Where ankle fusion stands today

Ankle Arthrodesis: Indications, Outcomes, and Patient Satisfaction

Background

Osteoarthritis of the ankle, which has a prevalence of 3.4% in the general population and affects 70% of candidates post-traumatically, is less common than hip or knee arthritis. Despite the recent progress in ankle arthroplasty surgery, ankle arthrodesis is still considered the gold-standard treatment for severe osteoarthritis of the ankle joint and can achieve impressive improvements in pain and function in the majority of patients. Our objective is to assess the clinical and functional outcomes of ankle arthrodesis, postoperative complications, and patient satisfaction.

Methodology

This was a descriptive cross-sectional study that took place at Future Hospital in Khartoum, Sudan, from July 2015 to July 2022. Our institute performed 102 ankle fusion surgeries; 14 patients were excluded from the study because they did not show up for their follow-up visit, meaning 88 candidates were included. Two cannulated screws (6.5 mm) were used for ankle fixation in all patients. The outcome was assessed two years after surgery. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to assess ankle function before surgery and two years after the procedure. Postoperative complications and patient satisfaction were reported. The primary researcher collected data through direct interviews.

Result

The mean age of the study participants was 52.2 years, with 36.4% being between 40 and 50 years of age. The study consisted of 43 women and 45 men. The male-to-female ratio was almost 1:1. In 56.8% of candidates, the right ankle was involved. The overall rate of complications was 11.4%. Concerning patient satisfaction, 75% of the patients were fully satisfied. Moreover, significant correlations were found between the mean postoperative AOFAS score and age group, diabetes mellitus, complications, and patient satisfaction.

Conclusion

Ankle arthrodesis was demonstrated to be an excellent surgical method for reducing pain and enhancing ankle joint function. The most frequent complications were delayed wound healing, infection, and non-union. The functional outcome and patient satisfaction of this procedure were statistically high; patients with a higher functional score had higher levels of satisfaction. In contrast, diabetic and elderly patients had higher rates of complications.

What Is the Treatment "Algorithm" for Infection After Ankle or Hindfoot Arthrodesis?

RECOMMENDATION

There is no universal algorithm for addressing the infected ankle or subtalar arthrodesis. A potential algorithm created by consensus is.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Clinical and Radiological Mid- to Long-term Outcomes Following Ankle Fusion

BACKGROUND

The aims of this study were to establish the likelihood of additional surgery after ankle fusion, determine the interval for developing osteoarthrosis in the ipsilateral subtalar or Chopart joints, and evaluate its clinical relevance.

MATERIAL AND METHODS

A retrospective clinical and radiological study with a minimum follow-up of 24 months was performed. Short-Form 36 Heath Survey, Foot Function Index, American Orthopaedic Foot and Ankle Society Score (AOFAS) and a visual analog scale (VAS) were used to evaluate pain level and quality of life in at least 62 adult patients.

RESULTS

A total of 57% of our patients developed osteoarthrosis in at least one of the related joints and 28% of them required additional surgery due to pain. Patients who received workers' compensation had significantly lower AOFAS and higher VAS pain values.

CONCLUSION

More than half of the study cohort developed osteoarthrosis in the related joints after ankle fusion, but fewer than one-third required further joint fusion surgery as a consequence.

Functional and clinical outcomes of total ankle arthroplasty in elderly compared to younger patients

BACKGROUND

Total ankle arthroplasty (TAA) is becoming an increasingly utilized procedure for the management of end-stage ankle arthritis. Elderly patients are the fastest growing segment of the population in the western world, creating a unique challenge to the health economics of our era. Determining if elderly patients with end-stage ankle arthritis demonstrate the same improvements in clinical outcomes and functional measures of gait following TAA would be valuable. This can aid to evaluate the utilization of TAA in this enlarging cohort of our population.

