‘So, if my client does not respond to non-operative measures, what are the surgical options thereafter for post-traumatic arthritis of the ankle? What are the chances of success?’ A perfectly reasonable question from a legal perspective, but complex to answer!
Surgery in PTA can be divided into procedures that conserve the native joint (such as supra-malleolar osteotomy, autologous chondrocyte implantation (ACI), debridement, & joint distraction) and those that eliminate the painful native joint by arthrodesis or arthroplasty.
The majority of ankle arthritis is post-traumatic, but many publications do not state the precise make-up of the series they describe. In some series the inclusion of neurological cases can be seen to reduce the overall functional results. It is very useful to clarify for yourself whether it is a PTA series or whether there is an identifiable PTA sub-group. Otherwise differences in outcome between one study and the next can be due to differences in the make up of the series (patient selection).
Some useful reviews of the management of ankle arthritis have been published:
Martin, Stewart, & Conti, ’Posttraumatic Ankle Arthritis: An Update on Conservative and Surgical Management’. Journal of Orthopaedic & Sports Physical Therapy | volume 37 | number 5 | may 2007 | 253-259. These authors suggest that micro fracture and autologous chondrocyte implantation (ACI) are more appropriate for small osteochondral lesions of the talus. As they point out, arthroscopic washout and debridement does not change the pathological process and is likely to have only a temporary benefit. With the physiotherapy perspective, the rehabilitation gets better coverage than in other reviews.
Ewalefo et al, ‘Management of Posttraumatic Ankle Arthritis: Literature Review’. Current Reviews in Musculoskeletal Medicine (2018) 11:546–557 https://doi.org/10.1007/s12178-018-9525-9. Arthroscopic debridement & microfracture held to be helpful in small talar lesions (less than 1.5cm). ACI thought to be helpful, despite high failure and re-operation rates, particularly in older individuals. Joint distraction noted to be helpful in a number of series, but stringent follow-up and meticulous regimes of care required. Supramalleolar osteotomy is felt to be indicated where varus or valgus OA is present with at least 50% preservation of tibio-talar articular cartilage. Comment: I feel that the number of occasions where this might be appropriate is small. This review has an extensive reference list (120) of mostly 21st century papers.
Vu Le et al, ‘Ankle Arthritis’, Foot & Ankle Orthopaedics, 2019, Vol. 4(3) 1-16. There is better coverage of minimally invasive procedures in this review. In addition, the place of joint-sparing techniques of debridement, re-alignment osteotomies, and joint distraction are reviewed. These are seen as more appropriate in earlier disease and in younger patients.
Procedures that conserve the native joint.
Marijnissen et al, ‘Clinical Benefit of Joint Distraction in the Treatment of Severe Osteoarthritis of the Ankle. Proof of Concept in an Open Prospective Study and in a Randomized Controlled Study’. ARTHRITIS & RHEUMATISM Vol. 46, No. 11, November 2002, pp 2893–2902. DOI 10.1002/art.10612.
n= 57. Severe ankle arthritis, otherwise to be considered for arthrodesis. Significant benefit was found in three-fourths. Improvement appeared to increase with time (!) The randomized controlled trial element only contained 17 patients. Follow-up was short overall. Comment: I am wary of reading too much into this study.
Nguyen et al, J Bone Joint Surg Am. 2015;97:590-6 d http://dx.doi.org/10.2106/JBJS.N.00901. ‘Intermediate-Term Follow-up After Ankle Distraction for Treatment of End-Stage Osteoarthritis’. These authors found that the benefits of joint distraction deteriorated with time:
‘Twenty-nine patients (81%) were followed for a minimum of five years (mean and standard deviation, 8.3 ± 2.2 years). Sixteen (55%) of the twenty-nine patients still had the native ankle joint whereas thirteen patients (45%) had undergone either ankle arthrodesis or total ankle arthroplasty. Positive predictors of ankle survival included a better AOS score at two years (hazard ratio [HR] = 0.048, 95% confidence interval [CI] = 0.0028 to 0.84, p = 0.04), older age at surgery (HR = 0.91, 95% CI = 0.83 to 0.99, p = 0.04), and fixed distraction (HR = 0.094, 95% CI = 0.017 to 0.525, p <
0.01). Radiographs and advanced imaging revealed progression of ankle osteoarthritis at the time of final follow-up.
Conclusions: Ankle function following joint distraction declines over time.’
Comment: This is a worthwhile paper that has longer follow-up than most. My impression is that joint distraction may buy some more time for some individuals, but the investment of time-in-treatment is significant & eats into the time gained by the procedure. Perhaps joint distraction might be better employed before the ‘end-stage’ is reached?
Herrera-Perez et al, Knee Surgery, Sports Traumatology, Arthroscopy
https://doi.org/10.1007/s00167-018-5156-3. ‘Debridement and hinged motion distraction is superior to debridement alone in patients with ankle osteoarthritis: a prospective randomized controlled trial’.
