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Yano K, Ikari K, Okazaki K. Stress fractures in the forefoot after arthrodesis of the hindfoot in a patient with rheumatoid arthritis: A case report. Mod Rheumatol Case Rep 2023; 7:19-23. [PMID: 35460244 DOI: 10.1093/mrcr/rxac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/23/2022] [Accepted: 04/18/2022] [Indexed: 01/07/2023]
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease that attacks multiple joints throughout the body. Ankle arthrodesis (AA) has been the gold standard surgery for end-stage ankle arthritis in patients with RA. Here, we report the case of a 67-year-old woman with RA who had displacement and loosening of total ankle arthroplasty. The ankle was converted to AA using a metal spacer and an intramedullary nail. The patient had no complications in perioperative terms of arthrodesis. However, multiple fractures were found in the metatarsal bones at the routine 3-year follow-up. Although the patient did not remember any symptoms, the clinical outcome deteriorated compared to that a year before. The hindfoot in this case report was fixed completely by an intramedullary nail, while the midfoot had already involved ankylosis because of severe joint destruction present before the surgery. As a result, the range of motion in the joints of the midfoot and hindfoot was lost, and it is probable that an excessive load was applied to the forefoot during push-off by the toes, resulting in a stress fracture. Patients with RA remain at risk of future progressive joint destruction in every joint of their body. Therefore, surgeons should choose a surgery that preserves ankle motion to decrease the rate of adjacent joint degeneration for severe ankle arthropathy in patients with RA.
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Affiliation(s)
- Koichoro Yano
- Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan.,Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Katsunori Ikari
- Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan.,Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan.,Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Okazaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
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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.
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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
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Anastasio AT, Patel PS, Farley KX, Kadakia R, Adams SB. Total ankle arthroplasty and ankle arthrodesis in rheumatic disease patients: An analysis of outcomes and complications using the National Inpatient Sample (NIS) database. Foot Ankle Surg 2021; 27:321-325. [PMID: 32782226 DOI: 10.1016/j.fas.2020.07.006] [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] [Received: 04/25/2020] [Revised: 06/23/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rheumatoid arthritis (RA), can manifest as an inflammatory arthropathy in the ankle. As a result, this study sought to examine the role of RA with respect to complications in patients undergoing either total ankle arthroplasty or ankle arthrodesis by utilizing the National Inpatient Sample to assess for correlations. METHODS Admissions for TAA and AA were extracted from the National Inpatient Sample using primary ICD-9-CM diagnosis codes. Patients aged 18-65 years with a duration of hospital stay of >3 days and isolated complications were included. Multivariable regression was then performed within matched groups to determine differences. RESULTS There was decreased risk of myocardial infarction, pulmonary embolism, surgical site infection, and urinary tract infection in patients with RA. Postoperative development of pneumonia was seen at a higher rate in patients with RA. CONCLUSION RA is not associated with a markedly increased complication burden in the appropriately chosen surgical candidate for ankle arthrodesis and ankle arthroplasty.
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Affiliation(s)
| | - Preet S Patel
- Duke University Department of Orthopedic Surgery, United States.
| | - Kevin X Farley
- Emory University Department of Orthopedic Surgery, United States
| | - Rishin Kadakia
- Duke University Department of Orthopedic Surgery, United States
| | - Samuel B Adams
- Duke University Department of Orthopedic Surgery, United States
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Kruidenier J, van der Plaat LW, Sierevelt IN, Hoornenborg D, Haverkamp D. Ankle fusion after failed ankle replacement in rheumatic and non-rheumatic patients. Foot Ankle Surg 2019; 25:589-593. [PMID: 30321923 DOI: 10.1016/j.fas.2018.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/19/2018] [Accepted: 08/15/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND With longer follow-up, survival rate of total ankle replacements (TAR) diminishes. It is therefore important to have a reliable fall-back option in case of failed TAR. Revision arthroplasty is often impossible because of loss of bonestock or infection. Conversion to ankle fusion is then indicated. We investigated the clinical, radiographic and patient reported results for fusion after failed TAR in a consecutive group of patients. We concentrated on the influence of inflammatory joint disease (IJD) on union rate. METHODS Patient files and radiographic images of 46 consecutive patients (47 ankles) were reviewed. There were 22 patients with IJD. Fixation methods included; anterior plating, blade plate fixation, intramedullary nailing, compression screws and external fixation. Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) were used to determine patient related outcomes. RESULTS Forty out of 47 ankles (85%) Fused. Union rate in the non-IJD group (96%) was significantly higher compared to the IJD-group (73%, p=0.04). Revisions and complications were more frequent in the IJD group, but numbers were too small to detect a significant difference. Mean PROM scores were: FAOS-symptoms; 68.5, FAOS-pain; 70.3, FAOS-QoL; 43.7, FAOS-ADL; 68.1 and FAAM-ADL; 52.1, with no significant difference between IJD and non-IJD patients. CONCLUSIONS IJD-patients have a higher nonunion rate after ankle fusion for failed TAR. However, patient reported outcome is not significantly different between the two groups. LEVEL OF EVIDENCE IV, retrospective cohort.
