Letter regarding article by Hyun Jung Kim et al.: Total ankle arthroplasty versus ankle arthrodesis for the treatment of end-stage ankle arthritis: a meta-analysis of comparative studies

The controversy in surgical management of end-stage tibiotalar arthritis with Total Ankle Arthroplasty (TAA) versus Ankle Arthrodesis (AA) has grown in parallel with the evolution of both procedures. No randomized controlled trials exist due to the vast differences in surgical goals, patient expectations, and complication profiles between the two procedures. This makes high quality systematic reviews necessary to compare outcomes between these two treatment options. The aim of this study was to provide a systematic review with meta-analysis of publications reporting outcomes, complications, and revision data following third-generation TAA and/or modern AA published in the past decade. Thirtyfive articles met eligibility criteria, which included 4312 TAA and 1091 AA procedures. This review reports data from a mean follow-up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort. There was no significant difference in overall complication rate following TAA compared to AA (23.6% and 25.7% respectively, P-value 0.31). Similarly, there was no significant difference in revision rate following TAA compared to AA (7.2% and 6.3% respectively, P-value 0.65). Successful treatment of end-stage tibiotalar arthritis requires an understanding of a patients’ goals and expectations, coupled with appropriate patient selection for the chosen procedure. The decision to proceed with TAA or AA should be made on a case-by-case basis following an informed discussion with the patient regarding the different goals and complication profiles for each procedure.

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Evaluation of Clinical Effect of Ankle Arthrodesis and Total Ankle Arthroplasty for End-stage Ankle Arthritis

Clinical Research on Foot & Ankle ◽

10.4172/2329-910x.1000129 ◽

2014 ◽

Vol 02 (02) ◽

Author(s):

Yu Xiaobing, Zhao

Keyword(s):

Clinical Effect ◽

Ankle Arthrodesis ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Ankle Arthroplasty ◽

End Stage

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Conversion of Ankle Fusions to Ankle Replacements

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00515 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0051

Author(s):

Stephen White ◽

Bruce Cohen ◽

Carroll Jones ◽

Michael Le ◽

W. Hodges Davis

Keyword(s):

Ankle Arthrodesis ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Ankle Arthroplasty ◽

Patient Reported ◽

Fusion Site ◽

Foot Function ◽

Patient Related Outcome ◽

Improved Function

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis remains a prominent treatment choice for ankle arthritis in a majority of patients. Long term studies have shown a compensatory development of ipsilateral adjacent joint arthritis after ankle arthrodesis, and some patients who receive an ankle arthrodesis develop pain in surrounding joints, or even at the fusion site. As total ankle arthroplasty (TAA) design, instrumentation, and techniques have improved, the use of total ankle arthroplasty has become more widespread. Very few studies have been published on conversion of ankle arthrodesis to ankle arthroplasty, but they have shown improved function and patient-related outcome scores. The purpose of this study was to assess the radiographic, clinical, and patient-reported outcomes of patients undergoing ankle arthroplasty after conversion from a CT-confirmed ankle arthrodesis. Methods: This was a retrospective cohort study of patients with previous CT-confirmed ankle arthrodesis who underwent conversion to total ankle arthroplasty. Minimum follow up was 1 year. Nonunions of ankle arthrodesis were excluded. AOFAS ankle-hindfoot score, foot function index (FFI), pain, revision surgeries, complications, and patient demographics were assessed. Radiographs prior to TAA, and at latest follow-up were also reviewed. Results: 10 patients were included in the study with an average age of 54.5 years. No implants had to be revised. 1/10 (10%) patients had to undergo secondary surgery for heterotopic ossification removal. The same patient had to undergo another subsequent surgery for posterior ankle decompression. 2/10 (20%) patients had a mild talar subsidence of the TAA at latest follow-up, with no patients having tibial subsidence. Talar osteolysis was noticed in 2 patients (20%) at latest follow-up, with no patients having tibial osteolysis. Only one patient (10%) was noted to have a mild valgus alignment of TAA with no varus malalignments. All radiographic changes noted were clinically asymptomatic. The average AOFAS total score was 58 (range 23,89). The mean FFI total score was 41.9 (range 0,90). Conclusion: Conversion of ankle fusion to TAA is a challenging operation but can be a viable option for patients with ongoing pain after an ankle arthrodesis. We noted low revision rates and few complications at 1 year.