METHODS

Consecutive series of twenty-one patients over the age of 70, who underwent TAA for end-stage ankle arthritis, was prospectively compared to a series of twenty-one patients aged 50-60, who underwent the same procedure by single surgeon during same time period. Clinical outcomes were measured with outcome scores including VAS pain score, AOFAS Ankle and Hindfoot Score, and the SF-36. Three-dimensional gait analysis was performed preoperatively and at a minimum of one year postoperatively, to measure temporal-spatial, kinematic, and kinetic parameters of gait. Mixed model multivariate statistical analysis was used to evaluate and compare the independent contributions to outcomes of the surgical intervention over time; of patient age; and of time-plus-age interaction, as these influenced both the clinical outcomes and the functional gait outcomes.

RESULTS

Statistically significant improvements in VAS pain scores, AOFAS ankle/hindfoot scores, and SF-36 scores were demonstrated in both age groups. Following surgery, there were improvements in all parameters of gait, including temporal-spatial parameters as step length and walking velocity; kinematic parameters, including, increase in total range of motion to a total of 17-19°; and kinetic parameters, including increase in ankle power and moment. The improvements both in clinical and gait outcomes were equivalent in the two age groups.

CONCLUSIONS

In this comparative study, it is shown that both elderly patients over the age of 70 and younger patients aged 50-60 demonstrated equivalent improvements clinical and gait outcomes following ankle arthroplasty. This may be important data both for clinical decision-making and the health economics for our ageing population.

Comparison of gait after total ankle arthroplasty and ankle arthrodesis

BACKGROUND

Prior studies reported improved gait after total ankle arthroplasty and better parameters of gait than those reported in earlier studies of patients after ankle arthrodesis. However, there are very limited data prospectively evaluating the effects on gait after ankle arthroplasty compared with ankle arthrodesis. Controversy remains regarding the relative advantages and disadvantages of these 2 treatments and especially the differences in function between them.

METHODS

We performed a prospective study involving 28 patients with posttraumatic and primary ankle osteoarthritis and a control group of 14 normal volunteers. We compared gait in 14 patients who had undergone ankle arthrodesis with the gait of 14 patients who had ankle arthroplasty preoperatively and at 1 year postoperatively. Three-dimensional gait analysis was performed with a 12-camera digital-motion capture system. Temporospatial measurements included stride length and cadence. The kinematic parameters that were measured included the sagittal plane range of motion of the ankle and the coronal plane range of motion of the ankle. Double force plates were used to collect kinetic parameters such as ankle coronal and plantar flexion-dorsiflexion moments and sagittal plane ankle power. Center of pressure (CoP) and its progression in gait cycle were calculated.

RESULTS

Baseline parameters showed comparability among the treatment and control groups. Temporospatial analysis, using time as the main effect, showed that compared with ankle arthrodesis, patients with total ankle arthroplasty had higher walking velocity attributable to both increases in stride length and cadence as well as more normalized first and second rockers of the gait cycle. Kinematic analysis, using time and intervention as the main effects, showed that patients who had ankle arthroplasty had better sagittal dorsiflexion (P = .001), whereas those undergoing ankle arthrodesis had better coronal plane eversion (P = .01). Neither ankle arthrodesis nor arthroplasty altered the CoP progression during stance phase. Total ankle arthroplasty produced a more symmetrical vertical ground reaction force curve, which was closer to that of the controls than was the curve of the ankle arthrodesis group.

CONCLUSIONS

Patients in both the arthrodesis and arthroplasty groups had significant improvements in various parameters of gait when compared with their own preoperative function. Neither group functioned as well as the normal control subjects. Neither group was superior in every parameter of gait at 1 year postoperatively. However, the data suggest that the major parameters of gait after ankle arthrodesis in deformed ankle arthritis are comparable to gait function after total ankle arthroplasty in nondeformed ankle arthritis.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Clinical outcome and gait analysis of ankle arthrodesis

BACKGROUND

The purpose of our study was to describe and analyze the functional outcomes of mid-term followup patients with ankle arthrodesis.

METHODS

Twenty patients who had an isolated ankle arthrodesis were followed for a mean of 3 years after surgery. We performed physical and functional examination, radiographic examination and CT scan. Each completed standardized, self-reported outcome questionnaires SF-36, AOFAS and Mazur scores. All subjects were evaluated with a kinetic and kinematic gait analysis and a plantar pressure study.