50 patients with PTA randomized into debridement -v- debridement plus hinged distraction. Follow-up 46 months (36-78 months). These cases were Grade 2 or less, sub(total) disappearance or deformation of joint space (end-stage PTA) was excluded.
‘…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, the rate of postoperative revision surgery was substantially higher in the ankle debridement alone group’.
Comment: The results of debridement + joint distraction seem to be better than debridement alone, if performed before the end-stage. More than half lasted 5 years.
Greenfield et al, ‘Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis’. Strategies in Trauma and Limb Reconstruction (2019): 10.5005/jp-journals-10080-1429. n=144 contacted out of 258. As well as distraction, adjunctive procedures were performed such as supra-malleolar osteotomy, microfracture, & removal of osteophytes. At 5 years 84% survived, at 10 years, about 60%. There appears to be a gender difference. 5 year survival of the native joint in men was 88%, in women 80%. Results were worse if talar AVN was present.
Comment: These seem to be encouraging results, with relatively long follow-up. The multiplicity of techniques employed, and the change of techniques during the series, makes it difficult to be sure which techniques contributed most to the results. The significant drop out of 114 cases out of 258 does raise question marks about the general applicability of these results.
Procedures that sacrifice the native joint: Arthrodesis (fusion).
The historical results of ankle arthrodesis left considerable scope for improvement:
In 1980, Davis & Millis reported a long-term retrospective study,’Ankle Arthrodesis in the Management of Traumatic Ankle Arthrosis: A Long-term Retrospective Study’. (Journal of Trauma-Injury Infection & Critical Care).
Their abstract:
‘A retrospective study was carried out of 48 patients who underwent ankle arthrodesis for traumatic arthritis from January 1967 through January 1976. Following ankle fusion, the most common complaint was subtalar pain and the most frequent finding was limitation of subtalar motion (56%). Subtalar or triple arthrodesis was required in 12 patients, with good results in the majority of the cases. An infection rate of 22% was encountered, felt to be consequent to the failure to properly employ prophylactic antibiotics; which, when employed, were associated with less than 6% incidence of sepsis. 69% of patients were improved from their status before ankle arthrodesis; 12% had come to below-knee amputation (three for resistant pain, two for chronic osteomyelitis, and one for vascular insufficiency). Fusion of the subtalar joint seems curative, and early mobilization of the subtalar joint by ankle fusion techniques that do not immobilize the entire foot may play a preventive role.‘
The long-term results of ankle arthrodesis were reported by Boobbyer (Acta Orthop. Scand. 52, 107-110, 1981). 23 were cases of post-traumatic arthritis, where the latency between injury and arthrodesis was 2 months to 50 years. Poor results were recorded in 11/37 at 1-17 years (average 8) follow-up. The incidence of union was 78%. 3 amputations were performed, though only 1 of these came from the PTA group.
In 1986, Hagen report the results of 21 compression ankle arthrodeses in Clinical Orthopaedics & Related Research, Number 202, January 1986, 152-162. 11 patients (65%) obtained a sound arthrodesis, of whom 3 developed subtalar pain. There were 6 nonunions. There were 2 subsequent amputations (~10%).
In 1990, Helm reported the results of ankle arthrodesis in 47 ankles of 44 patients. ‘The results of ankle arthrodesis’. J Bone Joint Surg [Br] 1990; 72-B: 141-3. Infection occurred in 19%, nonunion in 14.9% and malposition requiring re-operation in 8.5%. 3 patients (6%) required amputation. He felt varus/valgus influenced the results more than the degree of plantar/dorsiflexion. The reasons for the arthrodesis were not given, but most ankle OA follows trauma.
Perlman & Thordarson (Foot & Ankle International August 1999, vol 20, no8, 491-496) reported on ankle fusion in a high risk population. n=88, 67 had adequate follow-up records. 85% had PTA. 19/67 progressed to nonunion. Among 17 patients with open trauma, 9 developed non-union (p=0.03). A trend for nonunion was noted for patients who smoked, drank alcohol, used illegal drugs, had diabetes, or had a psychiatric disorder.
Coester et al, J Bone Joint Surg Am, 2001 Feb;83(2):219-219. http://dx.doi.org/ published ‘Long-Term Results Following Ankle Arthrodesis for Post-Traumatic Arthritis’. n= 23; follow-up 12-44 years (mean 22). They concluded: ‘At a mean of twenty-two years, the majority of the patients had substantial, and accelerated, arthritic changes in the ipsilateral foot but not the knee. They were often limited functionally by foot pain. Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction’.