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The Impact of Concomitant Ipsilateral Knee Pain on Functional Outcomes in Total Ankle Arthroplasty

Foot & Ankle Specialist ◽

10.1177/1938640020950893 ◽

2020 ◽

pp. 193864002095089

Author(s):

Michael J. Symes ◽

Alastair Younger ◽

Mario Escudero ◽

Murray J. Penner ◽

Kevin Wing ◽

...

Keyword(s):

Outcome Measures ◽

Knee Pain ◽

Functional Outcomes ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Pain Group ◽

Ankle Arthroplasty ◽

End Stage ◽

The Impact ◽

Disease Specific

In end-stage ankle arthritis, little is known about the impact of concomitant knee pathology, including the impact of ipsilateral knee pain on total ankle arthroplasty (TAA) outcomes. The aim of this study was to determine the prevalence of ipsilateral preoperative knee pain in patients undergoing TAA and analyze its impact on patient-reported functional outcome measures (PROMs). A retrospective review was performed on the Vancouver End Stage Ankle Arthritis Database at a single institution. In total, 114 patients were studied, with patient demographics collected preoperatively, including the presence or absence of knee pain. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs, including the Ankle Osteoarthritis Score (AOS) and Ankle Arthritis Score (AAS). Multivariate mixed-effects linear regression models compared the scores between the groups. In total, 31 patients (27.2%) presented with concomitant ipsilateral knee pain. Despite more females in the knee pain group (64.5% vs 36.1%) there were no other significant differences at baseline between the knee pain and no knee pain groups in terms of demographics or baseline primary disease specific PROMs. At 5 years, the patients with knee pain had significantly worse AAS (37.9 ± 23.8 vs 21.2 ± 16.3, P = .004) and AOS total scores (38.1 ± 24.1 vs 21.9 ± 15.5, P = .005) compared with the no-knee pain group. Both groups improved significantly from baseline across all outcome measures; however, the magnitude of improvement was less in the knee pain group. Our study demonstrated that over one-quarter of patients with end-stage ankle arthritis undergoing TAA present with ipsilateral concomitant knee pain. If present, it is associated with worse functional outcomes at the 5-year mark. Further studies are needed to evaluate if knee pain influences complications, implant failure rates, and survival. Levels of Evidence: Level III

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Quality of Modern Total Ankle Arthroplasty Research

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00160 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0016

Author(s):

Daniel Bohl ◽

Emily Vafek ◽

Simon Lee ◽

Johnny Lin ◽

George Holmes ◽

...

Keyword(s):

Cohort Studies ◽

Case Reports ◽

Case Series ◽

The United States ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Level Of Evidence ◽

Ankle Arthroplasty ◽

End Stage

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is gaining popularity as an alternative to ankle arthrodesis in the setting of end-stage ankle arthritis. However, compared to hip and knee arthroplasty, there is a relative dearth of evidence to support its use. This study assesses the quality of literature surrounding modern TAA designs. Methods: A search of all peer-reviewed, English-language journals was conducted to identify publications involving TAA. The initial search identified 444 articles published during 2006-2016. Of these, 182 were excluded because they were not clinical outcomes studies, 46 because the TAA implant was no longer available, and 15 because the primary outcome of the study was not related to TAA, leaving 201 articles for analysis. Results: No Level I studies were identified. Seventeen (8%) studies were Level II, 48 (24%) Level III, 128 (64%) Level IV, and 8 (4%) Level V. One hundred forty-three studies (71%) were retrospective in nature. Stratification by study design revealed 128 (64%) case series, 33 (16%) experimental cohort studies, 19 (10%) case-control studies, 13 (6%) observational cohort studies, and 8 (4%) case reports. The number of studies published each year steadily increased from 2006 to 2016. A total of 51% of TAA research was published in only two journals: Foot and Ankle International and the Journal of Bone and Joint Surgery. Publications from the United States accounted for 36% of total publications. The most published implant was the Scandinavian Total Ankle Replacement (Figure 1). Conclusion: While the number of TAA studies published each year has steadily increased since 2006, the quality of this research as measured by level of evidence remains suboptimal. This analysis highlights the need for continued improvement in methodology and development of robust prospective registries to advance our knowledge of TAA as a treatment for end-stage ankle arthritis.

