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The Journal of Bone and Joint Surgery (American) 85:923-936 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Current Concepts Review

Ankle Arthritis

Rhys H. Thomas, BSc, FRCS(Orth) and Timothy R. Daniels, MD, FRCS(C)

Rhys H. Thomas, BSc, FRCS(Orth)
Timothy R. Daniels, MD, FRCS(C)
Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada. E-mail address for R.H. Thomas: rhyshthomas{at}ntlworld.com E-mail address for T.R. Daniels: danielst@smh.toronto.on.ca

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. The John Charnley and British Orthopaedic Association/Wishbone Trusts supported R. H. Thomas's fellowship.


   Introduction
Top
 Introduction
Pathophysiology and Epidemiology...
 Nonoperative Treatment
 Operative Treatment
 Overview
 References
 
• Trauma is the most common cause of ankle arthritis.

• Unlike the hip and knee joints, the ankle is rarely affected by primary arthritis, even in the elderly.

• Modern techniques of ankle arthrodesis provide a high rate of union with few complications.

• Gait analyses and clinical studies have shown the preferred position of ankle fusion to be plantigrade with 5° of hindfoot valgus, external rotation comparable with that of the contralateral extremity, and the talus translated posteriorly in relation to the tibia.

• Precise indications for total ankle replacement are yet to be defined.

The ankle joint is subjected to more weight-bearing force per square centimeter and is more commonly injured than any other joint in the body, but the prevalence of symptomatic arthritis at the ankle is approximately nine times lower than that at the knee and hip 1-3 . Various mechanical, biochemical, and anatomical particularities of the ankle account for its apparent resilience to the processes of aging and trauma. Once arthritis has developed, treatment includes medication, bracing, shoe modifications, arthroscopic débridement, arthrodesis, and/or arthroplasty. Arthrodesis is regarded as the preferred treatment in the presence of end-stage arthritis and failure of conservative management 4 . Since Albert's 5 first description in 1879, numerous techniques for achieving a fusion have been described, and the general principles of alleviating pain, correcting deformities, and maintaining hindfoot stability remain unchanged. Modern techniques have yielded good intermediate-term results and can provide an active individual with a functional extremity 5-10 . However, the reliability of long-term outcomes has been questioned 11 . Moreover, major modifications in the design and techniques of arthroplasties have challenged the notion that arthrodesis is the treatment of choice 12-16 .

In this review, we will provide an overview of the pathophysiology of ankle arthritis and the biomechanics of the ankle joint. We will then review the current indications, techniques, results, and complications of arthrodesis and arthroplasty with an emphasis on recent advances.


   Pathophysiology and Epidemiology of Ankle Osteoarthritis
Top
 Introduction
 Pathophysiology and Epidemiology...
Nonoperative Treatment
 Operative Treatment
 Overview
 References
 
Epidemiology
Unlike the hip and knee, the ankle joint is rarely affected by osteoarthritis 17 . Trauma and/or abnormal ankle mechanics are the most common causes of degenerative changes; less common are inflammatory arthropathies, hemochromatosis, infection, neuropathic arthropathy, or tumor 18,19 . Traumatic injuries include fractures of the malleoli, tibial plafond, and talus as well as isolated osteochondral damage of the talar dome. Ankle instability due to chronic lateral ligament laxity can lead to degenerative changes, particularly on the medial side 20 . While the reported prevalence of posttraumatic arthritis in the ankle has been variable, an important predictor is the severity of the injury to the articular cartilage.

Lindsjo reported on a series of more than 300 ankle fractures treated with open reduction and internal fixation 21 . The prevalence of posttraumatic arthritis was 14% and was directly correlated with the fracture pattern. The prevalence increased from 4% in association with fractures that were Type A according to the Weber classification 22 to 33% in association with Type-C fractures. The presence of a posterior malleolar fragment—even a small one—indicated a more severe injury and was associated with a higher rate of ankle arthritis, a finding that agreed with those of other studies 23,24 . Lindsjo's study also demonstrated that the adequacy of the reduction strongly influences the outcome of treatment. Patients with a nonanatomic reduction had a significantly higher rate of poorer clinical results than did those with a rigidly fixed anatomic reduction (p < 0.001). When arthritic changes developed following an ankle fracture, they tended to be seen on radiographs within two years 21 . A strong correlation was observed between the radiographic severity of the arthritis and the clinical result.