Fuchs et al, J Bone Joint Surg [Br] 2003;85-B:994-8, published ‘Quality of life 20 years after arthrodesis of the ankle – a study of adjacent joints’. n=18 arthrodesis in 17 patients. Follow up 20-33 years, mean 23 years. They found:
‘Subjectively, 50% of patients were not handicapped
in the performance of daily activities and 44% were in
the same job as at the time of injury. At follow-up the
mean Olerud Molander Ankle (OMA) score was 59.4 points, the visual analogue scale was 1.99 and the radiological score was 2.7. The
SF-36 for physical function, emotional disturbance and bodily pain revealed significant deficits. There was a significant correlation between the OMA and the radiological score (p = 0.05), and between the clinical and the SF-36 score (p = 0.01), but no significant correlation between the radiological score and the SF-36 score.
Arthrodesis of the ankle leads to deficits in the functional outcome, to limitations in the activities of daily living and to radiological changes in the adjoining joints. The clinical outcome score correlates closely with
the SF-36 score.’
Comment:
- Only ankle arthrodesis is considered here, but in clinical practice various combinations of arthrodesis have to be considered when other joints are also involved in the damage, commonly the subtalar joint. These other types of arthrodesis combinations will be considered in a later post.
- The deficits and limitations mentioned in Fuchs paper have to be seen in the context of the deficits and limitations of alternative methods of management. Very few publications allow any such comparison to be made, but here is one:
Haddad et al, J Bone Joint Surg Am. 2007;89:1899-905 • doi:10.2106/JBJS.F.01149. ‘Intermediate and Long-Term Outcomes of Total Ankle Arthroplasty and Ankle Arthrodesis –
A Systematic Review of the Literature.’ These authors studied papers that met their criteria. There were 10 evaluating total ankle arthroplasty (second generation implants), (n= 852), and 39 which evaluated ankle arthrodesis (n= 1262). They found:
‘The mean AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale score was 78.2 points (95% confidence interval, 71.9 to 84.5) for the patients treated with total ankle arthroplasty and 75.6 points (95% confidence interval, 71.6 to 79.6) for those treated with arthrodesis.
Meta-analytic mean results showed 38% of the patients treated with total ankle arthroplasty (TAA) had an excellent result, 30.5% had a good result, 5.5% had a fair result, and 24% had a poor result.
The five-year implant survival rate was 78% (95% confidence interval, 69.0% to 87.6%) and the ten-year survival rate was 77% (95% confidence interval, 63.3% to 90.8%). The revision rate following total ankle arthroplasty was 7% (95% confidence interval, 3.5% to 10.9%) with the primary reason for the revisions being loosening and/or subsidence (28%).
In the arthrodesis group, the corresponding values were 31% excellent, 37% good, 13% fair, and 13% poor.
The revision rate following ankle arthrodesis was 9% (95% confidence interval, 5.5% to 11.6%), with the main reason for the revisions being nonunion. One percent of the patients who had undergone total ankle arthroplasty required a below-the-knee amputation compared with 5% in the ankle arthrodesis group.
Comment: Many of these series were not randomized prospective trials, although some were; some were retrospective, and some were uncontrolled case series. Some selection bias is therefore to be expected. The difference in amputation rate may be as a result of patient selection, or differences in length of follow-up. The main concern about TAA in young patients is durability of the implant in the long term, and late secondary surgery with uncertain outcome; correspondingly the main concern for arthrodesis is the durability of the other joints of the foot.
Procedures that sacrifice the native joint: Arthroplasty (replacement).
Bolton-Maggs et al, J Bone Joint Surg [Br] 1985, Vol 65-B, No5, November, 785-790. The results of early ankle arthroplasty were not encouraging. The London Hospital retrospective long-term results of ankle arthroplasty were reported in 1985. n=65, follow-up averaged 5.5 years. Only 13 were considered satisfactory. 13 had been removed, and arthrodesis attempted. Because of poor results with arthroplasty, they recommended arthrodesis for painful stiff arthritic ankles.
Thankfully over subsequent years the results of TAA have improved.
Bai et al compared the results in patients with osteoarthritis and post-traumatic arthritis, where the HINTEGRA prosthesis had been used. (‘Total ankle arthroplasty outcome comparison for post-traumatic and primary osteoarthritis’. Bai et al, Foot & Ankle International, Vol 31, No. 12, 1048-1056, December 2010). The incidence of complications (38% in PTA, 27% in OA) and additional procedures (54% in PTA, 27% in OA) was significantly higher in PTA (p = 0.014 for complications, p = 0.013 for additional procedures).
They concluded:
‘The clinical and radiographic outcomes of total ankle arthroplasty for post-traumatic and primary osteoarthritis were comparable, although the incidence of complications after total ankle arthroplasty was higher in the post-traumatic osteoarthritis group. More preceding or concomitant surgeries were required in order to make the posttraumatic cases suitable for total ankle arthroplasty.’