SLR - July 2014 - Nick Dang

Intermediate-Term Results of Total Ankle Replacement and Ankle Arthrodesis 

Reference: Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-Term Results of Total Ankle Replacement and Ankle Arthrodesis. J Bone Joint Surg Am. 2014 Jan 15; 96(2):135-42.

Scientific Literature Review
 
Reviewed By: Nick Dang, DPM
Residency Program: Franciscan Health System/St Francis Hospital
 
Podiatric Relevance: For a select group of patients with end-stage arthritis, total ankle replacement is slowly becoming an acceptable alternative to ankle arthrodesis. Although fusion remains the gold standard, ankle replacement is often preferred by patients because they maintain partial motion at the ankle joint. Ankle arthrodesis versus ankle replacement continues to be a topic of debate in the field of podiatry. The reviewed study hypothesized that patient-reported clinical outcomes would be similar for both procedures.
 
Methods: This prospective cohort study included 388 ankles, of which 281 were treated with ankle replacement and 107 were treated with ankle arthrodesis. The surgeries were performed by six subspecialty trained orthopaedic surgeons at four centers between 2001 and 2007. Procedure selection was reached by consensus between surgeon and patient. Ankle arthrodesis was performed either arthroscopically or open, without a standard approach in joint preparation. Ankle replacement was performed using one of four prostheses including the Agility, STAR, Mobility and HINTEGRA according to manufacturers’ recommendations. Patient assessments were completed by the orthopaedic surgeon preoperatively, at one year following surgery and annually after. Clinical outcomes were recorded using the Foot and Ankle Follow-up Questionnaire, which includes the AOS and SF-36.
 
Results: Of the ankles included in this study, 83 percent were evaluated at a mean follow-up of 5.5 years. Eight major complications occurred in the arthrodesis group, with one amputation. Sixty major complications were observed in the ankle replacement group, which included four amputations. Seven (7 percent) of the arthrodesis ankles and forty-eight (17 percent) of the ankle replacements underwent revision. The AOS total, pain, and disability scores and SF-36 Physical Component Summary scores all improved between baseline and final follow-up assessment. Changes in the SF-36 Mental Component Summary scores were minimal. The AOS total score improved from a mean of 53.4 to 33.6 (19.5) for the arthrodesis group and from 51.9 to 26.4 (25.7) in the ankle replacement group. After adjustments for baseline characteristics and surgeon, differences in AOS and SF-36 scores between ankle replacement and ankle arthrodesis were minimal.

Conclusions: The authors concluded that in a diverse cohort, both procedures produced acceptable results in the intermediate-term for end-stage arthritis. Even with the revision patients in the ankle replacement group included, the patient-reported clinical outcomes were comparable in both groups. However, the rates of major complications and surgical revision were higher in the ankle replacement group. Foot and ankle surgeons should be cognizant of the development of current total ankle implants and be prepared to deal with its postoperative complications.  

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