SLR - August 2021 - Monica Jung

Management of Ankle Arthritis After Severe Ankle Trauma

Reference: Coetzee C, McGaver R, Seiffert K, Giveans R. Management of Ankle Arthritis After Severe Ankle Trauma. J Orthop Trauma. 2020 Feb;34(1):s26-s31. doi: 0.1097/BOT.0000000000001697

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Monica Jung, DPM
Residency Program: Kaiser North Bay Consortium - Vallejo, CA 

Podiatric Relevance: The most common cause of ankle arthritis is trauma. Managing ankle arthritis after severe ankle trauma poses different challenges in comparison to primary ankle arthritis due to the degree of soft tissue scarring, the existence of previous hardware, and compromised vascularity and bone stock. In this study, the authors aimed to investigate the best treatment for severe ankle arthritis in patients undergoing an ankle fusion for post-traumatic arthritis (PTA), total ankle arthroplasty (TAA) for PTA, and TAA for primary osteoarthritis (OA) as measured by the Veterans Rand 12-Item Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), Visual Analog Pain Scale (VAS), the American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS), and a patient satisfaction survey.

Methods: Starting in May 2008, a retrospective review of patients who presented to a single surgeon at a single institution with severe ankle arthritis due to PTA or OA was performed. All patients participated in outcome studies and completed outcome surveys at every visit, and three groups of patients were examined. Group 1 included ankle fusion using the anterior approach with anterior plating for PTA, Group 2 included TAA for ankle PTA, and Group 3 included TAA for OA. One hundred consecutive surgeries in each of the three groups were compared for their results in outcomes and complications. Patients with significant vascular compromise, insulin dependent diabetes, neuromuscular disorders, or previous ankle infections were excluded. Outcome scores were collected preoperatively and postoperatively at three months, six months and annually. 

Results: One hundred surgeries in each of the three groups were compared. The AOS, VAS, VR-12 and AOFAS improved significantly after all three surgeries (P < 0.001). The TAA-PTA group had the greatest pre to post-operative pain change from 68.5 to 20.2. and disability scores improved significantly (P < 0.001) after all 3 surgeries. Again, the results of the patient satisfaction survey showed that 63 percent of TAA-PTA patients felt their results to be “very good to excellent” in regards to pain reduction, in comparison to the 26 percent and 55 percent of the fusion, and TAA-OA respectively.

Conclusions: This study demonstrates that TAA following post-traumatic arthritis results in the greatest improvement in quality of life with an overall satisfaction of 92.5 percent compared to 84 percent of the fusion group. All scores of the three groups improved from pre-operative to the latest post-operative outcomes, but the TAA following post-traumatic arthritis consistently resulted in the best postoperative outcomes. This study is relevant as choosing between a fusion and a total ankle in the correct patient may often times be a difficult decision based on a variety of factors including patient comorbidities, activity, ankle joint alignment, and the soft tissue envelope. The statistically significant improvement in patient outcomes following a TAA serves as a helpful tool for moving forward with a TAA versus an ankle fusion in patients with indications for both options. 

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