Point-Counterpoint: Is Ankle Arthrodesis A Better Option Than Total Ankle Replacement?

Ankle arthrodesis.

In a thorough review of the literature, this author says despite the promising innovation of total ankle arthroplasty, the “gold standard” for ankle osteoarthritis is still ankle arthrodesis.
 

By Patrick A. DeHeer, DPM, FACFAS

The newest, shiniest, most leading edge technology/product, whether it is a cell phone or television, can be very exciting and compelling. The problem is that it is not always the best choice. Oftentimes, the newest technologies or products have problems that require ironing out and may not even better their predecessors. (Take Microsoft Windows 8 for example.) Total ankle arthroplasty has great appeal when it comes to joint motion preservation, being an advanced procedure and providing podiatrists a comparable procedure to total shoulder, knee and hip arthroplasty.  

There is literature to support total ankle arthroplasty. However, there is an overriding question regarding total ankle arthroplasty versus ankle arthrodesis: Is there enough significant difference between the procedures to justify the expense and complications that go with total ankle arthroplasty? We still consider ankle arthrodesis the “gold standard” for painful ankle arthritis. Is it possible that total ankle arthroplasty will become the “gold standard,” replacing ankle arthrodesis? What would need to transpire for this to happen?

We cannot steer down the wrong path with a broad examination of the literature, using the highest levels of evidence possible to make our decision. With this type of objective examination, the answers to the above questions become clear. Ankle arthrodesis is still the “gold standard” and surgeons should limit the use of total ankle arthroplasty to very specific cases.  

What The Research Reveals
In 2011, Schuh and colleagues compared total ankle arthroplasty with ankle arthrodesis.¹ Their patient group consisted of 41 patients (21 ankle arthrodesis and 20 total ankle arthroplasty). They examined patients at 34.5 months post-op using the University of California at Los Angeles (UCLA) activity scale and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale to assess clinical and functional outcomes. The study noted no difference postoperatively between the two groups in activity level, participation in sports, UCLA or AOFAS scores. The ankle arthrodesis group did show a reduction in sports participation but this was not statistically significant.

In 2010, Saltzman and coworkers also examined the treatment of osteoarthritis of the ankle with ankle arthrodesis versus total ankle arthroplasty.² Their study consisted of 42 total ankle arthroplasty patients with 37 (89 percent) available for follow-up and 29 ankle arthrodesis patients with 23 (73 percent) available for follow-up. The mean follow-up period of the study was 4.2 years. The clinical results were almost equivalent for both groups. The total ankle arthroplasty group had better pain relief but also had more complications requiring revisional surgery.

Hahn and colleagues performed a comparative gait analysis between arthrodesis and total ankle arthroplasty in 2012.³ The authors measured preoperative and postoperative gait measures in 18 patients with ankle osteoarthritis. There were nine patients in each surgical group. Postoperatively, there was improvement in pain and gait function for both groups at 12 months. The total ankle arthroplasty group had more normal ankle function with increased range of motion but one has to question this finding as arthrodesis inherently does not improve range of motion by definition.

Krause and coworkers examined the impact of complications in total ankle arthroplasty and ankle arthrodesis.⁴ Their study included 114 total ankle arthroplasty patients with a mean follow-up of 39 months and 47 ankle arthrodesis patients with a mean follow-up of 37 months. They analyzed the impact of complications with the Ankle Osteoarthritis Scale. There was no significant difference between the improvement for both groups. However, the complication rates were significantly different. The complication rate was 54 percent for total ankle arthroplasty and 26 percent for ankle arthrodesis. The impact of major complications was significant for both groups, according to the Ankle Osteoarthritis Scale.

Hadad and coworkers in 2007 did a literature review comparing ankle arthrodesis to total arthroplasty.⁵ The results were very similar to the aforementioned studies. The total ankle arthroplasty group consisted of 10 studies with 852 patients and the ankle arthrodesis group consisted of 39 studies with 1,262 patients. The mean AOFAS score was 78.62 for the total ankle arthroplasty group and 75.6 for the ankle arthrodesis group. The revision rate for the total ankle arthroplasty group was 7 percent (the primary reason was loosening) and the revision rate for ankle arthrodesis was 9 percent (primarily non-union). Their conclusion was that the outcomes for both groups were similar.

SooHoo and colleagues compared the reoperation rates between the two procedures.⁶ Researchers used the California hospital discharge database to identify patients who had either procedure from 1995 through 2004. There were a total of 4,705 ankle fusions and 480 total ankle arthroplasties. The rates for major revision for total ankle arthroplasty were 9 percent at one year and 23 percent at five years in comparison to ankle arthrodesis rates of 5 and 11 percent respectively. The ankle arthrodesis group did have a statistically significant higher rate of subsequent subtalar arthrodesis procedures (2.8 percent to 0.7 percent).