RESULTS

Only one patient used a cane and seven patients required an insole to walk. We observed no relation between the scores obtained. Most of the patients showed good functional results and poor life quality scores. The joints that were significantly more degenerated were the Chopart and the subtalar joints, which were affected in 16 patients in the fused limb. The kinematic parameters showed compensatory motion in the neighboring joints and the kinetic parameters studied were similar in the arthrodesis limb and the control limb. There was no significant difference between the arthrodesis limb and the contralateral limb for plantar pressures.

CONCLUSION

Although ankle arthrodesis will help to relieve pain and to improve overall function, it is considered to be a salvage procedure that causes persistent alterations in gait, with the possible development of symptomatic osteoarthritis in the other joints of the foot. Patients and treating physicians should also expect overall pain and functional limitations to increase over time.

Outcome of ankle arthrodesis in posttraumatic arthritis

BACKGROUND

Ankle arthrodesis is still a gold standard salvage procedure for the management of ankle arthritis. There are several functional and mechanical benefits of ankle arthrodesis, which make it a viable surgical procedure in the management of ankle arthritis. The functional outcomes following ankle arthrodesis are not very well known. The purpose of this study was to perform a clinical and radiographic evaluation of ankle arthrodesis in posttraumatic arthritis performed using Charnley's compression device.

MATERIALS AND METHODS

Between January 2006 and December 2009 a functional assessment of 15 patients (10 males and 5 females) who had undergone ankle arthrodesis for posttraumatic arthritis and/or avascular necrosis (AVN) talus (n=6), malunited bimalleolar fracture (n=4), distal tibial plafond fractures (n=3), medial malleoli nonunion (n=2). All the patients were assessed clinically and radiologically after an average followup of 2 years 8 months (range 1-5.7 years).

RESULTS

All patients had sound ankylosis and no complications related to the surgery. Scoring the patients with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, we found that 11 of the 15 had excellent results, two had good, and two showed fair results. They were all returned to their preinjury activities.

CONCLUSION

We conclude that, the ankle arthrodesis can still be considered as a standard procedure in ankle arthritis. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function. Still, one should keep in mind that it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of subtalar arthritis.

Tibio-talo-calcaneo fusion using a locked intramedullary compressive nail

We present the clinical results and outcomes of 30 consecutive patients (31 ankles) who have undergone tibio-talo-calcaneal arthrodesis using an intramedullary nail to achieve bony union. This was a prospective study and surgery was performed by the senior author in a single hospital. We achieved high levels of satisfaction and outcome via the AOFAS and SF-36 scoring systems. We propose that this method of arthrodesis is reliable and easily reproducible for patients with severe arthritis and bone loss at the ankle and subtalar joints.

Sagittal plane motion of the hindfoot following ankle arthrodesis: a prospective analysis

BACKGROUND

The progression of subtalar and midfoot arthritis is well documented following ankle arthrodesis, and gait analysis has suggested that a functional gait pattern following arthrodesis may be due to tarsal hypermobility compensating for lost tibiotalar motion. We present a prospective radiographic study comparing the pre- and postoperative range of motion of the foot following ankle arthrodesis utilizing reliable anatomic landmarks to measure the sagittal range of motion.

MATERIALS AND METHODS

Between 2002 and 2006, we performed 154 arthrodesis procedures of the ankle. Patients were suitable for inclusion in this study if an isolated arthrodesis of the ankle was performed for post traumatic arthritis only with a minimum of 1-year followup and who had not undergone any prior nor subsequent hindfoot surgery. Standardized pre- and postoperative passive plantar- and dorsiflexion radiographs were obtained, and reproducible anatomic landmarks were then used to measure and compare tibiotalar, subtalar and medial column (talonavicular, naviculo-middle cuneiform and middle cuneiform-first metatarsal) motion. These measurements were repeated at 6, 12, and a mean of 33 months at final followup evaluation. The SF-36, calcaneal pitch, and the presence of radiographic and symptomatic hindfoot arthritis were noted for each patient pre and postoperatively.

