Literature Update: Options for Treating Ankle Arthritis

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher E. Gross, MD, in response to the May 18, 2016 JBJS Specialty Update on Foot and Ankle Surgery.

Ankle arthritis occurs along a spectrum of severity—ranging from minor cartilage lesions to significant degenerative disease.

To preserve ankle function and to prevent possible evolution into arthritic changes, osteochondral lesions should be treated as soon as they become symptomatic. In one prospective cohort study summarized by Lin and Yeranosian in the May 18, 2016 JBJS Specialty Update, thirty patients with talar osteochondral lesions underwent arthroscopic implantation of bone marrow-derived cells onto a collagen scaffold.  Patients who received adjunctive biophysical stimulation by pulsed electromagnetic fields (PEMFs) had higher AOFAS scores at one year post-operatively than those who did not.¹ The proposed explanation for this outcome is that PEMFs decrease inflammatory cytokines and help differentiate stem cells into chondrocytes.

Total ankle replacements (TARs) have become a viable surgical option for patients with end-stage ankle arthritis. In a study comparing patients undergoing TAR with those undergoing  arthrodesis,²  TAR patients had higher expectations of their surgery than fusion patients and were more likely to have higher satisfaction scores post-operatively.  In a functional comparison of TAR and arthrodesis, Jastifer, et al. found that patients who received a TAR had an easier time walking uphill and down/upstairs.³  In another study evaluating functional biomechanics following TAR surgery, groups whose procedure included Achilles tendon lengthening were compared to those who had TAR alone.⁴  There were no between-group differences in functional outcomes or gait mechanics.

In a study comparing results and complications of TAR in patients with rheumatoid arthritis to patients who had ankle replacements due to either traumatic or primary arthritis, the authors found similar functional outcomes and complication rates.

Despite these many examples of TAR success in the recent literature, the procedure is not without its shortcomings. Rahm, et al.⁵ compared patients who underwent primary ankle fusion to those who underwent salvage ankle arthrodesis because of a failed TAR.  Those who had a salvage procedure had more pain and decreased functionality compared to those who underwent a primary fusion.

Christopher E. Gross, MD is an orthopaedic surgeon specializing in foot and ankle disorders at the Medical University of South Carolina in Charleston.

References

1. Cadossi M, Buda RE, Ramponi L, Sambri A, Natali S, Giannini S. Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study. Foot Ankle Int. 2014 Oct;35(10):981-7.
2. Younger AS, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, et al. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
3. Jastifer J, Coughlin MJ, Hirose C. Performance of total ankle arthroplasty and ankle arthrodesis on uneven surfaces, stairs, and inclines: a prospective study. Foot Ankle Int. 2015 Jan;36(1):11-7.
4. Queen RM, Grier AJ, Butler RJ, Nunley JA, Easley ME, Adams SB, Jr., et al. The influence of concomitant triceps surae lengthening at the time of total ankle arthroplasty on postoperative outcomes. Foot Ankle Int. 2014 Sep;35(9):863-70.
5. Rahm S, Klammer G, Benninger E, Gerber F, Farshad M, Espinosa N. Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis. Foot Ankle Int. 2015 Apr;36(4):349-59.