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Affiliation(s)
- J Kruidenier
- MC Slotervaart, Department of Orthopedics, Louwesweg 6, 1066EC Amsterdam, Noord-Holland, The Netherlands
| | - L W van der Plaat
- Noordwest Ziekenhuisgroep, Department of Orthopedics, Wilhelminalaan 12, 1815 JD Alkmaar, Noord-Holland, The Netherlands
| | - I N Sierevelt
- MC Slotervaart, Department of Orthopedics, Louwesweg 6, 1066EC Amsterdam, Noord-Holland, The Netherlands
| | - D Hoornenborg
- MC Slotervaart, Department of Orthopedics, Louwesweg 6, 1066EC Amsterdam, Noord-Holland, The Netherlands
| | - D Haverkamp
- MC Slotervaart, Department of Orthopedics, Louwesweg 6, 1066EC Amsterdam, Noord-Holland, The Netherlands.
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Abstract
BACKGROUND Over the past decade, total ankle arthroplasty (TAA) has become a mainstay in the treatment of end-stage ankle arthritis. Currently in its fourth generation, the Scandanavian Total Ankle Replacement (STAR) is the only 3-piece mobile bearing ankle prosthesis available in the United States. Our current study reports implant survivorship at 15 years and patient outcomes for a subset of these survivors available for study. METHODS Eighty-four TAAs were performed between 1998 and 2000. Metal component survivorship at 15 years was calculated with a Kaplan-Meier curve. Twenty-four (29%) of 84 patients were available for participation with a minimum 15-year follow-up. Any radiographic changes were documented. All additional procedures and complications were recorded. Clinical findings, self-reported performance and pain evaluations, and AOFAS ankle/hindfoot scores were noted. RESULTS Metal implant survival was 73% at 15 years. Of the 24 patients available for clinical evaluation, 18 of 24 patients (70.7%) had no change in prosthetic alignment from the immediate postoperative radiograph. Only 1 subtalar fusion was required for symptomatic adjacent joint arthritis. Three patients sustained a broken polyethylene component. AOFAS scores improved from an average of 39.6 points preoperatively, to an average of 71.6. More than half (52.4%) of patients with retained implants required an additional surgical procedure; 3 required 2 additional procedures. The average time to subsequent procedure was 10.2 years. CONCLUSION Our small cohort demonstrated STAR ankles with retention at 9 years were highly likely to survive to 15 years, and patients continued to have significant improvement in pain relief and minimal decrease in function. At 15 years from TAA, metal survivorship was 73%. As with all ankle replacements, supplementary procedures were common. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ariel Palanca
- 1 Department of Orthopaedic Surgery, Stanford University Medical Center, Redwood City, CA, USA
| | - Roger A Mann
- 2 Oakland Bone and Joint Specialsts, Oakland, CA, USA
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Usuelli FG, D'Ambrosi R, Manzi L, Maccario C, Indino C. Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach. J Vis Exp 2018. [PMID: 29443030 DOI: 10.3791/56396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.
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Affiliation(s)
| | - Riccardo D'Ambrosi
- Galeazzi Orthopedic Institute for Research and Care; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano
| | - Luigi Manzi
- Galeazzi Orthopedic Institute for Research and Care
| | - Camilla Maccario
- Galeazzi Orthopedic Institute for Research and Care; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano
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Henricson A, Kamrad I, Rosengren B, Carlsson Å. Bilateral Arthrodesis of the Ankle Joint: Self-Reported Outcomes in 35 Patients From the Swedish Ankle Registry. J Foot Ankle Surg 2016; 55:1195-1198. [PMID: 27614825 DOI: 10.1053/j.jfas.2016.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Indexed: 02/03/2023]
Abstract
Bilateral ankle arthrodesis is seldom performed, and results concerning the outcome and satisfaction can only sparsely be found in published studies. We analyzed the data from 35 patients who had undergone bilateral ankle arthrodesis in the Swedish Ankle Registry using patient-reported generic and region-specific outcome measures. Of 36 talocrural arthrodeses and 34 tibio-talar-calcaneal arthrodeses, 6 ankles (9%) had undergone repeat arthrodesis because of nonunion. After a mean follow-up period of 47 ± 5 (range 12 to 194) months, the mean scores were as follows: self-reported foot and ankle score, 33 ± 10 (range 4 to 48); the EuroQol Group's EQ-5D™ score, 0.67 ± 0.28 (range -0.11 to 1), the EuroQol Group's visual analog scale score, 70 ± 19 (range 20 to 95), 36-item Short Form Health Survey (SF-36) physical domain, 39 ± 11 (range 16 to 58); and SF-36 mental domain, 54 ± 14 (range 17 to 71). Patients with rheumatoid arthritis seemed to have similar self-reported foot and ankle scores but possibly lower EQ-5D™ and SF-36 scores. Those with talocrural arthrodeses scored higher than did those with tibio-talar-calcaneal arthrodeses on the EQ5D™ and SF-36 questionnaires (p = .03 and p = .04). In 64 of 70 ankles (91%), the patients were satisfied or very satisfied with the outcome. In conclusion, we consider bilateral ankle arthrodesis to be a reasonable treatment for symptomatic hindfoot arthritis, with high postoperative mid-term satisfaction and satisfactory scores on the patient-reported generic and region-specific outcome measures, when no other treatment option is available.
