Joint distraction as an alternative for the treatment of osteoarthritis

Autologous matrix induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC) in chondral lesions at the ankle as part of a complex surgical approach - 5-year follow-up

BACKGROUND

The aim of the study was to assess 5-year-follow-up (5FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle as part of a complex surgical approach.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included. Size and location of the chondral lesions, the Visual-Analogue-Scale Foot and Ankle (VAS FA) and the EFAS Score before treatment and at 5FU were analysed and compared with previous 2-year-follow-up (2FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and twenty-nine patients with 136 chondral lesions were included in the study. The chondral lesions were located as follows (n (%)), medial talar shoulder only, 62 (46); lateral talar shoulder only, 42 (31); medial and lateral talar shoulder, 7 (10); tibia, 18 (13). The average for lesion size was 1.8 cm², for VAS FA 45.7 and for EFAS Score 9.8. 2FU/5FU was completed in 105 (81 %)/104(81 %) patients with 112/111 previous chondral lesions. VAS FA improved to 79.8/84.2 and EFAS Score to 20.3/21.5 (2FU/5FU). No parameter significantly differed 2FU and 5FU.

CONCLUSIONS

AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores at 2FU/5FU. 2FU and 5FU did not differ.

Autologous matrix induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC) in chondral defects of the first metatarsophalangeal joint - 5-year follow-up

BACKGROUND

The aim of the study was to assess the 5-year-follow-up (5FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral defects at the first metatarsophalangeal joint (MTP1).

MATERIAL AND METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at MTP1 that were treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included. Size and location of the chondral lesions, the Visual-Analogue-Scale Foot and Ankle (VAS FA) and the EFAS Score before treatment and at 5FU were analysed and compared with previous 2-year-follow-up (2FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and ninety-eight patients with 238 chondral defects were included. In 21 % of patients no deformities in the forefoot were registered. The average degree of osteoarthritis was 2.2. The chondral defect size was 1.0 cm² on average. The most common location was metatarsal dorsal (33 %), and in most patients one defect was registered (74 %). Corrective osteotomy of the first metatarsal was performed in 79 %. 176 (89 %)/164 (83 %) patients completed 2FU/5FU. VAS FA/EFAS Score were preoperatively 46.8/11.9 and improved to 74.1/17.1 at 2FU and 75.0/17.3 at 5FU on average. No parameter significantly differed between 2FU and 5FU.

CONCLUSIONS

AMIC+PBC as treatment for chondral defects at MTP1 as part of joint preserving surgery led to improved and high validated outcome scores at 2FU and 5FU. The results between 2FU and 5FU did not differ.

The Role of Distraction Arthroplasty in Managing Ankle Osteoarthritis

Ankle distraction arthroplasty (DA) is a joint-preserving option for the treatment of ankle osteoarthritis. The ideal patient is a young, active person who is compliant with follow-up and understands that clinical improvements may not be fully evident until 1 year after surgery. The procedure promotes cartilage healing and regeneration by removing mechanical stress at the joint surface through the application of a joint-spanning external fixator. There is an array of adjuvant procedures commonly performed to optimize healing potential-including microfracture, osteophyte removal, osteotomies, and soft tissue balancing procedures. Short- and intermediate-term studies have been promising, though there is a wide variance in reported failure and complication rates.

Autologous matrix-induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC) in chondral defects of the first metatarsophalangeal joint

OBJECTIVE

Chondral restoration in chondral defects of the 1st metatarsophalangeal joint (MTP1) using autologous matrix-induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC).

INDICATIONS

Chondral defects MTP1.

CONTRAINDICATIONS

Acute infection.

SURGICAL TECHNIQUE

Thigh tourniquet. Medial approach. Tenolysis of all tendons, arthrolysis, synovectomy. Bursectomy in case of bursitis. Resection osteophytes, optional cheilectomy. Debridement of chondral defects until surrounding cartilage stable. Microfracturing with 1.6 mm K‑wire. 15 cc peripheral venous blood harvested with double lumina syringe. Centrifugation (10 min, 1500 RPM). Aspiration of supernatant including the entire fluid layer directly above the erythrocyte layer (peripheral blood concentrate [PBC]). Chondro-Gide matrix was cut to size and impregnated in PBC 3 min (impregnation). Fixation of the matrix into the chondral defect with fibrin glue (AMIC+PBC). Joint motion to ensure stable fixation. Insertion drainage and wound infiltration catheter. Layer wise closure.

POSTOPERATIVE MANAGEMENT

Full weightbearing in a dressing shoe. Joint motion exercise starting at the day of surgery.

