1
|
Cho BK, An MY, Ahn BH. Comparison of Clinical Outcomes After Total Ankle Arthroplasty Between End-Stage Osteoarthritis and Rheumatoid Arthritis. Foot Ankle Int 2021; 42:589-597. [PMID: 33557617 DOI: 10.1177/1071100720979923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total ankle arthroplasty (TAA) is known to be a reliable operative option for end-stage rheumatoid arthritis. However, higher risk of postoperative complications related to chronic inflammation and immunosuppressive treatment is still a concern. With the use of a newer prosthesis and modification of anti-rheumatic medications, we compared clinical outcomes after TAA between patients with osteoarthritis and rheumatoid arthritis. METHODS Forty-five patients with end-stage osteoarthritis (OA group) and 19 with rheumatoid arthritis (RA group) were followed for more than 3 years after 3 component mobile-bearing TAA (ZenithTM). Perioperative anti-rheumatic medications were modified using an established guideline used in total hip and knee arthroplasty. Clinical evaluations consisted of American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM). RESULTS In the preoperative and postoperative evaluation at final follow-up, there were no significant differences in AOFAS, FAOS, and FAAM scores between 2 groups. Despite statistical similarity in total scores, the OA group showed significantly better scores in FAOS sports and leisure (mean, 57.4 ± 10.1) and FAAM sports activity (mean, 62.5 ± 13.6) subscales than those in the RA group (mean, 52.2 ± 9.8, P = .004; and 56.4 ± 13.2, P < .001, respectively). There were no significant differences in perioperative complication and revision rates between 2 groups. CONCLUSION Patients with end-stage ankle RA had clinical outcomes comparable to the patients with OA, except for the ability related to sports activities. In addition, there were no significant differences in early postoperative complication rates, including wound problem and infection. LEVEL OF EVIDENCE Level III, prognostic, prospective comparative study.
Collapse
Affiliation(s)
- Byung-Ki Cho
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea.,Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Min-Yong An
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Byung-Hyun Ahn
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Korea
| |
Collapse
|
2
|
Yasui Y, Hannon CP, Seow D, Kennedy JG. Ankle arthrodesis: A systematic approach and review of the literature. World J Orthop 2016; 7:700-708. [PMID: 27900266 PMCID: PMC5112338 DOI: 10.5312/wjo.v7.i11.700] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/15/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
3
|
Lareau CR, Deren ME, Fantry A, Donahue RMJ, DiGiovanni CW. Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature. Foot Ankle Surg 2015; 21:150-9. [PMID: 26235852 DOI: 10.1016/j.fas.2015.03.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 03/25/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior. METHODS A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material. RESULTS This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables. CONCLUSION Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Craig R Lareau
- Department of Orthopaedics, OrthoCarolina Foot and Ankle Institute, Charlotte, NC, United States
| | - Matthew E Deren
- Department of Orthopaedics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, United States
| | - Amanda Fantry
- Department of Orthopaedics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, United States.
| | - Rafe M J Donahue
- Department of Biostatistics, Vanderbilt University School of Medicine, 1161 21st Avenue South S-2323 Medical Center North, Nashville, TN 37232, United States
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 3300, 3F, Boston, MA 02114, United States
| |
Collapse
|
4
|
Results of arthrodiastasis in postraumatic ankle osteoarthritis in a young population: Prospective comparative study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013. [DOI: 10.1016/j.recote.2013.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
5
|
Herrera-Pérez M, Pais-Brito JL, de Bergua-Domingo J, Aciego de Mendoza M, Guerra-Ferraz A, Cortés-García P, Déniz-Rodríguez B. [Results of arthrodiastasis in postraumatic ankle osteoarthritis in a young population: prospective comparative study]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 57:409-16. [PMID: 24126145 DOI: 10.1016/j.recot.2013.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 07/29/2013] [Accepted: 07/30/2013] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- M Herrera-Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Canarias, La Laguna, Tenerife, España; Facultad de Medicina, Universidad de La Laguna, La Laguna, Tenerife, España; Unidad de Tobillo y Pie, Hospital Universitario de Canarias, La Laguna, Tenerife, España.
| | | | | | | | | | | | | |
Collapse
|
6
|
Abstract
Rheumatoid arthritis is an autoimmune disease that may affect multiple joints, both small and large, and leads to numerous complications. The standard surgical treatment for a rheumatoid arthritic ankle has been an arthrodesis. The ideal candidate for an ankle replacement in a rheumatoid patient is one who is moderately active, has a well-aligned ankle and heel, and a fair range of motion in the ankle joint. Good surgical technique and correction of any hindfoot deformity will result in satisfactory alignment of the ankle with regard to the mechanical axis, and this will lead to increased prosthetic longevity.
