Motion versus fixed distraction of the joint in the treatment of ankle osteoarthritis: a prospective randomized controlled trial

Proximal fibular osteotomy in conjunction with supramalleolar osteotomy in concurrent management of ankle and knee osteoarthritis: A case series

Management of ankle osteoarthritis (OA) remains a challenge due to its profound impact on pain, function, and quality of life. Supramalleolar osteotomy (SMO) is a joint-preserving procedure that addresses malalignment and redistributes joint loads, while proximal fibular osteotomy (PFO) targets varus deformities and lateral instability. This study explores the outcomes of combining SMO and PFO to treat concurrent ipsilateral ankle and knee OA, providing a comprehensive approach to lower limb pathology. We report two cases of patients with symptomatic ankle and knee OA managed using a combined surgical strategy. Both patients underwent preoperative clinical evaluations, radiographic assessments, and standardized rehabilitation protocols postoperatively. Surgical procedures included ankle arthroscopic debridement, microfracture, SMO, PFO, and lateral ligament reconstruction as required. Postoperative outcomes demonstrated improvements in alignment, pain, and function. Patient-reported outcome measures showed marked improvements 6 months postoperatively, with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores increasing from 40 to 67 in one patient and from 69 to 94 in the other. Pain scores on the visual analog scale (VAS) showed substantial reductions in both cases, and quality of life domains assessed via the RAND 36-item health survey (RAND 36) questionnaire, including physical function and vitality, demonstrated marked gains. Radiographic analysis confirmed effective realignment and increased joint space, with improvements in key angles such as the tibial anterior surface (TAS) angle and talar tilt (TT). These cases highlight the synergistic effect of SMO and PFO in managing complex ipsilateral lower limb OA. Radiographic and patient-reported outcomes demonstrated improved alignment, pain relief, and functionality. SMO addressed varus malalignment in the ankle, while PFO facilitated medial opening and enhanced correction of TT. Additionally, combining these techniques reduced mechanical stress on the medial knee compartment. This dual approach shows some promise as a joint-preserving alternative for patients with moderate to severe ipsilateral ankle and knee OA. However, meticulous preoperative planning and patient selection remain essential to optimize outcomes. Further studies with larger cohorts and long-term follow-up are needed to validate these findings and refine surgical indications. LEVEL OF EVIDENCE: Level V, Case report.

Effect of Distraction Arthroplasty in the Treatment of Moderate-to-Severe Ankle Arthritis

OBJECTIVE

Currently, the traditional treatment of moderate-to-severe ankle arthritis is joint fusion or joint replacement. The aim of this article is to explore the clinical efficacy of distraction arthroplasty in the treatment of moderate-to-severe ankle arthritis.

METHODS

A retrospective analysis was conducted with a total of 34 cases who were diagnosed with moderate-to-severe ankle arthritis and treated by distraction arthroplasty from January 2007 to November 2021. The average age was 42.3 years. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and pain visual analog scale (VAS) were used to evaluate ankle pain and functional improvement before surgery and at the last follow-up. Based on age, the patients were divided into the ≤45-year-old group [young group, 15 cases, age (36.37 ± 4.31) years old] and the >45-year-old group [middle-aged and elderly group, 19 cases, age (53.74 ± 3.17) years old]. The analysis included comparing preoperative and postoperative AOFAS ankle-hindfoot and VAS scores and the influence of age on distraction arthroplasty.

RESULTS

All 34 patients were followed up, and the follow-up time ranged from 13 to 143 months, with an average of 45.3 months. The follow-up times for the young and middle-to-elderly groups were (33.19 ± 21.37) months and (55.63 ± 29.69) months, respectively. At the last follow-up, the AOFAS ankle-hindfoot and VAS scores were significantly improved compared with the preoperative assessment (p < 0.05). According to the etiological analysis, except for Pilon fracture, which showed no differences pre- and postoperation in the AOFAS ankle-hindfoot score and VAS score (p > 0.05), all other patients showed significant differences in these two scores (p < 0.05). The difference in preoperative AOFAS ankle-hindfoot scores between the young and middle-to-elderly groups was statistically significant (t = 3.422, p = 0.021). The preoperative and postoperative comparison of preoperative VAS scores, AOFAS ankle-hindfoot scores, and VAS scores before and after surgery showed no differences (p > 0.05). The joint space width (JSW) of 10 patients who were followed up for more than 5 years was (2.9 ± 0.5) mm. Two patients who were followed up for more than 10 years showed 3.3 and 3.0 mm, respectively, JSW.

CONCLUSION

Distraction arthroplasty with the Ilizarov external fixator can achieve satisfactory results in the treatment of moderate-to-severe ankle arthritis (except arthritis caused by Pilon fracture surgery). Age has no statistical impact on the efficacy of distraction arthroplasty.

Outcomes of ankle joint distraction in a paediatric and young adult cohort presenting with symptomatic ankle arthritis

Ankle arthritis in paediatric and young adult patients causes significant morbidity; therefore, joint-preserving procedures are preferable. Ankle joint distraction (AJD) is a technique that preserves the native joint. However, only short-term outcomes are reported in paediatric patients. Therefore, this study reports on intermediate-term outcomes in a paediatric cohort. Demographics for all patients who underwent AJD at two centres were prospectively collected. Case records were reviewed retrospectively for complications and further intervention. Mean joint space at baseline and follow-up radiographs were evaluated by two independent observers. All patients were contacted for completion of a Foot and Ankle Outcome Score (FAOS). Seven patients received AJD between February 2016 and June 2019. Median age at surgery was 15 years (9.0-24.6 years). Complications included one superficial pin-site infection and one patient death due to complications from juvenile idiopathic arthritis 6.2 years post-operatively. Two patients were converted to fusion, at 12.6 months and 26.2 months following frame removal; one patient underwent spontaneous fusion at 9 months following frame removal. The four patients who continued without further intervention achieved 2.59 mm mean joint space at last follow-up (0.65-5.08 mm) and FAOS of 35-79%. Mean follow-up length was 4.3 years (2.9-6.3 years) with final radiographs at mean 2.6 years. While recognising the limitations of this retrospective review, several patients had significant, sustained improvements in joint space with good clinical outcome. Complications for this procedure are minimal, and it is a potential joint-preserving option for managing end-stage ankle arthritis in young patients.

Low annual revision rate in ankle distraction for ankle osteoarthritis: A systematic review and meta-analysis

PURPOSE

Ankle osteoarthritis severely impacts patients' mental and physical quality of life. Besides total ankle replacement and ankle arthrodesis, ankle distraction has been shown to be a promising alternative. The primary aim of the present study was to determine the annual revision rates (ARRs) after ankle distraction. The secondary aim was to obtain an overview of patient-reported outcome measures and functional outcomes.

METHODS

A literature search until November 2023 was performed. Methodological quality was assessed using the methodological index for non-randomised studies criteria. Primary outcome was the ARR which was log-transformed and pooled using a random effects model. Secondary outcomes were pooled using a simplified pooling technique and included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), range of motion (ROM) and post-operative complications.

RESULTS

The literature search resulted in 287 articles, of which 10 studies, comprising 602 patients, were included. The patients had a pooled mean age of 47 years (range of means: 40-68) and a mean follow-up of 35 months (range of means: 24-48). The overall methodological quality was moderate to fair. The pooled ARR after ankle distraction was 4% (95% confidence interval [CI], 3%-7%). Pooling of AOFAS showed mean 26-point improvement (from 54 to 80). Additionally, ROM dorsiflexion improved at 5°, and the plantarflexion remained at 31°. The overall complication rate was 41% (95% CI, 35%-48%), of which 77% (95% CI, 67%-85%) were pin-tract infections.

