Ankle fusion continues to be a predictable treatment for degenerative tibiotalar arthritis. It improves both pain and function from primary osteoarthritis and degeneration related to chronic instability or trauma. JBJS has published several recent studies demonstrating that the outcomes of fusion compare favorably with those of total ankle replacement, particularly in higher-demand patients. (See, for example, Effectiveness and Safety of Ankle Arthrodesis Versus Arthroplasty and Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis.)
Many clinicians have wondered why outcomes after ankle arthrodesis are typically so much better than those after arthrodesis of other mobile joints. In the April 1, 2020 issue of The Journal, Lenz et al. provide an answer. Using dual fluoroscopy integrated with 3-D CT, the authors compared the subtalar motion of the surgically fused ankle in 10 patients with the motion of the untreated, asymptomatic side. The findings strongly suggest that compensatory increased plantar flexion of the subtalar joint allows improved function following successful arthrodesis. The authors found that this increased motion occurred during both normal plantigrade ambulation and bilateral heel raises.
Clinicians can use this important information to explain to patients who are deciding between ankle arthrodesis and arthroplasty how fusion can not only improve pain, but can also result in good functional range of motion. On the other hand, the authors surmise that the compensatory increase in subtalar joint plantar flexion may explain the reported increased risk of future subtalar osteoarthritis in surgically fused ankles. However, to answer that question, we’ll need larger, longitudinal clinical studies that evaluate the relationship between the compensatory post-fusion subtalar kinematics discovered by Lenz et al. and radiographic findings and patient-reported pain and function.
Marc Swiontkowski, MD
Many foot and ankle surgeons would relish a simple measurement made from a readily available imaging modality to help detect whether patients with adult acquired flatfoot deformity (AAFD) are at high risk for progressive collapse—and to help them with surgical planning. According to the findings from a case-control study by de Cesar Netto et al. in the October 16, 2019 issue of The Journal of Bone & Joint Surgery, that wish may soon be realized.
The authors made standing, weight-bearing computed tomography (CT) scans of 30 patients with stage-II AAFD (mean age of 57.4 years) and 30 matched controls (mean age of 51.8 years). From those images, 2 fellowship-trained surgeons, who were blinded regarding the patient cohorts, measured the amount of subluxation (percentage of uncoverage) and the incongruence angle of the middle facet of the subtalar joint in the coronal plane. The authors found substantial to almost perfect intraobserver and interobserver reliability for both measurements.
Based on these middle-facet measurements, the mean value for joint uncoverage in patients with AAFD was 45.3% compared with 4.8% in controls. Similarly, the mean incongruence angle in the AAFD group was 17.3° in the AAFD group and 0.3° in controls. Further analysis led the authors to conclude that “an incongruence angle of >8.4° and an uncoverage percentage of 17.9% were found to be highly diagnostic for symptomatic stage-II AAFD.”
De Cesar Netto et al. say the biomechanics of the subtalar joint made focusing on the middle facet a sensible approach, and they attributed the high reliability of the measurements to the relatively simple anatomy of the middle facet. Still, because clinical outcomes were not assessed in this study, the role of the middle facet as a marker of peritalar subluxation and a tool for deformity correction in AAFD patients needs further investigation in prospective, longitudinal studies.