Collapse
Affiliation(s)
- Sean Y C Ng
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital La Tour, Geneva, Switzerland
| | | | | |
Collapse
|
7
|
Abstract
This article examines synovectomy and ankle arthrodesis for the rheumatoid ankle joint. Reviews of osteoimmunology and gait analyses specific to rheumatoid arthritis are included. Comparison studies including ankle arthrodesis and total ankle arthroplasty are reviewed.
Collapse
Affiliation(s)
- Joseph R Treadwell
- Foot & Ankle Specialists of Connecticut, PC, 6 Germantown Road, Danbury, CT 06810, USA.
| |
Collapse
|
8
|
Abstract
BACKGROUND AND PURPOSE Total ankle arthroplasty (TAA) has gained popularity in recent years. If it fails, however, salvage arthrodesis must be reliable as a rescue procedure. We therefore investigated the clinical, radiographic, and subjective outcome after salvage arthrodesis in a consecutive group of patients, and concentrated on the influence of the method of fixation on union rate and on salvage in inflammatory joint disease. PATIENTS AND METHODS Between 1994 and 2005, salvage arthrodesis was performed on 18 ankles (18 patients). Diagnosis was inflammatory joint disease (IJD) in 15 cases and osteoarthritis (OA) in 3. Tibio-talar fusion was performed in 7 ankles, and tibio-talocalcaneal fusion in 11. Serial radiographs were studied for time to union. Clinical outcome at latest follow-up was measured by the AOFAS score, the foot function index (FFI) and by VAS scores for pain, function, and satisfaction. RESULTS Blade plates were used in 7 ankles (4 IJD, 3 OA); all united. Nonunion developed in 7 of the 11 rheumatic ankles stabilized by other methods. 11 patients (8 fused ankles, 3 nonunions) were available for clinical evaluation. Their mean AOFAS score was 62 and mean overall FFI was 70. VAS score for pain was 20, for function 64, and for satisfaction 74. The scores were similar in united and non-united ankles. INTERPRETATION Blade plate fixation is successful in salvage arthrodesis for failed TAA. A high nonunion rate was found after salvage ankle arthrodesis in IJD with other methods of fixation. Clinical results were fair to good.
Collapse
Affiliation(s)
- H Cornelis Doets
- Department of Orthopedics, Slotervaartziekenhuis, Amsterdamthe Netherlands
| | - Arthur W Zürcher
- Department of Orthopedics, Slotervaartziekenhuis, Amsterdamthe Netherlands
| |
Collapse
|
9
|
Artroplastia total de tobillo. Primeros 25 casos. Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1888-4415(08)74825-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
10
|
Álvarez-Goenaga F. Total ankle replacement. First 25 cases. Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1988-8856(08)70100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
11
|
Abstract
This article defines specific risks associated with rheumatoid arthritis, including an increased incidence of medical comorbidities, the use of steroids and other immunosuppressive agents, osteoporosis, vascular disease, and the common occurrence of severe deformity. This article suggests approaches for management and techniques that may improve specific surgical issues in this challenging patient population.
Collapse
Affiliation(s)
- Vincent James Sammarco
- Cincinnati Sports Medicine and Orthopaedic Center, 10663 Montgomery Road, Cincinnati, OH 45242, USA.
| |
Collapse
|
12
|
Abstract
There is a wide variety of hindfoot disease seen in patients with rheumatoid arthritis. Initial treatment is conservative including optimizing medical management to control the disease process. Should symptoms persist, surgical treatment may be performed, although there is an increased complication rate related to both the disease and the side effects of the medications used to treat it.