The importance of anatomic reduction of the posterior fragment for maintenance of the ankle contact area was emphasized by a cadaveric study by Macko et al. 25 . The contact area within the ankle joint decreased in inverse proportion to the size of the posterior malleolar fragment, with decreases as high as 35% for fragments involving half of the articular surface. The benefit of an anatomic reduction is not in question, but whether similar results can be obtained with a closed reduction remains controversial.

Fractures of the tibial plafond are often the result of high-energy forces, and such fractures are associated with a high rate of posttraumatic arthritis, caused by a combination of articular damage, avascular necrosis of the articular fracture fragments, postoperative infection, and/or difficulty in obtaining an adequate reduction. The influence of an anatomic reduction on the prevalence of posttraumatic arthritis is debatable. Some studies have demonstrated a direct correlation between reduction and functional outcome 26 while others have shown no correlation 27-29 . Marsh et al. 30 argued that the severity of the injury to the articular cartilage is the primary determinant of posttraumatic arthritis. All of these studies suggest that the best outcome is associated with minimal articular damage, anatomic reduction, early mobilization, and a lack of complications. Ruedi 26 observed in his clinical series that an ankle free of arthritis at two years after treatment showed no radiographic signs for another five to ten years.

Fractures of the talus, although rarer than plafond and malleolar fractures, may also cause ankle arthritis. Following talar neck fractures, posttraumatic arthritis may be seen at both the tibiotalar and the subtalar joint as a direct result of articular damage, subchondral collapse from avascular necrosis, or malunion causing abnormal joint mechanics. The frequency of arthritis following a talar fracture has ranged from 47% to 97% 31 .

The ankle moves mainly as a rolling joint and exhibits congruency at high load. The knee, on the other hand, exhibits a combination of rolling, sliding, and rotation, and this may predispose it to a higher frequency of arthritis 32 . The ankle cartilage has distinct characteristics with regard to thickness, mechanical properties, and metabolism 1,32-41 . While this distinction may protect the ankle from osteoarthritis, it also predisposes it to posttraumatic arthritis.

Articular Cartilage Thickness
The thickness of articular cartilage affects the stresses and strains occurring in the cartilage matrix 40 . The thickness and uniformity of the cartilage have been observed to differ among the hip, knee, and ankle 36,40 . Shepherd and Seedhom 40 studied cartilage thickness in these joints and found that the ankle had the thinnest cartilage and the knee had the thickest. An inverse relationship was found between cartilage thickness and its compressive modulus—i.e., the thin ankle cartilage has a high compressive modulus. Ankle cartilage is relatively uniform in thickness, ranging from 1 to 1.7 mm, whereas the thickness of knee cartilage ranges from 1 to 6 mm. Simon et al. 42 proposed a link between the cartilage thickness and joint congruency, with the most congruent joints having the thinnest cartilage to better equalize stresses.

Articular Contact Area
The loaded ankle joint has a smaller surface contact area than the hip or knee 38,43,44 : at a 500-N load, it measures 350 mm 2 whereas the surface contact area of the hip measures 1100 mm 2 and that of the knee measures 1120 mm 2 . The ankle carries loads of up to five times body weight during normal level walking 17 . More than 75% of the load is distributed through the superior articular surface of the talus 45 , and the force per unit area is greatest over the anterior and lateral portions of the talar dome 38 . The remaining load is distributed through the medial and lateral facets, with the former accepting twice the load of the latter 46 .

During gait, the contact area and the pressure distribution pattern within the ankle joint change. The contact area is the largest with the talus in neutral or dorsiflexion, which is the position of the talus during 50% of the stance phase 45 . The total contact area decreases by 13% to 18%, and the force per unit area increases, with the talus in plantar flexion 46 . The change in pressure distribution during the normal gait cycle may have a beneficial effect on cartilage lubrication and nutrition 1 .