RESULTS

The aim of the study was to compare matrix-associated stem cell transplantation (MAST) with AMIC+PBC. Patients who were treated with MAST from October 1, 2011 to July 15, 2016 (n = 623) or with AMIC+PBC from July 17, 2016 to March 19, 2018 (n = 230) were included. In all, 480 (89%)/176 (89%) patients (MAST/AMIC+PBC) completed 2‑year follow-up. The average degree of osteoarthritis was 2.1/2.2. The chondral defect size was 0.9/1.0 cm² on average. Visual Analogue Scale Foot and Ankle (VAS FA) and European Foot and Ankle Society score (EFAS score) improved to 72.4/74.1//16.8/17.1 (MAST//AMIC+PBC) at follow-up, respectively. No parameter significantly differed between the MAST and AMIC+PBC cohorts.

Distraction Arthroplasty as Acute and Definitive Treatment for Open Ankle Fracture Dislocation

A 73-year-old woman with significant medical comorbidities presented with a grade I open left ankle fracture dislocation. Distraction arthroplasty was used as a definitive treatment for this injury. The patient tolerated the procedure and had no postoperative complications. The external fixator was removed at 6 months. The patient maintained good ankle function at the 1-year postoperative visit. Distraction arthroplasty is a viable acute and definitive treatment option for ankle fracture in patients with significant medical comorbidities. [Orthopedics. 2021;44(1):e148-e150.].

Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty

Background

Ankle distraction arthroplasty has emerged as an alternative treatment for ankle arthritis. There are few reports on the magnetic resonance imaging (MRI) findings after distraction arthroplasty. This study sought to determine whether there are positive changes on MRI after ankle distraction and improvements on X-ray. Additionally, patient-reported outcomes and joint range of motion (ROM) after ankle distraction are described.

Materials and methods

Thirty-two patients (mean age 49 years) who underwent ankle distraction had pre-operative and one-year postoperative MRIs, which were graded using a modified whole-organ magnetic resonance imaging score (WORMS). Ankle joint space and ROM were measured. A non-validated three-item questionnaire was administered to assess functional outcomes.

Results

Although the anterior quadrant of the ankle showed a trend to improvement in cartilage morphology on the postoperative MRI, the WORMS did not demonstrate a significant difference in any of its subcategories. While reduction in joint osteophytes was observed and maintained short term, this was mainly due to resection intraoperatively. X-rays revealed a significant increase in joint space, and there was a significant increase in ankle dorsiflexion. Eight-seven percent of the patients were satisfied with their functional outcome.

Conclusion

At short-term follow-up, MRI scores after ankle distraction arthroplasty did not demonstrate significant improvement despite positive changes on X-ray and improved clinical outcomes and ankle ROM. Further study on larger patient numbers with longer follow-up is required.

Level of evidence

IV, Case Series

How to cite this article

Haleem AM, Galal S, Nwawka OK, et al. Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty. Strategies Trauma Limb Reconstr 2020;15(3):157–162.

Matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach- 5-year-follow-up in 100 patients

BACKGROUND

The aim of the study was to assess the 5-year-follow-up after matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to May 31, 2012 were included. Size and location of the chondral lesions, method-associated problems and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested from the ipsilateral pelvic bone marrow and centrifuged (10min, 1500RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide) that was fixed into the chondral lesion with fibrin glue.

RESULTS

One hundred and twenty patients with 124 chondral lesions were included in the study. Age at the time of surgery was 35 years on average (range, 12-65 years), 74 (62%) were male. VAS FA before surgery was 45.2 on average (range, 16.4-73.5). Lesions were located at medial talar shoulder, n=55; lateral talar shoulder, n=58 (medial and lateral, n=4); tibia, n=11. Lesion size was 1.7cm² on average (range, .8-6cm²). One hundred patients (83%) completed 5-year-follow-up after. VAS FA improved to 84.4 (range, 54.1-100; t-test, p<0.01).

CONCLUSIONS

MAST as part of a complex surgical approach led to improved and high validated outcome scores in the mid-term-follow-up. No method related complications were registered. Even though a control group is missing, we conclude that MAST as part of a complex surgical approach is an effective method for the treatment of chondral lesions of the ankle for at least five years.

Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis

Aim

The treatment algorithm for end-stage ankle arthritis is imperfect. Young or active patients are challenging to treat as fusion and replacement carry predictable consequences. Ankle distraction arthroplasty is a less commonly utilized surgical procedure for the treatment of osteoarthritis of the ankle. The purpose of this study was to report intermediate-term survival of ankle distraction and to identify factors associated with earlier time to failure.