Collapse
Affiliation(s)
- Michael S Aronow
- Department of Orthopaedic Surgery, University of Connecticut Health Center Medical Arts and Research Building, 263 Farmington Avenue, Farmington, CT 06034-4037, USA.
| | | |
Collapse
|
13
|
Doets HC, Brand R, Nelissen RGHH. Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. J Bone Joint Surg Am 2006; 88:1272-84. [PMID: 16757761 DOI: 10.2106/jbjs.e.00414] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Interest in mobile-bearing total ankle arthroplasty has increased in recent years. However, to our knowledge, no study has focused exclusively on patients with the diagnosis of inflammatory joint disease or has provided a detailed analysis of the risk factors for failure. METHODS A prospective observational study of the results of cementless mobile-bearing total ankle arthroplasty in patients with inflammatory joint disease (mainly rheumatoid arthritis) was conducted at two centers. Ninety-three total ankle arthroplasties were performed. The LCS (low contact stress) prosthesis was used initially, in nineteen ankles, between 1988 and 1992, and a modification of the LCS prosthesis, the Buechel-Pappas design, was used in seventy-four ankles between 1993 and 1999. Clinical and radiographic follow-up was performed at yearly intervals. Three clinical scoring systems were used, and any complication was recorded throughout follow-up. Actuarial survival (with revision as the end point), multivariate analysis, and a competing risk approach were used to describe the long-term outcome. RESULTS The clinical result at one year after surgery showed a significant improvement in the scores on all three scoring systems (p < 0.05). Ankle dorsiflexion (mean, 7 degrees ) also improved significantly (p < 0.05) compared with the preoperative state. The most frequent complication was a malleolar fracture, which occurred in twenty ankles. Only when it occurred in combination with a deformity in the frontal plane did this complication have an adverse effect on the end result. At a mean follow-up of eight years, seventeen patients (twenty-one ankles) had died and fifteen ankles had been revised because of aseptic loosening (six ankles), primary or secondary axial deformity with edge-loading (six ankles), deep infection (two ankles), and a severe wound-healing problem (one ankle), leaving fifty-seven ankles (61%) that were evaluated. The mean overall survival rate at eight years was 84%. An increased failure rate was encountered in ankles with a preoperative deformity in the frontal plane of >10 degrees (p = 0.03) and in ankles in which an undersized tibial component had been implanted (p = 0.02). CONCLUSIONS Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used. Aseptic loosening and persistent deformity are the most important modes of failure.
Collapse
Affiliation(s)
- H Cornelis Doets
- Department of Orthopaedic Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
| | | | | |
Collapse
|
14
|
Kennedy JG, Hodgkins CW, Brodsky A, Bohne WH. Outcomes after standardized screw fixation technique of ankle arthrodesis. Clin Orthop Relat Res 2006; 447:112-8. [PMID: 16741477 DOI: 10.1097/01.blo.0000203480.04174.0e] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Several methods of obtaining ankle fusion have been described, with numerous studies reporting on patient populations with varied diagnoses and various methods of fixation. This has led to outcome analyses that are difficult to interpret. Our hypothesis is that using a standard method of fusion, without the aid of allograft, a solid ankle fusion can be achieved in patients with end-stage ankle arthritis, and that this outcome can be reflected in standardized outcome tools. Forty-one consecutive ankle fusions in 40 patients were included in our study, with a minimum followup of 3 years. All patients had an ankle arthrodesis using two parallel retrograde 7.3-mm screws and local fibular graft. All but two patients obtained a solid talocrural union (95%), with a mean postoperative improvement in the American Orthopaedic Foot and Ankle Society score of 23 points. Results of our study showed that a simple technique based on sound mechanical and biologic principles can yield excellent outcomes for patients.
