Background

 

Ankle OAOA ORIF

 

Epidemiology

 

Much less common than hip and knee OA
Patients tend to be younger

 

Etiology

 

Primary ankle OA is uncommon, 80% of ankle OA is post-traumatic

 

Valderrabano et al CORR 2009

- 406 patients with end stage ankle OA

- 80% post-traumatic

- 13% secondary OA

- 9% primary OA

 

Trauma

 

Ankle Fracture Plafond Fracture Talus Ligament Instability

Swierstra et al EFORT Open Rev 2022

- systematic review ankle fractures

- 25% OA

Harris et al Foot Ankle Int 2006

- 79 tibial plafond ORIF

- 2 year follow up

- 40% OA

Talus osteochondral lesions

Talus malunion / AVN post neck fracture

Lofenberg et al Foot Ankle Int 1994

- 37 patients with chronic ankle instability

- 20 year follow up 13% OA

OA ORIF Tibial plafond OA talus avn Valgus OA

 

Secondary OA

 

Rheumatoid OA / Inflammatory OA / Infection / Hemochromatosis / Hemophilia / Charcot

 

Anatomy

 

Thin cartilage 1 mm

 

Joint highly congruent
- 1mm shift causes 40% decrease in contact area

- increases tibio-talar contact stresses

 

Clinically

 

Pain

- with weight bearing

- nightime

 

Stiff ankle joint

 

Xray

 

Ranges from anterior spurring to severe OA

80% of post-traumatic OA is varus

 

Takakura classification

 

Grade Description
1 Early sclerosis and formation of osteophytes
2 Narrowing of the medial joint space
3A Obliteration of the medial joint space with subcondral bone contact
3B Obliteration of joint space over roof of talar dome, with subchondral bone contact
4 Obliteration of joint space with complete tibiotalar contact

 

Anterior spur

Type 1: Anterior spurs

 

Ankle OAType 3b

Type 3A: Obliteration of medial joint space               Type 3B: Obliteration medial joint space plus tibio-talar contact with varus

 

Ankle OA AP XrayAnkle OA Lateral Xray

Type 4 complete obliteration

 

CT

 

Ankle CT Anterior Osteophyte

Small anterior tibial spur

 

ankle OACtCT

Large cysts in patient with ankle OA

 

MRI

 

Ankle OA MRIANkle MRIAnkle MRI

 

Management

 

Non Operative

 

PRP

 

Ding et al Int Orthop 2023

- systematic review of 4 studies using PRP for ankle OA

- evidence of improved pain and function at 6 months

 

Hyaluronic acid

 

Vannbouathong et al Foot Ankle Int 2018

- systematic review of HA for ankle OA

- 3 RCTs
- evidence for improved pain with HA versus saline at 6 months

 

Operative

 

Options

 

Arthroscopy

Ankle distraction arthroplasty / arthrodiastasis

Arthrodesis

Supramalleolar osteotomy

Arthroplasty

 

Arthroscopic debridement

 

Indication

 

Anterior impingement

- kissing osteophytes on anterior tibia and talar neck

 

www.boneschool.com/footandankle/anteriorimpingement

 

Ankle distraction arthroplasty / arthrodiastasis

 

Theory

 

Allows some cartilage regeneration and healing

Young patient

 

Technique

 

Vumedi ankle distraction arthroplasty

 

Hinged external fixation distracting joint

- 3 - 4 months
- distracted 5 mm
 

Results

 

Arshad et al Foot Ankle Surg 2022

- systematic review distraction arthroplasty

- most improvement at or slightly above MCID (minimal clinically important difference)

- 50% revision to arthrodesis or arthroplasty

 

Supramalleolar Osteotomy

 

Valgus OAOsteotomySupramall osteotomy

Varus OA treated with medial opening wedge supramalleolar osteotomy

 

Indications

 

Varus / valgus malalignment

Asymmetric OA with preserved cartilage in 50% of ankle (Grade 2 and 3A)

 

Technique

 

Surgical technique supramalleolar osteotomy PDF

 

Surgical technique supramalleolar osteotomy video

 

Results

 

Butler et al KSSTA 2023

- systematic review of 24 studies and 1200 patients

- failure rate 7%

- complication rate 5%

- nonunion rate 2%

 

Arthrodesis versus Arthroplasty

 

Functional outcome

 

Shih et al Foot Ankle Surg 2020

- meta-analysis arthrodesis v arthroplasty last 10 years (3rd generation ankle arthroplasty)

- no difference in total outcome scores / pain / gait / satisfaction between two groups

- improved function and ROM with arthroplasty

- higher complication and reoperation with arthroplasty

 

Liu et al Int Orthop 2023

- meta-analysis of 37 studies comparing arthrodesis and arthroplasty

- Arthroplasty PROMs > arthrodesis in the short term (<2y)

- Arthroplasty PROMs = arthrodesis in the medium term (2-5y)

- Arthrodesis PROMs > arthroplasty in the long term (>5y)

 

Revision rate

 

SooHoo et al JBJS Am 2007

- database of ankle fusions v arthroplasty

- 5 year subtalar arthrodesis rate: ankle fusion 3%

- 5 year subtalar arthrodesis rate: arthroplasty 0.7%

 

Subtalar arthritis

 

SooHoo et al JBJS Am 2007

- database of ankle fusions v arthroplasty

- 5 year subtalar arthrodesis rate: ankle fusion 3%

- 5 year subtalar arthrodesis rate: arthroplasty 0.7%

 

Ankle Arthrodesis

 

www.boneschool.com/footandankle/anklearthrodesis

 

Ankle Arthroplasty

 

http://www.boneschool.com/lower-limb/foot-and-ankle/ankle-arthroplasty