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Affiliation(s)
- Anders Henricson
- Orthopedic Surgeon, Department of Orthopedics, Falu Central Hospital and Center of Clinical Research Dalarna, Falun, Sweden.
| | - Ilka Kamrad
- Orthopedic Surgeon, Department of Orthopedics and Clinical Sciences, Lund University and Skåne University Hospital, Malmö, Sweden
| | - Björn Rosengren
- Orthopedic Surgeon, Department of Orthopedics and Clinical Sciences, Lund University and Skåne University Hospital, Malmö, Sweden; Associate Professor, Department of Orthopedics and Clinical Sciences, Lund University and Skåne University Hospital, Malmö, Sweden
| | - Åke Carlsson
- Orthopedic Surgeon, Department of Orthopedics and Clinical Sciences, Lund University and Skåne University Hospital, Malmö, Sweden; Associate Professor, Department of Orthopedics and Clinical Sciences, Lund University and Skåne University Hospital, Malmö, Sweden
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Iwata T, Ito H, Furu M, Ishikawa M, Azukizawa M, Yoshitomi H, Fujii T, Akiyama H, Matsuda S. Subsidence of total ankle component associated with deterioration of an ankle scale in non-inflammatory arthritis but not in rheumatoid arthritis. Mod Rheumatol 2016; 27:417-424. [DOI: 10.1080/14397595.2016.1220049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Takahiro Iwata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
| | - Hiromu Ito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
| | - Moritoshi Furu
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
- Department of the Control for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
| | - Masahiro Ishikawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
- Department of the Control for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
| | - Masayuki Azukizawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
| | - Hiroyuki Yoshitomi
- Department of Tissue Regeneration, The Institute for Frontier Medical Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan, and
| | - Takayuki Fujii
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan,
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Usuelli FG, Maccario C, Manzi L, Gross CE. Clinical Outcome and Fusion Rate Following Simultaneous Subtalar Fusion and Total Ankle Arthroplasty. Foot Ankle Int 2016; 37:696-702. [PMID: 27030230 DOI: 10.1177/1071100716642751] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with arthritis or severe dysfunction involving both the ankle and subtalar joints can benefit from tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. TTC fusion is considered by many as a salvage operation resulting in a stiff ankle and hindfoot, considerably limiting global foot function. With the evolution of prosthetic design and operative techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion. METHODS This study included 25 patients who underwent primary TAR and simultaneous subtalar fusion between May 2011 and November 2014. Sixteen males (64%) and 9 females (36%) were enrolled with a mean age of 58 years (25-82). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Total follow-up time was 24.2 ± 11.6 months. Radiographic examination included a postoperative computed tomographic (CT) scan obtained 12 months after surgery. Three surgeons independently reviewed the CT scans and interobserver reliability was calculated. Functional scores were also assessed. RESULTS At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92%. There was a statistically significant increase in American Orthopaedic Foot & Ankle Society ankle/hindfoot score from 27.9 to 75.1. Ankle range of motion significantly increased from 12 to 32.8 degrees. Additionally, there was a statistically significant decrease in visual analog scale pain score from 8.6 to 2.1. CONCLUSIONS TAR and simultaneous subtalar joint fusion were reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopedic surgeons in determining the degree of successful fusion of subtalar arthrodesis. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Camilla Maccario
- USPeC, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy Universita' degli Studi di Milano, Milan, Italy
| | - Luigi Manzi
- USPeC, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy Seconda Università degli Studi di Napoli, Napoli, Italy
| | - Christopher Edward Gross
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, USA
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Usuelli FG, Maccario C, Manzi L, Tan EW. Posterior Talar Shifting in Mobile-Bearing Total Ankle Replacement. Foot Ankle Int 2016; 37:281-7. [PMID: 26443698 DOI: 10.1177/1071100715610426] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND End-stage ankle osteoarthritis frequently involves multiplanar malalignment in both the coronal and the sagittal planes. Sagittal malalignment often includes anterior translation of the talus relative to the tibia. Restoration of the correct tibial and talar alignment is essential for the long-term survival of total ankle replacement. METHODS This study includes 66 consecutive patients who underwent total ankle arthroplasty with the Hintegra prosthesis from May 2011 to April 2014. There were 28 females (42.4%) and 38 males (57.6%) with a mean age of about 57 years (25-82 years). Patients were clinically and radiologically assessed preoperatively and at 2, 6, and 12 months postoperatively. RESULTS At 12 months postoperatively, there was a statistically significant increase in American Orthopaedic Foot & Ankle Society scores from 31.9 to 72.3. Range of motion significantly increased from 9.5 to 25.4 degrees. In addition, there was a statistically significant decrease in visual analog scale (VAS) pain score from 8.9 to 2.2. Furthermore, there was a significant increase in the Tibio-Talar ratio from 2 to 6 months postoperatively (34.6%-37.2%). CONCLUSIONS This study demonstrated significant improvements in clinical and radiologic outcomes after Hintegra total ankle arthroplasty. Significant movement of the talus occurs within the first 6 months postoperatively. This may be the result of rebalancing of muscle and ligament forces after surgery. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | | | - Luigi Manzi
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy Seconda Università degli Studi di Napoli, Napoli, Italy
| | - Eric W Tan
- University of Southern California, Los Angeles, USA
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11
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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.
