Outcome after single technique ankle arthrodesis in patients with rheumatoid arthritis

Impact of Bone Graft on Fusion Rates in Primary Open Ankle Arthrodesis Fixated With Cannulated Screws: A Systematic Review

There is currently no consensus on the importance of bone graft use in ankle arthrodesis. Despite this, bone graft is widely used. We aimed to summarize the available literature on primary open ankle arthrodesis fixated with cannulated screws in order to assess the importance of bone graft in achieving more favorable rates of fusion. PubMed and Embase were queried for articles reporting on primary open ankle arthrodesis fixated with cannulated screws which specified use or non-use of bone graft. Pooled data analysis was performed. Modified Coleman Methodology Scores were calculated to assess reporting quality. Twenty-seven studies met our inclusion criteria and were divided into three groups: no bone graft (NBG), fibular onlay with bone graft (FOBG), and use of bone graft (BG). All three groups had comparable fusion rates of 94.7%, 95.3%, and 95.1% respectively (p = .98). Number needed to treat was 7 and Absolute Risk Reduction was 14.8%. The reviewed literature was largely of moderate quality, with an overall Coleman score of 60.6 and no significance between the 3 groups (p = .93). In conclusion, primary open ankle arthrodesis fixated with cannulated screws generally had favorable fusion rates, and bone graft use did not have a significant effect on union rates. The available literature suggests that bone graft may not be needed in routine tibiotalar arthrodesis in low-risk patients. It may more significantly impact patients who are at high-risk of fusion failure, and dedicated research on this high-risk subset of patients is required.

Open Ankle Arthrodesis: a Systematic Review of Approaches and Fixation Methods

BACKGROUND

Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA.

METHODS

A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation.

RESULTS

We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95-0.99) for the anterior, 96% (95% CI 0.92-0.98) for the lateral and 96% (95% CI 0.68-1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93-0.98) and plate-fixation 99% (95% CI 0.96-0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance.

CONCLUSION

This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA.

LEVEL OF EVIDENCE

Level IIa.

Pattern of recovery and outcomes of patient reported physical function and pain interference after ankle fusion: a retrospective cohort study

Background

Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient’s perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication.

Methods

This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120–365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points.

Results

The linear mixed model analysis for PF after the 120–149 days, and for PI, after 90–119 days, indicated recovery plateaued at 39–40 for PF and 57–59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of − 5.4 (95% CI − 7.7 to − 3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance.

Conclusion

Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis.

Level of evidence

Level II, prospective single cohort study.

A Comparison of Talar Surface Area Occupied by 2- Versus 3-Screw Fixation for Ankle Arthrodesis

Background. Ankle arthrodesis is a procedure utilized in the treatment of end-stage ankle arthritis. Internal fixation with screws is traditionally relied on to achieve union. Although the use of screw fixation alone has produced satisfactory outcomes, nonunion rates can range from 9% to as high as 35%. Adding an additional screw to the traditional 2-screw fixation construct may improve the likelihood of union by adding strength and stiffness; however, this addition may counteract the theoretical fusion enhancement benefit by reducing the joint surface area (SA) available for fusion. Methods. A cadaver study was performed to compare the amount of SA lost from a standard 2-screw (group 1) versus the 3-screw ankle fusion construct (group 2). A total of 10 fresh cadaveric below-knee specimens were used. Cannulated 7.0-mm partially threaded screws were placed across the ankle joint. Each talus was examined to precisely determine joint SA loss following each procedure. Results. The mean total talus SA in group 1 was 1833.71 mm² compared with 2125.76 mm² in group 2. The mean SA lost by the 2-screw construct was 5.91%, versus 9.51% in the 3-screw construct group. The talus SA loss percentage difference between groups reached statistical significance (P = .0220). Conclusion. The addition of a third 7.0-mm screw to a 2-screw ankle fusion construct raised the percentage of joint surface lost from 5.91% to 9.5%. Clinical Relevance. Surgeons may consider using extra-articular plates with 1 or 2 intra-articular screws instead of the traditional 3-screw construct if there is an elevated concern for nonunion. Levels of Evidence: Level IV: Cadaveric case series.

Sports Participation, Functional Outcome, and Complications After Ankle Arthrodesis: Midterm Follow-up

BACKGROUND

Ankle arthrodesis provides satisfactory functional outcome based on basic daily activities, but information regarding more demanding tasks is limited. Also, studies reporting longer term survival and complication rates are sparse and concern small study populations. This study reports functional outcome with more focus on demanding tasks and sports and reports the mid- to long-term union and complication rates in a large study population.