Materials and methods

A single-centre, multi-surgeon cohort of 258 cases of ankle arthritis, treated with ankle distraction or ankle distraction with supramalleolar osteotomy (SMO), was identified. Patients were contacted by phone to determine the status of the ankle (natural vs fused/replaced). Data were collected through chart review. This included patient demographics, medical comorbidities, surgical procedure, and X-ray characteristics including pattern and severity. A Cox regression model was used to determine factors associated with failure during 10 years of follow-up. Risk factors were analysed as hazard ratios (HRs) and 95% confidence intervals (CIs). Time to failure was illustrated with Kaplan–Meier (KM) curves.

Results

In total, 144 cases were successfully contacted with median follow-up of 4.57 years. In total, 16.7% of ankles failed (24/144). The 5-year survival was 84% (95% CI: 78–91%). In adjusted Cox regression, female sex (HR = 2.68, p = 0.049) and avascular necrosis (AVN) of the talus (HR = 3.77, p = 0.041) were significantly associated with failure risk.

Conclusion

Avascular necrosis of the talus and male/female gender differences in survival were found to be significant. Our experience shows that ankle distraction is a valid and effective operation for the treatment of end-stage ankle arthritis.

Clinical significance

This work is clinically significant in that it demonstrates excellent intermediate-term survival data for hinged ankle distraction for treatment of osteoarthritis of the ankle. Additionally, it evaluated patient and disease characteristics allowing improved patient counselling with regard to survival longevity.

Level of evidence

IV cohort study.

How to cite this article

Greenfield S, Matta KM, McCoy TH, et al. Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis. Strategies Trauma Limb Reconstr 2019;14(2):65–71.

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.

Matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle is safe and effective - 2-year-followup in 130 patients

BACKGROUND

The aim of the study was to assess the 2-year-follow-up of matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle.

METHODS

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from October 1, 2011 to July 31, 2013 were analyzed. Size and location of the chondral defects, method-associated problems and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analyzed. Stem cell-rich blood was harvested from the ipsilateral pelvic bone marrow and centrifuged (10min, 1500rpm). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide). The matrix was fixed into the chondral defect with fibrin glue.

RESULTS

One hundred and forty-four patients with 150 chondral defects were included in the study. The age of the patients was 35 years on average (range, 12-68 years), 85 (59%) were male. The VAS FA before surgery was 48.5 on average (range, 16.5-78.8). The defects were located as follows, medial talar shoulder, n=62; lateral talar shoulder, n=66 (medial and lateral talar shoulder, n=6), tibia, n=22. The defect size was 1.6cm² on average (range, .6-6cm²). 130 patients (90%) completed 2-year-follow-up. The VAS FA improved to an average of 87.5 (range, 62.1-100; t-test (comparison with preoperative scores), p=.01).

CONCLUSIONS

MAST led to improved and high validated outcome scores. No method related complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects of the ankle.

Matrix-associated stem cell transplantation (MAST) in chondral defects of the 1st metatarsophalangeal joint is safe and effective-2-year-follow-up in 20 patients

The aim of the study was to assess the 2-year-follow-up of matrix-associated stem cell transplantation (MAST) in chondral defects of the 1st metatarsophalangeal joint (MTPJ). In a prospective consecutive non-controlled clinical follow-up study, 20 patients with 25 chondral defect at the 1st MTPJ that were treated with MAST from October 1st, 2011 to March, 30th, 2013 were analysed. The size and location of the chondral defects range of motion (ROM), and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were registered. Stem cell-rich blood was harvested from the ipsilateral pelvic bone marrow and centrifuged (10min, 1500 RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Guide). The matrix was fixed into the chondral defect with fibrin glue. The age of the patients was 42 years on average (range, 35-62 years). The VAS FA before surgery was 50.5 (range, 18.3-78.4). The defects were located as follows, dorsal metatarsal head, n=12, plantar metatarsal head, n=5, dorsal & plantar, n=8 (two defects, n=5). The defect size was 0.7cm² (range, .5-2.5cm²). ROM was 10.3/0/18.8° (dorsal extension/plantar flexion). All patients completed 2-year-follow-up. VAS FA improved to 91.5 (range, 74.2-100; t-test, p<.01). ROM improved to 34.5/0/25.5 (p=.05). The surgical treatment including MAST led to improved clinical scores and ROM. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects of the 1st MTPJ.

Intermediate-term follow-up after ankle distraction for treatment of end-stage osteoarthritis

BACKGROUND

Treatment of end-stage ankle osteoarthritis remains challenging, especially in young patients. Initial reports have shown early benefits of joint distraction for the treatment of ankle osteoarthritis. We report the five to ten-year results of a previously described patient cohort following ankle distraction surgery.

