SLR - June 2015 - Kendra Anderson

Investigating the Relationship Between Ankle Arthrodesis and Adjacent-Joint Arthritis in the Hindfoot

Reference: Ling JS, Smyth JA, Fraser EJ, Hogan MV, Seaworth CM, Ross KA, Kennedy JG. Investigating the Relationship between Ankle Arthrodesis and Adjacent-Joint Arthritis in the Hindfoot. J Bone Joint Surg Am. 2015 March 18; 97(6): 513-20.

Scientific Literature Review

Reviewed By: Kendra Anderson, DPM
Residency Program: Southern Arizona VA Health Systems

Podiatric Relevance: The question of how to best treat ankle arthritis is a common debate especially with the continued advancement of total ankle replacement. For years ankle arthrodesis was the most reliable option, but due to concerns and support from early studies of development of arthritis in the adjacent joints, ankle replacement systems were aggressively developed. Recently, these earlier studies have been called into question. The argument being that often those patients requiring ankle arthrodesis will have arthritis in the surrounding joints before the surgery and an arthrodesis does not create significant arthritis in adjacent joints.

Methods: A literature search was performed using multiple terms on the PubMed/Medline and Embase electronic databases from 1974 to January 2013 and references were reviewed.  The inclusion criteria were as follows: published in, assess the clinical or biomechanical outcomes, included biomechanical and gait analyses performed with multi-segment foot model, evaluation of radiographic appearance of the midfoot and rearfoot joints, publication in peer reviewed journal, and evaluation of prevalence of arthritis in the adjacent joints following ankle arthrodesis. Exclusions included exclusive focus on inflammatory arthritis as etiology for ankle arthritis.  The information from the relevant articles was recorded on a data sheet to record relevant extracted data.

Results: Twenty-four studies were determined eligible for inclusion. One multi-segment gait analysis study found significant decrease in hindfoot and forefoot motion in all planes and all phases of gait. Five biomechanical studies studied motion and pressure changes after arthrodesis. These studies found changes in pressure to the plantar foot but only when on an incline were these pressures significant. It was also found that the range of motion of the foot decreased in all three planes but the motion was improved with plantarflexion and dorsiflexion of the foot in cadavers. Of the studies providing information on the range of motion of adjacent joints there were no conclusive findings. Some found an increase in motion, others found a decrease in motion, and one found variable motion. It was found that the subtalar joint was most likely to have arthritis followed by talonavicular then the calcaneocuboid. One study found that after an average of 23 years most patients had moderate to severe restriction in subtalar joint range of motion and half of the patients had swelling in the hindfoot/midfoot. Another study found four years post arthrodesis only 10.4 percent of patients had progression of adjacent joint arthritis. More recent publications have found that most patients undergoing an arthrodesis had subtalar joint arthritis before surgery. Despite the high prevalence of subtalar joint arthritis only 34 percent had the arthritis progress. Even in the studies where arthritis developed in the adjacent joints on radiograph it was not always clinically significant but the studies provided conflicting findings. Of the two studies with the longest follow up, one found that there were significant findings for pain and arthritis while the other found no clinical correlation between radiographs and functional ankle score. Of the studies that included 675 patients, only 12 required subsequent arthrodesis of adjacent joints.

Conclusions: The previous assumption of ankle arthrodesis leading to arthritis in the surrounding joints is not as straight forward as once originally thought. Some patients have arthritis in the adjacent joints but have no further issues after ankle arthrodesis while others develop clinically significant adjacent joint arthritis. Further study with prospective studies with analysis of pre-ankle arthrodesis adjacent joints and the development/progression of the arthritis are needed to aid in answering the question of how the ankle arthrodesis affects the adjacent joints.

Educational Opportunities