SLR - August 2018 - Viraj Rathnayake

Total Ankle Arthroplasty Versus Ankle Arthrodesis: A Comparison of Outcomes Over the Last Decade

Lawton C, Butler B, Dekker R, Prescott A, Kadakia A. Total Ankle Arthroplasty Versus Ankle Arthrodesis: A Comparison of Outcomes Over the Last Decade. Journal of Orthopaedic Surgery and Research. 2017 12:76

Scientific Literature Review

Reviewed By: Viraj Rathnayake, DPM
Residency Program: Westside Regional Medical Center, Plantation FL

Podiatric Relevance: Tibotalar joint end-stage arthritis can cause functional debilitation, episodic tenderness and overall decreased quality of life. There has been an increase in use of total ankle implants due to the increase in the quality of products. Although ankle arthrodesis is considered to be the gold standard of treatment for end-stage arthritis in the tibiotalar joint, there has been controversy on whether ankle replacement would provide better outcomes and patient satisfaction. This article compared six studies reporting outcomes on total ankle arthroplasty (TAR) and five studies reporting on ankle arthrodesis (AA). The authors reviewed outcomes and pooled data analysis to demonstrate the difference between the two modalities of treatment and to elicit any advantages from one over the other.

Methods: A level three study was performed from a review of the PubMed database between January 2006 and July 2016 using the keywords of “ankle arthritis,” “tibiotalar,” “ankle arthroplasty” and “ankle arthrodesis.” Inclusion criteria for the total ankle arthroplasty study selection were a minimum of 200 ankles reporting on complications, reoperation and/or revision data and exclusion criteria being studies published before January 2006, abstracts, review articles and surgical technique articles, not reporting primary research outcomes, and use of implants other than HINTEGRA, STAR, Salto and INBONE. The AA study selection inclusion criteria were a minimum of 80 ankles with reports on complications, reoperation and/or revision data, with exclusion criteria being similar to the TAR except articles reporting only on restricted patient cohorts and studies reporting solely on fusion accomplished by external fixation or revision ankle arthrodesis. The TAR vs. AA study selection inclusion was similar to the other two study selections except there was no minimum cutoff for number of ankles or data reported, and exclusion criteria were similar except for no studies reporting on revision TAA or AA.  

Data was collected and analyzed with inclusion of demographic information, adjusted means, complications, nonrevision reoperations, revisions and adjusted rate of complications.

Results: For the TAR study selection, there were total of six studies (five studies prospective and one retrospective study) with 682 INBONE, 455 STAR, 380 Salto and 722 HINTEGRA ankles. There were five studies for the AA study selection with 577 ankles through open approach and 58 ankles through arthroscopic approach. The most frequent complications in the TAR group were aseptic loosening (5.8 percent), wound complications (5.4 percent), fracture (4.9 percent) and deep infection (0.9 percent). In the AA group, the most frequent complications were wound complications (9.8 percent), nonunion (7.9 percent), deep infection (3.6 percent) and fracture (0.8 percent). The pooled mean nonrevision reoperation rate was higher in AA (12.9 percent) vs. TAR (9.5 percent), and revision rate was higher in TAR (7.9 percent) vs. AA (5.4 percent). Ten studies were included in the TAR vs. AA with three studies prospective and seven retrospective. Two studies reported no significant difference between TAR and AA cohorts, and five studies found better gait analysis outcomes after TAR than AA.  

Conclusion: Over the past several years, the improved design and surgical techniques of AA and TAR have improved outcomes with both procedures. The majority of the studies in circulation focus on outcomes from outdated techniques and older-generation TAR implants, which this study helped refocus. Currently, though, there is a lack of high-quality randomized controlled trials comparing the two treatment modalities with current techniques/implants. There were limitations in this study, such as lack of randomized controlled trails, existing studies having clinical heterogeneity making comparison difficult and inconsistent reporting of outcomes, complications and revisions, as well as length of follow-up. Overall, until further data is available demonstrating any advantage between the two treatment modalities, current treatment is largely patient- and surgeon-dependent.

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