METHODS

Between 2005 and 2010, an ankle arthrodesis was performed on 185 ankles. Clinical results were retrospectively assessed with the Foot Function Index (FFI), visual analog scale (VAS) for pain, and the Foot and Ankle Ability Measure (FAAM). Information regarding sports pre- and postoperatively was obtained through a questionnaire. In addition, postoperative complications, reoperations, and failures (defined as nonunion of the ankle arthrodesis) were determined. Mean follow-up time was 8 years.

RESULTS

FFI scores significantly improved, the FAAM ADL score was 70%, and the mean VAS for pain at the ankle/hindfoot at follow-up was 20. Sports participation slightly diminished from 79.5% prior to the onset of disabling complaints to 68.9% postoperatively. Of the patients, 73.1% were able to hike with a median hiking time of 40 minutes (range, 2-600 minutes). Kneeling could be performed on average 10 minutes (range, 2-60 minutes) in 39.8% and jumping down from steps by 23.5% of the patients. A small selection of patients was able to sprint (14%), and 16.8% of the patients were able to run a median distance of 60 meters (range, 3-1000 meters). Failure occurred in 9.2% and other postoperative complications were present in 21.6%, requiring reoperation in 8.6% of the cases.

CONCLUSION

Ankle arthrodesis led to satisfactory functional outcome and pain reduction. Most patients remained active in sports, but a transition to less demanding sporting activities was seen. The complication and failure rates were similar with previous literature, and the incidence of nonrevision secondary surgery was relatively low.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anterior ankle arthrodesis

Ankle arthrodesis is a common procedure that resolves many conditions of the foot and ankle; however, complications following this procedure are often reported and vary depending on the fixation technique. Various techniques have been described in the attempt to achieve ankle arthrodesis and there is much debate as to the efficiency of each one. This study aims to evaluate the efficiency of anterior plating in ankle arthrodesis using customised and Synthes TomoFix plates. We present the outcomes of 28 ankle arthrodeses between 2005 and 2012, specifically examining rate of union, patient-reported outcomes scores, and complications. All 28 patients achieved radiographic union at an average of 36 wk; the majority of patients (92.86%) at or before 16 wk, the exceptions being two patients with Charcot joints who were noted to have bony union at a three year review. Patient-reported outcomes scores significantly increased (P < 0.05). Complications included two delayed unions as previously mentioned, infection, and extended postoperative pain. With multiple points for fixation and coaxial screw entry points, the contoured customised plate offers added compression and provides a rigid fixation for arthrodesis stabilization.

The mid-term outcome of total ankle arthroplasty and ankle fusion in rheumatoid arthritis: a systematic review

Background

While arthrodesis is the standard treatment of a severely arthritic ankle joint, total ankle arthroplasty has become a popular alternative. This review provides clinical outcomes and complications of both interventions in patients with rheumatoid arthritis.

Methods

Studies were obtained from Pubmed, Embase and Web of Science (January 1980 – June 2011) and additional manual search. Inclusion criteria: original clinical study, > 5 rheumatoid arthritis (population), internal fixation arthrodesis or three-component mobile bearing prosthesis (intervention), ankle scoring system (outcome). The clinical outcome score, complication- and failure rates were extracted and the methodological quality of the studies was analysed.

Results

17 observational studies of 868 citations were included. The effect size concerning total ankle arthroplasty ranged between 1.9 and 6.0, for arthrodesis the effect sizes were 4.0 and 4.7. Reoperation due to implant failure or reoperation due to non-union, was 11% and 12% for respectively total ankle arthroplasty and arthrodesis. The methodological quality of the studies was low (mean 6.4 out of a maximum of 14 points) and was lower for arthrodesis (mean 4.8) as compared to arthroplasty (mean 7.8) (p = 0.04).

Conclusions

17 observational and no (randomized) controlled clinical trials are published on the effectiveness of arthroplasty or arthrodesis of the ankle in rheumatoid arthritis. Regardless of the methodological limitations it can be concluded that both interventions show clinical improvement and in line with current literature neither procedure is superior to the other.

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

INTRODUCTION

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

An unusual cause of pain post ankle arthrodesis in patients with rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease which frequently affects the ankle and foot. End stage ankle arthritis from rheumatic disease is commonly managed by the established practice of ankle arthrodesis. Among the adverse sequelae causing pain following this surgery is infection, pseudo-arthrosis and non-union. Stress fracture of the distal third is a recognised but unusual cause of pain of tibia following ankle arthrodesis. The authors' present three patients with rheumatoid arthritis who sustained a stress fracture of the distal tibia following arthrodesis, and discuss the contributing factors and highlight the need for orthopaedic surgeons to be suspicious of this complication post surgery.

