Patients seeking treatment for symptoms of ankle arthrosis are seen routinely in the practice of orthopaedic surgery. The signs and symptoms are well known to all orthopaedic surgeons. Unlike the other major joints of the lower extremity, primary or idiopathic osteoarthrosis of the ankle joint is relatively rare.37 Arthrosis of the ankle is associated most frequently with trauma to the ankle joint and the surrounding bony and ligamentous structures.3,29-31 As with arthrosis elsewhere in the body, other causes include congenital deformities, collagen vascular diseases, osteonecrosis, infections, neoplasms, prior surgery, and any other condition that compromises the alignment and function of the joint.
For patients presenting with symptomatic ankle arthrosis, initial treatment is aimed at relieving symptoms and includes rest (change of activities) and nonsteroidal anti-inflammatory drugs. A cane, ankle braces, intraarticular injections, and shoes with a rocker bottom sole all have been shown to reduce symptoms and increase activity tolerance. When patients present with evidence of instability and complaints of weakness and giving way, physical therapy for muscle strengthening and proprioceptive training can be beneficial. In more severe cases, custom ankle foot orthoses, either of the molded polypropylene type or metal double upright types, are useful for decreasing symptoms and increasing endurance.37,38 For even more severe cases, for which full weightbearing is painful, a patella tendon bearing ankle foot orthosis can be used for joint immobilization and to reduce weightbearing forces across the ankle joint. In less severe cases, when pain is present mainly on push off, a less restrictive device to limit pain is an ankle foot orthosis with a dorsiflexion stop and a shoe with a stiff rocker bottom sole.36 Heel lifts to limit dorsiflexion and impingement of anterior osteophytes also have been shown to be effective.19,37,39 Casting can be used to calm the inflamed ankle and to show the effects of immobilization of an ankle foot orthosis or eventual ankle arthrodesis.33,38
In patients with severe rheumatoid arthritis, cast immobilization may result in a spontaneous fusion. In general, for patients with rheumatoid arthritis, radiologic changes in the ankle appear relatively late in the disease and do not correlate well with clinical function. Although radiographs may show significant loss of articular cartilage, there may be only minimal complaints of pain or discomfort. The ankle joint usually becomes symptomatic with the development of a varus or valgus deformity and bone loss.33 Besides pain control, conservative bracing measures should be aimed at preventing deformity or limiting its progression.
In general, surgical intervention is reserved for patients whose conservative measures have failed. One possible exception to this axiom is the patient with a posttraumatic malunion of the ankle. Rather than waiting for the symptoms to worsen during conservative management, early reconstruction of the malunited ankle fracture has been shown to be effective in alleviating symptoms and halting progression of the joint deterioration.24,34,35,41
Although arthrodesis of the ankle generally is considered to be the most reliable procedure for the treatment of severe ankle arthrosis, it is not the only surgical option available and may not be the first surgical procedure of choice. Because of the permanent loss of ankle motion, occasional difficulty in achieving a fusion, and the potential for postoperative complications, ankle arthrodesis should be considered a salvage procedure to be used when other more conservative surgical measures have failed or are not deemed appropriate. Other, less aggressive, surgical options include: synovectomies, debridement of impinging osteophytes and loose bodies, and bone and ligament reconstruction with corrective osteotomies and internal fixation of malunited and ununited fragments. These lesser procedures may not be as durable or predicable in alleviating symptoms, but can preserve or restore function. Because of limited long term success, total ankle arthroplasty is not recommended routinely and is not covered here.