Pathological conditions such as a malunited ankle fracture result in changes in the contact stresses and contact area. In a cadaveric study with a constrained ankle model, Ramsey and Hamilton 47 demonstrated that a 1-mm lateral talar shift reduced the tibiotalar contact area by 42%. However, this finding was not reproduced in dynamic, unconstrained models 48,49 . Clarke et al. 49 found that when the deltoid ligament was intact, <=6 mm of lateral fibular displacement did not change the tibiotalar contact area. When medial instability was produced by sectioning the deltoid ligament, the total contact area was decreased by 15% to 20%. Pereira et al. 48 demonstrated no significant effect of mortise widening on contact area. They postulated that, under load, the talus moves to a position of maximum congruency within the ankle mortise. These physiological studies demonstrated that ankle congruency is affected by both the fracture reduction and the integrity of the medial supporting structures.

Mechanical Properties
A number of studies have compared the biomechanical properties of the cartilage of the ankle with those of the hip and knee 33,47-51 . Kempson 50 compared the effects of aging on the mechanical properties of normal, intact cartilage of the hip and ankle. He observed that, whereas the tensile strength of the femoral head cartilage decreased considerably with age, the tensile strength of the talar cartilage decreased only slightly with age. Even in the eighth and ninth decades of life, the talar cartilage was strong enough to resist everyday physiological stresses.

Compared with the knee, the normal ankle has stiffer cartilage that is more resistant to indentation 41 . This is due to the fact that the cartilage matrix of the ankle joint is more uniform than that of the hip or the knee 39 . It has been postulated that areas of cartilage subjected to high stress adapt through increased stiffness and uniformity 41 . Normally, the compressive deformity of cartilage during cyclical loading is restricted to the more superficial regions of the cartilage mantle. In the talus, the superficial layer makes up a greater proportion of the cartilage thickness, and this may play a role in resisting the development of osteoarthritis 32 . It has also been found that the subchondral bone in an arthritic ankle does not increase in density as it does in other joints, which suggests that the subchondral bone of the ankle is less responsive to alterations in load 51 .

Prevalence of Ankle Arthritis
The true prevalence of ankle arthritis is difficult to determine given the variations in degenerative change and clinical correlation. Cadaveric, radiographic, and clinical studies all have indicated that arthritis is less common at the ankle than it is at the knee or hip 1-3,52,53 . Epidemiological studies 54 have shown that 6% of the population is affected by arthritis of the knee and 10% of people older than sixty-five years of age are so affected. Although symptomatic ankle arthritis does occur, it is rare even in the elderly. In clinical practice 1-3 , eight to nine times as many patients are seen with a symptomatic knee than with a symptomatic ankle. It is estimated that total knee replacement is performed about twenty-four times more frequently than are ankle arthrodesis and arthroplasty combined 55 .


   Nonoperative Treatment
Top
 Introduction
 Pathophysiology and Epidemiology...
 Nonoperative Treatment
Operative Treatment
 Overview
 References
 
Conservative treatment for symptomatic ankle arthritis is limited, and there is a paucity of scientific reports and comparative studies on various nonoperative options. Most therapy starts with a combination of medications, orthotic devices, and footwear modifications. Nonsteroidal anti-inflammatory drugs may help to relieve the pain associated with arthritis, but their long-term use should be carefully monitored.

Intra-articular injection of corticosteroids is often used to decrease inflammation and pain 8 . Its efficacy in the arthritic ankle has not been studied, to our knowledge; most clinical studies have involved the knee 56-62 . The beneficial effects are often limited to a period of eight weeks 62 , with no difference between the effects of steroids and placebos over a longer time-period 61 . Side effects (although uncommon) are primarily infection and local skin reactions such as depigmentation at the injection site 63 . To date, repeated corticosteroid injections seem to have no serious deleterious effect on articular cartilage 63,64 .