CONCLUSION

Ankle distraction results in an ARR of 4% (95% CI, 3%-7%) with clinically relevant improved AOFAS scores. The overall complication rate is 41% and is mainly attributable to treatable pin-tract infections (77% of recorded complications).

LEVEL OF EVIDENCE

Level IV, Systematic Review and Meta-Analysis.

Ankle Distraction Arthroplasty: A Survivorship Review and Meta-Analysis

Multiple treatments exist for ankle osteoarthritis. Ankle arthrodesis is the gold standard in late-stage osteoarthritis, but sacrifices range of motion and risks nonunion. Total ankle arthroplasty is typically reserved for low-demand patients as the long-term outcomes are poor. Ankle distraction arthroplasty is a joint sparing procedure which utilizes external fixator frame to unload the joint. This promotes chondral repair and improves function. This study aimed to organize clinical data and survivorship in published papers and direct further research efforts. Thirty-one publications were evaluated and 16 were included in the meta-analysis. The Modified Coleman Methodology Score was used to assess quality of the individual publications. Random effects models were used to estimate the failure risk after ankle distraction arthroplasty. Ankle Osteoarthritis Score (AOS), American Orthopedic Foot and Ankle Score (AOFAS), Van Valburg, and Visual Analog Scores (VAS) all improved postoperatively. Random effects model analysis revealed an overall failure ratio of 11% (95% CI: 7%-15%; p value ≤ .001; I2 = 87.01%) after 46.68 ± 7.17 months follow up, 9% (95% CI: 5%-12%; p value≤0.001 I2=81.59%) with less than 5 years follow-up and 28% (95% CI: 16%-41%; p value≤0.001 I2=69.03%) for patients with more than 5 years follow-up. Ankle Distraction Arthroplasty has promising short to intermediate term outcomes which makes this a reasonable treatment option to delay joint sacrificing surgery. The selection of the optimal candidates and consistent technique would improve research and subsequently outcomes. Based on our meta-analysis, negative prognostic factors include female sex, obesity, ROM < 20°, leg muscle weakness, high activity level, low preoperative pain levels, higher preoperative clinical scores, inflammatory arthritis, septic arthritis, and deformity.

Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies

BACKGROUND

Plain radiographs cannot identify all scaphoid fractures; thus ED patients with a clinical suspicion of scaphoid injury often undergo immobilisation despite normal imaging. This study determined (1) the prevalence of scaphoid fracture among patients with a clinical suspicion of scaphoid injury with normal radiographs and (2) whether clinical features can identify patients that do not require immobilisation and further imaging.

METHODS

This systematic review of diagnostic test accuracy studies included all study designs that evaluated predictors of scaphoid fracture among patients with normal initial radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analyses included all studies.

RESULTS

Eight studies reported data on 1685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 9.0%. Most studies were at overall low risk of bias but two were at unclear risk; all eight were at low risk for applicability concerns. The most accurate clinical predictors of occult scaphoid fracture were pain when the examiner moved the wrist from a pronated to a supinated position against resistance (sensitivity 100%, specificity 97.9%, LR+ 45.0, 95% CI 6.5 to 312.5), supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR+ 3.7, 95% CI 2.2 to 6.1), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR+ 2.3, 95% CI 1.8 to 3.0) and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR+ 2.0, 95% CI 1.2 to 3.2). Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1%, specificity 48.4%, LR- 0.2, 95% CI 0.0 to 0.7).

CONCLUSION

No single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation.

TRIAL REGISTRATION NUMBER

CRD42021290224.

Developing a core outcome set for foot and ankle disorders in rheumatic and musculoskeletal diseases: A scoping review and report from the OMERACT 2022 foot and ankle special interest group session

OBJECTIVES

Foot and ankle involvement is common in rheumatic and musculoskeletal diseases, yet high-quality evidence assessing the effectiveness of treatments for these disorders is lacking. The Outcome Measures in Rheumatology (OMERACT) Foot and Ankle Working Group is developing a core outcome set for use in clinical trials and longitudinal observational studies in this area.

METHODS

A scoping review was performed to identify outcome domains in the existing literature. Clinical trials and observational studies comparing pharmacological, conservative or surgical interventions involving adult participants with any foot or ankle disorder in the following rheumatic and musculoskeletal diseases (RMDs) were eligible for inclusion: rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthropathies, crystal arthropathies and connective tissue diseases. Outcome domains were categorised according to the OMERACT Filter 2.1.

RESULTS

Outcome domains were extracted from 150 eligible studies. Most studies included participants with foot/ankle OA (63% of studies) or foot/ankle involvement in RA (29% of studies). Foot/ankle pain was the outcome domain most commonly measured (78% of studies), being the most frequently specified outcome domain across all RMDs. There was considerable heterogeneity in the other outcome domains measured, across core areas of manifestations (signs, symptoms, biomarkers), life impact, and societal/resource use. The group's progress to date, including findings from the scoping review, was presented and discussed during a virtual OMERACT Special Interest Group (SIG) in October 2022. During this meeting, feedback was sought amongst delegates regarding the scope of the core outcome set, and feedback was received on the next steps of the project, including focus group and Delphi methods.

CONCLUSION

Findings from the scoping review and feedback from the SIG will contribute to the development of a core outcome set for foot and ankle disorders in RMDs. The next steps are to determine which outcome domains are important to patients, followed by a Delphi exercise with key stakeholders to prioritise outcome domains.

The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature

Introduction

Knee joint distraction (KJD) is a potential technique for cartilage regeneration in young patients with osteoarthritis of the knee. Static distraction has been utilised typically; however, a significant proportion of patients complain of knee stiffness post-distractor removal. The use of a hinged distractor may reduce the duration and severity of post-treatment knee stiffness by maintaining the range of motion during distraction. Furthermore, improved cartilage regeneration has been demonstrated in hinged ankle joint distraction as compared to static, and this may also be demonstrated at the knee. An evidence review was undertaken to inform further research and a potential change in practice.

Aim

A systematic review of all primary research on hinged knee joint distraction for cartilage regeneration.

Methods

An online systematic search of citation databases was conducted. Quality assessment and data extraction were undertaken by two separate researchers.

Results

The literature search returned a small number of relevant studies, of which 7 were included. Three of these were animal studies, two cadaveric and two case series. The study quality was low or very low. There was significant methodological heterogeneity with difficulties encountered in the transfer of constructs from animal and cadaveric studies to humans. Issues faced included difficulties with hinge placement and pin site pain in motion.

Conclusion

The feasibility of hinged knee joint distraction has yet to be proven. Any further research attempting to establish the benefits of hinged-over static knee distraction will have to take construct design considerations into account.

How to cite this article

Lineham B, van Duren B, Harwood P, et al. The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature. Strategies Trauma Limb Reconstr 2023;18(1):37-43.

[Ankle distraction hinged motion arthroplasty in the Ilizarov frame]

OBJECTIVE

To study distraction hinged motion arthroplasty of the ankle joint in combined treatment of osteoarthritis in terminal stages.

MATERIAL AND METHODS

Ankle distraction hinged motion arthroplasty in the Ilizarov frame was performed in 10 patients with terminal post-traumatic osteoarthritis (mean age 54±6.2 years). Surgical technique and design of the Ilizarov frame, as well as additional reconstructive interventions are described.

RESULTS

Preoperative VAS score of pain syndrome was 7±2.3 cm, after 2 postoperative weeks - 1±0.5 cm, 4 weeks - 0.5±0.5 cm, 9 weeks or before dismantling - 0±0.5 cm. Arthroscopic debridement of anterior part of the ankle joint was carried out in 6 cases, posterior part - 1 case, anchor reconstruction of lateral ligamentous complex (InternalBrace technique) - 1 case, anchor reconstruction of medial ligamentous complex - 2 cases. Restoration of anterior portion of syndesmosis was performed in 1 case. Pin site infections occurred in 2 cases. In one case, there was a breakdown of the wire fixator holding the pin passed through the talus in 5 weeks after surgery.