For patients with rheumatoid arthritis and synovitis of the ankle, synovectomy can be a joint preserving technique.33 When there are minimal erosions of the weightbearing areas, synovectomy is a useful procedure especially in the presence of bulky synovitis. After debridement of the synovium, either open or arthroscopically, the joint is immobilized in a compressive dressing. Early range of motion (ROM) exercises are initiated when the swelling has subsided.9,33
In many patients with mild to moderate arthrosis of the ankle, impinging bone spurs and synovitis can be the predominant sources of pain.19,37,38 Impinging exostoses that are seen in athletes or dancers may represent an early stage of arthrosis or may be a separate entity that may lead to arthrosis.19,37 For these patients, the pain is located in the anterior aspect of the ankle and is induced by forced dorsiflexion as with deep knee bends or when landing from a jump. Patients may have persistent symptoms or only have symptoms during the extremes of motion and after prolonged activity. In the normal ankle, the anterior tibial margin does not impinge on the neck of the talus, and the tibial and talar articular surfaces remain congruent. With impingement of the talar neck and the anterior margin of the tibia with dorsiflexion, the posterior portion of the ankle joint widens and the articular surfaces are no longer parallel and congruent. This places increased stress on the anterior articular surfaces with the potential for increased wear. Anterior tibiotalar impingement consists of anterior tibiotalar contact and posterior ankle joint widening.19 If the origin of the pain is unclear, injection of a local anesthetic around the suspicious osteophyte may help confirm the diagnosis.37
For patients who do not respond to conservative measures, surgical treatment for anterior tibiotalar impingement consists of debridement of impinging osteophytes off the leading edge of the tibia and the talar neck, excision of hypertrophic synovium and scar tissue, and removal of loose bodies from the anterior ankle. Debridement has been shown to be effective in reducing symptoms of impingement.19,37-39 Exostoses are removed from the tibia until the normal curve is restored. The joint may be debrided with anterolateral and/or anteromedial arthrotomies or arthroscopically. A direct correlation with the severity or size of the osteophytes and the time to recovery after debridement has been shown.39
Ankle fractures treated open or closed with inadequate reduction or loss of reduction often become symptomatic. Pain is secondary to increased loads on the articular surfaces of the ankle or subtalar joints from malposition, impingement, or nonunion. The end result of malalignment is shifting of the talus in the mortise with the loss of joint congruency and cartilage wear. Many authors recommend ankle joint reconstruction for patients with malunited ankle fractures.24,34,35,41 Roberts et al34 stated that when fibular shortening was present, ankle reconstruction could be achieved by fibular lengthening and could provide an alternative to early arthrodesis.
For detecting malunited lateral malleolar fractures, which are not always obvious, Weber and Simpson41 described three characteristics of the sprung mortise as seen on the mortise view radiograph:(1) A joint space that is no longer strictly parallel, particularly on the medial side where there is widening proportional to the degree of lateral shift of the talus; (2) a broken Shenton's line of the ankle. The dense subchondral bone contour is interrupted at the syndesmotic space because the small spike of the fibula lies more proximal as a result of shortening; and (3) a broken curve between the lateral part of the articular surface of the talus and the recess in the distal fibula because of fibular shortening.
Rosen35 stated that if the joint changes are not severe and the patient is younger than 50 to 60 years of age, fibular reconstruction should be considered to try to prevent the progression of the arthrosis. Marti et al.24 however, reported almost no progression of arthrosis after a successful reconstruction. They thought that arthrosis already present was well tolerated as long as the malalignment was corrected. Marti et al did not consider the time from the injury, the degree of arthrosis, or the age of the patient as a contraindication to surgical reconstruction. Their indications for ankle joint reconstruction included any malunited or nonunited fractures, including pilon fractures. The procedures of Marti et al included the following: realigning articular surfaces with osteotomies and bone grafting; removing debris, scar, and hypertrophic synovium; reconstructing malleoli; long bone osteotomies; and ligamentous repair. Based on the results of their study, they concluded that pain or diminished activity secondary to a malunited ankle fracture was a clear indication for late reconstruction. Marti et al reported that all the components of the malunion needed to be corrected with the goal of full restoration of normal anatomy.