Arthritic pain may also be managed by modifying footwear and/or applying a brace 65 . Adding a rocker-bottom sole and a solid ankle cushion heel (SACH) to the shoe improves forward progression of the tibia during gait and helps to normalize the gait pattern 18 . A polypropylene ankle-foot orthosis or a lace-up ankle support may also help, particularly when the arthritic joint is unstable and/or in axial malalignment. A trial period of immobilization in a walking plaster cast can produce the feeling of a fused ankle. Reducing ankle motion helps to alleviate pain, but orthotic devices cannot eliminate the axial forces during the stance phase of gait 66 .

Modifying or terminating vigorous activities such as sports and changing to a more sedentary job may make symptoms more manageable. Obese patients should be counseled about the importance of losing weight. Weight loss decreases the reactive forces within the arthritic joint and alleviates pain. Moreover, it improves the effectiveness of both conservative and surgical options 67 .


   Operative Treatment
Top
 Introduction
 Pathophysiology and Epidemiology...
 Nonoperative Treatment
 Operative Treatment
Overview
 References
 
Conditions amenable to a surgical débridement are impinging osteophytes, loose bodies, and chondral defects. Débridement can be achieved through an open approach, but arthroscopy is the more common choice 68 . Results are satisfactory when the arthritis is slight or when an isolated osteochondral lesion of <1 cm in diameter is débrided. Débridement is not indicated for advanced arthritis, joint-space narrowing, marked fibrosis, or deformity 69,70 .

Articular distraction of the ankle joint with an external fixation device 71-75 recently has been advocated for severe end-stage arthritis in patients who are candidates for arthrodesis. The procedure involves application of a ringed external fixator to the distal part of the tibia and the foot after open or arthroscopic débridement. The joint is distracted a total of 5 mm, in daily 1-mm increments. Weight-bearing is allowed, and hinges are applied to the fixator at six to twelve weeks to allow ankle flexion and extension. The fixator is removed at an average of fifteen weeks after application. Marijnissen et al. 75 reported on forty-six patients followed for an average of 2.8 ± 0.3 years. Thirteen patients withdrew from the study and underwent an arthrodesis. The remaining patients reported a significant reduction in pain (p < 0.0001) and improvement in function (p < 0.0001) and their clinical condition (p < 0.0001). The range of motion of the ankle improved but not significantly. Radiographically, the joint space had increased by 17% at the time of the one-year follow-up and 27% at the time of the third-year follow-up (p < 0.05). The functional and clinical outcome scores were significantly better at the time of the three-year follow-up compared with those at the time of the one-year follow-up (p < 0.05), suggesting that the clinical picture improved with time.

Acevedo and Myerson 76 reported on a group of nine patients who had undergone débridement and acute distraction (average, 5.8 mm; range, 4.5 to 8 mm). The fixator was removed at an average of eleven weeks. Only three patients reported functional improvement at the one-year follow-up examination, and three underwent arthrodesis of the ankle at an average of twelve months after the distraction procedure. While this treatment holds promise, data supporting a successful outcome are limited to the experience of a single group of physicians.

Occasionally, supramalleolar osteotomy of the tibia is considered to manage ankle arthritis 77-79 . Indications are limited to partial joint involvement, fracture malunion, or axial malalignment. Clinical studies to date have been retrospective and have involved a small number of patients; thus, general conclusions on the efficacy of this procedure cannot be ascertained from the current literature.

Ankle Arthrodesis
Indications
Debilitating posttraumatic arthritis is the most common indication for arthrodesis 65,80-82 . Arthrodesis is also indicated for pain and deformity secondary to previous infection, osteochondral defects, osteonecrosis of the talus, osteoarthritis, inflammatory arthropathies, and rheumatoid arthritis. Historically, surgery for neuropathic ankle arthropathy with deformity was discouraged because of an unacceptably high pseudarthrosis rate followed by recurrence of the deformity 83 . More recently, successful reconstruction and fusion have been achieved with use of modern methods of internal fixation 84-87 . Since the advent of total ankle replacement, arthrodesis is used to salvage failed arthroplasties 88-90 . It is rarely indicated as primary salvage following trauma 91 .