CONCLUSION

Preliminary results allow us to characterize the proposed design of the Ilizarov frame layout and surgical technique as relatively simple and promising for postponing radical surgery on the ankle joint.

Distraction Arthroplasty Combined with Autologous Bone Grafting for Diffuse-type Tenosynovial Giant Cell Tumour with Articular Cartilage Defect and Subchondral Bone Cysts: A Case Report

Tenosynovial giant cell tumour encompasses a group of lesions that present with synovial differentiation and most commonly occur in the joint synovium, bursae, and tendon sheaths. Diffuse-type tenosynovial giant cell tumour, previously known as pigmented villonodular synovitis, is one of the most common benign soft tissue tumours of the foot and ankle and usually affects young adults. The differential diagnosis of diffuse-type tenosynovial giant cell tumours remains a clinical problem because its clinical symptoms are similar to those of inflammatory arthritis, including rheumatoid arthritis. Moreover, persistent diffuse-type tenosynovial giant cell tumours can lead to articular deterioration, including osseous erosions and subchondral bone cysts. Joint-preserving procedures are considered optimal for treating younger patients with ankle osteoarthritis because the indication of ankle arthrodesis and total ankle arthroplasty is limited. Thus, ankle distraction arthroplasty could be an alternative for treating diffuse-type tenosynovial giant cell tumour with articular deterioration in young patients. Here, we report about a woman in her early 30s who presented with ankle pain owing to a diffuse-type tenosynovial giant cell tumour with an articular cartilage defect and subchondral bone cysts. We performed ankle distraction arthroplasty combined with an autologous bone graft. A follow-up examination at 2 years revealed preservation of physical function and pain alleviation. These findings suggest that distraction arthroplasty is a viable treatment option for remedying the destruction of the articular cartilage and subchondral bone owing to diffuse-type tenosynovial giant cell tumours in young adults.

Distraction arthroplasty in the management of osteoarthritis of the ankle: A systematic review

BACKGROUND

This study aimed to evaluate the use of distraction arthroplasty for ankle osteoarthritis, with respect to patient reported outcome measures (PROMs), complications, range of motion and radiographic outcomes.

METHODS

A computer-based search was performed in PubMed, Cinahl, Embase, Scopus and ISI Web of Science. Two reviewers independently performed title/abstract and full-text screening. Quality assessment was performed using The Methodological Index for Non-Randomised Studies (MINORS) and Joanna Briggs Institute criteria.

RESULTS

Whilst all studies evaluating PROMs reported significant (P < 0.05) improvement, these were either below or only slightly above the minimally clinically important difference. The rate of conversion to arthrodesis or total ankle arthroplasty was high, with failure rates of up to 52% reported.

CONCLUSION

Due to the inconsistent improvements in PROMs, which are likely overestimated due to substantial bias, and the high failure rate, this review suggests that distraction arthroplasty is not currently an effective treatment option for ankle arthritis.

LEVEL OF EVIDENCE

Level IV, systematic review of level I to IV studies.

[Mid- and long-term effectiveness analysis of distraction arthroplasty in treatment of moderate to severe ankle arthritis]

Objective

To investigate the mid- and long-term effectiveness of external fixator distraction arthroplasty in the treatment of moderate to severe ankle arthritis.

Methods

The clinical data of 23 patients with moderate to severe ankle arthritis treated with external fixation distraction arthroplasty who met the selection criteria between January 2007 and November 2019 were retrospectively analyzed. There were 20 males and 3 females; the age ranged from 21 to 65 years, with an average age of 43.7 years. Etiology included 8 cases of primary ankle arthritis, in which 5 cases combined with varus deformity; 15 cases of traumatic ankle arthritis, the cause of injury was 5 cases after ankle fracture surgery, 3 cases after Pilon fracture surgery, 5 cases of chronic ankle instability and repeated sprain, and 2 cases of other causes. According to Takakura staging system, there were 4 cases of stage ⅢA, 12 cases of stage ⅢB, and 7 cases of stage Ⅳ; according to Giannini staging system, there were 5 cases of stage Ⅱ and 18 cases of stage Ⅲ; according to Cheng staging system, 16 cases were in stage Ⅲ, and 7 cases stage Ⅳ. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) score were used to evaluate the improvement of ankle pain and function before operation and at last follow-up, and the data were analyzed according to different etiological groups. At last follow-up, the surgical results were evaluated subjectively and objectively. The changes of ankle joint space before operation and at last follow-up were compared. The patients were divided into two groups according to their age: ≤45 years old group [young group, 10 cases, aged (35.62±7.41) years old] and >45 years old group [middle-aged and elderly group, 13 cases, aged (54.20±6.20) years old]. The AOFAS ankle-hindfoot score and VAS score were compared before and after operation between the two groups, and the influence of age on distraction arthroplasty was analyzed.

Results

The external fixator was removed after 3 months of continuous distraction,12 patients got infection around the wire tunnels. All the 23 patients were followed up 13-143 months, with an average of 56.9 months; the follow-up time was (43.46±32.77) months and (69.80±37.79) months in the young group and middle-aged and elderly group, respectively. At last follow-up, the AOFAS ankle-hindfoot score and VAS score significantly improved when compared with those before operation ( P<0.05). According to etiological analysis, there was no significant difference in AOFAS ankle-hindfoot score and VAS score before and after operation ( P>0.05) in Pilon fracture patients, while the significant difference was found in remaining patients ( P<0.05). There was significant difference in AOFAS ankle-hindfoot score before operation between the young group and the middle-aged and elderly group ( t=2.110, P=0.040), but no significant difference in preoperative VAS score and the differences in VAS score and AOFAS ankle-hindfoot score before and after operation between the two groups ( P>0.05). The subjective and objective results of pain evaluation at last follow-up showed that 4 patients had no pain, 12 patients had moderate pain relief, 5 patients had mild pain relief, and 2 patients had no significant pain relief; among the 10 patients who were followed up more than 5 years, there were 2, 5, 2, and 1 patient, respectively; 2 patients who were followed up more than 10 years had moderate pain relief. At last follow-up, the ankle joint space was (3.7±0.4) mm, which significantly increased when compared with before operation [(1.5±0.2) mm] ( t=1.791, P=0.002). The ankle joint space was (2.9±0.5) mm in 10 patients who were followed up more than 5 years, and 3.3 mm and 3.0 mm in 2 patients who were followed up more than 10 years.

Conclusion

Distraction arthroplasty of the ankle joint can achieve satisfactory results in patients with moderate to severe ankle arthritis (except for arthritis caused by Pilon fracture), and age has no significant effect on distraction arthroplasty.

Ankle joint distraction is a promising alternative treatment for patients with severe haemophilic ankle arthropathy

INTRODUCTION

Haemophilic ankle arthropathy (HAA) causes major morbidity. When conservative treatment fails, major surgical interventions are indicated. An alternative treatment to maintain joint mobility and postpone these interventions is desired.

AIM

To gather prospective data on clinical/structural changes after ankle joint distraction (AJD) in HAA.

METHODS

This study includes patients with severe HAA insufficiently responding to conservative treatment. AJD was performed during 8-10 weeks by use of an external frame. Questionnaires, physical examination and radiology were used to evaluate pain, function and structural changes before and 6, 12, 24 and 36 months after distraction. Mixed effect models were used for analysis.