METHODS

All thirty-six patients who had undergone ankle distraction surgery between December 2002 and October 2006 were contacted. Patients were evaluated by a clinical investigator and completed the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) surveys. Radiographs as well as computed tomography and magnetic resonance imaging scans of the ankles were obtained at the follow-up visits.

RESULTS

Twenty-nine patients (81%) were followed for a minimum of five years (mean and standard deviation, 8.3 ± 2.2 years). Sixteen (55%) of the twenty-nine patients still had the native ankle joint whereas thirteen patients (45%) had undergone either ankle arthrodesis or total ankle arthroplasty. Positive predictors of ankle survival included a better AOS score at two years (hazard ratio [HR] = 0.048, 95% confidence interval [CI] = 0.0028 to 0.84, p = 0.04), older age at surgery (HR = 0.91, 95% CI = 0.83 to 0.99, p = 0.04), and fixed distraction (HR = 0.094, 95% CI = 0.017 to 0.525, p < 0.01). Radiographs and advanced imaging revealed progression of ankle osteoarthritis at the time of final follow-up.

CONCLUSIONS

Ankle function following joint distraction declines over time. Patients should be well informed of the commitment that they must make during the treatment period as well as the long-term results after surgery.

Minimum distraction gap: how much ankle joint space is enough in ankle distraction arthroplasty?

BACKGROUND

The success of ankle distraction arthroplasty relies on the separation of the tibiotalar articular surfaces.

QUESTION/PURPOSE

The purpose of this study was to find the minimum distraction gap needed to ensure that the tibiotalar joint surfaces would not contact each other with full weight-bearing while under distraction.

METHODS

Circular external fixators were mounted to nine cadaver ankle specimens. Each specimen was then placed into a custom-designed load chamber. Loads of 0, 350, and 700N were applied to the specimen. Radiographic joint space was measured and joint contact pressure was monitored under each load. The external fixator was then sequentially distracted, and the radiographic joint space was measured under the three different loads. The experiment was stopped when there was no joint contact under 700N of load. The radiographic joint space was measured and the initial (undistracted) radiographic joint space was subtracted from it yielding the distraction gap. The minimum distraction gap (mDG) that would provide total unloading was calculated.

RESULTS

The average mDG was 2.4 mm (range, 1.6 to 4.0 mm) at 700N of load, 4.4 mm (range, 3.7 to 5.8 mm) at 350N of load, and 4.9 mm (range, 3.7 to 7.0 mm) at 0N of load.

CONCLUSION

These results suggest that if the radiographic joint space of on a standing X-ray of an ankle undergoing distraction arthroplasty shows a minimum of 5.8 mm of DG, then there will be no contact between joint surfaces during full weight-bearing. Therefore, 5 mm of radiographic joint space, as recommended historically, may not be adequate to prevent contact of the articular surfaces during weight-bearing.

[Results of arthrodiastasis in postraumatic ankle osteoarthritis in a young population: prospective comparative study]

INTRODUCTION

The most common cause of osteoarthritis of the ankle is post-traumatic, and although tibiotalar arthrodesis remains the surgical gold standard, a number of techniques have been described to preserve joint mobility, such as joint distraction arthroplasty or arthrodiastasis.

OBJECTIVE

To evaluate the functional outcome and changes in Visual Analogue Scale (VAS) for pain after the application of the distraction arthroplasty for post-traumatic ankle osteoarthritis.

PATIENTS AND METHODS

A prospective comparative study of a group of 10 young patients with post-traumatic ankle osteoarthritis treated by synovectomy and arthrodiastasis, compared to a control group of 10 patients treated by isolated synovectomy. Results were calculated using the AOFAS scale and the VAS for pain before and after treatment.

RESULTS

As regards the pain measured by VAS, no difference was observed between the two groups before surgery (P=.99), but there was a difference at 3 months (P<.001), 6 months (P=.005), and 12 months (P=.006). No differences were observed in the AOFAS scale between the two groups before surgery (P=.99), or at 3 months (P<.99), but there was a difference at 6 months (P<.001).

CONCLUSIONS

Ankle arthrodiastasis is effective in reducing pain in post-traumatic ankle arthropathy, and is superior to isolated synovectomy.

Ankle joint distraction arthroplasty: why and how?

For select patients, distraction ankle arthroplasty may be a promising treatment approach for ankle osteoarthritis; however, there is still limited literature addressing its efficacy and clinical long-term results. In this article, the literature regarding the outcome after ankle distraction arthroscopy is reviewed, the indications and contraindication for this procedure are listed, our surgical technique is described, and our preliminary results with this procedure are presented.

Matrix-associated stem cell transplantation (MAST) in chondral defects of foot and ankle is effective

BACKGROUND

The aim of the study was to assess the feasibility and clinical results of matrix-associated stem cell transplantation (MAST) and 2-year-follow-up in chondral defects of foot and ankle.