Operative Techniques
Arthrodesis can be done with numerous techniques and approaches. Methods of stabilization vary and include external fixation; internal fixation with screws, plates, and onlay or dowel bone grafts; and cast fixation alone 92 . In 1951, Charnley developed a major technical innovation: application of compression across the arthrodesis site 93 . While experts do not concur on the best method of fixation, technical advances have led to increased use of internal fixation rather than external fixation 6,7,9,80,81,94 . Internal fixation achieves a higher rate of fusion with fewer complications and without the inconvenience of an external device 9,10 . Moeckel et al. 10 evaluated a group of sixty-six patients who had undergone a total of sixty-eight ankle arthrodeses, forty of which were stabilized with internal fixation (group 1) and twenty-eight of which were stabilized with external fixation (group 2). The two groups were similar with regard to age, gender, the reason for the arthrodesis, and the final position of the fused ankle. The rate of complications, including nonunion, delayed union, stress fracture, infection, and delayed wound-healing, was 61% (seventeen of twenty-eight) in group 2 and 28% (eleven of forty) in group 1. The nonunion rate was 21% (six of twenty-eight) in group 2 compared with 5% (two of forty) in group 1. Infections, mostly related to the pin tracks, developed in five of the twenty-eight ankles managed with external fixation and in none of the forty managed with internal fixation.

Biomechanical studies have demonstrated that internal fixation provides more stability against both rotational and sagittal forces than does an external compression device 95 . External fixation has a role in the treatment of active infections, open wounds, and situations in which compression screws would not provide adequate purchase (e.g., severely osteopenic bone). Another advantage of external fixation is that positional and compressive adjustments can be made postoperatively.

Studies comparing screw and plate fixation have shown an improved rate of union with screws 6,7,9,80,81,96 . Screw fixation can be obtained with less soft-tissue stripping, and that factor combined with better compression at the fusion site may account for the better fusion rate. Holt et al. 7 described a technique involving fixation with three screws, with preservation of the medial and lateral malleoli. A fibular osteotomy is performed and, after denuding of the cartilage, the fibula is secured to the tibia and talus with compression screws. A second screw is placed from the medial malleolus into the talus, and then a third screw (the so-called home-run screw) is inserted from the posterior malleolus into the neck of the talus. This screw is of primary importance as it stabilizes plantar flexion and dorsiflexion forces ( Figs. 1-A , 1-B , 1-C , and 1-D ). Laboratory studies have shown that two crossed screws create a more rigid construct than two parallel screws 94 . Cadaveric studies have shown that the use of three screws has the advantage of increased compression and better resistance to torque 97 . These variations aside 6,7,80,81,96,97 , most surgeons would agree that a minimum of two screws is necessary for adequate stability.



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  		Fig. 1-A: Fig. 1-A Anteroposterior radiograph of an arthritic ankle that had a history of recurrent sprains, joint-space narrowing, subchondral sclerosis, and subchondral cysts.

 


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  		Fig. 1-B: Fig. 1-B Lateral radiograph of the same ankle. The talus has translated forward as a result of chronic instability.

 


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  		Fig. 1-C: Fig. 1-C Anteroposterior radiograph of a fused ankle in which the fibula was used as a lateral support. The syndesmosis was fused, and the distal portion of the medial malleolus was excised to help to prevent malleolar impingement against the shoe. The lateral, middle, and medial columns of the talus were used for fixation (a three-column technique).

 


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  		Fig. 1-D: Fig. 1-D Lateral radiograph of the fused ankle. The talus was properly positioned in the sagittal plane. Neutral dorsiflexion of the foot is recommended. The posteroanterior ("home-run") screw helps to stabilize the talus against forces in the sagittal plane (plantar flexion-dorsiflexion). This screw can also be placed from the posteromedial side of the tibia, making it easier to remove.

 
Stability can be improved further by adding a fibular strut graft 98 , and the use of a T-plate has been shown to provide a stiffer construct than other types of fixation, but it requires more soft-tissue dissection 99,100 .