Weber and Simpson41 have written that reconstructive lengthening osteotomy of the fibula is well worthwhile when there are minimal osteoarthritic changes present, irrespective of the time from the original surgery. They thought that in the presence of advanced arthritic change, arthrodesis of the ankle was indicated in the patient with symptoms. In their study, they showed that the extent of arthrosis already present was more important than the length of time from the injury or the amount of lateral displacement of the talus and that there was no time limit for reconstructive intervention.
Rosen35 had 84% good to excellent results with ankle malunion reconstructions. Factors that he observed to have a positive influence on the outcome are the position of the talus in the mortise, stability of the syndesmosis, correct length and rotation of the fibula, and the condition of the joint surfaces at the time of the reconstruction. When reconstruction failed or was not feasible, he recommended ankle arthrodesis as the best means of gaining a painless joint.
Despite the permanent loss of ankle motion, the increased stress on the surrounding joints, and the significant number of reported complications, arthrodesis of the painfully arthritic ankle is the gold standard to which all other treatment options, conservative and surgical, are measured. Arthrodesis of the ankle is a highly successful operation that reliably can return the patient to a high level of activity by alleviating pain and deformity.20 Arthrodeses of the ankle have been done for more than 100 years.31 Although there is, for the most part, agreement on the indications for the arthrodesis, there is little agreement as to the preferred technique to achieve the arthrodesis.
Tibiotalocalcaneal, tibiocalcaneal, and pantalar arthrodeses are similar salvage procedures that are recommended for patients with coexisting painful arthrosis of the subtalar joint and hindfoot.17,18,20,21,28,31 These procedures are indicated especially in patients with prior osteomyelitis or avascular necrosis of the talus, failed ankle arthrodesis or total ankle arthroplasty, or severe rheumatoid arthritis. Although they may be technically more difficult and have a higher complication rate, the results of these procedures are similar to ankle arthrodeses concerning pain relief and improved function.17,20,21,31
The preferred position for arthrodesis of the ankle, either for a tibiotalar or for a pantalar arthrodesis, is also largely agreed on by most authors. Most authors think that the position of the arthrodesis is critical for a good result. Mann20 states the goal of an ankle arthrodesis is to create a plantigrade foot aligned as closely as possible to the uninvolved extremity. Most authors agree that the ankle should be fused in slight (5°-10°) external rotation and slight (5°-8°) valgus.5,17,20-22,31,33,40 The most frequently recommended position for dorsiflexion and plantar flexion is neutral5,17,20-22,29,30,31,33,40 with some authors preferring slight dorsiflexion5,26,30,33 and others preferring slight plantar flexion.3,29 Many authors stress the importance of positioning the center of the talar dome posterior to the midline of the tibia to improve the posterior lever arm of the calcaneus.17,31,40 Problems from malposition of the arthrodesis are some of the most frequently cited reasons for a less than satisfactory result.5,20
Several different techniques for achieving arthrodesis of the ankle have been used over the years with new variations being presented on a continual basis. Because of the significant complication rate and number of nonunions, the search for the best method continues. However, there is no single best surgical technique.31 The main differences in the many techniques are in the surgical approach, bony configuration, use of onlay or interposition bone graft, and the method of fixation.
The surgical approaches can be divided into anterior, medial and/or lateral, and posterior. The anterior approach directly exposes the dorsalis pedis artery and the deep peroneal nerve to injury, and, because of postoperative problems with neuromas and tendon adhesions, the early use of the anterior approach largely has been abandoned in favor of the internervous lateral and medial approaches.4,20,22,31 The posterior approach has been advocated for tibiotalocalcaneal arthrodeses done with the patient in the prone position and as a method to avoid anterior scarring.17,18 Because of cosmesis and the decreased incidence of postoperative complications, the most common approach today is the lateral or anterolateral with the addition of a medial incision if necessary.4,20,22,23,29,31
Many different methods of bony configurations for arthrodesis of the ankle and pantalar joints have been used throughout the years (Figs 1, 2). The most common methods consist of simply denuding the articular surfaces of the distal tibia and talar dome, either as two opposing curved surfaces15,29 (Fig 1A) or by removing the subchondral bone with flat parallel surfaces4,17,20,22,40 (Fig 1B) or with a chevron type cut23 (Fig 1C). A sliding graft with a distal portion of the anterior tibia has been used with or without avascular necrosis of the talus for ankle and pantalar type fusions27,31 (Fig 1D, 1I and 2D). In cases with loss of the talar body, from avascular necrosis, trauma, a failed total ankle arthroplasty, infection, or rheumatoid arthritis, a tibiocalcaneal arthrodesis with excision of the talar body and fusion of the neck of the talus to the tibia has been used20,31(Fig 2C). To maintain length, for tibiotalocalcaneal fusions, an extraarticular arthrodesis technique that does not disturb the tibiotalar and talocalcaneal joints has been described17,18 (Fig 2A).