RESULTS

This study includes eight cases (21-53 years). The fixed effects estimates of the visual analogue score (0-10) improved from 7.5 at baseline to 3.4 (p = .023) 3 years after distraction. The Haemophilia Activities List (HAL, 0-100) for basic/complex lower extremities functions improved from respectively 29.6 and 31.5 to 54.3 (p = .015) and 50.7 (p = .031). Joint mobility was maintained. Magnetic resonance imaging (MRI) showed thickened cartilage and reduced bone marrow oedema and subchondral cysts. Pin tract infections (n = 6) were effectively treated and no adverse bleeding events occurred. At 3-year follow-up, in none of the patients the originally indicated arthrodesis was performed.

CONCLUSION

This first prospective study showed that AJD in HAA results in decreased pain, improved function and decreased arthropathy-related MRI findings in the majority of patients for prolonged time. Although the study population is small and follow-up is relatively short, AJD may be promising to postpone invalidating interventions and might be a breakthrough treatment.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research.

LEVEL OF EVIDENCE

Level V, review article/expert opinion.

International Foot and Ankle Osteoarthritis Consortium review and research agenda for diagnosis, epidemiology, burden, outcome assessment and treatment

OBJECTIVE

To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research.

METHOD

Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion.

RESULTS

Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment.

CONCLUSIONS

Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition.

The Role of Distraction Arthroplasty in Managing Ankle Osteoarthritis

Ankle distraction arthroplasty (DA) is a joint-preserving option for the treatment of ankle osteoarthritis. The ideal patient is a young, active person who is compliant with follow-up and understands that clinical improvements may not be fully evident until 1 year after surgery. The procedure promotes cartilage healing and regeneration by removing mechanical stress at the joint surface through the application of a joint-spanning external fixator. There is an array of adjuvant procedures commonly performed to optimize healing potential-including microfracture, osteophyte removal, osteotomies, and soft tissue balancing procedures. Short- and intermediate-term studies have been promising, though there is a wide variance in reported failure and complication rates.

The Role of Anterior Ankle Arthroscopy in the Management of Ankle Arthritis: Literature Review, Patient Evaluation, Goals of Treatment and Technique

The current body of literature regarding anterior ankle arthroscopic debridement for anterior ankle impingement (AAI) cases with ankle osteoarthritis (OA) has significant limitations. The reported poor outcomes lack the necessary rigor in patient selection, preoperative evaluations and in most reports, the use of a systematic operative approach. Furthermore, the lack of postoperative evaluation by authors using physical examination and radiologic studies to determine the etiology of ongoing pain leaves open the possibility that treatment of impingement was incomplete. For these reasons, it would be inappropriate to conclude that anterior arthroscopic debridement has no role in the treatment of ankle OA. Critical analysis of some studies provides encouragement that this can be a useful intermediate treatment of appropriately selected patients with AAI and ankle OA. The level of required detail in the physical examination and radiologic evaluation is much greater than for more straight-forward cases of soft tissue impingement or simple osteophyte impingement in otherwise healthy joints. The success of the treatment requires a systematic approach to the evaluation and performance of the procedure, which is perhaps why results in the literature have been suboptimal in most series. Future studies should apply this rigorous approach to patient selection, procedure performance, and postoperative analysis to best clarify which patients can be best served with this procedure as part of the various intermediate treatment options for ankle OA.

Imaging and Treatment of Posttraumatic Ankle and Hindfoot Osteoarthritis

Posttraumatic osteoarthritis of the ankle and hindfoot is a common and frequently debilitating disorder. 70% to 90% of ankle osteoarthritis is related to prior trauma that encompasses a spectrum of disorders including fractures and ligamentous injuries that either disrupt the articular surface or result in instability of the joint. In addition to clinical evaluation, imaging plays a substantial role in the treatment planning of posttraumatic ankle and hindfoot osteoarthritis. Imaging evaluation must be tailored to specific clinical scenarios and includes weight bearing radiography that utilizes standard and specialty views, computed tomography which can be performed with a standard or a weight bearing technique, magnetic resonance imaging, and ultrasound evaluation. This review article aims to familiarize the reader with treatment rationale, to provide a brief review of surgical techniques and to illustrate expected imaging appearances of common operative procedures performed in the setting of posttraumatic ankle and hindfoot osteoarthritis, such as joint-preserving procedures, ankle fusion, subtalar fusion, tibiotalarcalcaneal fusion and ankle arthroplasty. Preoperative findings will be discussed along with the expected postoperative appearance of various procedures in order to improve detection of their complications on imaging and to provide optimal patient care.

Ankle distraction arthroplasty (ADA): A brief review and technical pearls

Ankle distraction arthroplasty (ADA) is a procedure based on the concept that mechanical unloading of an arthritic joint will initiate a healing response in the subchondral bone and articular cartilage. ADA utilizes the patient's own healing response, preserves joint motion, and is a great option for patients with osteoarthritis who are not ready for prosthetic arthroplasty or fusion. The procedure is well described and technically simple and adjunctive biologic therapies are exciting for joint regeneration. Complications are minor, and more serious adverse events are avoidable. Supramalleolar osteotomy pairs well with ankle distraction but requires some analysis and planning.

Large Osteochondral Defects of the Distal Tibia Plafond After Septic Arthritis of the Ankle Joint Treated by Arthrodiastasis and Iliac Bone Graft: A Case Report

Bone defects after septic arthritis of the ankle joint result in arthrodesis and severe loss of ankle motion. This must be prevented in young athletes. We report the case of a 17-year-old male patient with large osteochondral defects in the distal tibia plafond after septic arthritis, in whom iliac bone graft and arthrodiastasis were performed to preserve ankle motion. He was diagnosed with septic arthritis of the ankle joint postoperatively at the age of 16 years. After irrigation and hardware removal, C-reactive protein level was normal. However, he experienced continuous pain and could not walk; he was referred to our hospital. Computed tomography showed large osteochondral defects in the medial tibia plafond occupying ∼30% of the plafond articular surface. Simultaneous iliac bone block graft and arthrodiastasis with an external fixator were performed. We placed iliac bone graft into the defect in the medial tibia plafond using the anterior approach, and we placed an external fixator with hinge and tractioned and fixed the ankle joint. One week postoperatively, range of motion training of the ankle was started. We removed the foot ring at 3 months and the external fixator at 4 months postoperatively. The patient started jogging at 8 months and performing long jump at 1 year postoperatively. The Japanese Society for Surgery of the Foot ankle/hindfoot scale improved from 56 to 97 points at 2-year follow-up. Despite large osteochondral defects with septic arthritis, arthrodiastasis and iliac bone graft were beneficial for preserving the ankle joint and its function.

Subtalar distraction arthroplasty with bone marrow aspirate concentrate (BMAC), preliminary results of a new joint preservation technique

INTRODUCTION

Isolated subtalar osteoarthritis (OA) is a debilitating condition usually occurring after trauma and particularly in the setting of an intraarticular calcaneal fracture. Currently, subtalar (talo-calcaneal joint) fusion surgery is the treatment of choice in managing subtalar OA after failure of conservative treatment. Unfortunately, subtalar fusion eliminates joint motion and increases the load over the adjacent midfoot and ankle joints, which affects the outcome of the surgery over time. Popular in the ankle, distraction arthroplasty offers another joint-preserving option, particularly important for active patients. In contrast to fusion as a salvage procedure, subtalar distraction arthroplasty allows the possibility of maintaining the function of the arthritic subtalar joint while reducing pain and improving the overall function of the foot and ankle.

METHODS

We performed subtalar distraction arthroplasty using a circular external fixator combined with BMAC on seven patients with symptomatic and refractory subtalar OA. All these patients were interested in an alternative to fusion. We obtained clinical and radiographic data before and after surgery. Ankle Osteoarthritis Score (AOS) and the Marijnissen Distraction Clinical Score (MDCS) were obtained before surgery, after one year, and at latest follow-up.