Collapse
Affiliation(s)
- John Garrett Kennedy
- Foot and Ankle Department, Hospital for Special Surgery, New York, NY 10021, USA.
| | | | | | | |
Collapse
|
15
|
Anderson T, Linder L, Rydholm U, Montgomery F, Besjakov J, Carlsson A. Tibio-talocalcaneal arthrodesis as a primary procedure using a retrograde intramedullary nail: a retrospective study of 26 patients with rheumatoid arthritis. Acta Orthop 2005; 76:580-7. [PMID: 16195077 DOI: 10.1080/17453670510041592] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Arthrodesis of the ankle joint using screws or external fixation is often a demanding procedure, notably in patients with rheumatoid arthritis. We investigated whether tibio-talocalcaneal arthrodesis with the use of an intramedullary nail is a safe and simple procedure. PATIENTS AND METHODS We retrospectively reviewed 25 ankles (25 patients) at median 3 (1-7) years after tibio-talocalcaneal arthrodesis because of rheumatoid arthritis. All had been operated on by retrograde insertion of a retrograde nail. 5 types of nail had been used. Complications, functional outcome scores, and patient satisfaction were determined and the radiographs evaluated for healing. RESULTS All but 1 ankle had a radiographically healed arthrodesis. We recorded 3 deep infections, all healed--in 2 cases after extraction of the nail--and the arthrodesis healed in all 3 patients. The average functional scores at follow-up were high, considering that the patients suffered from rheumatoid arthritis. 23 patients were satisfied with the outcome. We found a correlation between the functional scores and the general activity of the disease expressed as a Health Assessment Questionnaire score. INTERPRETATION In patients with rheumatoid arthritis, tibio-talocalcaneal arthrodesis with a retrograde intra-medullary nail results in a high rate of healing, a high rate of patient satisfaction, and relatively few complications.
Collapse
Affiliation(s)
- Thomas Anderson
- Department of Orthopaedics, Malmö University Hospital, Sweden
| | | | | | | | | | | |
Collapse
|
16
|
Christ R, Hagena FW. Komplikationen und Revisionseingriffe nach OSG-Totalendoprothesen. ACTA ACUST UNITED AC 2005. [DOI: 10.1007/s10302-005-0128-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
17
|
Alonso-Vázquez A, Lauge-Pedersen H, Lidgren L, Taylor M. The effect of bone quality on the stability of ankle arthrodesis. A finite element study. Foot Ankle Int 2004; 25:840-50. [PMID: 15574246 DOI: 10.1177/107110070402501115] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite uniform operating techniques, lack of fusion still occurs after ankle arthrodesis. Differences in the biological healing potential may be a factor but the mechanical performance of the arthrodesis construct because of varying bone quality also may be important. Internal compression techniques are preferred because of higher union rates, shorter fusion times, and fewer complications. A three-screw configuration has been shown to be more stable than a two-screw configuration, but it is not obvious when it should be used. METHODS Three-dimensional finite element models of intact and flat-cut ankle arthrodeses were built, using two and three screws in different configurations. Poor bone quality was simulated by decreasing Young's modulus of the bone. The constructs were loaded in torsion and dorsiflexion, and micromotions at the fusion site were measured. RESULTS Bone quality had a marked effect on the stability at the arthrodesis site. Inserting two screws at 30 degrees relative to the longitudinal axis of the tibia in an intact arthrodesis seemed the best option, especially as bone quality worsened. The addition of a third screw increased the stability at the arthrodesis site. CONCLUSIONS Overall, intact joint surfaces and three-screw fixation, with the lateral and medial screws inserted produced the most stable arthrodesis constructs when bone quality was poor. CLINICAL RELEVANCE. Ankle arthrodeses are technically demanding because of the shape and small size of the talus. Preoperative planning is an absolute necessity to determine placement and number of screws. This study shows that poor bone quality decreases the stability of the arthrodesis constructs, suggesting that an attempt should be made to create the most stable three-screw configuration. Finite element models can be used as an effective preoperative tool for planning screw number and placement.