RESULTS

There were 48 patients who met the inclusion criteria. The mean preoperative sagittal motion (tibiotalar, medial column and subtalar combined) was 37.2 degrees, of which 17.8 degrees was tibiotalar motion. This decreased to a mean of 22.6 degrees postoperatively. The postoperative mean subtalar range of motion increased by 4.1 degrees (from 5.2 degrees to 9.3 degrees) (p < 0.0001), and the medial column motion increased by 2.1 degrees postoperatively (from 14.3 degrees to 16.4 degrees) (p < 0.003). Both of these results were statistically significant. There was a compensatory increase of the combined subtalar and medial column motion after arthrodesis of 10.8%. Using regression analysis, there was a significant correlation between the preoperative tibiotalar motion and the final difference in the subtalar range of motion (p = 0.03) and the combined motion of the medial column and the subtalar joint (p < 0.0001). Quality of life was positively associated with increased compensatory motion of the hindfoot and midfoot after ankle arthrodesis. There was an inverse association between the calcaneal pitch angle and the range of motion postoperatively.

CONCLUSION

This prospective study demonstrated a statistically significant relative hypermobility of the subtalar and medial column joints following ankle arthrodesis, and may account for the functional gait which can be achieved following ankle arthrodesis. The significantly increased subtalar range of movement appeared to cause impingement of the posterior part of the posterior facet of the subtalar joint which may account for the increased incidence of subtalar arthritis following arthrodesis. Preoperative arch height can be used to predict both residual motion and function after ankle arthrodesis.

An approach to the failed ankle arthrodesis

Ankle arthrodesis remains the gold standard of surgical treatment for advanced ankle joint arthritis. Failure can occur as a result of infection, nonunion or malunion, resulting in pain and poor function. This paper offers a systematic approach to preventing, and managing these problems should they occur. Revision arthrodesis performed with a detailed understanding of the appropriate alignment and mechanics of the ankle joint, combined with meticulous attention to understanding and reversing the cause of the failure can result in successful salvage and restoration of function.

A brief history of total ankle replacement and a review of the current status

Total ankle replacement (TAR) was first attempted in the early 1970s, but poor early results lead to it being abandoned in favour of arthrodesis. Arthrodesis is not totally satisfactory, often causing further hindfoot arthritis and this has lead to a resurgence of interest in joint replacement. New designs which more closely approximated the natural anatomy of the ankle and associated biomechanics have produced more encouraging results and led to renewed interest in total ankle replacement. Three prostheses dominate the market: Agility, Buechel-Pappas and STAR, and improving clinical results with these devices have led to more designs appearing on the market. Modern designs of prosthetic ankles almost exclusively consist of three part prostheses with a mobile bearing component, similar to the Buechel-Pappas and STAR. Clinical results of these newer designs are limited and short-term and have often been carried out by the designers of the implants. This paper presents a brief history of the development of total ankle replacement and a review of the current status.

Fresh ankle osteochondral allograft transplantation for tibiotalar joint arthritis

BACKGROUND

Conventional treatment for tibiotalar joint arthritis relies on arthrodesis or prosthetic arthroplasty. Fresh osteochondral allografting is an alternative procedure to replace diseased articular cartilage.

METHODS

Eleven patients (average age 43 years; range 18 to 65 years) had fresh osteochondral grafting of the tibiotalar joint. The diagnoses were posttraumatic arthritis in seven ankles, osteoarthritis in two, and an osteochondral defect in two. Precise cuts were made using the Agility (DePuy, Warsaw IN) ankle arthroplasty jigs. Bipolar replacements were used in nine ankles and unipolar in two. Results were evaluated using outcome scores, physical examinations, and standing ankle radiographs.