RESULTS

The average age was 56 years (range 45-69). The mean duration of post-operative follow-up was 35.4 months (range 15.2-53.5). The inversion of the ankle joint changed from 16.9° (10°-25°) pre-operatively to 14.3° (10°-20°) post-operatively (P = 0.28), and the eversion from 5.6° (0°-10°) to 10.0° (0°-20°) (P = 0.17). We found an increase in subtalar joint space from 1.4 mm (0-3) to 2.6 mm (2-4) before and after surgery (P = 0.01), respectively. Finally, Pixel Density Ratio (PDR) increased from 0.87 (0.66-1.30) to 1.01 (0.89-1.18) (P = 0.19). Compared to pre-operative conditions, we observed a decrease in subchondral sclerosis on X-ray in all cases post-operatively. The AOS score for ankle pain improved from 58.8 (47-74) to 15.1 (0-31) (p < 0.01). The AOS score for ankle disability improved from 68.2 (57-81) to 16.1 (0-43.5) (p < 0.001). We found improvement in the MDCS over time for all measured parameters. The clinical condition improved from 1.4 (0-2) to 0.8 (0-2) after one year and to 0.3 (0-2) at the latest follow-up (p < 0.001). Mobility was measured as ROM in the treated ankle relative to each patient's contralateral ankle. This increased from 35% (0-100) to 66% (15-120) to 76% (15-100) (p = 0.059). Function improved from 2.3 (0-3) to 1.3 (0-3) to 0.6 (0-3) (p < 0.001). Pain decreased from 7.4 (2-10) to 4.4 (2-8) to 2.1 (0-7) (p < 0.01). Complications include one patient with sensory neuralgia.

CONCLUSIONS

Preliminarily, results of subtalar distraction arthroplasty as a new joint preservation technique are encouraging. Our research suggests the possibility of subtalar distraction arthroplasty as an effective treatment for symptomatic subtalar OA. Furthermore, this new operation does not eliminate the possibility of a future surgery like fusion. Subtalar distraction arthroplasty can be helpful in the management of subtalar OA in active patients who desire preservation of foot and ankle motion.

An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013

BACKGROUND

The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials.

METHODS

A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted.

RESULTS

A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment.

CONCLUSIONS

The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

Functional and radiological medium term outcome following supramalleolar osteotomy for asymmetric ankle arthritis- A case series of 33 patients

Introduction

Ankle arthritis is one of the most disabling and painful conditions. Up to 37.5% of ankle arthritis presents as asymmetric arthritis with ankle malalignment. Supramalleolar osteotomy is a joint sparing operation, which aims to realign the ankle joint that will prevent progression of arthritis and relieve patient's symptoms.

Aim

The aim of this study is to analyse the medium term functional and radiographic outcomes of patients who underwent supramalleolar osteotomy for asymmetric ankle arthritis.

Materials and methods

This is a retrospective outcome study of medium term outcome for 33 patients who underwent Supramalleolar osteotomy for asymmetric ankle arthritis by a single surgeon. We assessed the functional outcome of the patients with AOFAS and VAS score. The radiological parameters measured were Tibial articular surface ankle (TAS), Hind foot alignment angle (HFA) and Talar tilt angle (TT). We used the paired Student's t-test to compare the preoperative and postoperative radiographic measurements, AOFAS and VAS scores. We set the significance level at P < 0.05.

Results

We had 21 patients who underwent lateral closing wedge osteotomy for varus deformity and 12 patients who underwent medial closing wedge osteotomy for valgus deformity. The mean followup was 72 months [29-73]. The mean AOFAS score significantly improved by 44.82 ± 7.97 (p < 0.0001). The VAS score significantly improved by 5.06 ± 1.41 (p < 0.0001). All the radiological parameters showed statistically significant improvement. All osteotomy united by 8-10 weeks. We had one case of late deep wound infection, which settled down with by metalwork removal. The arthritis progressed in three cases, two patients had fusion and one patient had ankle replacement. We had 90.9% survival rate for our osteotomy at 6 years.

Conclusion

Supramalleolar osteotomy is an excellent option for patients with asymmetric ankle arthritis with good functional and radiological outcome and good medium term survival rate.

Arthrofibrosis of the Ankle

Arthrofibrosis is a common, but often overlooked, condition that imparts significant morbidity following injuries and surgery to the foot and ankle. The most common etiologies are related to soft tissue trauma with subsequent fibrotic and contractile scar tissue formation within the ligaments and capsule of the ankle. This leads to pain, alterations in gait, and ankle dysfunction. Initial treatment often includes extensive physical therapy, however, if severe enough surgical options exist. Although the literature regarding ankle arthrofibrosis is scarce, this review article provides a greater understanding of the pathogenesis of arthrofibrosis and describes the current and future therapeutic options to treat fibrotic joints. Level of Evidence: Level V, expert opinion.

Ankle distraction arthroplasty for the treatment of severe ankle arthritis: Case report, technical note, and literature review

RATIONALE

Widely applied in the treatment of severe ankle arthritis (AA), ankle distraction arthroplasty (ADA) can avoid not only the ankle range of motion loss but also ankle fusion. However, the clinical outcomes of ADA for severe AA are poorly understood. This study aims to present our clinical outcomes of severe AA treated by ADA.

PATIENT CONCERNS

A 53-year-old man suffered right ankle sprain 10 years ago, endured right ankle pain and limited movement for 6 years.

DIAGNOSIS

The patient was diagnosed as severe AA.

INTERVENTIONS

He received ankle distraction arthroplasty. No adjuvant procedures were performed. The visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) score, the short-form (SF)-36 physical component summary (PCS) score and ankle activity score (AAS) were recorded to access the clinical outcomes pre- and postoperatively. Moreover, ankle joint space distance was evaluated on weight-bearing radiographs.

OUTCOMES

The patient derived effective pain relief and restored a satisfactory range of movement. There was a 13-month follow-up period after frame removal. The AOFAS score improved from 56 preoperatively to 71 postoperatively. The VAS score decreased from 6 prior to surgery to 1 after surgery. The SF-36 PCS was 47.2 and 71.8 pre- and postoperative, respectively. The AAS scores were improved from 3.4 preoperatively to 7.3 postoperatively.

LESSONS

ADA is reliable to achieve pain relief, functional recovery, and serve AA resolution. Besides, it is an alternative to ankle arthrodesis or total ankle arthroplasty in selected patients with severe AA.

Effect of Microfracture on Functional Outcomes and Subchondral Sclerosis Following Distraction Arthroplasty of the Ankle Joint

BACKGROUND

Treatment for post-traumatic osteoarthritis (PTOA) of the ankle remains challenging. Distraction arthroplasty (DA) is an alternative for patients who are averse to or poor candidates for arthrodesis or joint replacement. The purpose of this study was to examine the role of microfracture (MFX) and concentrated bone marrow aspirate (CBMA) on the outcome of patients undergoing DA for end-stage PTOA of the ankle joint.

METHODS

Ninety-five patients who underwent DA for the treatment of end stage PTOA from 2009 to 2014 were selected from the hospital ankle registry. Demographic data, functional activity levels, complications, and radiographs taken at 6, 12, 24, and 36 months postoperatively were reviewed. Foot and Ankle Outcome Scores (FAOS) were obtained at the same time intervals. A total of 78 patients were included in this study. Interventions were divided into 4 groups for comparison: DA+MFX (n = 8), DA+MFX+CBMA (n = 35), DA+CBMA (n = 22), and DA alone (n = 13).

RESULTS

Patients undergoing DA+MFX or DA+MFX+CBMA had significantly worse motion (P = .003) when compared with DA alone. Patients undergoing MFX had significantly reduced postoperative joint space and a greater length of time to return to activity when compared to subgroups not using MFX (P = .01). The use of MFX was associated with significantly lower FAOS scores.