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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
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12
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Vaughan P, Gordon D, Goldberg A, Cullen N, Singh D. Patient satisfaction and function after bilateral ankle arthrodeses. Foot Ankle Surg 2015; 21:160-3. [PMID: 26235853 DOI: 10.1016/j.fas.2014.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/21/2014] [Accepted: 11/03/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimum way to manage patients with bilateral ankle arthritis (AA) is unclear. METHODS This review was performed to report the midterm satisfaction and functional outcome of a series of patients who have undergone bilateral staged ankle arthrodesis. RESULTS Eight patients, median age 68.5 yrs (range 59-80) were followed-up for a median of 58.5 months (range 24-100). All fusions united in a median time of 12.8 weeks (range 10-19) Their median AOFAS hindfoot score was 79.5 (range 71-90). Six patients (75%) were very satisfied, one was satisfied, and the other neither satisfied nor dissatisfied. Two patients developed symptomatic subtalar arthritis requiring subtalar fusion. CONCLUSIONS This is the first study to report the outcome of bilateral AA independent to that of unilateral AA. Bilateral AA appears to give patients a good functional result with high patient reported satisfaction into the medium term.
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Affiliation(s)
- Philip Vaughan
- Foot & Ankle Unit, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK.
| | - David Gordon
- Foot & Ankle Unit, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK
| | - Andy Goldberg
- Foot & Ankle Unit, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK
| | - Nick Cullen
- Foot & Ankle Unit, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK
| | - Dishan Singh
- Foot & Ankle Unit, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK
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13
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Matsumoto T, Nakamura I, Juji T, Ito K. Severe pes planovalgus successfully treated in a patient with mutilating rheumatoid arthritis using a new surgical approach involving medial malleolar resection and medial displacement of the talus: A case report. Mod Rheumatol 2015; 27:1083-1088. [PMID: 25867229 DOI: 10.3109/14397595.2015.1040613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report the case of a 56-year-old female with mutilating rheumatoid arthritis, who developed severe pes planovalgus. The foot was successfully reconstructed through a combination of osteotomies, including medial displacement of the talus accompanied by resection of the medial malleolus. This maneuver enabled a ∼1-cm medial displacement of the hindfoot while minimizing the adverse effect on forefoot rotation.
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Affiliation(s)
- Takumi Matsumoto
- a Department of Rheumatology , Yugawara Hospital, Ashigara-shimo , Kanagawa , Japan
| | - Ichiro Nakamura
- a Department of Rheumatology , Yugawara Hospital, Ashigara-shimo , Kanagawa , Japan.,b Faculty of Medical Science for Health, Teikyo Heisei University , Toshima, Tokyo , Japan
| | - Takuo Juji
- a Department of Rheumatology , Yugawara Hospital, Ashigara-shimo , Kanagawa , Japan
| | - Katsumi Ito
- a Department of Rheumatology , Yugawara Hospital, Ashigara-shimo , Kanagawa , Japan
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14
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Matsumoto T, Nakamura I, Miura A, Momoyama G, Ito K. Radiologic patterning of joint damage to the foot in rheumatoid arthritis. Arthritis Care Res (Hoboken) 2014; 66:499-507. [PMID: 24106167 DOI: 10.1002/acr.22174] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 09/10/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Foot and ankle deformities greatly affect the quality of life of rheumatoid arthritis (RA) patients. The aim of this study was to elucidate the pattern of destruction of the RA foot and its impact on patients. METHODS We cross-sectionally investigated RA patients (274 patients and 542 feet) using radiographs. The grade of joint destruction was assigned using Larsen's grading system for 12 joints in the foot and ankle. Cluster analysis was performed using the K-means method to classify the pattern of joint destruction. Of the 274 patients evaluated radiographically, 212 were assessed for functional disability using questionnaires. RESULTS Cluster analysis revealed that 542 feet were divided into 5 clusters, named according to the characteristic distribution of joint destruction: cluster I (normal type), cluster II (forefoot type), cluster III (midfoot type), cluster IV (mid-hindfoot type), and cluster V (combined type). Radiographic measurements revealed the characteristic deformities of each cluster: splay foot for cluster II, flat foot for cluster III, hindfoot malalignment for cluster IV, and mixtures of these characteristics for cluster V. A distribution map of each cluster based on disease duration revealed that cluster III peaked in cases of 5-10-year disease duration and subsequently decreased, followed by a gradual increase of cluster IV and cluster V. Cluster IV and cluster V showed significant changes in functional disability compared to cluster III. CONCLUSION This report is the first to reveal the pattern of RA foot deformities and their impact on patients using statistical measures in a large series.
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15
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Nagashima M, Tachihara A, Matsuzaki T, Takenouchi K, Fujimori J, Yoshino S. Follow-up study of ankle arthrodesis in severe hind foot deformity in patients with rheumatoid arthritis using an intramedullary nail with fins. Mod Rheumatol 2014. [DOI: 10.3109/s10165-005-0410-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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16
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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.