RESULTS

At a minimum followup of 24 (average 33; range 26 to 45) months, six of the 11 ankles had successful grafting procedures. The average AOFAS score preoperatively improved from 55 to 73 postoperatively (p = 0.01). The patients' pain, gait, and walking surface scores were all significantly improved (p < 0.05). Of the five failures three underwent successful repeat allografting and one was revised to a total ankle arthroplasty, and one has had no further surgery. The ankle range of motion arc was 30 degrees or more in six ankles. Additional surgery included five talofibular joint debridements, three repeat graftings, two hardware removals, and one conversion to a prosthetic ankle replacement. There was one intraoperative fibular fracture and one superficial wound infection. The serum of 10 patients tested positive for cytotoxic HLA antibodies postoperatively. Radiographs revealed moderate and severe joint degeneration in six ankles; however, this did not necessarily correlate with a poor outcome. Poor results tended to occur in ankles with a graft-host size mismatch or graft thickness of less than 7 mm.

CONCLUSION

Fresh osteochondral transplantation for tibiotalar joint arthritis is a promising alternative to arthrodesis and prosthetic replacement. Early results demonstrate successful outcomes and good pain relief in over half the patients in this series.

Total ankle replacement

Total ankle replacement is emerging as a viable treatment for symptomatic ankle arthritis that has not responded to nonoperative treatment. Most modern implant designs involve the use of a three-component, mobile-bearing implant. Although the results of the different design approaches are encouraging in limited clinical series, there is still the need for careful, long-term analyses to estimate to what extent the current designs are mimicking the biomechanics of the ankle joint. More attention must be paid to more accurate implantation techniques that result in a well-balanced ligament and allow the ligaments to act together with the replaced surfaces in a most physiologic manner. To improve the stability of the bone-implant interface over time, specific efforts should be made to better understand the extrinsic and intrinsic forces of the ankle joint, including the forces that are created by the prosthesis itself.

Use of allografts in the management of ankle arthritis

Reconstruction of articular cartilage defects of the tibiotalar joint remains a challenge. Although arthrodesis and total ankle arthroplasty are treatment options, we present fresh tibiotalar allografting as an alternative technique. The average age of 12 patients who underwent tibiotalar allografting was 43 years. The average follow-up was 21 months. All grafts healed at the host/donor interface. Complications included intraoperative fracture in one patient and graft collapse that required revision allografting in another. Most patients were relieved of preoperative pain and were satisfied with the procedure. Postoperative function was also significantly improved, based on questionnaire and physician assessment. Fresh tibiotalar allografting is an exciting and promising technique in the treatment of articular cartilage defects in young, active patients.

Revision of ankle arthrodesis

From 1989 to 1996, we treated 18 cases (10 males, eight females; average age 48.2 years) of failed ankle arthrodesis by revision of ankle arthrodesis and followed their progress for at least two years. The average time interval between original surgery and revision was 17.3 months. Revisions were needed due to infection in one case, nonunion in 10 cases, and malalignment in seven cases. The salvage operations included debridement in the infected case, refreshed pseudoarthrosis in nonunion cases, and corrective osteotomy in malalignment cases. Sixteen cases were fixed by crossed screws with internal compression, one infected case was fixed by an external fixator, and one case with bone loss was fixed with buttress plate. The average follow-up period was 40.4 months. There was one nonunion and two delayed unions, with an ultimate fusion rate of 94%. The average AOFAS ankle-hindfoot score was 70.9 at final follow up. There was one excellent result (5.6%), five good results (27.8%), 11 fair results (61%), and one poor result (5.6%), and the overall results were poorer compared with our series of primary arthrodesis. The time to fusion also took longer in the revision cases (average 2.7 months in primary cases and 4.8 months in revision cases). Fusion techniques that ensure solid union in a functional position are essential. If an ankle arthrodesis fails, however, revision is a salvage procedure that can achieve an acceptable result.

Treatment of post-traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts

We report on tibiotalar osteochondral shell allografts for post-traumatic ankle arthropathy in seven patients. Average follow-up was 148 months (range, 85 to 198). Patients were evaluated by a questionnaire, SF-12 survey, ankle score, physical exam and radiographs. The ankle score increased from 25 preoperatively to 43 at latest follow-up (maximum score 100). SF-12 scores increased from 30 to 38 (Physical Component) and 46 to 53 (Mental Component). The failure rate was 42%. Four of seven patients reported good or excellent results. Five patients stated they would undergo a similar procedure again. Complications included graft fragmentation, poor graft fit, graft subluxation, and non-union. Follow-up radiographs demonstrated joint space narrowing, osteophytes, and sclerosis, even in cases with excellent clinical status. Fresh osteochondral shell allografting may provide a viable alternative for the treatment of post-traumatic ankle arthrosis in selected individuals.