CONCLUSION

The current study showed no benefit from MFX when combined with DA in the treatment of PTOA. CBMA may have helped mitigate the adverse effect of MFX but conferred no benefit when used with DA alone. DA remains a useful alternative to ankle arthrodesis and arthroplasty in patients with PTOA. However, MFX and biologic augmentation using CBMA appeared to have no additional benefit.

LEVEL OF EVIDENCE

Level III, comparative study.

Autologous Osteochondral Graft for Early Posttraumatic Arthritis of Tibiotalar Joints After Comminuted Pilon Fractures in Young Patients

BACKGROUND

Posttraumatic arthritis of tibiotalar joints after AO/OTA type C3 pilon fractures, especially in young patients with a significant osteochondral defect in the tibial plafond joint surface, is a challenging situation. We report a joint-preserving technique using autologous osteochondral graft in combination with ankle distraction and supramalleolar osteotomy (SMOT), if necessary, to improve its outcome.

METHODS

Seventeen patients with an average age of 32.1 years with Takakura grade 1 to 3A posttraumatic arthritis of the tibiotalar joint after AO/OTA type C3 pilon fractures received osteochondral autograft transplantation, ankle distraction, and SMOT, when supramalleolar malalignment was present, between February 2010 and November 2015. The visual analog scale (VAS), Short-Form 36 (SF-36) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and ankle range of motion were used for outcome analysis. Radiographic assessment of any SMOT and the apparent joint space was performed. Fourteen patients were followed for an average of 18 months.

RESULTS

The VAS, SF-36, and AOFAS scores as well as the ankle range of motion all improved significantly at the last follow-up after the surgery (P < .01). No deep surgical site infection, donor site complication, nonunion, osteochondral block loosening, or resorption was noted. No secondary arthrodesis was needed at the end of follow-up.

CONCLUSION

Autologous osteochondral graft transplantation in combination with ankle distraction and SMOT was a promising joint-preserving technique for early posttraumatic arthritis of tibiotalar joint after severe pilon fractures in young patients.

LEVEL OF EVIDENCE

Level IV, case series.

Debridement and hinged motion distraction is superior to debridement alone in patients with ankle osteoarthritis: a prospective randomized controlled trial

PURPOSE

To evaluate and compare complication rates and postoperative outcomes in patients with ankle debridement alone vs. debridement and hinged ankle distraction arthroplasty.

METHODS

A total of 50 patients with posttraumatic ankle osteoarthritis (OA) with a mean age of 40.0 ± 8.5 years were included into this prospective randomized study: 25 patients in ankle debridement alone group and 25 patients in debridement and hinged ankle distraction group. The mean follow-up was 46 ± 12 months (range 36-78 months). The clinical and radiographic outcomes were evaluated at the 6-month and 3-year follow-up using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, SF-36 quality of life score, and van Dijk OA classification. A Kaplan-Meier survival analysis was performed to calculate the 3-year and 5-year survival rates.

RESULTS

Both patient groups experienced significant pain relief, functional improvement, and improvement in quality of life postoperatively. In total, 26 major secondary procedures were performed. The overall survival rates in the debridement and ankle distraction group were 19 of 25 (74%) and 15 of 25 (59%) at 3 years and 5 years, respectively. The overall survival rates in the ankle debridement alone group were 12 of 25 (49%) and 9 of 25 (34%) at 3 years and 5 years, respectively.

CONCLUSIONS

The study demonstrated comparable postoperative functional outcome and quality of life. However, rate of postoperative revision surgery was substantially higher in ankle debridement alone group.

LEVEL OF EVIDENCE

Randomized controlled study, Level I.

Supramalleolar osteotomy with medial distraction arthroplasty for ankle osteoarthritis with talar tilt

BACKGROUND

An increased preoperative talar tilt (TT) angle was reported to be positively correlated with treatment failure after supramalleolar osteotomy (SMOT) for varus ankle osteoarthritis. Distraction arthroplasty was reported to have the ability to correct increased TT angles. The purpose of the current study was to compare the outcomes between SMOT with and without medial distraction arthroplasty (MDA) in the treatment of varus ankle osteoarthritis with increased TT angles.

METHODS

We retrospectively reviewed the functional outcomes and radiological findings of 34 patients who underwent SMOT with or without MDA for varus ankle osteoarthritis with increased TT angles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Ankle Osteoarthritis Scale (AOS) scores were used for functional evaluation. The tibial anterior surface (TAS) angle, talar tilt (TT) angle, tibial medial malleolar (TMM) angle, talocrural (TC) angle, tibial lateral surface (TLS) angle, and hindfoot alignment (HFA) angle were evaluated preoperatively and at the time of the last follow-up.

RESULTS

In the SMOT group, the AOFAS score and AOS pain and function scores were significantly improved (P < 0.01 for each) at a mean follow-up of 61 months. The TAS, TT, TC, TLS, and HFA angles were all significantly improved (P < 0.01 for each). Similarly, in the SMOT with MDA group, the AOFAS score, AOS pain and function scores, and the TAS, TT, TC, TLS, and HFA angles were all significantly improved postoperatively (P < 0.01 for each). When comparing the two groups, the postoperative TT angle was significantly smaller in the SMOT with MDA group (P = 0.023) than in the SMOT group. In addition, the failure rate of TT angle correction was significantly higher in the SMOT group (P = 0.016) than in the SMOT with MDA group.

CONCLUSION

SMOT is a promising procedure for functional improvement and malalignment correction for varus ankle osteoarthritis, even in patients with increased talar tilt. If SMOT is combined with MDA, there can be an improvement in the correction of the increased talar tilt.

LEVEL OF EVIDENCE

Level III, a retrospective comparative study.

Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis

Aim

The treatment algorithm for end-stage ankle arthritis is imperfect. Young or active patients are challenging to treat as fusion and replacement carry predictable consequences. Ankle distraction arthroplasty is a less commonly utilized surgical procedure for the treatment of osteoarthritis of the ankle. The purpose of this study was to report intermediate-term survival of ankle distraction and to identify factors associated with earlier time to failure.

Materials and methods

A single-centre, multi-surgeon cohort of 258 cases of ankle arthritis, treated with ankle distraction or ankle distraction with supramalleolar osteotomy (SMO), was identified. Patients were contacted by phone to determine the status of the ankle (natural vs fused/replaced). Data were collected through chart review. This included patient demographics, medical comorbidities, surgical procedure, and X-ray characteristics including pattern and severity. A Cox regression model was used to determine factors associated with failure during 10 years of follow-up. Risk factors were analysed as hazard ratios (HRs) and 95% confidence intervals (CIs). Time to failure was illustrated with Kaplan–Meier (KM) curves.

Results

In total, 144 cases were successfully contacted with median follow-up of 4.57 years. In total, 16.7% of ankles failed (24/144). The 5-year survival was 84% (95% CI: 78–91%). In adjusted Cox regression, female sex (HR = 2.68, p = 0.049) and avascular necrosis (AVN) of the talus (HR = 3.77, p = 0.041) were significantly associated with failure risk.

Conclusion

Avascular necrosis of the talus and male/female gender differences in survival were found to be significant. Our experience shows that ankle distraction is a valid and effective operation for the treatment of end-stage ankle arthritis.

Clinical significance

This work is clinically significant in that it demonstrates excellent intermediate-term survival data for hinged ankle distraction for treatment of osteoarthritis of the ankle. Additionally, it evaluated patient and disease characteristics allowing improved patient counselling with regard to survival longevity.

Level of evidence

IV cohort study.

How to cite this article

Greenfield S, Matta KM, McCoy TH, et al. Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis. Strategies Trauma Limb Reconstr 2019;14(2):65–71.