Optimal Position for Ankle Fusion
The optimal position for ankle fusion, which has been well defined, is neutral dorsiflexion, 5° of hindfoot valgus, and external rotation comparable with that of the contralateral extremity. The talus should be translated posteriorly with regard to the tibia 101 . The gait mechanics of a fused ankle have been evaluated in several studies. King et al. 102 demonstrated that an ankle fused in neutral causes an average of 10° of plantar flexion to occur through the midfoot at heel strike. This approximates the normal ankle and produces a relatively normal barefoot gait pattern. If the ankle is fused in equinus, midtarsal motion cannot compensate since these joints do not normally dorsiflex past neutral. The equinus position prompts a premature heel rise during the stance phase, creating a vaulting gait. (A shoe with a slightly elevated heel can compensate for this gait abnormality.) Hefti et al. 103 also recommended a fusion in neutral in the sagittal plane. In addition, they recommended shifting the talus backward and fusing it in 5° to 10° of external rotation to reduce the lever arm of the foot, allowing mild push-off by pronation through the subtalar complex. Current opinion is that a neutral position best utilizes midfoot motion to simulate the normal ankle, thus yielding the best functional outcome.

Gait analysis of patients with a fused ankle has shown (1) decreased knee flexion before heel strike; (2) less time in single-limb stance; (3) reduced sagittal ground-reaction force, which is important only with barefoot walking; and (4) increased external rotation when the ankle is fused in equinus. There is decreased time between heel-off and toe-off and an elevation of the center of gravity during stance with an abrupt depression at terminal stance 102-105 .

In 1979, Mazur et al. 106 concluded that for a fused ankle to function well, compensatory movement should occur at the midfoot, the contralateral ankle should be normal, and appropriate shoes should be worn. Arthrodesis does not substantially alter the gait pattern: gait efficiency is decreased by only 10% compared with normal. A fused ankle requires 3% greater energy expenditure than its normal counterpart at a similar pace of walking 107 .

Wu et al. 104 studied the effects of arthrodesis on gait from the perspective of three-dimensional kinematics of the foot and ankle. They found that sagittal hindfoot movement decreased, but sagittal forefoot movement and transverse hindfoot and forefoot movements increased. Altered electromyographic activity in the soleus muscle tended to increase eversion during stance. The authors did not attempt to make any clinical correlations in this detailed study.

Results and Complications
Good functional outcomes with low complication rates can now be achieved with arthrodesis 6,80,81,106,108 despite previous reports of high rates of infection, nonunion, and amputation 109-111 . A direct comparison of techniques is difficult because of differences in patient populations and surgical methods. Chen et al. 6 reviewed the results of arthrodesis performed with internal compression by means of crossed screws in forty-two ankles in forty relatively young patients (mean age, forty-nine years). Only one nonunion and two infections were recorded, and the functional result was excellent or good in thirty-six cases. These results concurred with those of Morgan et al. 81 , who reviewed the results of 101 fusions performed with the same method and reported a pseudarthrosis in five patients (all of whom had a sensory deficit), a superficial infection in one, and a deep infection in one. The clinical result was good or excellent in 90% of the patients. Most of the unsatisfactory results were related to a nonunion or symptomatic arthritis of the ipsilateral foot 80 . Interestingly, Morgan et al. found no association between the radiographic evidence of the arthritis and the severity of the symptoms.

Functional assessment of patients with rheumatoid arthritis is difficult because of the generalized nature of the disease. However, pain relief from a successful arthrodesis permits a certain level of function 112 . Recent studies have shown the satisfaction and union rates following ankle arthrodesis in patients with rheumatoid arthritis to be comparable with those of patients with osteoarthritis 113,114 .

The most common complications of ankle arthrodesis are nonunion, malunion, and infection. Others include neurovascular injury, stress fracture of the tibia, and subsequent development of arthritis at other joints of the hindfoot and midfoot. Reported rates of nonunion have ranged from 0% to 41% 9,115 . These rates have steadily declined with the use of rigid internal compression, and the union rate has been >90% in most recently reported clinical series 9,81,116,117 . Factors associated with nonunion include infection, tobacco use, impaired vascularity, neuropathy, osteonecrosis of the talus, malalignment, poor technique, and postoperative noncompliance 118,119 . The link between smoking and nonunion is well recognized. A case control study that compared twenty-two patients with a nonunion following an ankle arthrodesis with twenty-two who had a successful ankle arthrodesis showed that the relative risk of nonunion was nearly four times greater in patients who smoked at the time of surgery 118 .