In 2009, Saltzman and colleagues did a prospective study using ankle arthrodesis as the control group.⁷ The pivotal study consisted of 158 total ankle arthroplasty cases and 66 arthrodesis cases. In the continued access study, the authors evaluated 416 total ankle arthroplasties at 24 months postoperative. In the pivotal study, the total ankle arthroplasty group had more complications and required revisional surgery more frequently. The continued access study patients that had arthroplasty did show a decrease in secondary procedures by over half in comparison to the pivotal arthroplasty group. Both study groups did show better functional outcomes but the method the authors used to evaluate functionality was a non-validated instrument. Pain relief was equivalent in each group.

Flavin and coworkers compared the gait for ankle arthrodesis and total ankle arthroplasty patients in 2013.⁸ The study was a prospective study of 28 patients with ankle osteoarthritis (14 each for total ankle arthroplasty and ankle arthrodesis) and 14 control patients. Employing a gait analysis system at one year post-op, the researchers noted gait improvement in various parameters for both operative groups in comparison to the preoperative evaluation but less function postoperatively than control groups. Neither surgical group was superior in all parameters of gait examination.

After patients had total ankle arthroplasty, Ajis and coworkers examined the change in total range of motion, one of the presumed benefits of this procedure, in 2013.⁹ Assessing three different ankle replacement systems in 119 procedures, the study authors evaluated range of motion at six weeks, three months, six months and one year. No significant improvement in ankle range of motion occurred at six months with a discrepancy in increased dorsiflexion and decreased plantarflexion in comparison to preoperative values. There were similar findings at one year postoperatively in comparison to the preoperative range of motion measurements.

In 2011, Courville and coworkers discussed the cost of the two procedures in Clinical Orthopedic Related Research.¹⁰ The cost for ankle arthrodesis was $7,900 in comparison to total ankle arthroplasty at $28,000. Their analysis did state that total ankle arthroplasty was still a cost-effective alternative.

The Verdict On Total Ankle Arthroplasty Versus Ankle Arthrodesis
With analysis of these and other articles, the picture starts to come into focus more on total ankle arthroplasty versus ankle arthrodesis. Verified outcome measurements have shown the following:

• no statistical difference in outcomes
• sports participation was not significantly different
• mixed results on the level of pain improvement between the groups
• higher levels of complications associated with the total ankle arthroplasty group with more frequent reoperation rates
• no significant difference in gait analysis between groups
• no significant improvement in ankle range of motion for total ankle arthroplasty in comparison to preoperative values
• substantially higher cost for total ankle arthroplasty

With objective evaluation and removing the “shiny, new toy concept” of total ankle arthroplasty, the evidence is clear. The “gold standard” is and continues to be ankle arthrodesis for osteoarthritis of the ankle. 
 
Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis.

References
1. Schuh R, Hofstaetter J, Krismer M, Bevoni R, Windhager R, Trnka HJ. Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome. Int Orthop. 2012;36(6):1207-14.
2. Saltzman CL, Kadoko RG, Suh JS. Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop Surg. 2010;2(1):1-7.
3. Hahn ME, Wright ES, Segal AD, Orendurff MS, Ledoux WR, Sangeorzan BJ. Comparative gait analysis of ankle arthrodesis and arthroplasty: initial findings of a prospective study. Foot Ankle Int. 2012;33(4):282-9.
4. Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger AS. Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement. J Bone Joint Surg Am. 2011; 93(9):830-9.
5. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalyshyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007; 89(9):1899-1905.
6. SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am. 2007; 89(10):2143-2149.
7. Saltzman CL, Mann RA, Ahrens, JE, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009; 30(7):579-596.
8. Flavin R, Coleman SC, Tenenbaum S, Brodsky JW. Comparison of gait after total ankle arthroplasty and ankle arthrodesis. Foot Ankle Int. 2013;34(10):1340-8.
9. Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013;34(5):645-56.
10. Courville XF, Hecht PJ, Tosteson AN. Is total ankle arthroplasty a cost-effective alternative to ankle fusion? Clin Orthop Relat Res. 2011;469(6):1721-7.

Editor’s note: For a related article, see “A Closer Look At The Mini-Open Ankle Arthrodesis” in the January 2009 issue of Podiatry Today.

Total ankle replacement.

Ankle arthrodesis is not an ideal surgery for many patients and with judicious patient selection, total ankle replacement can be quite successful in maintaining ankle motion. 