Management of Posttraumatic Ankle Arthritis: Literature Review

PURPOSE OF REVIEW

Trauma is the principle cause of osteoarthritis in the ankle, which is associated with significant morbidity. This review highlights the current literature for the purpose of bringing the reader up-to-date on the management of posttraumatic ankle arthritis, describing treatment efficacy, indications, contraindications, and complications.

RECENT FINDINGS

Recent studies on osteoarthritis have demonstrated variability among anatomic locations regarding the mechanisms and rates of development for posttraumatic osteoarthritis, which are attributed to newly discovered biological differences intrinsic to each joint. Regarding surgical management of posttraumatic ankle arthritis, osteochondral allograft transplantation of the talus, and supramalleolar osteotomies have demonstrated promising results. Additionally, the outpatient setting was found to be appropriate for managing pain following total ankle arthroplasty, associated with low complication rates and no readmission. Management for posttraumatic ankle arthritis is generally progressive. Initial treatment entails nonpharmacologic options with surgery reserved for posttraumatic ankle arthritis refractory to conservative treatment. Patient demographics and lifestyles should be carefully considered when formulating a management strategy, as outcomes are dependent upon the satisfaction of each set of respective criteria. Ultimately, the management of posttraumatic ankle arthritis should be individualized to satisfy the needs and desires, which are specific to each patient.

Current Advancements in Ankle Arthrodiastasis

Ankle arthrodiastasis offers an option for patients with end-stage primary or posttraumatic ankle osteoarthritis. The process allows for a joint salvage procedure as an alternative to arthrodesis or ankle implant arthroplasty. The distraction within the joint optimizes the intraarticular environment to permit equilibration of hydrostatic pressure, promoting subchondral morphoangiogenesis, and decreases subchondral sclerosis, thereby mitigating pain. This article highlights new advances and useful adjunctive procedures in this interesting approach to the management of ankle pain secondary to loss of functional joint surface.

Supramalleolar Osteotomy With Distraction Arthroplasty in Treatment of Varus Ankle Osteoarthritis With Large Talar Tilt Angle: A Case Report and Literature Review

We treated a 57-year-old female with modified Takakura stage 3B varus ankle osteoarthritis. Her preoperative talar tilt angle was 21.3°. The patient wished to avoid ankle joint arthrodesis or replacement. Therefore, medial opening wedge supramalleolar osteotomy with fibular osteotomy was used for her varus ankle osteoarthritis. Also, fixed medial distraction arthroplasty was performed to improve her talar tilt. After 3 months, the external device was removed, and the patient was allowed partial weightbearing and began full weightbearing 4 months postoperatively after the osteotomy site had reached bony union radiographically. At the 3-year follow-up visit, a radiograph showed the medial ankle joint space enlargement had been maintained. The talar tilt angle had decreased to 3.3°, and the modified Takakura stage had improved to stage 1. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score had improved from 26 points preoperatively to 85 points at 3 years postoperatively. Our findings suggested that good clinical and radiologic results can be achieved with supramalleolar osteotomy combined with distraction arthroplasty in the treatment of varus ankle osteoarthritis with a large talar tilt angle.

Orthopedic Surgical Options for Joint Cartilage Repair and Restoration

The limited natural capacity for articular cartilage to regenerate has led to a continuously broadening array of surgical interventions. Used once patients' symptoms are not relieved by nonoperative management, these share the goals of joint preservation and restoration. Techniques include bone marrow stimulation, whole-tissue transplantation, and cell-based strategies, each with its own variations. Many of these interventions are performed arthroscopically or with extended-portal techniques. Indications, operative techniques, unique benefits, and limitations are presented.

Distraction arthroplasty compared to other cartilage preservation procedures in patients with post-traumatic arthritis: a systematic review

Post-traumatic arthritis (PTA) is characterized by the deterioration of articular cartilage temporally associated with an articular injury. With a paucity of literature comparing joint preservation techniques, we performed a systematic review of the literature intending to describe and summarize the results of ankle distraction arthroplasty as it compares with studies on tibio-talar microfracture, allograft, and autograft for ankle joint preservation in the post-traumatic population under 50 years of age. Research databases were searched and abstracts screened for relevance on our topic of interest. Abstracts meeting screening criteria with high interobserver reliability underwent full-manuscript review and coding for pertinent citation, study level, treatment, and outcome variables. Outcome variables for patient-reported pain scales, validated outcome measurement tools, radiographic progression, reoperation/re-treatment rates, and complication rates were recorded. Out of 105 unique citations, 10 publications were included. The distraction arthroplasty studies had 36 out of 181 patients requiring reoperation for complications (19.9%), while other joint-preserving procedures studies had 40 out of 177 patients requiring reoperations for complications (22.6%). Clinical outcome scores at mean follow-up time ranging from 2 to 10 years between studies were similar. Reported results for a variety of cartilage preservation procedures, including distraction arthroplasty, are satisfactory and reoperation rates for complication are similar. Limitations in available data and underlying study quality affect synthesis of the results therein. While distraction arthroplasty is an option for cartilage preservation in patients with PTA of the ankle, the technique is highly specialized which may affect the external validity.

Level of evidence: III.

Technical feasibility of personalized articulating knee joint distraction for treatment of tibiofemoral osteoarthritis

BACKGROUND

Knee osteoarthritis is a highly prevalent degenerative joint disorder characterized by joint tissue damage and pain. Knee joint distraction has been introduced as a joint preserving surgical procedure to postpone knee arthroplasty. An often used standard externally fixation device for distraction poses a burden to patients due to the absence of joint flexion during the 6weeks treatment. Therefore, a personalized articulating distraction device was developed. The aim of this study was to test technical feasibility of this device.

METHODS

Based on an often applied rigid device, using equal bone pin positions and connectors, a hinge mechanism was developed consisting of a cam-following system for reproducing the complex joint-specific knee kinematics. In support, a device was developed for capturing the joint-specific sagittal plane articulation. The obtained kinematic data were translated into joint-specific cam shapes that were installed bilaterally in the hinge mechanism of the distraction device, as such providing personalized knee motion. Distraction of 5mm was performed within a range of motion of 30deg. joint flexion. Pre-clinical evaluation of the working principle was performed on human cadaveric legs and system stiffness characteristics were biomechanically evaluated.

FINDINGS

The desired range of motion was obtained and distraction was maintained under physiologically representative loading. Moreover, the joint-specific approach demonstrated tolerance of deviations from anatomical and alignment origin during initial placement of the developed distraction device.

INTERPRETATION

Articulation during knee distraction is considered technically feasible and has potential to decrease burden and improve acceptance of distraction therapy. Testing of clinical feasibility is warranted.

Supramalleolar Osteotomies

Distal tibial malalignment can result from posttraumatic malunion, physeal disturbances, congenital or metabolic diseases, and degenerative arthritis. Malalignment leads to an altered load distribution across the joint leading to early ankle joint arthritis. If a substantial part of the joint is salvageable, ankle fusion or joint replacement is not always the best option. Realignment of the distal tibia with a joint-sparing supramalleolar osteotomy is a valuable procedure in correcting deformity at the distal tibia. The goal of a supramalleolar osteotomy is to restore axial alignment. Several studies have demonstrated the successes of the osteotomy in improving function and relieving pain.

Joint Distraction in Advanced Osteoarthritis of the Ankle

BACKGROUND

Ankle joint distraction (AJD) avoids the potential complications associated with ankle fusion or total ankle replacement (TAR) in patients with advanced ankle osteoarthritis (OA). AJD could a tenable option to ankle fusion or TAR.

METHODS

A review has been performed on the role of AJD in advanced OA of the ankle. The exploration machine was MedLine. The keywords utilized were: joint distraction ankle. Three hundred and eleven articles were found. Of the above-mentioned, only 14 were chosen and analyzed because they were rigorously focused on the issue and the question of this paper.