METHODS

In a prospective, consecutive, non-controlled clinical follow-up study, all patients with chondral defects, that were treated with MAST from April 1st to November 30th, 2009 were analyzed. The size and location of the chondral defects, method-associated problems and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were registered and analyzed.

RESULTS

Twenty-six chondral defects in 25 patients were included in the study. The mean age of the patients was 33 years (range, 16-48 years), 18 (72%) were male. The VAS FA before surgery was 49.2 on average (range, 24.3-68.4). The defects were located as follows: medial talar shoulder, n=9; lateral talar shoulder, n=13 (medial and lateral talar shoulder, n=1); distal tibia, n=1; posterior calcaneal facet, n=1; head of 1st metatarsal, n=2. The defect size was 1.1cm(2) on average (range, .5-6 cm(2)). All patients completed 2-year-followup. No complications or consecutive surgeries were registered. The mean VAS FA at follow-up was 94.5 (range, 73.4-100; t-test, p<.01).

CONCLUSIONS

MAST led to good clinical scores. No complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects. The main advantage of MAST in comparison with ACI and MACI is the single procedure methodology. The advantage in comparison with AMIC is the potential higher concentration of stem cells.

Tibiotalocalcaneal arthrodesis

Combined arthrodesis of the ankle and subtalar joint is a challenging but potentially rewarding procedure for certain patients. The author discusses multiple aspects of the procedure from patient counseling to postoperative complications.

Ankle arthrodiastasis and interpositional ankle exostectomy

Arthrosis of the ankle joint, typically posttraumatic in nature, can affect younger and older populations alike. A multitude of procedures exist for treatment, such as arthrodesis, total joint replacement, arthrodiastasis, and articular repair. Current literature has demonstrated success in articular surface repair and arthrodiastasis as separate procedures. This article reviews the technique of ankle arthrodiastasis and interpositional ankle exostectomy, consisting of background, mechanism of action, indications, patient selection criteria, complications, and advantages in the current literature.

Evidence-based indications for distraction ankle arthroplasty

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Hinged external fixation distraction for treatment of first metatarsophalangeal joint arthritis

Treatment for hallux rigidus varies from joint preservation to joint destructive procedures. The objective of the present study was to report an alternative method of treatment of hallux rigidus using hinged external fixation distraction of the first metatarsophalangeal joint and to present our surgical technique. Ten distractions were performed in 9 patients (9 female feet [90%] and 1 male foot [10%]). The mean age at surgery was 41.0 (range 20 to 64) years. All patients had stage II or III hallux rigidus on the Regnauld classification system for hallux rigidus. The patients were evaluated clinically and radiographically before and after the distraction treatment. The mean period of fixation was 16.40 (range 7 to 21) weeks. Six of the patients (60%) with distraction experienced pin tract infections that were treated with oral antibiotics. The reported mean preoperative categorical pain score in 7 patients (7 feet) was 8.2 (range 5 to 10), and the postoperative score was 0.83 (range 0 to 2; p = .001). Of the 6 patients (6 feet) who responded to the remaining portion of the survey, 4 (66.67%) were very satisfied with their results, and 2 (33.33%) were satisfied with their surgical result. None of the patients required additional surgical treatment during the mean 2.2 (range 1.2 to 3.3) years of follow-up. Hinged first metatarsophalangeal joint distraction with external fixation has been shown to be a viable treatment option for joint preservation for stage II and III hallux rigidus in the short term.

First metatarsophalangeal joint arthrodiastasis and biologic resurfacing with external fixation: a case report

The primary goal in the treatment of arthritic joints is elimination of pain associated with limited motion. Several surgical techniques have been developed to treat varying degrees of hallux rigidus of any cause. This case report details an alternative surgical approach to address hallux rigidus and associated hallux valgus deformity through a combination of joint debridement, resurfacing, and arthrodiastasis.

Arthrodiatasis for management of knee osteoarthritis

Osteoarthritic disease is the result of mechanical and biological events that destabilize the normal processes of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix, and subchondral bone. Osteoarthritis of the knee can cause symptoms ranging from mild to disabling. Initial management of most patients should be nonoperative, but because of the progressive nature of the disease, many patients with osteoarthritis of the knee eventually benefit from operative treatment. Various procedures have been described for treatment of the osteoarthritic knee, ranging from arthroscopic lavage and debridement to total knee arthroplasty. The aim of this study was to evaluate the clinical results of distraction arthroplasty combined with arthroscopic lavage and drilling of cartilage defects for treatment of osteoarthritis of the knee. Nineteen patients (15 women and 4 men; age range, 39-65 years) were operated on. Pre- and postoperative findings were compared. A control group comprising 42 patients treated with only arthroscopic procedures was evaluated for comparison. Follow-up ranged from 3 to 5 years. Results were evaluated both clinically and radiologically postoperatively and throughout the follow-up period. Clinically, pain and walking capacity improved in most patients. Radiologically, joint space widening and improvement of the tibiofemoral angle was noted in nearly all patients.

