Ankle Arthritis

Introduction

Primary osteoarthritis of ankle is rare. The common causes of secondary arthritis in the ankle include previous fractures of the ankle or the talus, long-term ligament instability, previous infection, inflammatory arthritis, AVN of the talus and Charcot joint.

For symptomatic patients, non-surgical treatments include lifestyle and activity modifications, reducing high-impact activities, maintaining an appropriate weight for age and height, a stiff rocker bottom walking boot and NSAIDs.

Surgical options in mild to moderate cases include ankle arthroscopy and debridement, which has been shown to minimize pain, swelling and stiffness in the short-term (90% good to excellent results at 2-years).

For end-stage arthritis, the definitive surgical options include ankle arthrodesis and arthroplasty.

In the UK, approximately 29000 patients seek advice for symptoms of ankle arthritis annually and around 300 of these opt for surgical intervention. The final treatment choice of the treatment is based on the information provided by the treating surgeon regarding pros and cons of each option, surgeon's experience, patient's activity level and medical co-morbidities. However there is lack of quality evidence to correctly guide the patient in this regard.

 

​COFAS Classification​

The Canadian Orthopaedic Foot and Ankle Society (COFAS) classification system for end-stage ankle arthritis.

Type 1 - isolated ankle arthritis
 
Type 2 - ankle arthritis with intra-articular varus or valgus deformity or a tight heel cord, or both
   
Type 3 - ankle arthritis with  hindfoot deformity, tibial malunion, midfoot ab- or adductus, supinated midfoot,  plantarflexed first ray
 
Type 4 - types 1-3  plus subtalar, calcaneocuboid or talonavicular arthritis

 

Surgical Treatment

Ankle Arthrodesis

Ankle arthrodesis has traditionally been considered the 'gold-standard' choice for ankle arthritis. The indications, in addition to end-stage arthritis, also include neurological deformities, revision of a failed ankle arthroplasty and failed ORIF.

The goals of surgery are to achieve a pain-free plantigrade foot and improve the functions of daily living. The optimal position for fusion is neutral dorsiflexion, 5° external rotation and 5° valgus. Arthrodesis in plantarflexion will lead to genu-recurvatum and in varus will lead to lateral border overload and hindfoot pain.

Arthrodesis can be performed arthroscopically or by open technique. By either technique, the aim is to remove all the residual articular cartilage, create flat surfaces and achieve flat surfaces. This can be done by using shavers, burrs or curette arthroscopically, and by saw, osteotomes or sharp chisels in open procedures.

​

Arthroscopic arthrodesis

​Arthroscopic option is reserved for minimal or no deformity (less than 15°), and for patients at higher risks of wound related complications (immune-compromised, diabetics). Usually performed through anterior approach, however, posterior approach is also practiced and has provided comparable union rates in a study by Nickish et al.. Once the surfaces are prepared, usually 6.5mm cannulated screws are used for fixation.

​Winson et al. reviewed 118 arthroscopically fused ankles and reported 92% union rates. Gougoulis et al. reviewed 78 ankles reporting 97% union rates. Yin et al. reported 100% union rates in 68 patients. Various other studies with number of patients ranging from 10-55 have reported union rates 0f 70-100%. The average union rate is considered to be 94%.

​

Open arthrodesis

​Open arthrodesis is preferred for moderate to severe deformities. Common approaches are anterior (b/w EHL and Tib. Ant.) and lateral (transfibular), however, posterior, medial and combined approaches are also used. Once the surfaces are prepared, the options of fixation include 6.5mm cannulated screws (2 or 3, crossed or parallel, conventional or headless), arthrodesis plates (anterior, posterior, lateral) or a combination of the two. Clifford et al. described the combination of a compression screw and plate to be the strongest construct biomechanically. In cases of complex deformities or poor skin quality, an external fixation can also be used, however the union rates are inferior to internal fixation.

​Colman et al. reported in 48 and Smith et al. in 25 open ankle fusions reported 96% union rates in their studies. Various other studies have reported 64-100% union rates with varying number of patients, but the average union rate is considered to be 89%.

​There are 4 studies which directly compare arthroscopic and open techniques (Myerson et al, O'Brian et al., Nielson et al., Townsend et al.). The combined average union rates were reported to be 91% after arthroscopic fusion and 89% after open fusion. Functional outcomes were slightly better in arthroscopic fusions.

​There is insufficient evidence to report the incidence of adjacent joint disease OA after ankle fusion. Ling et al. suggested that it was difficult to establish whether pre-existing OA in the adjacent joints got worse or ankle fusion lead to OA in these joints.