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Affiliation(s)
- Sean Y C Ng
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital La Tour, Geneva, Switzerland
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17
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Schenk K, Lieske S, John M, Franke K, Mouly S, Lizee E, Neumann W. Prospective study of a cementless, mobile-bearing, third generation total ankle prosthesis. Foot Ankle Int 2011; 32:755-63. [PMID: 22049861 DOI: 10.3113/fai.2011.0755] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The SALTO total ankle prosthesis is a noncemented mobile bearing anatomic design characterized by dual Ti-HA coating. This study reviews our results with this prosthesis. MATERIALS AND METHODS Between 2001 and 2007, 413 consecutive SALTO prostheses were implanted in our institution in 215 women and 198 men, aged 57.1 +/- 11.9 years. At the last visit, 401 implants (47% in the left ankle) were available with a mean followup of 29 (range, 1 to 84) months. RESULTS Based on the results of the 218 patients with at least 2 years of postoperative followup, the 5-year estimated survivorship, with the primary end-point being implant removal, was 86.6% and ranged from 85.1% in patients with post-traumatic osteoarthritis to 95.6% in those with rheumatoid arthritis. The AOFAS score increased from 50.9 +/- 16.8 points preoperatively to 82.2 +/- 14 points at followup (mean difference, 31.1 +/- 1.4, 95% confidence interval (C.I.) for the difference, 28.3 to 33.8, p < 0.001). Visual analog scale for pain decreased from 7.4 +/- 1.1 preoperatively to 2.0 +/- 2.0 postoperatively (mean difference, -5.4 +/- 0.7, 95% C.I. for the difference, -5.6 to -5.2, p < 0.001). Flexion/extension ROM increased from 25.2 +/- 14.1 degrees to 33.1 +/- 13.6 degrees at the last followup visit (mean difference, 7.9 +/- 0.5 degrees, 95% C.I. for the difference, 4.3 to 7.2, p < 0.001), while pronation/supination ROM increased from 23.8 +/- 13.7 degrees to 25.4 +/- 14.5 degrees (mean difference, 1.6 +/- 0.7 degrees, 95% C.I. for the difference, 0.9 to 2.2, p = 0.005). CONCLUSION The SALTO prosthesis provided good clinical and functional results and we believe helps validate the concept of anatomic replacement.
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Affiliation(s)
- Katja Schenk
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
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18
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Abstract
BACKGROUND There has been a resurgence of interest in total ankle replacement (TAR) due to improved results with newer prostheses. However, long-term survivorship data has been limited. The STAR™ Ankle prosthesis is the first three-part prosthesis approved for use in the United States. MATERIALS AND METHODS Eighty-four total ankle replacements were performed in 80 patients using the STAR™ Ankle prosthesis and followed prospectively. Postoperatively, patients were evaluated with the AOFAS score for pain and function, and serial radiographs were evaluated for stability and alignment of the prosthesis. Implant failure, secondary procedures, and complications were recorded. RESULTS Ninety-one percent of prostheses remain implanted at an average followup of 9.1 years. The probability of implant survival was 96% at 5 years and 90% at 10 years. An average 39-point improvement in the AOFAS ankle-hindfoot score was noted, from a mean of 43 to a mean of 82 points. We noted a statistically significant increase in both average pain and function sub-scores. Postoperative range of motion averaged 4.5 degrees of dorsiflexion and 35 degrees of plantarflexion. Ninety-two percent of the patients were satisfied with their outcome. Ten patients (13%) developed concerning osteolytic lesions. Change in prosthetic alignment and adjacent joint arthritis were similar to previous reports. We report 21 complications, which included 14 additional surgical procedures. CONCLUSION The first U.S. prospective long-term survivorship data with the STAR™ Ankle prosthesis found it to be an excellent long-term option for the treatment of ankle arthritis.
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Affiliation(s)
- Jeffrey A Mann
- Oakland Bone and Joint Specialist, Orthopedic Surgery, 80 Grand Avenue, 5th floor, Oakland, CA 94612, USA.
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19
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Atkinson HDE, Daniels TR, Klejman S, Pinsker E, Houck JR, Singer S. Pre- and postoperative gait analysis following conversion of tibiotalocalcaneal fusion to total ankle arthroplasty. Foot Ankle Int 2010; 31:927-32. [PMID: PMID: 20964976 DOI: 10.3113/fai.2010.0927] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Expert Opinion
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20
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Haber L, Womack E, Zimmerman C, Hughes J. Clinical manifestations and treatment of the pediatric rheumatoid patient. Clin Podiatr Med Surg 2010; 27:219-33. [PMID: 20470954 DOI: 10.1016/j.cpm.2009.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The management goal of juvenile rheumatoid arthritis (JRA) is to achieve early diagnosis and treatment so that arthritis can be resolved at an early stage, which avoids long-term damage and provides a good outcome of the affected inflammatory joints. This article describes presentation, classification, evaluation, and treatment of JRA as it relates to the foot and ankle. Because the course of JRA is complex and the optimal management is highly variable in each patient, this article can only offer recommendations. Actual treatment should be individualized to meet the conditions of each patient.
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Affiliation(s)
- Lawrence Haber
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
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21
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Reeves CL, Peaden AJ, Shane AM. The complications encountered with the rheumatoid surgical foot and ankle. Clin Podiatr Med Surg 2010; 27:313-25. [PMID: 20470960 DOI: 10.1016/j.cpm.2009.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic, degenerative, systemic disease that leads to the destruction of articular cartilage of the joints. Complications, including infection, delays in wound healing, malunion, nonunion, implant failure, and degeneration of adjacent joints soon after primary fusion, have been described in the literature and are generally accepted as commonplace in reconstructive surgeries of the foot and ankle. The combined efforts of the surgeon and supporting physicians to maintain optimal health for the patient, along with the principles discussed in this article, can lead to superior outcomes with fewer complications in the postoperative course.
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Affiliation(s)
- Christopher L Reeves
- Department of Podiatric Surgery (East Orlando Campus), Florida Hospital East Orlando, 7975 Lake Underhill Road, Suite 210, Orlando, FL 32822, USA.
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22
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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.
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Affiliation(s)
- Joseph R Treadwell
- Foot & Ankle Specialists of Connecticut, PC, 6 Germantown Road, Danbury, CT 06810, USA.