The Salto total ankle arthroplasty: survivorship and analysis of failures at 7 to 11 years

BACKGROUND

Despite the appearance of new-generation, mobile-bearing, cementless prostheses, total ankle arthroplasty remains controversial. Among the criteria guiding the choice between arthrodesis and arthroplasty, the long-term survival and postoperative function are of critical importance. The mobile-bearing Salto prosthesis has been used in Europe since 1997, but only 2 to 5 years of followup data have been reported.

QUESTIONS/PURPOSES

We analyzed the longer-term survivorship and causes of failures of the Salto prosthesis in a cohort of previously studied patients. We asked whether this prosthesis provided a functional ankle (AOFAS score) and durable radiographic fixation.

PATIENTS AND METHODS

We retrospectively reviewed 96 prospectively followed patients with 98 prostheses implanted between 1997 and 2000. Of those, 85 patients (87 prostheses) had a minimum followup of 6.8 years (mean, 8.9 years; range, 6.8-11.1 years).

RESULTS

The survival rate was 65% (95% CI, 50-80) with any reoperation of the ankle and 85% (95% CI, 75-95) with revision of a component as the end points. Six prostheses were removed for arthrodesis, and 18 ankles underwent reoperation without arthrodesis. We observed three main causes of reoperations: bone cysts (11 patients), fracture of the polyethylene (five patients), and unexplained pain (three patients). The mean AOFAS score was 79 ± 12 points. Radiographic subsidence was observed in three patients and bone cysts in eight patients.

CONCLUSIONS

Our data suggest a high rate of reoperations but only six revisions with arthrodesis with mid-term followup. We observed few patients with loosening and/or subsidence.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Biologic resurfacing of the ankle and first metatarsophalangeal joint: case studies with a 2-year follow-up

The goal of biologic resurfacing is to provide a smooth joint surface with a low coefficient of friction, which allows the joint to function with near normal biomechanics, as well as provide intermittent pressure, to the subchondral and cancellous bone. This unique combination often results in the formation of a "neocartilage-like" structure that can reduce pain and restore biomechanics. As well as giving a brief history of cutis arthroplasty, this article describes cases in which the ankle and first metatarsophalangeal joint underwent biologic resurfacing, with a 2-year postoperative follow up.

Ankle function and sports activity after total ankle arthroplasty

BACKGROUND

The return to sporting activities after ankle arthroplasty has rarely been evaluated. The purpose of the present study was to evaluate function and return to sports after total ankle arthroplasty.

MATERIALS AND METHODS

One hundred seventy-nine Salto Total Ankle Arthroplasties (TAA) were implanted between 1997 and 2005. A self-administered questionnaire including the Foot Function Index (FFI) and Foot and Ankle Ability Measurement (FAAM) was sent to all patients. At last followup, six were deceased, 22 were not available for evaluation, and six questionnaires were incomplete. One hundred forty-five questionnaires were available. The mean age was 60.9 years and the mean followup was 53.8 months. The main indications for TAA were osteoarthritis (OA) in 100 cases and Rheumatoid arthritis (RA) in 40 cases.

RESULTS

15.2% of the patients said that their operated ankle was "normal'' 60.7%" nearly normal''; 20% "abnormal'' and 4.1% "highly abnormal.'' The FFI scores were 13.7 +/- 17 for "activity limitations'', 31.7 +/- 23 for "disability'' and 16.9 +/- 19 for "pain''. The FAAM scores were 74.9 +/- 18 for activities of daily living and 48.9 +/- 28 for sports activities. On a Visual Analog Scales (0 to 100 were 100 is the "pre-pathology level'') the mean rating was 70.2 +/- 19.6 for Activities of Daily Living and 53.7 +/- 28 for sport activities. In the OA patients, 38 regularly road bicycle, 21 perform recreational gymnastics, 58 swimming, 50 home gardening, 27 dancing, and 43 hiking. Seven patients regularly practice tennis, nine cross-country skiing, 17 downhill skiing, and six regularly run more than 500 m.

CONCLUSION

This study showed that TAA improved the quality of life and that return to recreational activities was generally possible but the return to impact sport was rarely possible.