Whether to leave28,29 (Fig 1G), to remove4,17,20,21,22,30,40 (Fig 1E), or to remove and replace15,17,23 (Fig 1F) the malleoli, is a source of variation in many techniques. Many authors think that the malleoli may impinge on the shoes postoperatively and should be removed.17,31 Others think the medial malleolus may impinge on the calcaneus and prevent bone apposition or limit compression and either should be removed totally or removed partially.20,31 Other authors use the medial malleolus as a medial buttress to help secure the talus.4,20 Many authors think that cosmesis is improved by malleolar excision, especially for female patients.4,30,31 Removal of the fibula has not been shown to alter adversely the function of the subtalar joint.22 Laboratory studies have shown some improved strength of the arthrodesis with reattachment of the malleoli with lag screws,40 and other authors think that the lateral malleolus should be used as a strain relieving graft.15
The most common method of achieving an ankle arthrodesis has been intraarticular by the apposition of two well vascularized bony surfaces, cleared of all soft tissues.4,20-22,31,40 The additional use of intraarticular or extraarticular bone graft also has been a source of variation between the many described techniques. The extreme cases consist of vascularized bone graft used to span large defects in the tibia,2 or with bone transport as is seen with Ilizarov techniques.13,16 Another extraarticular technique uses a large amount of posterior onlay graft(Fig. 2A) of corticocancellous bone to limit shortening and obtain an arthrodesis in difficult cases.17,18 Other techniques consist of interposition grafts of harvested bone with either tricortical iliac crest or dowel grafts (Fig 1H), with an internal fibular graft (Fig 2B), or with sliding tibial grafts31 (Fig 1D, 1I and 2D). The most common methods, however, do not require additional bone other than what is harvested locally to perform the arthrodesis.20,22,29
Method of Fixation
The area where ankle arthrodesis techniques vary the most is in the method of fixation. The early methods ranged from no fixation, to external fixation, to limited internal fixation. Compression has been shown to improve the success of the bony fusions. Kirschner wires, Steinmann pins, and staples provide stabilization and are easy to remove, but apply no compression.31 Although external fixation devices can apply compression, advances in internal fixation techniques and instrumentation have led to increased use of internal compression devices over external compression devices.15,20,31,40
Many early advocates of external fixation have abandoned it in favor of internal fixation for numerous reasons.8,15,18,21,27,38 Laboratory studies have shown increased strength with internal fixation methods over external fixation methods.40 Some authors think that external fixation is unsatisfactory because it is unstable under shear stresses and does not maintain the exact position of the foot in the sagittal plane.15 Others cite increased complication rates with external fixation as was documented in a study by Moeckel et al27 which compared results of external and internal fixation.4,11,15,40 In the study by Moeckel et al, the external fixation group had a significantly higher rate of complications, including nonunion, delayed union, and infection. With the exception of the Ilizarov techniques, most recent studies have recommended internal fixation as the preferred method of fixation.4,8,11,15,20,27,40 Internal fixation techniques allow cast immobilization to reinforce the arthrodesis, allow early motion at the midfoot and subtalar joints, and have a low rate of complications (infections and nonunions) and a higher rate of patient satisfaction.4,11
Although most recent studies advocate internal fixation, there has not been much agreement as to the best type or orientation of the fixation. Lag screws have been the most widely used internal fixation device.15,20,22,29,40 Laboratory studies have shown that there is increased strength with crossed screws over parallel screws.11 However, it has been reported that crossed screws may prevent compression and inhibit fusion.31 Other authors think that crossed screws are the procedure of choice.28 Holt et al15 have used parallel 6.5-mm cancellous screws to secure the talus to the tibia with the addition of what they call the most important screw placed from the posterior malleolus into the neck and head of the talus to stabilize dorsiflexion and plantar flexion stresses. Sliding or onlay grafts attached with compression screws provide stability but not compression to the arthrodesis site.31