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23
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Nihal A, Gellman RE, Embil JM, Trepman E. Ankle arthrodesis. Foot Ankle Surg 2009; 14:1-10. [PMID: 19083604 DOI: 10.1016/j.fas.2007.08.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Revised: 07/03/2007] [Accepted: 08/20/2007] [Indexed: 02/04/2023]
Abstract
Numerous techniques for ankle arthrodesis have been reported since the original description of compression arthrodesis. From the early 1950s to the mid 1970s, external fixation was the dominant technique utilized. In the late 1970s and 1980s, internal fixation techniques for ankle arthrodesis were developed. In the 1990s, arthroscopic ankle arthrodesis was developed for ankle arthrosis with minimal or no deformity. The open technique is still widely used for ankle arthrosis with major deformity. For complex cases that involve nonunion, extensive bone loss, Charcot arthropathy, or infection, multiplanar external fixation with an Ilizarov device, with or without a bone graft, may achieve successful union. The fusion rate in most of the recently published studies is 85% or greater, and may depend on the presence of infection, deformity, avascular necrosis, and nonunion.
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Affiliation(s)
- Aneel Nihal
- Southside Health Service District, Logan Hospital, South Brisbane, Queensland, Australia
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24
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Kim C, Catanzariti AR, Mendicino RW. Tibiotalocalcaneal arthrodesis for salvage of severe ankle degeneration. Clin Podiatr Med Surg 2009; 26:283-302. [PMID: 19389600 DOI: 10.1016/j.cpm.2008.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tibiotalocalcaneal arthrodesis is a successful and proven surgical procedure for patients who have significant arthritic changes, deformity, and failed previous operations. Surgical technique varies depending on the type of fixation. Basic surgical principles should not be violated. Correction of the deformity with appropriate joint preparation and stable fixation is important for a good outcome. Other adjunctive materials, such as bone growth stimulators and orthobiologics, should be used appropriately to ensure adequate primary arthrodesis.
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Affiliation(s)
- Chul Kim
- Department of Foot and Ankle Surgery, The Western Pennsylvania Hospital, Pittsburgh, PA, USA
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25
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Takenouchi K, Morishita M, Saitoh K, Wauke K, Takahashi H, Nagashima M. Long-term Results of Ankle Arthrodesis Using an Intramedullary Nail with Fins in Patients with Rheumatoid Arthritis Hindfoot Deformity. J NIPPON MED SCH 2009; 76:240-6. [DOI: 10.1272/jnms.76.240] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kenji Takenouchi
- Department of Neurological, Nephrological and Rheumatological Science, Graduate School of Medicine, Nippon Medical School
- Department of Joint Disease and Rheumatism, Nippon Medical School Hospital
| | - Minoru Morishita
- Department of Neurological, Nephrological and Rheumatological Science, Graduate School of Medicine, Nippon Medical School
- Department of Joint Disease and Rheumatism, Nippon Medical School Hospital
| | - Kimihisa Saitoh
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital
| | - Kouichi Wauke
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital
| | | | - Masakazu Nagashima
- Department of Neurological, Nephrological and Rheumatological Science, Graduate School of Medicine, Nippon Medical School
- Department of Joint Disease and Rheumatism, Nippon Medical School Hospital
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital
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Schönherr R, Fuss S, Körbl M, Trepte CT, Parsch D. [Short-term results after STAR total ankle replacement]. DER ORTHOPADE 2008; 37:783-7. [PMID: 18629468 DOI: 10.1007/s00132-008-1311-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This retrospective study was performed to investigate the clinical and radiological results after STAR total ankle replacement. MATERIAL AND METHODS Between January 2000 and September 2004, 49 patients with an average age of 62.5 years underwent total ankle replacement with the STAR prosthesis. At an average follow-up of 30.4 months, 48 patients were examined clinically and radiologically. The Kofoed ankle score and the patients' subjective satisfaction were evaluated. RESULTS The operation improved the Kofoed ankle score significantly, from 28 to 86 points, 90% of the patients were satisfied with the results. The revision rate was 10%. CONCLUSION The early results after implantation of the STAR ankle prosthesis are encouraging. With correct indication, a high rate of pain reduction and patient satisfaction can be achieved. The long-term benefit of this procedure has yet to be determined.
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Affiliation(s)
- R Schönherr
- Baumann-Klinik, Karl-Olga-Krankenhaus, Hackstrasse 61, 70190, Stuttgart.
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27
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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
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28
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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
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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.
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Affiliation(s)
- Vincent James Sammarco
- Cincinnati Sports Medicine and Orthopaedic Center, 10663 Montgomery Road, Cincinnati, OH 45242, USA.
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30
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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.
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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.
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31
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Abstract
Combined ankle and subtalar arthritis is a difficult problem for which there are varied solutions. Each solution has its advantages and disadvantages. Treatment must be specifically tailored to the patient's needs, comorbidities, and expectations. Because of the complicated nature of this condition and its treatment, complications are common and should be anticipated.
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Affiliation(s)
- Lucille B Andersen
- Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Orthopaedics and Rehabilitation, H089, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850, USA.