Collapse
Affiliation(s)
- Ana Alonso-Vázquez
- Bioengineering Sciences Research Group, School of Engineering Sciences, University of Southhampton, Southampton SO17 1BJ, UK
| | | | | | | |
Collapse
|
18
|
Alonso-Vázquez A, Lauge-Pedersen H, Lidgren L, Taylor M. Initial stability of ankle arthrodesis with three-screw fixation. A finite element analysis. Clin Biomech (Bristol, Avon) 2004; 19:751-9. [PMID: 15288463 DOI: 10.1016/j.clinbiomech.2004.04.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2003] [Accepted: 04/30/2004] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Compare the initial stability at the fusion site of ankle arthrodesis fixed with two and three screws. DESIGN Finite element models of ankle arthrodesis were developed from computed tomography images. Two-screw constructs were augmented with a third screw in different orientations and subjected to loads likely to affect the ankle postoperatively. BACKGROUND More stable fixation seems to increase the chance of fusion, as it minimises the motion between the tibiotalar interfaces. METHODS Non-linear elastic finite element analyses were performed in external torsion and dorsiflexion. The micromotions at the tibiotalar interface were computed to compare the two- and three-screw fixation in intact and flat-cut arthrodesis. RESULTS Adding a third screw reduced the micromotions at the fusion site. Inserting the third screw anteriorly predicted lower peak micromotions than inserting the screw posteriorly, except for the intact arthrodesis tested in dorsiflexion. Three-screw intact arthrodesis predicted lower peak micromotions than flat-cut arthrodesis. CONCLUSIONS Better stability was predicted for three-screw ankle arthrodesis. In flat-cut arthrodesis, a third screw inserted anteriorly performed better than a posterior screw. In intact arthrodesis, a posterior screw seemed a better option when flexion stability was the main concern. Even with three-screw fixation, the configuration of the first two-crossed screws may still be important to improve the stability at the fusion site.
Collapse
Affiliation(s)
- Ana Alonso-Vázquez
- Bioengineering Sciences Research Group, School of Engineering Sciences, University of Southampton, Southampton SO17 1BJ, UK.
| | | | | | | |
Collapse
|
19
|
Bonnin M, Judet T, Colombier JA, Buscayret F, Graveleau N, Piriou P. Midterm results of the Salto Total Ankle Prosthesis. Clin Orthop Relat Res 2004:6-18. [PMID: 15241138 DOI: 10.1097/01.blo.0000132407.75881.a0] [Citation(s) in RCA: 195] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The Salto Total Ankle Prosthesis is noncemented with mobile bearings and is characterized by an anatomic design and a dual Ti-HA coating. Between 1997 and 2000, 98 consecutive Salto prostheses were implanted. At last followup, two patients were deceased, one patient was lost to followup, and two prostheses were removed in two patients. Ninety-three implants in 91 patients were available with a mean followup of 35 months (range, 24-68 months). Survivorship at 68 months, with the end point implant removal, then was 98% (favorable scenario) to 94.9% (unfavorable scenario). The American Orthopaedic Foot and Ankle Society score was 32.3 points preoperatively and 83.1 points at followup. Seventy-two patients are pain-free, 54 patients walk unlimited distances, and 25 patients have limitation but walk more than 1 km. Sixty-seven patients have no limp but seven need walking aids. Fifty-eight patients can walk on tiptoes, 49 patients can walk on uneven ground, 14 patients can run, 76 patients ascend stairs normally, and 63 patients descend stairs normally. Range of motion as measured on stress radiographs improved from 15.2 degrees preoperatively to 28.3 degrees at followup. Preliminary results of the Salto prosthesis are encouraging and validate the concept of anatomic replacement.
Collapse
Affiliation(s)
- M Bonnin
- Clinique Sainte Anne Lumière, 85 Cours Albert Thomas, F-69003 Lyon, France.
| | | | | | | | | | | |
Collapse
|
20
|
Abstract
The painful ankle arthrodesis is an unsolved clinical problem. In many cases, transtibial amputation may be the best option for functional recovery. Recent reports of early success with second generation ankle implants show takedown of the problematic ankle fusion and conversion to total ankle arthroplasty may be an alternative to amputation. This study is a retrospective review of 23 ankles in 22 patients scheduled to have this procedure. Four patients were lost to followup, leaving 19 ankles in 18 patients at an average followup of 39 months. Three patients chose to have an amputation because of continued pain. In the remaining 16 ankles, the mean AOFAS ankle-hind foot outcome score improved from 42-68. Patients who had a clear source of pain with the ankle arthrodesis (such as subtalar arthrosis) had a better result than patients without a clear source of pain. All the patients who had the lateral malleolus resected during previous arthrodesis had complicated courses after arthroplasty. For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation.
