, Barg A, Knupp M, Valderrabano V. Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty. J Bone Joint Surg Am. 2009; 91: 850-8
  6. Lee KB, Cho SG, Hur CI, Yoon TR. Perioperative complications of HINTEGRA total ankle replacement: our initial 50 cases. Foot Ankle Int. 2008; 29: 978-84.
  7. Gougoulias N, Khanna A, Maffulli N. How successful are current ankle replacements? : a systematic review of the literature. Clin Orthop Relat Res. 2010; 468: 199-208.
  8. Naal FD, Impellizzeri FM, Loibl M, Huber M, Rippstein PF. Habitual physical activity and sports participation after total ankle arthroplasty. Am J Sports Med. 2009;37: 95–102.
  9. Valderrabano V, Pagenstert G, Horisberger M, Knupp M, Hintermann B. Sports and recreation activity of ankle arthritis patients before and after total ankle replacement. Am J Sports Med. 2006; 34: 993–999. 
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