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Shi K, Hayashida K, Hashimoto J, Sugamoto K, Kawai H, Yoshikawa H. Hydroxyapatite augmentation for bone atrophy in total ankle replacement in rheumatoid arthritis. J Foot Ankle Surg 2006; 45:316-21. [PMID: 16949529 DOI: 10.1053/j.jfas.2006.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although total ankle replacement is routinely used for rheumatoid arthritis of the ankle, it has been hampered by early implant failures such as loosening and subsidence of the tibial component due to poor bone quality. To prevent this complication, total ankle replacement augmented by a specially designed hydroxyapatite coating was used in 14 patients (16 feet). Patients were reviewed after an average follow-up of 23.1 months, and the mean clinical rating scale significantly improved from 30.7/100 points preoperatively to 65.9/100 at final follow-up, especially with respect to pain relief. Radiographs taken immediately postoperatively and at final follow-up were analyzed for the position and sinking of the tibial component. The position was evaluated by measurement of the alpha and beta angles, formed by the tibial long axis and tibial component on anteroposterior and lateral radiographs, respectively. The mean alpha and beta angles were 87.4 degrees and 79.3 degrees postoperatively and 87.7 degrees and 81.0 degrees at final follow-up, respectively. No significant change was noted in either angle between the immediate postoperative views and at final follow-up, and no significant subsidence was noted. Radiographs were also assessed for the presence of a lucent zone: 1 case demonstrated a clear zone between hydroxyapatite and bone, 9 cases between hydroxyapatite and the tibial component, and 6 cases between the tibial component and bone. These results suggest that hydroxyapatite helps to secure implant fixation firmly to the bone, making it a useful augmentation for tibial bone atrophy in total ankle replacement for rheumatoid arthritis.
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Affiliation(s)
- Kenrin Shi
- Department of Orthopedics, Hoshigaoka Koseinenkin Hospital, Osaka, Japan
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Sekiya H, Horii T, Kariya Y, Hoshino Y. Arthroscopic-assisted tibiotalocalcaneal arthrodesis using an intramedullary nail with fins: a case report. J Foot Ankle Surg 2006; 45:266-70. [PMID: 16818155 DOI: 10.1053/j.jfas.2006.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Arthroscopic arthrodesis of the ankle has become popular because of the reduced invasiveness of the procedure and good bony consolidation compared with conventional open techniques. However, arthroscopic arthrodesis of the subtalar joint has not been as universally accepted. Rheumatoid arthritis frequently involves the talocalcaneal joint in addition to the tibiotalar joint. In such cases, simultaneous fixation of both tibiotalar and talocalcaneal joints is desirable. We undertook arthroscopic-assisted arthrodesis of the tibiotalocalcaneal joint using intramedullary nails with fins for a 76-year-old man with rheumatoid arthritis. Although the patient presented with poor skin condition and osteoporotic bone due to long-term use of systemic corticosteroids, weight bearing was allowed 2 weeks after the surgery. Solid fusion of the tibiotalocalcaneal joint occurred without any complications. Given the twin benefits of reduced invasiveness and secure fixation, this method should be considered for patients requiring both tibiotalar and talocalcaneal joint fusion, when a more extensive surgical exposure would be more risky.
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Affiliation(s)
- Hitoshi Sekiya
- Orthopaedic Department, Jichi Medical School, Tochigi, Japan.
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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.
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Affiliation(s)
- H Cornelis Doets
- Department of Orthopaedic Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
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35
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Nagashima M, Tachihara A, Matsuzaki T, Takenouchi K, Fujimori J, Yoshino S. Follow-up study of ankle arthrodesis in severe hind foot deformity in patients with rheumatoid arthritis using an intramedullary nail with fins. Mod Rheumatol 2005; 15:269-74. [PMID: 17029076 DOI: 10.1007/s10165-005-0410-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2005] [Accepted: 05/25/2005] [Indexed: 11/29/2022]
Abstract
We report herein a retrospective study of 25 cases of ankle arthrodesis performed in 23 patients with rheumatoid arthritis (RA) using an intramedullary nail with fins, developed in 1994. Surgical treatment, postoperative management, and clinical evaluation are described. Clinical evaluation, at an average follow-up period of 7 years 1 month, was based on foot disease scores from the Japanese Orthopedic Association; we compared these scores pre- and postoperatively, and during follow-up. These parameters showed a significant difference between preoperation and the follow-up period. However, instability only significantly improved when compared between pre- and postoperation. Arthrodesis using an intramedullary nail with fins was effective for the treatment of severe deformity of the hind foot. Nonunion was not observed and no remarkable changes of the Chopart joint were recognized between preoperation and the follow-up period. In our series, delayed wound healing was recognized in 6 of 25 joints. However, infection or neuropathy and other complications were not found. Arthrodesis using an intramedullary nail with fins is a viable treatment option for severe deformity of the hind foot in RA patients, because nonunion was not recognized and the clinical results over an average 7-year follow-up period were good or satisfactory.
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Affiliation(s)
- Masakazu Nagashima
- Department of Joint Disease and Rheumatism, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
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36
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Abstract
Rheumatoid arthritis is a systemic disease that often affects the foot and ankle. Approximately 20% of patients with rheumatoid arthritis present initially with foot and ankle symptoms, and most patients will eventually develop foot and ankle symptoms. Although early intervention includes conservative measures, operative treatment often is needed to adequately treat rheumatoid patients. Treatment of foot and ankle problems in patients with rheumatoid arthritis is directed to maintaining ambulatory capacity. This article reviews the clinical presentation, evaluation, and treatment of rheumatoid arthritis affecting the foot and ankle.
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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.
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Affiliation(s)
- Ana Alonso-Vázquez
- Bioengineering Sciences Research Group, School of Engineering Sciences, University of Southhampton, Southampton SO17 1BJ, UK
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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.