Recent laboratory studies have shown that medial and lateral T plate fixation consistently provided a more rigid construct than either crossed screws or fibular strut fixation.7 Although plates are reported to provide excellent stability, some authors think that they are more cumbersome than screws and require more soft tissue stripping.15,31 Other authors have had very good results with T plate fixation.4,8
To increase strength and decrease complications, retrograde intramedullary nailing for tibiocalcaneal or tibiotalocalcaneal arthrodeses has been introduced recently as a method to replace external fixation for these difficult situations.18,28 It also is recommended in patients with very osteopenic bone, because it provides stable fixation that allows early weightbearing. Because of the risk of prior bacterial contamination, it should be used with caution in extremities previously treated with external fixation devices.28 A recent anatomic study has shown that retrograde intramedullarly nailing is not without its own set of potential problems caused by its insertion through the sole of the foot.32 This study showed that the optimal insertion site is at the junction of the sustentaculum tali and the body of the calcaneus. Structures shown to be at risk include the plantar fascia, the flexor digitorum brevis, the abductor hallucis, abductor digiti minimi, the lateral planter nerve and artery, nerve to the abductor digiti minimi, the quadratus plantae, and the flexor hallucis longus.
The use of the Ilizarov technique for ankle arthrodesis has introduced numerous limb lengthening and arthrodesis options, not previously available, as an alternative to amputation.13,16 Indications include osteomyelitis, leg length discrepancy, and concomitant foot deformities.13 The technique is difficult, requires extensive experience, and continuous patient followup evaluations to achieve satisfactory results.16 Because the treatment is long, potentially painful, and fraught with complications, it requires a compliant and dedicated patient.13 In one series, monofocal compression arthrodesis was used successfully in patients after failed infected ankle fusions.16 All patients had soft tissue infections develop around pin tract sites but no deep infections or pin tract sequestra were seen.16
Although most of the complications seen are relatively minor, the complication rate for ankle and pantalar arthrodeses are fairly high.30 One of the more serious and frequently reported complications is nonunion.3,20,30,31 The reported incidence ranges from 0% to 60%. The results of most series are not comparable because the patient populations differ significantly. Those studies that include patients with peripheral neuropathy or avascular necrosis of the talus have much higher rates of nonunion.6,10,15,31 Other factors associated with higher rates of nonunion include prior deep infections, open injuries, pilon fractures, spasticity, the smoking habits of the patient, and other major medical problems.6,15,28 Cobb et al6 showed statistically that the relative risk of nonunion was increased 3.75 times for patients who actively smoke tobacco products. When patients did not have any known risk factors for nonunion, the risk of nonunion for those who smoked tobacco products was 16 times the risk for those who do not smoke tobacco products. Factors reported not to be associated with an increase risk for nonunion include age, prior triple or subtalar arthrodesis, and the technique of the arthrodesis.10 The problem is generally too little fixation rather than too much.17 Many authors, however, do think that external fixation does have a greater nonunion rate and the recent trend toward internal fixation may explain, at least partially, the higher union rates in most recent series.4,8,15,20,22,23,29,31
Another frequent source of complications or poor results somewhat unique for ankle arthrodeses is the position of the arthrodesis. Malunion or malalignment account for a significant number of unsatisfactory results.5,20 A varus position is associated with instability of the subtalar joint and lateral foot pain, whereas medial knee pain is seen with excessive valgus alignment. Metatarsalgia and back knee thrust problems are seen with equinus positioning whereas increased heel pad pain and stress are associated with excessive dorsiflexion.3,5,20,31