Arthodesis of the infected ankle and subtalar joint

Arthrodesis of the ankle or subtalar joint for limb salvage in joint sepsis is extremely complicated, and produces a protracted course of management. A successful outcome is founded on the diligence of the surgeon in the preoperative evaluation, intraoperative technique, and postoperative care of the patient. Liberal consultation with infectious disease specialists, vascular, and plastic surgeons is recommended. Recognition of patient-specific comorbidities is essential to the selection of appropriate limb salvage candidates.

Tension-band technique for ankle fusion

A prospective study was conducted to develop a better technique for ankle fusion. Eleven consecutive patients were treated using the tension-band technique for ankle fusion and underwent follow-up for a minimum of 2 years (range: 2-5 years). All 11 patients achieved solid fusion for a fusion rate of 100%. Average time to fusion was 3 months (range: 2-6 months). The indication for ankle fusion was intractable aching pain that could not be controlled by conservative methods. Two of 11 patients underwent surgery due to infected arthritis. After ankle fusion, there was no recurrence of infection during a 3-year follow-up period. The technique included osteotomy of the bimalleoli from the inside out, removal of articular cartilage and preserving wedge space for cancellous bone grafting, with or without staple stabilization, and external immobilization supplementation. The functional outcome in all 11 patients improved from unsatisfactory preoperatively to satisfactory at latest follow-up (P<.001). No significant complications were noted. This simple technique proved excellent for ankle fusion with a satisfactory outcome and is recommended for treating severe ankle arthropathies.

Long-term results of arthrodesis for osteoarthritis of the ankle

A bone graft in the shape of a triangular prism was taken from the anterior surface of the tibia and used in the arthrodesis in 43 joints of 42 patients with primary and secondary osteoarthritis of the ankle. The modified anterior sliding inlay graft method was used. The average period of external immobilization was 5.8 weeks (range, 27-84 days), and followup ranged from 2 years 4 months to 14 years 11 months (average, 7 years 2 months). Nonunion was detected in three (7%) patients: one patient returned to work without additional treatment, and the other two patients underwent followup surgery within 7 months, and bony union was achieved. The final rate of nonunion was 2.3%. After the operation, excellent alleviation of pain was obtained. However, dorsiflexion of the foot decreased from the preoperative average value of 10.5 degrees to the postoperative value of 4.2 degrees, and plantar flexion also decreased from the preoperative value of 24.7 degrees to the postoperative value of 14 degrees. In addition, the range of motion of the subtalar and Chopart joints gradually improved with little effect on daily living activities. The most appropriate position of arthrodesis of the ankle appears to be in the neutral position between dorsal and plantar flexion. In addition, the varus and valgus angle of the hindfoot should be in a neutral or slightly valgus position. Degenerative arthritis developed and advanced in the subtalar joint in 32.5% of the patients, and these degenerative changes were exacerbated in many patients if such changes were present before surgery. Tibial stress fracture occurred in two (4.7%) patients as a complication that was specific to the current surgical method. Thus, the surgical procedure was modified to prevent the onset of tibial stress fracture.

Arthroscopically assisted arthrodesis of the ankle joint

In 26 patients we performed an arthroscopically assisted arthrodesis of the ankle. The patients' ages ranged from 31 to 69 years. The male:female ratio. Sixteen patients had posttraumatic degenerative joint disease, three patients suffered from a previous infection, four patients had rheumatoid arthritis, and three patients had an osteochondritis dissecans in their past history. The time taken for surgery ranged from 65 to 135 min. Compared with open procedures we documented less postoperative swelling and minor use of analgesics. Time of follow-up was a minimum of 6 months and a maximum of 75 months. In 22 patients we found solid fusion at the time of followup. Fusion was accomplished by 2 months postoperatively in four patients, by 3 months in nine patients, by 4 months in another six patients, and by 6 months in 3 patients. Three patients did not evidence any bony fusion, but they were free of pain. In one patient an open revision was necessary. According to our experience, we recommend arthroscopically assisted arthrodesis of the ankle in patients with degenerative joint disease without rotational or varus/valgus malalignment, severe bone defects or neuropathic disease.