By Thomas S. Roukis, DPM, PhD, FACFAS

There is no arguing the fact that a solidly united ankle arthrodesis predictably relieves pain and when the subtalar joint and talonavicular joints are not arthritic, the patient can reliably expect to have a normal gait when wearing a shoe and while ambulating on a flat surface.^1-4 Further, one can treat frontal and sagittal malalignment at the time of arthrodesis and once osseous union develops, there are no concerns over instability or deformity recurrence.⁵ Infection is rare and when it happens, one can usually manage it in a way that does not affect the final outcome. Direct implant costs, especially screw constructs, are low with ankle arthrodesis.⁶ Finally, surgeons can perform ankle arthrodesis with a number of different incision approaches and this affords flexibility to accommodate any soft tissue limitations that prior surgical procedures imposed.

However, ankle arthrodesis is not the best option in a large number of patients one encounters in practice and significant long-term problems with the procedure do exist. Although the incidence of nonunion following isolated ankle fusion with open techniques using modern fixation methods is unknown, two studies estimate it at 15 percent and 8 percent in arthroscopic procedures.^7,8 The incidence of malunion remains unknown but appears to occur more frequently than nonunion, is difficult to manage conservatively and can lead to debilitating subtalar arthritis.⁹

Some arthrodesis patients eventually require further surgery. Even with a well-aligned, solid ankle arthrodesis in a satisfied patient, common complaints include difficulty managing uneven surfaces, limitation of crouching/genuflecting, problems ascending and descending stairs, altered ability to use driving pedals, and difficulty putting on boots or tight pants.

Although not clearly defined, adjacent subtalar and talonavicular degenerative joint disease plays a large role in decision making.¹⁰ While intuitive and supported by cadaveric studies, fusion of both the ankle and subtalar or ankle and talonavicular joints markedly limits foot motion and adaptability.^11-13 Unfortunately, except for post-polio and neuropathic limb treatment, there is little information on function for patients who undergo tibiotalocalcaneal or tibiotalar navicular arthrodesis procedures.

Despite this lack of functional outcome data, one could make a strong argument for total ankle replacement for end-stage ankle arthritis with concomitant subtalar and/or talonavicular degenerative joint disease, even for young people. Further, it is reasonable to presume that young people in the prime of their work years would benefit from a total ankle replacement with minimal bone resection to preserve the subtalar and/or talonavicular joints through middle age. However, until data comparing these circumstances becomes more robust, this discussion remains a matter for conjecture. In comparison to ankle arthrodesis, the primary benefit of total ankle replacement is maintenance of motion of the ankle that, especially in patients with rigid foot characteristics or contralateral foot/ankle pathology, has advantages over fusion.

Key Considerations With Total Ankle Replacement

Although historically quite robust, the list of absolute contraindications to total ankle replacement has dwindled to a few.^14-16 Patients with altered peripheral nerve sensation who cannot sense malalignment or pain are not good candidates for total ankle replacement unless they permanently wear ankle foot orthoses (AFOs). Since the available total ankle replacement systems require bone ongrowth for successful mating of the metallic components with the bone, one should consider distal tibial or talar avascular osteonecrosis that reduce the likelihood of osseous integration a contraindication unless there is full resection. This is especially true of total ankle replacement systems that disrupt the intra-osseous talar vasculature.^17,18

Active or recurrent infection, history of trauma with severe bone loss, hostile soft tissues about the foot and ankle, a completely absent fibula and uncorrectable peripheral vascular disease remain as the only true contraindications to total ankle replacement and authors have even challenged these.¹⁹

Despite much debate, we simply do not know if there should be an absolute weight limit for patients undergoing total ankle replacement.²⁰ Clearly, larger patients will exert more force on their total ankle replacements with each step but many of them take far fewer steps than normal sized patients.

Frontal and (to a lesser degree) sagittal plane deformity remain commonly discussed concerns with total ankle replacement.^21-23 I will offer total ankle replacement to patients over the age of 50 regardless of the presence of sagittal or frontal plane ankle deformity as long as I can provide reliable correction to neutral with periprosthetic osteotomy, soft tissue release, tendon transfer or ligament reconstruction.^21-22,24-26

Much of the concern over deformity depends on surgeon experience with the specific total ankle replacement prosthesis in use and the ability to perform all necessary secondary procedures to achieve a well-aligned foot and ankle. The stability profile and contact characteristic of the total ankle replacement system one employs also plays a role. It should be obvious that even modern generation total ankle replacements involve simple mechanical parts that must align well to prolong wear and afford smooth gliding between the surfaces.