In addition to the list of common orthopaedic complications such as infection, neurovascular injury, skin slough, and delayed unions, other complications associated with ankle and pantalar arthrodeses include limb shortening, limb atrophy, stress fractures, and progression of arthrosis of the surrounding joints.15,20,22,25,26,30-32 Radiographic changes do not necessarily correlate with complaints of pain or the functional result in patients who have arthrosis of the adjacent joints develop after arthrodesis of the ankle.30 Because there is less residual compensatory motion available in patients who have had an extensive pantalar arthrodesis, tibial stress fractures have been reported.26,31 Injury to the soft tissue structures at risk near the insertion site after retrograde intramedullary nailing may lead to hammering or clawing of the toes.32
Mann20 has recommended numerous surgical techniques to reduce postoperative complications. His methods to decrease the risk for infection include maintaining meticulous technique, removal of all devitalized tissues, hemostasis, and perioperative antibiotics. Skin sloughs can be minimized by using full thickness skin flaps, adequate exposure, drains, and compressive dressings. Neurovascular injury can be avoided through the use of well planned surgical approaches. Neuromas should be identified and resected. Mann's methods to improve the success of the bony fusion include adequate fixation, ensuring adequate vascularity of the bone, and meticulous attention to positioning.
With recent trends toward internal fixation, proper patient selection, and emphasis on proper alignment, there has been a definite trend of improved results seen in the recent literature.20,22,29,31 Long term studies have shown that good results have been shown to hold up well with time.30
Motion studies confirm a loss of 60% to 70% of total tibiopedal motion after an ankle arthrodesis.14,31 Dorsiflexion is decreased by 50% and plantar flexion is decreased by 70% with the remaining motion occurring at the transverse tarsal and tarsometatarsal joints.12,14,28 After a pantalar(tibio-talo-calcaneo-cuboid-navicular) arthrodesis, dorsiflexion is limited by 62.8% and plantar flexion by 82.2%.12 However, visual gait analysis is normal in 2/3 of patients with an ankle arthrodesis.31 Detailed gait analysis indicates that walking speed is decreased secondary to a shortened stride length25 and is improved with modified shoes with a shock absorbing cushioned heel and a rocker bottom sole.25,31
Many studies have confirmed an unexplained loss of subtalar motion after an ankle arthrodesis.3,25,28,30,31 Opinions differ as to whether there is a compensatory increase in transverse tarsal motion after an ankle arthrodesis.1,31 Some studies have shown an increase in transverse tarsal motion,25,29 whereas others have reported no such increase.1,30 Morrey and Wiedeman30 described a fairly consistent ROM of the forepart of the foot from 0° dorsiflexion to 15° plantar flexion despite the varied positions in which the talus was fused in their study. In a recent study, Abdo and Wasilewski1 have shown that there was no correlation between patient satisfaction or the functional result and tarsal motion. Their statistical analysis showed that an ankle arthrodesis had no effect on the total tarsal motion when compared with the unfused side. They thought the outcome was determined more by the preexistence or development of subtalar and midtarsal arthrosis than by the mobility of the tarsal joints.
Many treatment options exist for patients with painful arthrosis of the ankle. The treatment of choice, of course, depends on the demands of the patient and the findings on physical examination and radiographs. The best final procedure of choice, after all else fails, is arthrodesis. Ankle arthrodesis is an effective and durable method to reduce pain and improve function in patients with severe arthrosis. Although most patients are not completely free of symptoms and do have some functional limitations, most are satisfied with the results.
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