Role of internal and external fixation in ankle fusion

Between August 1980 and September 1993, 35 tibiotalar arthrodeses in 34 patients with primary and secondary osteoarthritis of the ankle were performed. Two different surgical techniques were employed. Internal screw fixation according to Wagner and Pock [20] and an external fixation method according to the resection compression arthrodesis by Charnley and Muller [14]. Twenty patients with 21 fusions could be investigated retrospectively. For evaluation we used self-assessment, clinical examination and radiographic analysis in combination with the score described by McGuire et al. [12]. In 80% the results were good and satisfactory with a median improvement of 23 score points on a scale of 100% 95 points, respectively. The most important advantages were pain relief and increase of walking distance. The fusion rate was 95%. We found osteoarthritis in the neighbouring joints did not have any influence on the surgical result. With respect to the two surgical techniques, the internal screw fixation method achieved fusion earlier with fewer complications and better improvement according to the McGuire score. Tibiotalar fusion is a safe therapy with reproducible good results involving pain relief, full weight-bearing and increase of walking distance.

Technique and clinical evaluation of arthroscopic ankle arthrodesis

Arthroscopic ankle arthrodesis has recently been shown to be an effective procedure with significant advantages when properly indicated. We report on the results of arthroscopic ankle fusion in 16 patients with idiopathic or posttraumatic osteoarthritis and rheumatoid disease. We used standard ankle arthroscopic technique and simple noninvasive distraction with hanging weights. All 16 patients had a successful fusion at an average of 9.5 weeks postoperatively. Complications included 1 lateral cutaneous neuroma, and 1 patient who required removal of screws because of superficial pain. Postoperative evaluation showed complete resolution of pain in 14 of 16 patients and significant improvement in gait. Fourteen of 16 patients were completely satisfied with the result and cosmesis, and only 1 patient required shoe modification. These results substantiate previous reports that arthroscopic ankle arthrodesis is successful, and where indicated, has significant advantages over the open technique.

Ankle arthrodesis: a long-term study

Few studies of ankle arthrodesis have assessed tarsal mobility. This study was performed to evaluate radiographically the effect of ankle arthrodesis on tarsal motion. Thirty patients (31 ankles) returned for clinical and radiographic examination, review of charts, and completion of questionnaire forms. Radiographs were evaluated for success of fusion, position of fusion, tarsal motion, hindfoot position, and subtalar and midtarsal arthritis. The median follow-up time was 7.0 years (range 2-20 years). Results showed that fusion was achieved in 22 patients (71%). The evaluation score based on the grading system of Mazur et al. correlated with success of fusion and patient satisfaction. However, no correlation existed between evaluation score and tarsal motion or position of fusion in the sagittal or coronal planes. Radiographic evaluation showed no significant difference between tarsal motion of the fused side and the unfused side. Tarsal mobility was not affected by ankle arthrodesis or by the techniques performed to achieve fusion.

Ankle fusion: a retrospective review

The results of ankle fusion were reviewed in 26 patients who underwent 32 arthrodesis procedures. Posttraumatic degenerative arthritis was the most common indication for fusion (54%). Crossed cancellous screws were the primary method employed (43%), with an external fixator being used in 22% of cases. The overall union rate was 81%, with both crossed cancellous screws and external fixation attaining the best results (86%). Nonunion and infection were the most frequent complications. Progression of subtalar arthritis was demonstrated in 29% of patients postoperatively. Seventy-eight percent of patients graded extremity appearance as excellent or good, with the majority being able to return to work.