​Jeng et al and Schwienbacher et al. in similar studies, assessed the ability to drive after ankle fusion. They used a driver simulator and reported that the brake reaction time was reduced in individuals with ankle fusion but it was still within the safe braking time criteria.

​Bilateral ankle fusion are also in practice but very rarely performed with sound indications. There are very few studies reporting their outcomes. Houdek et al. in reported 31 patients over a period of 30 years, with an average f/u of 11 years, an average age of 57 years, and showed significant improvement in functional scores and development of adjacent joint disease in most of these patients.

​Vaughan et al. reported 8 patients with an average f/u of 5 years, average age of 68 years and 7 patients being satisfied with both ankles being fused. Swedish registry reports 35 patients with an average f/u of 52 months and 91% satisfaction rates after bilateral ankle fusions.

​

Ankle Arthroplasty

​Initial results using the STAR prosthesis has a 5-year survival rate of 78% and 90% in two different studies, whilst another recent study has shown metal component survival of 73% at 15 years follow-up (24 of 84 patients available for final follow-up). 

The Salto prosthesis has been reported to have an 85% survival rate at 10 years.  The Hintegra prosthesis in 722 ankles (684 patients) has been reported to show implant survival of 94% and 84% at 5 and 10 years respectively. 

Meta-analyses of several implants reported a 90% survival rate at 5 years, and a 73% - 89% survival rate at 10 years, with a wide variability between different implants and centers, and an annual failure rate of around 1.5%.

​The main complications of ankle arthroplasty include infection, wound related problems, malleolar fracture, nerve injury, malpositioning, gutter pain, stiffness, subsidence, aseptic loosening, edge-loading, implant failure, bearing fracture/dislocation and CRPS.

​Clough et al reviewed the complication rate in a consecutive series of 278 TARs (251 patients) over a period of six years (184 Mobility, 87 Zenith and seven Salto implants) with a mean follow-up of 7 years. They reported the following complications: intraoperative malleolar fracture; medial 9.7%, lateral 1.4%, early postoperative fracture (<4 months) 1.4%, late fracture (>4 months) 3.5%, wound healing problems 3.2%, superficial infection 7.2%, deep infection 2.2%, aseptic loosening and osteolysis 5.8%, edge-loading 2.5%, gutter pain 11%, stiffness 1.8%, soft tissue injuries 1.8% and thromboembolic episode of 0.7%.

Clough et al, in another recent study, published the long-term results of a large cohort of patients with STAR implants. They reported an implant survival rate of 76.16% in a consecutive series of 200 implants out of which 87 implants (84 patients) were still alive, at an average follow-up of 15.8 years. Although STAR implants have largely been superseded by the newer implants design (Infinity), but these results act as a benchmark for this widely used implant in the previous years.

Infinity TAR is used in approximately 60% ankle replacements according to the last published NJR report in the UK. Some early results have started to emerge in the literature. King et al reported on 20 Infinity implants with no implant requiring revision at a minimum of 2-years follow-up. They reported satisfactory functional results with significantly improved alignment with the use of intraoperative image intensifier use. Penner et al presented the results of 67 Infinity implants and reported an implant survival of 97% at an average of 35.4 months. In contrast, Cody et al reported on 159 Infinity implants with an average follow-up of 20 months, and reported a revision rate of 10% (16 implants). The primary reasons for revision were aseptic loosening of tibial component and deep infection. Like any other implant, the long-term results (when available in future) with larger number of implants will reveal the accurate results of this new design of TAR.

​

TAR vs Arthrodesis

​TARVA trial (Total Ankle Replacement versus Arthrodesis) is the 1st randomised controlled trial currently being performed in the UK, and is an attempt to find the relevant answers by comparing the outcomes of these two treatments. It is a multicentre, non-blinded trial across the targeted 16 centres in the UK and aims to recruit 164 patients in each group between the ages of 50 to 85 years.

Currently available studies comparing ankle arthroplasty versus arthrodesis are observational and there are no published guidelines as to the most appropriate management.​

​A meta-analysis of the literature by Haddad et al. showed similar intermediate-term outcomes after TAR and arthrodesis in terms of clinical scores, patient satisfaction and revision rate. Both have been shown to improve quality of life at 1 year but with no difference between the two operations. Implant survival rates were 78% at 5 years and 77% at 10 years.

Another study, which was population based, showed a higher risk of major revision surgery after ankle replacement, but higher risk of adjacent-joint fusion with ankle arthrodesis.

​Numerous studies have recently attempted to analyse the hindfoot movements after TAR. Flavin et al. prospectively compared patients who underwent ankle replacement with those who underwent ankle arthrodesis to study changes in gait parameters pre-operatively and post-operatively. Patients who underwent TAR had higher walking velocity, more normal first and second rockers of the gait cycle as well as improved sagittal dorsiflexion.