Collapse
Affiliation(s)
- Justin Greisberg
- Department of Orthopaedic Surgery, Columbia University, 622 West 168th Street, PH 1121, New York, NY 10032, USA.
| | | | | | | |
Collapse
|
21
|
Ankle and hindfoot reconstruction: what is new in ankle arthroplasty, allograft, and fusion. ACTA ACUST UNITED AC 2004. [DOI: 10.1097/00001433-200404000-00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
22
|
Nishikawa M, Tomita T, Fujii M, Watanabe T, Hashimoto J, Sugamoto K, Ochi T, Yoshikawa H. Total ankle replacement in rheumatoid arthritis. INTERNATIONAL ORTHOPAEDICS 2004; 28:123-6. [PMID: 15224171 PMCID: PMC3474485 DOI: 10.1007/s00264-003-0512-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2003] [Indexed: 10/26/2022]
Abstract
We reviewed 21 patients with rheumatoid arthritis who had a total ankle replacement between 1984 and 2000. The average follow-up was 72 (15-169) months. Clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score. At the latest review, three ankles had been revised. Two ankles were excellent, seven good, three fair, and 12 poor. Eleven patients with 13 ankles had residual pain, with radiographs showing a high incidence of radiolucent lines. Migration of the tibial component was seen in 13 ankles and collapse of talus in nine. Although clinical results were poor, patient satisfaction was not.
Collapse
Affiliation(s)
- Masataka Nishikawa
- Department of Orthopaedics, Osaka University Graduate School of Medicine, 2–2 Yamada-oka, 565–0871 Suita, Osaka, Japan
| | - Tetsuya Tomita
- Department of Orthopaedics, Osaka University Graduate School of Medicine, 2–2 Yamada-oka, 565–0871 Suita, Osaka, Japan
| | - Masakazu Fujii
- Department of Orthopaedic Surgery, Garacia Hospital, Japan
| | - Tetsu Watanabe
- Division of Computer Integrated Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Jun Hashimoto
- Department of Orthopaedics, Osaka University Graduate School of Medicine, 2–2 Yamada-oka, 565–0871 Suita, Osaka, Japan
| | - Kazuomi Sugamoto
- Department of Orthopaedics, Osaka University Graduate School of Medicine, 2–2 Yamada-oka, 565–0871 Suita, Osaka, Japan
| | - Takahiro Ochi
- Division of Computer Integrated Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedics, Osaka University Graduate School of Medicine, 2–2 Yamada-oka, 565–0871 Suita, Osaka, Japan
| |
Collapse
|
23
|
|
24
|
Kennedy JG, Harty JA, Casey K, Jan W, Quinlan WB. Outcome after single technique ankle arthrodesis in patients with rheumatoid arthritis. Clin Orthop Relat Res 2003:131-8. [PMID: 12838063 DOI: 10.1097/01.blo.0000071755.41516.a0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The established treatment for severe rheumatoid arthritis in the ankle is arthrodesis. Numerous reports in the literature describe outcomes in patients with degenerative and posttraumatic arthrosis and rheumatoid disease. This has led to results that are difficult to interpret. In addition, in the few studies that have evaluated patients with rheumatoid disease many techniques of arthrodesis are reported, further confounding assessment of one fusion method. One technique of 20 ankle fusions in patients with rheumatoid disease was evaluated. A modified Wagner arthrodesis was used through a transfibular approach using parallel compression screws. The scoring systems of Mazur et al, Moran et al, and the Short-Form-36 were used to evaluate the outcome. The mean time to followup was 3 years 10 months. Eighteen of 20 fusions obtained a solid talocrural union (90%). No correlation was found between the scores of Mazur et al and Moran et al. Correlation was achieved between the scores for the Short Form-36 and Moran et al. The modified Wagner ankle arthrodesis is a simple, reliable, reproducible technique with a 90% union rate. The value of the technique has been confirmed in patients with rheumatoid arthritis by evaluating the outcome using a scoring system that is validated and relevant to this population.