Combined medial displacement calcaneal osteotomy, subtalar joint arthrodesis, and ankle arthrodiastasis for end-stage posterior tibial tendon dysfunction

Combining an ankle arthrodiastasis with a medial displacement calcaneal osteotomy and a subtalar joint arthrodesis offers surgeons a joint-sparing procedure for young and active patients who have end-stage posterior tibial tendon dysfunction and ankle joint involvement. An isolated subtalar joint arthrodesis or triple arthrodesis combined with an ankle arthrodiastasis is an option that can be used in certain case scenarios. Delaying the need for a joint destructive procedure through an ankle arthrodiastasis, however, may have a great impact in the near future, as advancements are underway to improve the use of ankle endoprosthesis.

MRI evaluation of ankle distraction: a preliminary report

Ankle joint distraction has been shown to be a viable alternative to ankle arthrodesis or ankle replacement. The authors' approach to ankle joint preservation includes articulated ankle joint distraction, resection of blocking osteophytes, release of muscle and joint contractures, and realignment osseous ankle procedures. In a previous study that used this technique, 78% of patients maintained their ankle range of motion and had none to occasional moderate pain that could be managed generally with nonsteroid anti-inflammatory drugs alone. The rationale as to why joint distraction is successful is largely unknown. Therefore, the purpose of this study was to evaluate pre- and postoperative ankle MRI scans of patients who underwent hinged ankle joint distraction with external fixation.

Joint preservation of the osteoarthritic ankle using distraction arthroplasty

BACKGROUND

In recent years ankle distraction arthroplasty has gained popularity in the treatment of ankle arthritis as a means of both maintaining range of motion and avoiding fusion. We present a retrospective review of 25 patients who have undergone ankle distraction from 1999 to 2006.

MATERIALS AND METHODS

The mean age was 43 years; 16 were male, and 7 were female. Followup was 30 months after frame removal (range, 12 to 60 months). We were able to obtain followup on 23 of 25 patients. Adjuvant procedures were performed in some cases including Achilles tendon lengthening (5), ankle arthroscopy (4), open arthrotomy (1), and supramalleolar tibial and distal fibular osteotomy to correct distal tibial deformity (6).

RESULTS

Twenty-one patients (91%) reported improved pain with those furthest post-op experiencing the best results. The average preoperative AOFAS score was 55 (range, 29 to 82), and the average postoperative score was 74 (range, 47 to 96). The difference between pre- and postoperative scores was significant (p = 0.005). SF-36 scores showed modest improvement in all components. Only two of the patients in the study underwent fusion after ankle distraction. Total ankle motion was maintained in all patients with improvement in the functional arc of motion in five patients who started with mild equinus contractures.

CONCLUSION

We feel that ankle distraction offers a promising solution for many people with ankle arthritis.

Use of circular external fixation for combined subtalar joint fusion and ankle distraction

The authors discuss a novel technique not previously published that incorporates a subtalar joint arthrodesis with an ankle joint arthrodiastasis as an alternative to a tibiotalocalcaneal arthrodesis. Young and active patients who experience refractory pain and stiffness to the rearfoot and ankle secondary to combined severe subtalar and ankle arthrosis are suitable candidates for this surgical procedure. This new approach is based on sound principles in the treatment of severe arthrosis affecting the ankle and subtalar joint. The authors are currently prospectively reviewing their surgical experience with this procedure and believe that it provides an alternative option for the patient, with potentially promising long-term results.

Ankle arthroplasty alternatives with allograft and external fixation: preliminary clinical outcome

Tibiotalar joint reconstruction for the treatment of osteoarthritic and post-traumatic arthritic joint remains controversial and unsatisfactory. While the current literature recommends joint arthrodesis as a gold standard, current developments in allograft technology may aid in the repair of articular damage; avoid any metallic implant wear, failure, and revision; and preserve normal musculoskeletal biomechanics. The purpose of this retrospective study was to report the early clinical outcomes of ankle arthroplasty with allograft and with the application of a monolateral external fixation in the treatment of ankle arthritis. Eighteen patients (18 ankles, n = 18) with end-stage ankle arthritis, underwent surgical intervention. The mean preoperative AOFAS score was 32.0 +/- 1.1 (30-33) while the postop was 87.33 +/- 7.6 (81-97) (P = .000). There were no complications associated with the allograft material. There were also no complications with the external fixator. The early clinical outcome results provided an optimistic view of this procedure as another alternative treatment for the arthritic ankle, with subjective patient improvement and satisfaction, as well as a statistically significant and functionally increased range of motion and joint space and objective improvements. Allograft implantation with external fixation for the arthritic tibiotalar joint provided encouraging preliminary results and patient satisfaction mirroring current outcomes from shoulder and animal studies.