Surgery on the rheumatoid ankle joint: efficacy versus effectiveness

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.

Anterior double plating for rigid fixation of isolated tibiotalar arthrodesis

BACKGROUND

Arthrodesis is the most common procedure used to treat end-stage osteoarthritis of the ankle, particularly in patients with difficult conditions such as poor bone quality. While many techniques are available to fuse the ankle, current recommendations favor the use of internal fixation with screws and/or plates. Despite of progress, the complication rate remains a major concern. Non-union is one difficult problem especially with difficult bone conditions, particularly the loss of bone stock on the talar side. Therefore, fusion of the tibiotalar joint is often extended to the talocalcaneal joint to provide sufficient stability. To preserve the subtalar joint, an anterior double plate system for rigid fixation of isolated tibiotalar arthrodesis was developed. This is a preliminary report on the clinical and radiological outcome with this technique.

MATERIALS AND METHODS

Twenty-nine patients (15 men, 14 women; one ankle per patient) were treated from October 2006 to September 2007. We converted 16 ankles with osteoarthritis and difficult bone conditions, four non-united ankle arthrodeses, and nine failed total ankle replacements to an isolated tibiotalar arthrodesis using anterior double plating. If necessary, we used solid allograft to fill bony defects. Outcomes included bone union as assessed by radiographs, pain as indicated by the American Orthopaedic Foot and Ankle Society scores, and patient satisfaction.

RESULTS

Solid arthrodesis was achieved after an average of 12.3 (eight to 26) weeks in the 16 ankles without bone graft interposed between the tibia and talus, and 14.3 (range, 8 to 26) weeks in the 13 ankles with interpositional bone allograft. Radiographs showed that the position of arthrodesis obtained at the time of surgery did not change in any patient up to one year after surgery. The mean American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Score increased from 37 (range, 20 to 63) preoperatively to 68 (range, 50 to 92) at the last followup. Twenty-seven patients (93%) were satisfied with their outcome and indicated they would have the operation again. No complications were noted.

CONCLUSION

The anterior double plating system was shown be a reliable method to achieve solid isolated tibiotalar arthrodesis, even in ankles with difficult conditions such as loss of bone stock due to failed total ankle arthroplasty.

Ankle arthrodesis

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.

The outcome of arthroscopic and open surgery ankle arthrodesis: a comparative retrospective study on 107 patients

PURPOSE

To evaluate the results of arthroscopic guided ankle arthrodesis, and the results of open surgery arthrodesis in two comparable groups of patients.

METHODS

A group of 58 arthroscopic guided ankle arthrodeses was compared to a group of 49 ankles arthrodeses operated by open technique. The patients and ankles in both groups fulfilled the same criteria of inclusion except that the ankles operated by open technique had a varus/valgus malalignment exceeding 5 degrees. The pre- and postoperative treatment protocols were identical.

RESULTS

The patients in the arthroscopic group were discharged on average 2.27 days earlier than the patients operated by open technique (p<0.01). Ninety percent of the patients in the arthroscopic group and 57% in the open group showed bony union after 12 weeks (p<0.01). The rate of union after 1 year was 95% in the arthroscopic group and 84% in the open group (n.s.).

CONCLUSION

Arthroscopic guided ankle arthrodesis represents a safe and cost saving procedure.

Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach

For patients with refractory retrocalcaneal bursitis (Haglund's syndrome), the most effective surgical approach has not been defined. We asked whether patients undergoing the tendon-splitting approach and the lateral approach would have comparably effective relief of pain for both types of calcaneal ostectomies. We retrospectively reviewed 30 patients (31 feet) who underwent the tendon-splitting approach and compared their results with 32 previous patients (35 feet) who had a lateral incision. Minimum followup was 12 months (mean, 16 months; range, 12-23 months) for the tendon-splitting group and 15 months (mean, 51 months; range, 15-109 months) for the lateral group. The mean American Orthopaedic Foot and Ankle Society score improved from 43 points preoperatively to 81 points (range, 8-100 points) postoperatively in the tendon-splitting group and from 54 points to 86 points (range, 55-100 points) in the lateral group. The mean physical component score of the Short Form-36, version 2, at followup was 52 (range, 22-61) in the tendon-splitting group and 49 (range, 34-63) in the lateral group. The median return to normal function was 4.1 months (range, 3-13 months) in the tendon-splitting group and 6.4 months (range, 4-20 months) in the lateral group. Both approaches to calcaneal ostectomy provided symptomatic pain relief. However, patients in the tendon-splitting group returned to normal function quicker than patients in the lateral group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Ankle arthrodesis in rheumatoid arthritis: techniques, results, and complications

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.