Additionally, if it is necessary to remove more bone from the tibia to obtain frontal plane realignment, it may change the center of rotation of the prosthetic joint and adversely effect soft tissue constraint. This may also require thicker polyethylene during the primary implantation that limits future revision options. Therefore, since uncorrectable deformities preclude these things from happening, they should be contraindications for total ankle replacement.

Age at the time of primary total ankle replacement is a major consideration.^10,27-29 I have a bias toward total ankle replacement in patients over the age of 35 with moderate subtalar and/or talonavicular arthritis, or if they have had a prior arthrodesis of those joints.³⁰ I also prefer total ankle replacement in younger individuals with inflammatory arthritis since they are likely to have lower demands but also an enhanced likelihood for involvement of other joints.³¹ Obviously, with young patients, one needs to factor in failure of the total ankle replacement requiring repeated and unpredictable revision surgeries over time.^32,33

A strategy for getting patients to their eighth decade of life should be part of the index planning. Ideally, the primary total ankle replacement one selects should have a proven track record over an extended period of time with readily available revision components and should conserve bone, thereby allowing for revision even if additional tibial or talar bone loss occurs.

Additionally, patients whose lifestyle or employment require walking up and down inclines may have an advantage in undergoing total ankle replacement since there is a theoretical advantage for a procedure that allows continued sagittal plane motion under these circumstances. Following total ankle replacement, one can allow patients to walk, do light jogging and participate in non-competitive motion sports.^34-37 The difficulty arises when patients have interests that involve rapid acceleration and deceleration forces, or frontal plane stress on the articulating surfaces as this will predictably lead to premature wear or fracture of the polyethylene component of their total ankle replacement. In these situations, if these forces are required for their occupation (active duty military, farmer, etc.) or patient-centric desired activities (outdoorsman/hunter), I generally recommend the use of a lace-up, high-topped boot and/or ankle brace for protection of the total ankle replacement during these activities.

In Summary

Total ankle replacement is not intended for every patient and neither is ankle arthrodesis. As is true with all patient-related care, what matters most for achieving a successful result is aligning patient expectations and outcomes with the surgeon’s capabilities and adequate support of the available literature using cost-effective care.^38-47 In this context, forthcoming research would ideally involve community-based surgeon directed, large-volume prospective clinical trials including bilateral gait analysis and validated patient satisfaction outcome metrics that compare the available primary total ankle replacements with ankle arthrodesis.

The United States should strive to develop a national total ankle joint replacement registry to provide timely feedback to surgeons and industry about total ankle replacement complications and thereby reduce patient morbidity and minimize the widespread adoption of a poor implant design.⁴⁸ Direct comparison of the incidence of revision between the various contemporary total ankle replacements in common use is also warranted since limited information exists to guide prosthesis selection.^49-52 Finally, caution against rapid adoption of newly released total ankle replacements, especially ones without readily available revision components, seems prudent.

Dr. Roukis is an attending foot and ankle surgeon within the Department of Orthopaedics, Podiatry and Sports Medicine with the Gundersen Health System in La Crosse, Wis. He is a Fellow and the President of the American College of Foot and Ankle Surgeons.
    