RESULTS

The types of articles published until now have a poor level of evidence (levels III and IV). The overall number of patients managed until now by way of AJD is 249. The published mean follow-up is very variable, from 1 year to 12 years.

CONCLUSION

The rate of good outcomes ranged between 73% and 91%. The percentage of failure (final ankle arthrodesis or TAR) ranged between 6.2% and 44%. A minimum of 5.8 mm of distraction gap must be achieved. Ankle function after AJD deteriorates over time. Putting together ankle movement and distraction will result in an early and maintained profitable influence on outcome.

Ankle joint distraction arthroplasty for severe ankle arthritis

BACKGROUND

Ankle distraction arthroplasty is one option for the treatment of severe ankle arthritis in young patients. The outcomes and factors predicting success in distraction arthroplasty are poorly understood.

METHODS

From January 2011 to May 2015, 16 patients who had undergone ankle distraction arthroplasty for ankle arthritis were operated, including six males and ten females. All patients were available for analysis. The main outcome measurements included joint space on weight bearing radiographs, AOFAS-AH scores (American Orthopaedic Foot & Ankle Society ankle-hindfoot score), VAS scores and SF-36 scores.

RESULTS

All 16 patients were followed for a mean follow-up of 40.9 ± 14.7 months (range, 17-67 months). Fourteen of the 16 patients still had their native ankle joints. One patient had undergone ankle arthrodesis 1 year after the operation and one patient had converted to spontaneous ankle fusion at the 3 years follow-up postoperative. The VAS score improved from 5.9 ± 0.8 to 3.7 ± 2.2 (p = 0.0028). The mean AOFAS-AH score improved from 41.9 ± 7.2 preoperatively to 68.1 ± 20.0 postoperatively (p = 0.001). The mean SF-36 score improved from 43.1 ± 7.6 preoperatively to 62.7 ± 18.8 postoperatively (p = 0.002). A weight-bearing ankle space larger than 3 mm at 1 year following distraction is a positive predictive factor.

CONCLUSIONS

In this study, the treatment of ankle motion distraction for end stage ankle arthritis showed benefit in 9/16 (56.25%) patients at 41 months. It is a promising method for young patients with severe ankle arthritis.

Mid- to Long-term Results of Supramalleolar Osteotomy

BACKGROUND

Good clinical and radiographic short-term results have been reported for patients who underwent realignment surgery of the hindfoot for treatment of early- and mid-stage ankle osteoarthrosis (OA). However, no mid- to long-term results have been reported. The aim of this study was to gain a better insight into the indications and contraindications for realignment surgery.

METHODS

Two hundred ninety-four patients (298 ankles) underwent realignment surgery between December 1999 and June 2013. Kaplan-Meier survival analysis was performed with total ankle replacement and arthrodesis of the ankle joint as endpoints. A Cox proportional hazards model was performed to identify risk factors for failure. The mean time to follow-up was 5.0 ± 3.7 years.

RESULTS

The overall 5-year survival rate was 88%. Thirty-eight patients (12.9%) underwent either secondary total ankle replacement or ankle arthrodesis (30 total ankle replacements, 8 ankle arthrodesis). Risk factors for failure following realignment surgery were age at the time of surgery and a Takakura score of 3b preoperatively.

CONCLUSION

Realignment surgery of the hindfoot was an excellent treatment option for young and physically active patients with early to mid-stage ankle OA.

LEVEL OF EVIDENCE

Level IV, prospective observational study.

Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes

Ankle distraction is an alternative to ankle arthrodesis or total ankle arthroplasty in younger patients with arthritis. Ankle distraction involves the use of external fixation to mechanically unload the ankle joint, which allows for stable, congruent range of motion in the setting of decreased mechanical loading, potentially promoting cartilage repair. Adjunct surgical procedures are frequently done to address lower-extremity malalignment, ankle equinus contractures, and impinging tibiotalar osteophytes. Patients can bear full weight during the treatment course. The distraction frame frequently uses a hinge, and patients are encouraged to do daily range-of-motion exercises. Although the initial goal of the procedure is to delay arthrodesis, many patients achieve lasting clinical benefits, obviating the need for total ankle arthroplasty or fusion. Complications associated with external fixation are common, and patients should be counseled that clinical improvements occur slowly and often are not achieved until at least 1 year after frame removal.

Functional analysis of distraction arthroplasty in the treatment of ankle osteoarthritis

Background

Ankle joint distraction arthroplasty (AJDA) is an alternative surgical procedure for the management of moderate to severe ankle osteoarthritis. However, the benefit of this procedure and failure relative factors are still in debate. The purpose of the current study was to evaluate the functional outcomes of AJDA in treatment of moderate to severe ankle OA and to evaluate the relative factors correlated with treatment failure.

Methods

Forty-six van Dijk stages II and III ankle osteoarthritis patients were included. Fifteen males and 31 females with a mean age of 54.8 (range, 42–71) years were followed with a mean of 42.8 (range, 24–68) months. The Ankle Osteoarthritis Scale (AOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used for functional outcome evaluation. The talar tilt (TT) angle and ankle joint space distance (AJSD) were evaluated. The risk ratio (RR) was calculated for each potential failure relative factor.

Results

The AOS and AOFAS scores were significantly improved at the last follow-up time (P < 0.01). The AJSD was improved in 61% of patients and with a significant improvement compared with the preoperative conditions (P < 0.01). The TT angle and range of motion reached no significant difference. The failure rate was 21.7%. Patients with large TT (≥5°) angle (RR = 3.81, 95% CI 1.28–11.33, P = 0.02) and obesity (RR = 3.58, 95% CI 1.30–9.89, P = 0.01) were found to have positive correlation with failure. No correlation was found between failure and gender, or overweight, or side, or age, or type and stage of OA, or pin infection.

Conclusions

The current study confirmed the early functional outcomes of ankle distraction arthroplasty. However, this procedure still has a relatively high failure rate, especially for those obese patients and patients with large TT angles.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-017-0519-x) contains supplementary material, which is available to authorized users.

Joint distraction for thumb carpometacarpal osteoarthritis: a feasibility study with 1-year follow-up

OBJECTIVE

The purpose of this pilot study was to evaluate the feasibility of joint distraction of the first carpometacarpal (CMC1) joint in patients with CMC1 osteoarthritis (OA).

METHODS

An external joint distractor was placed over the CMC1 joint by K-wire fixation in the trapezium and the metacarpal. The joint was distracted 3 mm during surgery. The device was then kept in place for 8 weeks. Disabilities of the Arm, Shoulder, and Hand (DASH) score, Michigan Hand Outcome Questionnaire (MHQ), Visual Analogue Scale (VAS), and grip strength were recorded preoperatively and at set postoperative intervals.

RESULTS

Five female patients with an average age of 53 years (range = 41-61) were included. One year postoperatively, average DASH, MHQ, and VAS scores improved compared to preoperative values; DASH 53 to 27, MHQ 48 to 76, and VAS pain 48 to 14. There were no technical problems associated with the device. One patient had a local pin site infection treated successfully with oral antibiotics.

CONCLUSIONS

This study concludes that joint distraction of the osteoarthritic CMC1 joint is technically feasible. In this small, prospective pilot study the majority of the results were favourable during short-term follow-up.

Supramalleolar Osteotomies for the Treatment of Ankle Arthritis

Supramalleolar osteotomy is a joint-preserving surgical treatment for patients with asymmetric valgus or varus ankle arthritis. The primary goal of the procedure is to realign the spatial relationship between the talus and tibia and thereby normalize joint loading within the ankle. Procedures to balance the soft tissues, as well as hindfoot osteotomy and arthrodesis, may also be necessary. Clinical studies of supramalleolar osteotomy demonstrate that correction of the altered biomechanics associated with asymmetric arthritis improves functional outcomes.