Cenni et al. studied patients who had undergone TAR looking at the overall function of the whole locomotor apparatus. Patients had an overall improvement in global function although their replaced ankles had their own limitations.

Raikin et al., in their study, showed that patients undergoing TAR maintained a statistically significant greater arc of motion compared with patients who underwent arthrodesis (34.2° compared with 24.3°; p < 0.001). The movement in the arthrodesis group resulted from compensatory hypermobility at the adjacent midfoot articulations. As a result, the mean movement across the midfoot was more normally maintained in patients undergoing TAR.

​A level III study comparing 12250 ankle fusions with 3002 ankle replacements over a period of 10 years showed similar incidence of perioperative medical complications and length of stay in the two groups, however ankle replacement was associated with higher cost.

​A systematic review with meta-analysis demonstrated an excellent mean AOFAS score in 38% and 31% of patients who underwent arthroplasty and arthrodesis of the ankle, respectively.

​Saltzman et al performed a level II prospective, nonrandomized, 2-phase comparison of ankle arthrodesis and Scandinavian Total Ankle Replacement (STAR) with a minimum 2-year follow-up. In the first phase, major complications and need for secondary procedures were more common (P = .045) in the arthroplasty group (8.9%) compared to the arthrodesis group (1.5%). However, functional outcomes were superior in the arthroplasty group, while pain outcomes were equivalent between the two groups. In the second phase of the same trial, major complication rate decreased to 5.3% in the arthroplasty group. However, the difference was not significant.