Perioperative wound infection in elective orthopaedic surgery

Between 1981 and 1987, 12,907 [corrected] consecutive open elective orthopaedic procedures were performed. The in-patient infection rate was 1.43%. There was a significantly greater risk of infection in revision total knee replacement (15.3%), ankle fusion (9.3%), subtalar fusion (5.8%), primary total knee replacement (5.7%), spinal fusion (5.7%) and revision total hip replacement (4.5%). Revision surgery carried approximately a threefold greater risk than primary procedures. Staphylococci were present in 83% of positive wound cultures. Infection rates varied among surgeons but when number and type of procedure were taken into account only two surgeons differed significantly from that expected. Patients undergoing spinal and hindfoot fusion suffered considerable morbidity as a consequence of wound infection. Antibiotic prophylaxis may be helpful in these procedures.

Total ankle arthroplasty using biological fixation components compared to ankle arthrodesis

When conservative measures fail to alleviate pain and disability of ankle joint disease, tibiotalar arthrodesis is the present accepted surgical treatment. Unfortunately, ankle arthrodesis also carries a significant rate of complications and the success rate does not parallel the results of hip and knee joint arthroplasties. A large percentage of ankle arthrodeses remain painful, and function is not normal. There is no satisfactory "salvage procedure" to a painful ankle fusion. Patients with primary ankle arthritis tend to develop bilateral ankle involvement as well as involvement of the subtalar and midtarsal joints; bilateral ankle fusion results in a severe handicap to gait and function. Ankle fusion with involvement of the subtalar or midtarsal joints might well result in a painful fusion. Maintenance of tibiotalar motion appears essential in both instances. It is apparent that all ankle problems cannot be dealt with by fusion and a successful long-term ankle arthroplasty is needed. Total ankle arthroplasty using cement fixation remains controversial. Continued use of polymethylmethacrylate and additional design changes do not appear to be the answer to possible ankle joint replacement. Initial success using the PCA concept of biological cementless fixation of the Scholz total ankle prosthetic components appears to offer a new dimension in the success of total ankle arthroplasty.

[Arthrodesis of the upper ankle joint following trauma. Follow-up study]

During a period of more than 20 years, 63 patients having undergone a trauma were submitted to arthrodesis of the upper ankle joint. 31 out of them could be followed up from autumn 1982 through spring 1983. The primary reasons and the individual courses making necessary the arthrodesis varied to such an extent that there were no identical anamneses in any of the patients. The destruction of the upper ankle joint by high kinetic energy was apparently an essential factor in the anamnesis of arthrodesis of the upper ankle joint. There is no correlation between the number of posttraumatic arthrodeses and the number of fractures of the ankle joint treated by surgery during the same period. A "good" or "satisfactory" result was achieved in nine out of ten cases submitted to arthrodesis, and it seemed to be unimportant which of the usual techniques was applied. The high complication rate reported in literature, too, has possibly to be considered as a consequence of the gravity of the disease. It seems to be independent of the previously existing risk factors. The follow-up period is very long.

The long-term results of ankle arthrodesis

Thirty-seven patients who had ankle arthrodesis carried out from 1-17 years previously were reviewed. The commonest indication in this series was post-traumatic osteoarthritis. Five different methods of fusion were used, the most common being the Charnley compression technique. The incidence of union, the fusion position, gait, subtalar stiffness and midtarsal hypermobility were recorded and analysed. Objective and subjective assessments were carried out. Poor results were recorded in 11 patients and these results are reported in more detail. The incidence of union was 78.4 per cent.

Late results of ankle fusion

Forty-four ankle joint fusions performed in the period 1950-1972 at the Department of Orthopedic Surgery, Malmö General Hospital, were evaluated. Thirty-one patients were re-examined. The mean follow-up time was 12.3 years (6.4-28 years). Two-thirds of the patients were much better or better than before operation, but still a lot of problems existed. Two-thirds of the patients had some kind of pain localized to the subtalar region. Three out of four patients had to use special footwear. The rate of forefoot deformities was not increased. In conclusion, patients with ankle fusion often have persistent trouble; therefore technical and clinical development of total ankle joint replacement seems to be indicated.