Pain developing months or years following a fusion may be related to a tibial stress fracture 120 , which usually occurs in the middle to distal third of the bone. The etiology is multifactorial: stress-risers caused by the internal fixation at the tibial insertion site, increased forces transmitted to the tibia from a longer lever arm of a more rigid foot, osteopenia, a malpositioned hindfoot, and other underlying osseous disease can all play a role.

In the past, investigators reported good clinical outcomes of arthrodesis, and satisfactory outcomes, compared with those of alternatives such as the first generation of total ankle arthroplasties, were widely expected 121 . However, most of the investigators reported only the intermediate-term results, and few utilized validated methods to assess functional outcomes 12 . On critical analysis, long-term outcome studies have uniformly demonstrated progressive arthritis associated with restricted motion of the subtalar joint complex 11,12,106,111,122-125 .

Takakura et al. 108 evaluated forty-two patients (forty-three fused ankles) who had been followed for an average of seven years and two months. They identified progression of subtalar arthritis in thirteen cases and noted that patients with pre-existing arthritis were at increased risk for radiographic signs of progression. Coester et al. 11 reviewed the results of isolated ankle fusion in twenty-three patients followed for an average of twenty-two years. They found a substantial increase in arthritis in the joints of the ipsilateral foot compared with that found on the unaffected side. Most patients were functionally limited by foot pain resulting from the arthritic joints surrounding the fused ankle. Interestingly, the ipsilateral knee was unaffected. Clinical studies that have focused on the sagittal (dorsiflexion-plantar flexion) arc of motion of the midtarsal (Chopart) joints have shown variable results: some have demonstrated increased motion 81,106,108,122,125 and some, decreased or unchanged motion 111,123,126,127 .

Patients with a fused ankle and progressive arthritis of the ipsilateral hindfoot have few alternatives, and increasing stiffness of the foot and additional arthrodesis of the arthritic joint or joints is the likely outcome. Recent studies employing gait analysis and validated functional outcome measures to study patients with isolated ankle fusion have demonstrated that even the most satisfied patients have major physical limitations compared with healthy controls 128 . Despite the high level of satisfaction with the results of arthrodesis, it is a salvage procedure with limitations 11,12,111,124,125 . If the expected outcome of treatment of end-stage arthritis is restoration of normal physical function, then preservation of ankle motion is essential.

Total Ankle Replacement
First-Generation Total Ankle Arthroplasties
The development of and enthusiasm for total ankle arthroplasty have evolved over the past several decades. Beginning in the 1970s, approximately twenty-three different types of ankle arthroplasties have been developed 129 . Disappointing outcomes were largely attributed to flaws in the design of both the tibial and the talar component 130 —namely, excessive bone resection, poor instrumentation, inaccurate positioning of the implant, improper soft-tissue balancing, and poorly designed implants (such as non-metal-backed components and excessively thick components) ( Figs. 2-A and 2-B ).



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  		Fig. 2-A: Fig. 2-A Anteroposterior radiograph of a failed first-generation total ankle replacement. The tibial component is not metal-backed, and both components were stabilized with cement. There is extensive osteolysis on both the tibial and the talar side. The talar component subsided proximally, causing the malleoli to become prominent and thus making shoe wear difficult. The talar component subsided into the talar body. Both components tipped into varus.

 


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  		Fig. 2-B: Fig. 2-B Lateral radiograph, which emphasizes the subsidence of the talar component. The horizontal axis of the ankle joint migrated proximally, further restricting motion and increasing forces on the components. This ankle will be difficult to salvage because of the lack of bone stock, particularly in the talar body directly distal to the talar implant.

 
Even if the replacement survived the first two years of use, several clinical difficulties remained. First, given that the ankle joint is made up of three articular surfaces—medial, superior, and lateral—persistent pain at the lateral talofibular articulation was not uncommon. Second, obtaining a functional range of ankle dorsiflexion continued to be difficult. Third, despite reports of a pain-free gait, arthroplasties were not capable of normalizing gait kinetics or kinematics 17,131 .