​

References

  • Goldberg AJ, Zaidi R, Thomson C, et al. Total ankle replacement versus arthrodesis (TARVA): protocol for a multicentre randomised controlled trial. BMJ Open 2016;6:e012716. doi:10.1136/bmjopen-2016- 012716.
  • Zaidi R, Pfeil M, Macgregor AJ, et al. How do patients with end-stage ankle arthritis decide between two surgical treatments? A qualitative study. BMJ Open 2013;3:e002782.
  • Haddad SL, Coetzee JC, Estok R, et al. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis.A systematic review of the literature. J Bone Jt Surg Am 2007;89:1899–905.
  • Slobogean GP, Younger A, Apostle KL, et al. Preference-based quality of life of end-stage ankle arthritis treated with arthroplasty or arthrodesis. Foot Ankle Int 2010;31:563–6.
  • SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Jt Surg Am 2007;89:2143–9.
  • D. I. Pedowitz, J. M. Kane,G. M. Smith, H. L. Saffel, C. Comer, S. M. Raikin Total ankle arthroplasty versus ankle arthrodesis; a comparative analysis of arc of movement and functional outcomes; Bone Joint J 2016;98-B:634–40.
  • Flavin R, Coleman SC, Tenenbaum S, Brodsky JW. Comparison of gait after total ankle arthroplasty and ankle arthrodesis. Foot Ankle Int 2013;34:1340–1348.
  • Cenni F, Leardini A, Pieri M, et al. Functional performance of a total ankle replace- ment: thorough assessment by combining gait and fluoroscopic analyses. Clin Bio- mech (Bristol, Avon) 2013;28:79–87.
  • McHenry BD, Exten EL, Long J, et al. Sagittal subtalar and talocrural joint assess- ment with weight-bearing fluoroscopy during barefoot ambulation. Foot Ankle Int 2015;36:430–435.
  • S.L. Haddad, MD, J.C. Coetzee, MD, R. Estok, RN, BSN, K. Fahrbach, PhD, D. Banel, BA, and L. Nalysnyk, MD, MPH; Intermediate and Long-Term Outcomes of Total Ankle Arthroplasty and Ankle Arthrodesis A Systematic Review of the Literature; J Bone Joint Surg Am. 2007;89:1899-905; doi:10.2106/JBJS.F.01149.
  • Saltzman et al. Prospective Controlled Trial of STAR Total Ankle Replacement Versus Ankle Fusion: Initial Results; Foot & Ankle International; doi: 10.3113/FAI.2009.0579.
  • Glazebrook et al. Evidence-based classification of complications in total ankle arthroplasty, Foot and Ankle International, 2009, 30 (10): 945-949.
  • Winson IG, Robinson DE, Allen PE. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br 2005; 87: 343-347 [PMID:15773643 DOI: 10.1302/0301-620X.87B3.15756].
  • Townshend D, Di Silvestro M, Krause F, Penner M, Younger A, Glazebrook M, Wing K. Arthroscopic versus open ankle arthrodesis: a multicenter comparative case series. J Bone Joint Surg Am 2013; 95: 98-102 [PMID: 23235956 DOI: 10.2106/JBJS. K.01240.
  • O'Brien TS, Hart TS, Shereff MJ, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis: a comparative study. Foot Ankle Int 1999; 20: 368-374 [PMID: 10395339 DOI: 10.1177/107110079902000605].
  • Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop Relat Res 1991; (268): 84-95 [PMID: 2060232].
  • Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul P, Femino JE, Amendola A. Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Joint Surg Am 2012; 94: 439-446 [PMID: 22398738 DOI: 10.2106/JBJS.K.00069].
  • Clifford C, Berg S, McCann K, Hutchinson B. A biomechanical comparison of internal fixation techniques for ankle arthrodesis. J Foot Ankle Surg 2015; 54: 188-191 [PMID: 25116232 DOI: 10.1053/j.jfas.2014.06.002].
  • Smith R, Wood PL. Arthrodesis of the ankle in the presence of a large deformity in the coronal plane. J Bone Joint Surg Br 2007; 89: 615-619 [PMID: 17540746 DOI: 10.1302/0301-620X.89B5.18109].
  • Colman AB, Pomeroy GC. Transfibular ankle arthrodesis with rigid internal fixation: an assessment of outcome. Foot Ankle Int 2007; 28: 303-307 [PMID: 17371653 DOI: 10.3113/FAI.2007.0303].
  • Gougoulias NE, Agathangelidis FG, Parsons SW. Arthroscopic ankle arthrodesis. Foot Ankle Int 2007; 28: 695-706 [PMID:17592700 DOI: 10.3113/FAI.2007.0695].
  • Ling JS, Smyth NA, Fraser EJ, Hogan MV, Seaworth CM, Ross KA, Kennedy JG. Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review. J Bone Joint Surg Am 2015; 97: 513-520 [PMID: 25788309 DOI: 10.2106/JBJS.N.00426].
  • Schwienbacher S, Aghayev E, Hofmann UK, Jordan M, Marmotti A, Röder C, Ipach I. Driving and emergency braking may be impaired after tibiotalar joint arthrodesis: conclusions after a case series. Int Orthop 2015; 39: 1335-1341 [PMID: 25947900 DOI: 10.1007/s00264-015-2789-4].
  • Jeng CL, Lin JS, Amoyal K, Campbell J, Myerson MS. Driving brake reaction time following right ankle arthrodesis. Foot Ankle Int 2011; 32: 896-899 [PMID: 22097166 DOI: 10.3113/FAI.2011.0896].
  • Yasui Y, Vig KS, Murawski CD, Desai P, Savage-Elliott I, Kennedy JG. Open Versus Arthroscopic Ankle Arthrodesis: A Comparison of Subsequent Procedures in a Large Database. J Foot Ankle Surg 2016; 55: 777-781 [PMID: 27067198 DOI: 10.1053/j.jfas.2016.03.007].
  • Wood PL, Deakin S. Total ankle replacement. The results in 200 ankles. J Bone Joint Surg Br. 2003;85(3):334-41.
  • Maffulli N, Longo UG, Locher J, Romeo G, Salvatore G, Denaro V. Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status. Br Med Bull. 2017;124(1):91-112.
  • Palanca A, Mann RA, Mann JA, Haskell A. Scandinavian Total Ankle Replacement: 15-Year Follow-up. Foot Ankle Int. 2018;39(2):135-42.
  • Krause et al. Foot Ankle Int 2010;31:103-108
  • T. Clough, F. ALvi, H. Majeed, Total ankle arthroplasty: what are the risks? A Guide to Surgical Consent and a Review of the Literature, Bone Joint J 2018;100-B:1352–8.
  • T. Clough, K. Bodo, H. Majeed, J. Davenport, M. Karski, Survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants, Bone Joint J  2019;101-B:47–54.
  • Penner, M., Hodges Davis, W., Wing, K., Bemenderfer, T., Waly, F., & Anderson, R. B. (2018). The Infinity Total Ankle System: Early Clinical Results With 2- to 4-Year Follow-up. Foot & Ankle Specialist.
  • Cody, E. A., Taylor, M. A., Nunley, J. A., Parekh, S. G., & DeOrio, J. K. (2019). Increased Early Revision Rate With the INFINITY Total Ankle Prosthesis. Foot & Ankle International, 40(1), 9–17.
  • Andrew King, Navjit Bali, Al-Amin Kassam, Adrian Hughes, Nicholas Talbot, Ian Sharpe, Early outcomes and radiographic alignment of the Infinity total ankle replacement with a minimum of two year follow-up data, Foot and Ankle Surgery, Available online 22 November 2018.