Collapse
Affiliation(s)
- John G Kennedy
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USA.
| | | | | | | | | |
Collapse
|
25
|
Abstract
It has been generally accepted that residual cartilage and subchondral bone has to be removed in order to get bony fusion in arthrodeses. In 1998 we reported successful fusion of 11 rheumatoid ankles, all treated with percutaneous fixation only. In at least one of these ankle joint there was cartilage left. This was confirmed by arthrotomy in order to remove an osteophyte, which hindered dorsiflexion. More than 25 rheumatoid patients with functional alignment in the ankle joint have subsequently been operated on with the percutaneous technique, and so far we have had only one failure. Patients with rheumatoid arthritis are known to sometimes fuse at least their subtalar joints spontaneously, and the destructive effect of the synovitis on the cartilage could contribute to fusion when using the percutaneous technique. In a rabbit study we therefore tested the hypothesis that even a normal joint can fuse merely by percutaneous fixation. The patella was fixated to the femur with lag screw technique without removal of cartilage, and in 5 of 6 arthrodeses with stable fixation bony fusion followed. Depletion of synovial fluid seemed to be the mechanism behind cartilage disappearance. The stability of the fixation achieved at arthrodesis surgery is an important factor in determining success or failure. Dowel arthrodesis without additional fixation proved to be deleterious. A good fit of the bone surfaces appears necessary. In the ankle joint, it would be technically demanding to retain the arch-shaped geometry of the joint after resection of the cartilage. Normally the joint surfaces are resected to produce flat osteotomy surfaces that are thus easier to fit together, encouraging healing to occur. On the other hand it is considered an advantage to preserve as much subchondral bone as possible, as the strong subchondral bone plate can contribute to the stability of the arthrodesis. Ankle arthrodesis can be successfully performed in patients with rheumatoid arthritis by percutaneous screw fixation without resection of the joint surfaces. This procedure has two advantages: first, it is less surgically traumatic, second, both the arch-shaped geometry and the subchondral bone are preserved, and thus both could contribute to the postoperative stability of the construct. Intuitively, preservation of the arch-shape should increase rotational stability. The results of our experimental sawbone study indicate that the arch shape and the subchondral bone should be preserved when ankle arthrodesis is performed. The importance of this is likely to increase in weak rheumatoid bone. In a finite element study the initial stability provided by two different methods of joint preparation and different screw configurations in ankle arthrodesis, was compared. Better initial stability is predicted for ankle arthrodesis when joint contours are preserved rather than resected. Overall, inserting the two screws at a 30-degree angle with respect to the long axis of the tibia and crossing them above the fusion site improved stability for both joint preparation techniques. The question rose as to whether patients with osteoarthritis could also be operated on solely by percutaneous fixation technique. The first metatarsophalangeal joint in patients with hallux rigidus was chosen as an appropriate joint to test the percutaneous technique. In this small series we have shown that it is possible to achieve bony fusion with a percutaneous technique in an osteoarthrotic joint in humans, but failed to say anything about the fusion rate.
Collapse
|
26
|
Abstract
Complications occur in patients with rheumatoid arthritis who require surgical correction of painful deformities of the foot and ankle. These patients probably are more likely to have complications develop because they: (1) have a systemic disease; (2) use medications that may lead to complications; (3) require multiple operations; and (4) usually have advanced deformities resulting in extensive complicated operations. Despite these difficulties, results of surgical procedures in patients with rheumatoid arthritis remain uniformly excellent. Most complications can be treated successfully, and the overall failure of selected operations is low. However, surgical reconstruction of foot and ankle deformities in patients with rheumatoid arthritis must be meticulously planned and done. These operations are most successful in eliminating pain and in correcting severe deformities.
Collapse
Affiliation(s)
- J Nassar
- Department of Orthopaedic Surgery, UCLA Medical Center, Los Angeles, CA 90095, USA
| | | |
Collapse
|
27
|
Abstract
Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors' institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeon's attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0-5 degrees of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.
Collapse
Affiliation(s)
- H Mäenpää
- Rheumatism Foundation Hospital, Heinola, Finland.
| | | | | |
Collapse
|
28
|
|