LEVEL OF CLINICAL EVIDENCE

4.

Distraction arthroplasty of the ankle--how far can you stretch the indications?

Ankle joint distraction has been shown to be a viable alternative to ankle arthrodesis or ankle replacement. The à la carte approach to ankle joint preservation (resection of blocking osteophytes, release of muscle/joint contractures, and realignment osseous ankle procedures) presented in this article as important for a successful outcome as is the hinged ankle joint distraction technique itself. The authors reviewed 32 patients who underwent this ankle joint distraction technique and found 78% of patients had maintained their ankle range of motion and have no pain to occasional moderate pain that can be managed generally with nonsteroidal anti-inflammatory drugs alone. Only one has required an ankle fusion, and only one has been converted to an ankle joint replacement. The longevity of these results and the higher percent of good or excellent results when compared with other studies suggest that combining adjunctive procedures and articulation with ankle distraction improves the results of this procedure.

Distraction arthroplasty

Few joint-preserving surgical options exist for the patient who has ankle arthritis refractory to conservative measures. Therefore, continuous effort is afforded to the development of additional treatment options for such patients. Distraction arthroplasty has been proposed as one of these options for the patient in whom fusion or joint replacement is not appropriate. Although the mechanism of action remains unknown, the reports of several researchers support the potential beneficial effects that can be obtained from joint distraction arthroplasty in the severely osteoarthritic ankle. Furthermore, the studies published to date suggest that these effects may not only persist for years but also improve as time progresses during the first several years after treatment. Although additional laboratory studies are needed to understand the biochemical and biomechanical effects of distraction, additional prospective clinical studies are also needed to further understand its efficacy and appropriate patient population. The data thus far suggests that joint distraction arthroplasty may be a viable alternative treatment to arthrodesis and replacement for the young patient who has a congruent, painful, mobile, arthritic ankle joint.

Unloading joints to treat osteoarthritis, including joint distraction

PURPOSE OF REVIEW

Patients are increasingly becoming interested in nonpharmacologic approaches to manage their osteoarthritis. This review examines the recent literature on the potential beneficial effects of unloading joints in the treatment of osteoarthritis, with a focus on joint distraction.

RECENT FINDINGS

Mechanical factors are involved in the development and progression of osteoarthritis. If "loading" is a major cause in development and progression of osteoarthritis, then "unloading" may be able to prevent progression. There is evidence that unloading may be effective in reducing pain and slowing down structural damage. This review describes unloading by footwear and bracing (nonsurgical), unloading by osteotomy (surgical), and has a focus on unloading by joint distraction. Excellent reviews in all these three fields have been published over the past few years. Recent studies argue for the usefulness of a biomechanical approach to improve function and possibly reduce disease progression in osteoarthritis.

SUMMARY

To improve patient function and possibly reduce disease progression, a biomechanical approach should be considered in treating patients with osteoarthritis. Further research (appropriate high-quality clinical trials) and analysis (clinical as well as preclinical and fundamental) are still necessary, however, to understand, validate, and refine the different approaches of unloading to treat osteoarthritis.

Ankle joint distraction

Ankle joint distraction is a viable alternative to ankle arthrodesis or ankle replacement. A congruent, painful, mobile, and arthritic ankle joint that is treated with this technique can achieve good to excellent results. Attention to the principles (anterior osteophyte resection, equinus contracture release, and ankle joint realignment procedures) is as important for a successful outcome as the accurate application of the hinged ankle joint distraction technique itself.

No beneficial effects of joint distraction on early microscopical changes in osteoarthrotic knees. A study in rabbits

BACKGROUND

Although promising results have been reported, on the use of joint distraction in osteoarthrotic joints, the mechanism behind the effects has not yet been expland.

MATERIAL AND METHODS

24 rabbits were randomly divided into 4 groups and osteoarthrosis was induced by papain injection. The first group served as control and the others were treated by simple external fixation (group 2), articulated distraction (group 3) or nonarticulated distraction (group 4).

RESULTS

Histologically, there was no significant difference between the first, the second and the third groups. However, osteoarthrosis increased in group 4.

INTERPRETATION

We conclude that joint distraction has no beneficial effect on the osteoarthrotic cartilage in papain-induced osteoarthrosis, and nonarticulated distraction worsens the results.

Biomechanics of external fixation and limb lengthening

Surgeons who use external fixators for foot and ankle conditions need to understand the biomechanical principles to ensure good outcomes. Fixators can be used for fracture fixation, correction of contractures, distraction osteogenesis, and distraction arthroplasty. A two-ring fixator with wire fixation remains the gold standard with which all other frames are compared. Small changes in mechanical characteristics can have major implications on new bone or cartilage formation.