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Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review

BACKGROUND

Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with end-stage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis.

METHODS

A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted, including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis radiographs and medical records were available for analysis.

RESULTS

The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints and patient symptoms was not established in a number of the clinical studies reviewed.

CONCLUSIONS

There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings and clinical presentation in this cohort of patients has not been conclusively demonstrated.

Tibiotalar nonunion corrected by hindfoot arthrodesis

A 65-year-old man without significant comorbidities was referred to the senior author (EG) 9 months after an ankle arthrodesis procedure with complaints of pain, swelling, and progressive hindfoot valgus. The patient had elected to have the index surgery because of severe ankle arthritis due to longstanding lateral ankle instability. Physical examination revealed a well-healed anterior, midline ankle incision with normal pulses and sensation. Painful, limited ankle and subtalar range of motion was noted along with 20 degrees of hindfoot valgus and subfibular impingement. Radiographs of the ankle revealed an attempted ankle fusion using a knee arthroplasty trabecular metal augment placed vertically at the tibiotalar joint. There were no screws or other hardware present to provide compression and stability of the fusion. A computed tomography scan showed a tibiotalar nonunion, erosion of the talar body, and severe tibiotalar and subtalar arthritis. Inflammatory markers were within normal range. Based on the findings of a failed fusion and progressive painful hindfoot deformity, it was determined that the patient would benefit from removal of the hardware and revision fusion surgery. Tibiotalocalcaneal (TTC) hindfoot fusion was planned because of the patient's talar collapse and tibiotalar/ subtalar arthritis. The TTC procedure was performed with a retrograde intramedullary nail, femoral head allograft, and morselized fibular autograft enriched with platelet-rich plasma. The femoral head was used as a structural allograft to fill the large bone defect, prevent limb shortening, and assist in correction of the hindfoot deformity. Intraoperative findings revealed severe metallic synovitis of the ankle and subtalar joints, metal debris at the site of the trabecular implant, and segmental defects of the distal tibia and talus. Weight bearing was permitted after 16 weeks when evidence of successful ankle fusion was confirmed radiographically. At 24 months, the patient was pain free and ambulating without difficulty.

Rehabilitation of ligamentous ankle injuries: a review of recent studies

There are many treatment modalities for ankle rehabilitation. These are reviewed, and the most effective training programme for rapid restoration of ankle movement, strength, endurance, and proprioception is selected.