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A Survey for End-Stage Ankle Arthritis Treatment: Ankle Arthrodesis Versus Ankle Arthroplasty

The Journal of Foot & Ankle Surgery ◽

10.1053/j.jfas.2019.09.007 ◽

2020 ◽

Vol 59 (2) ◽

pp. 330-336 ◽

Cited By ~ 3

Author(s):

Kerry Tai ◽

Christopher Vannabouathong ◽

Sohail M. Mulla ◽

Christina L. Goldstein ◽

Christopher Smith ◽

...

Keyword(s):

Ankle Arthrodesis ◽

Ankle Arthritis ◽

Ankle Arthroplasty ◽

End Stage

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Population-based Projections of Ankle Arthrodeses

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00231 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0023

Author(s):

Christopher Gross ◽

Justin Rabinowitz ◽

Elizabeth Durante

Keyword(s):

Age Groups ◽

Ankle Arthrodesis ◽

Total Ankle Arthroplasty ◽

Utilization Rate ◽

Future Trends ◽

United States Census ◽

Ankle Arthritis ◽

United States Census Bureau ◽

Projection Model ◽

Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis is commonly performed for patients with end stage ankle arthritis. However, with improvements in long-term outcomes following total ankle arthroplasty it is possible that rates of ankle arthrodesis will decrease as utilization of ankle arthroplasty increases. The purpose of this study is to assess the current and future trends of ankle arthrodesis utilization. Methods: National Inpatient Sample (NIS) data from 1997-2014 was used to identify trends in the utilization of ankle arthrodesis. United States Census Bureau data from 1997-2014 was used to identify historical population data and future population estimates. A linear regression model was created using Mathematica v11.3 to project future demand for ankle arthrodesis. The data was stratified to show past and future trends based on gender and age. Results: The overall utilization rate of ankle arthrodesis remained relatively constant from 5897 procedures in 1997 to 5330 procedures in 2014. The overall demand for ankle arthrodesis is expected to increase slightly by 15 percent with 6141 procedures projected in 2045. Stratified by age groups, the number of procedures is predicted to decrease by 75% in ages 18-44 and 6% in ages 45-64, and predicted to increase by 133% in ages 65-84 by 2045. Stratified by gender, ankle arthrodesis is predicted to increase by 47% in males and decrease by 14% in females in 2045. Conclusion: Based on our projection model, the rate of ankle arthrodesis is predicted to stay relatively stable overall but decrease in younger populations. A projected increase in total ankle arthroplasty will likely contribute to decreased utilization of ankle arthrodesis. However, ankle arthrodesis will still be a valuable tool in the surgeon’s armamentarium to treat ankle arthritis.

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Total ankle arthroplasty and ankle arthrodesis affect the biomechanics of the inner foot differently

Scientific Reports ◽

10.1038/s41598-019-50091-6 ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

Yan Wang ◽

Duo Wai-chi Wong ◽

Qitao Tan ◽

Zengyong Li ◽

Ming Zhang

Keyword(s):

Contact Pressure ◽

Stance Phase ◽

Peak Stress ◽

Ankle Arthrodesis ◽

Total Ankle Arthroplasty ◽

Ankle Arthroplasty ◽

Plantar Pressure Distribution ◽

Metatarsal Bones ◽

Biomechanical Parameters ◽

End Stage

Abstract Ankle arthrodesis and total ankle arthroplasty are the two primary surgeries for treatment of end-stage degenerative ankle arthritis. The biomechanical effects of them on the inner foot are insufficient to identify which is superior. This study compared biomechanical parameters among a foot treated by ankle arthrodesis, a foot treated by total ankle arthroplasty, and an intact foot using computational analysis. Validated finite element models of the three feet were developed and used to simulate the stance phase of gait. The results showed total ankle arthroplasty provides a more stable plantar pressure distribution than ankle arthrodesis. The highest contact pressure, 3.17 MPa, occurred in the medial cuneonavicular joint in the total ankle arthroplasty foot. Neither of the surgeries resulted in contact pressure increase in the subtalar joint. The peak stress in the metatarsal bones was increased in both surgical models, especially the second and third metatarsals. This study enables us to get visual to the biomechanics inside of an intact foot, and feet treated by total ankle arthroplasty and ankle arthrodesis during walking.

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