References
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6. Peterson KS, Lee MS, Buddecke DE. Arthroscopic versus open ankle arthrodesis: a retrospective cost analysis. J Foot Ankle Surg. 2010; 49(3):242-247.
7. Abicht BP, Roukis TS. Incidence of nonunion after isolated arthroscopic ankle arthrodesis. Arthrosc. 2013; 29(5):949-954.
8. Townshend D, Di Silvestro M, Krause F, Penner M, Younger A, Glazebrook M, Wing Arthroscopic versus open ankle arthrodesis: a multicenter comparative case series. J Bone Joint Surg. 2013; 95-A(2):98-102.
9. Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle: A study of adjacent joints. J Bone Joint Surg. 2003; 85-B(7):994-998.
10. Krause FG, Schmid T. Ankle arthrodesis versus total ankle replacement: how do I decide? Foot Ankle Clin. 2012; 17(4):529-543.
11. Gellman H, Lenihan M, Halikis N, Botte MJ, Giordani M, Perry J. Selective tarsal arthrodesis: an in vitro analysis of the effect on foot motion. Foot Ankle Int. 1987; 8(3):127-133.
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14. Gougoulias NE, Khanna A, Maffulli N. How successful are current ankle replacements? A systematic review of the literature. Clin Orthop Relat Res. 2010; 468(1):199-208.
15. Van den Heuvel A, Van Bouwel S, Dereymaeker G. Total ankle replacement: Design evolution and results. Acta Orthop Belg. 2010; 76(2):150-161.
16. Easley ME, Adams SB, Hembree WC, DeOrio JK. Current concepts review: Results of total ankle arthroplasty. J Bone Joint Surg. 2011; 93-A(15):1455-1468.
17. Oppermann J, Franzen J, Spies C, Faymonville C, Knifka J, Stein G, Bredow J. The microvascular anatomy of the talus: a plastination study on the influence of total ankle replacement. Surg Radiol Anat. 2014; 36(5):487-494.
18. Tennant JN, Rungprai C, Pizzimenti MA, Goetz J, Phisitkul P, Femino J, Amendola A. Risks of blood supply of the talus with four methods of total ankle arthroplasty: A cadaveric injection study. J Bone Joint Surg. 2014; 96-A(5):395-402.
19. Steck JK, Anderson J. Total ankle arthroplasty: indications and avoiding complications. Clin Podiatr Med Surg. 2009; 26(2):303-304.
20. Barg A, Knupp M, Anderson AE, Hintermann B. Total ankle replacement in obese patients: component stability, weight change, and functional outcome in 118 consecutive patients. Foot Ankle Int. 2011; 32(10):925-932.
21. Choi WJ, Yoon HS, Lee JW. Techniques for managing varus and valgus malalignment during total ankle replacement. Clin Podiatr Med Surg. 2013; 30(1):35-46.
22. Trajkovski T, Pinsker E, Cadden A, Daniels T. Outcomes of ankle arthroplasty with preoperative coronal-plane varus deformity of 10 or greater. J Bone Joint Surg. 2013; 95-A(15):1382-1388.
23. DeOrio JK, Lewis JS. Silfverskiöld’s test in total ankle replacement with gastrocnemius recession. Foot Ankle Int. 2014; 35(2):116-122.
24. Roukis TS. Modified Evans peroneus brevis lateral ankle stabilization for balancing varus ankle contracture during total ankle replacement. J Foot Ankle Surg. 2013; 52(6):789-792.
25. Roukis TS. Tibialis posterior recession for balancing varus ankle contracture during total ankle replacement. J Foot Ankle Surg. 2013; 52(5):686-689.
26. Roukis TS, Prissel MA. Reverse Evans peroneus brevis medial ankle stabilization for balancing valgus ankle contracture during total ankle replacement. J Foot Ankle Surg. 2014; 53(4):497-502.
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40. Stengel D, Bauwens K, Ekkernkamp A, Cramer J. Efficacy of total ankle replacement with meniscal-bearing devices: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2005; 125(2):109-119.
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43. Terrell RD, Montgomery SR, Pannell WC, Sandlin ML, Inoue H, Wang JC, SooHoo NF. Comparison of practice patterns in total ankle replacement and ankle fusion in the United States. Foot Ankle Int. 2013; 34(11):1486-1492.
44. Pugely AJ, Lu X, Amendola A, Callaghan JJ, Martin CT, Cram P. Trends in use of TAR and ankle arthrodesis in the US Medicare population. Foot Ankle Int. 2014; 35(3):207-215.
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46. SooHoo NF, Kominski G. Cost-effectiveness analysis of total ankle arthroplasty. J Bone Joint Surg. 2004; 86-A(11):2446-2455.
47. Courville XF, Hecht PJ, Tosteson AN. Is total ankle arthroplasty a cost-effective alternative to ankle fusion? Clin Orthop Rel Res. 2011; 469(6):1721-1727.
48. Roukis TS, Prissel MA. Registry data trends of total ankle replacement use. J Foot Ankle Surg. 2013; 52(6):728-735.
49. Roukis TS. Incidence of revision after primary implantation of the Agility total ankle replacement system: a systematic review. J Foot Ankle Surg. 2012; 51(2):198-204.
50. Prissel MA, Roukis TS. Incidence of revision after primary implantation of the Scandinavian total ankle replacement system: a systematic review. Clin Podiatr Med Surg. 2013; 30(2):237-250.
51. Valderrabano V, Pagenstert GI, Müller AM, Paul J, Henninger HB, Barg A. Mobile-and fixed-bearing total ankle prostheses: is there really a difference? Foot Ankle Clin. 2012; 17(4):565-585.
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Editor’s note: For related articles, see “A Closer Look At Total Ankle Replacement Revision” in the February 2014 issue of Podiatry Today, the December 2013 online-exclusive case study “When An Ankle Fusion Fails” and “Emerging Insights With The Ankle Implant Arthroplasty” in the October 2011 issue.