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Affiliation(s)
- M Bonnin
- Clinique Sainte Anne Lumière, 85 Cours Albert Thomas, F-69003 Lyon, France.
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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.
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Affiliation(s)
- Justin Greisberg
- Department of Orthopaedic Surgery, Columbia University, 622 West 168th Street, PH 1121, New York, NY 10032, USA.
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Abstract
Patients with rheumatoid arthritis commonly experience involvement of the ankle and hindfoot. Severe pain and functional limitations may develop as a result of tibiotalar arthritis, requiring surgical treatment. The advantages of total ankle arthroplasty over ankle arthrodesis include preservation of motion and decreased stresses on the midfoot and subtalar joints. Previous experience with early design ankle replacements revealed high complication rates and as much as 75% of component loosening. Modern ankle implants have been designed to achieve uncemented fixation with less articular constraint. Patients with rheumatoid arthritis who had total ankle replacement using two different types of second-generation ankle implants were examined clinically and radiographically. The average postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 81 of a possible 100, at a mean of 6.4 years after surgery. Radiographically, 88.5% of implants were stable without evidence of subsidence at a mean of 6.3 years. Three tibial components had subsided at an average of 7 years. There was evidence of tibial osteolysis with the Buechel Pappas Low Contact Stress implant in 11.5% of patients. Total ankle replacement in patients with rheumatoid arthritis, using a second-generation prosthesis, can provide reliable relief of pain and good functional results at intermediate-term followup, although the incidence of osteolysis warrants close followup.
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Affiliation(s)
- Edwin P Su
- Hospital for Special Surgery-Weill Medical College of Cornell University, 535 East 70th Street, New York City, NY 10021, USA
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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]
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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.
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Affiliation(s)
- John G Kennedy
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USA.
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Affiliation(s)
- Rhys H Thomas
- St. Michael's Hospital and University of Toronto, ON, Canada
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Vázquez AA, Lauge-Pedersen H, Lidgren L, Taylor M. Finite element analysis of the initial stability of ankle arthrodesis with internal fixation: flat cut versus intact joint contours. Clin Biomech (Bristol, Avon) 2003; 18:244-53. [PMID: 12620788 DOI: 10.1016/s0268-0033(02)00207-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Qualitative comparison of the initial stability provided by two joint preparation techniques and various screw configurations in ankle arthrodesis, using the finite element method.Design. A three-dimensional model of a healthy ankle was developed from computed tomography images. Two groups of models were built, one with the joint contours resected to produce flat surfaces, and the second with the joint contours preserved. In each case, a variety of screw orientations were examined. BACKGROUND Despite the improved results of ankle arthrodesis, failure rates due to non-union are still reported. The initial stability of the arthrodesis construct seems important in the final outcome of the fusion. METHODS Non-linear contact finite element analyses were performed in the arthrodesis constructs subjected to internal/external torsion and dorsiflexion. Micromotions at the bone-to-bone interface were calculated for frictionless and Coulomb friction contact, and compared for the two joint preparation techniques and screw configurations. RESULTS Overall lower peak micromotions were predicted when preserving the joint contours both in torsion and dorsiflexion. For both preparation techniques, the lowest micromotions tended to occur with the screws inserted at 30 degrees with respect to the long axis of the tibia, crossing above the fusion site. Inclusion of friction in the models caused a general decrease on the magnitude of the micromotions as compared to the frictionless case, but did not affect the ranking of the models. CONCLUSIONS The finite element method can be used as a qualitative tool to study the initial stability of ankle arthrodesis, overcoming the difficulties of measuring bone-to-bone interface micromotions experimentally. Better initial stability was predicted for ankle arthrodesis when the joint contours were preserved rather than resected. Crossing the screws above the fusion site at a steeper angle also tended to increase the stability at the fusion site. RELEVANCE Finite element analyses can help during the pre-operative planning of ankle arthrodesis. When bone density is not compromised, preserving the joint contour and inserting the screws at less than 45 degrees to the long axis of the tibia, crossing over the arthrodesis site, may offer better initial stability.
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Affiliation(s)
- Ana Alonso Vázquez
- Bioengineering Sciences Research Group, School of Engineering Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
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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.
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Anatomic Compression Arthrodesis Technique (ACAT) of the Ankle: Results of Treatment. TECHNIQUES IN FOOT AND ANKLE SURGERY 2002. [DOI: 10.1097/00132587-200209000-00005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Arthrodesis has remained the mainstay for treating arthritis and deformities of the ankle and hindfoot for more than a century. Formidable technical challenges exist in achieving a successful result, leading to numerous complications as high as 50% in some series. The most frequent complications after tibiotalar and tibiotalocalcaneal arthrodesis involve nonunion, malunion, infection, and wound complications among others. Meticulous preoperative consideration for the technical and biologic issues involved may lead to diminished complication rates. With advances in implant technology, revision arthrodesis can, in most cases, be expected to yield outcomes comparable with those of a primary procedure. Algorithms for the treatment of the most frequent complications are presented.
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Affiliation(s)
- P S Cooper
- Department of Orthopaedic Surgery, Foot and Ankle Center, Georgetown University Medical Center, Washington, DC, USA
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49
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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.
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Affiliation(s)
- J Nassar
- Department of Orthopaedic Surgery, UCLA Medical Center, Los Angeles, CA 90095, USA
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50
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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.
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Affiliation(s)
- H Mäenpää
- Rheumatism Foundation Hospital, Heinola, Finland.
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