Management of hindfoot disease in rheumatoid arthritis

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.

Transfibular ankle arthrodesis with rigid internal fixation: an assessment of outcome

BACKGROUND

Transfibular ankle arthrodesis with internal fixation and fibular onlay grafting has resulted in acceptable fusion rates. This study analyzed the results of ankle arthrodesis using one operative technique in a large series of patients with high and low risks for nonunions.

METHODS

Fifty consecutive patients had a transfibular ankle arthrodesis with rigid internal fixation and fibular onlay strut grafting from 1997 to 2004. Two patients were lost to followup. The remaining 48 patients had preoperative and postoperative clinical and radiographic examinations and then were stratified into high-risk and low-risk groups for ankle nonunions. Fifteen of 48 patients were considered at high risk for nonunion. Rate of osseous fusion, satisfaction with the procedure, correction of the deformity, and relief of pain were evaluated. Thirty-five of 48 patients were evaluated with the AOFAS ankle-hindfoot scale at an average 45 months after surgery.

RESULTS

Forty-six of 48 patients had bony union (96% union rate). Fourteen of 15 (93%) high-risk patients had bony fusion in an average of 83 days. Thirty-two of 33 patients (97%) in the low-risk group had bony fusion at an average of 81 days. The AOFAS ankle-hindfoot score improved from 38 to 74 in 12 of 15 patients in the high-risk group and from 34 to 69 in 24 of 33 patients in the low-risk group from preoperative to postoperative scores.

CONCLUSIONS

A transfibular ankle arthrodesis with rigid internal fixation and fibular onlay strut grafting can achieve a high rate of union in both a low-risk and high-risk patient populations. This technique can be an effective approach for most primary and revision cases with or without significant deformity. In addition the AOFAS ankle-hindfoot score improved significantly both in the high-risk and low-risk groups.

Outcomes after standardized screw fixation technique of ankle arthrodesis

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.

An analysis of talar surface area occupied by screw fixation in ankle fusions

BACKGROUND

Ankle arthrodesis remains the benchmark of treatment for end-stage arthrosis of the ankle joint. Despite that, the incidence of nonunion can be as high as 15%. Various strategies have been used to reduce the incidence of nonunion, including multiple compression screws and larger diameter screws to improve mechanical stability and compression. The space occupied by an increasing amount of hardware across a finite surface area available for fusion has prompted concern that this strategy may be counterproductive and may reduce the biological potential of the construct. The purpose of this study was to look at 40 anatomic sawbone specimens of the ankle to determine the amount of talar surface contact area used by the screw fixation during arthrodesis.

METHODS

Four groups were created to examine different techniques for arthrodesis. Simulated ankle arthrodeses were done using two- or three-screw fixation with 6.5-mm and 7.3-mm screws. Hardware was subsequently removed and the surface area used by the passing screws was measured. Total surface areas were calculated for each of the 40 specimens.

RESULTS

The maximal surface area of the talus occupied by screws occurred when using three 7.3-mm screws. This configuration used 16% of the possible talar surface area available for arthrodesis.

CONCLUSION

The use of additional screw fixation when performing an ankle arthrodesis does not sacrifice a major amount of the tibiotalar contact area and will most likely not affect the biologic environment needed to obtain fusion.

Ankle arthrodesis by compression screws in rheumatoid arthritis: primary nonunion in 9/35 patients

INTRODUCTION

Today, percutaneous or open arthrodesis of the ankle, using one or several screws for fixation, is a common method for treatment of the rheumatic ankle. However, there is very little information in the literature on the reliability of the method.

METHODS

We performed a retrospective radiographic and clinical study on 35 ankles of 35 patients. Function was evaluated using the Mazur and AOFAS scores. For evaluation of activity of the rheumatic disease, we used the HAQ score.

RESULTS

31 ankles had healed--26 at the first attempt and 5 after repeat arthrodesis. There was no difference between 13 cases operated on percutaneously and 22 cases operated on with open technique with respect to radiographic healing. Mean AOFAS total score was 56 of possible 86 points. The AOFAS total score correlated with the severity of the rheumatic disease. 20 patients were satisfied with the result, 12 were somewhat satisfied and 3 patients were dissatisfied although the ankle in 2 of these 3 patients had fused.

INTERPRETATION

The use of compression screws for fusion of the rheumatic ankle does not appear to give acceptable results regarding healing and function.