Several investigators evaluated the effects of the first-generation total ankle arthroplasties on gait mechanics. Demottaz et al. 131 assessed the results of twenty-one arthroplasties in nineteen patients, and Stauffer et al. 17 compared six patients who had had a total ankle replacement with five healthy men with no history of ankle disease (average age, twenty-five years). The findings of the two studies were similar: (1) patients were not bearing weight normally across the reconstructed ankle joint, (2) they were not utilizing the normal range of dorsiflexion during the stance phase, and (3) they were protecting the ankle from excessive stress, apparently subconsciously since none complained of pain during the gait analysis and most demonstrated a greater range of ankle dorsiflexion on physical examination than they did during gait. Both groups of investigators concluded that the objective outcomes of arthroplasty were not equivalent to the subjective results.

The failure of the first-generation total ankle prostheses can be related to several problems with their design, including the need for a large amount of bone resection, a change in the level of the ankle axis, failure to produce normal ankle kinematics, an inability to correct abnormal angulations at the ankle joint level 16 , and a lack of attention to soft-tissue rebalancing (i.e., ligament reconstruction and Achilles tendon lengthening). The unacceptable clinical results led to the removal or discontinuation of many of the first-generation ankle implants 130,132,133 .

Second-Generation Total Ankle Arthroplasties
The high failure rate of the first-generation arthroplasties, particularly in light of the satisfactory intermediate outcomes of ankle arthrodeses, further restricted the use of total ankle replacement as an alternative treatment for end-stage arthritis. However, increasing success of arthroplasty of other joints such as the knee and hip along with concerns about the long-term outcomes of ankle arthrodesis 11 has renewed interest in ankle arthroplasty over the last decade. The new implants have been designed with attention to reproducing normal ankle anatomy, joint kinematics, ligament stability, and mechanical alignment. Two or three-component designs are used to allow for sliding and rotational motions at the ankle joint. The development of a prosthesis that would accommodate the three articulations of the ankle has proceeded in two strategic directions. The first is replacement of all three articulations (talofibular, tibiotalar, and medial malleolar-talar) along with a fusion of the distal tibiofibular syndesmosis 13 . The second is replacement of the superior articulation with hemiarthroplasties of the medial and lateral malleolar articular surfaces 15 . The newer prostheses have also included metal backing with a porous surface, allowing for biological fixation and thereby decreasing the amount of bone resection necessary for implantation.

Two-Component Design with Syndesmosis Fusion
The prototype of the two-component design is the Agility Ankle (DePuy Johnson and Johnson, Warsaw, Indiana). This is a complete resurfacing arthroplasty, meaning that the medial, lateral, and superior articular surfaces of the ankle joint are replaced. The articular surface of the tibial component is larger than that of the talar component. The lack of congruency between the tibial and talar articulations allows for both the sliding and the rotational motions that are necessary to reproduce normal ankle kinematics 12 . The distal tibiofibular syndesmosis is fused, and the articular cartilage of the fibula is excised. This allows the fibula to act as a lateral stabilizer and increases the osseous surface area for biologic fixation of the tibial component ( Figs. 3-A and 3-B ). The surgical technique requires application of an external fixator and distraction of the joint to help obtain appropriate axial alignment and to minimize bone resection. The implant is placed in approximately 20° of external rotation relative to the tibial axis; this allows for external rotation through the arc of dorsiflexion, which has been observed in the normal kinematics of the ankle during midstance 45 .



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  		Fig. 3-A: Fig. 3-A Anteroposterior radiograph of a two-component total ankle replacement. The syndesmosis was fused and was stabilized with a low-profile plate. The talar component is smaller than the corresponding talar surface, which increases the likelihood of subsidence. The tibial component is supported by both the medial malleolus and the fibula. This increases the surface area for osseous ingrowth and improves the stability of the component. Incorporating the medial and lateral malleoli allows for a total joint replacement of both the medial and the lateral articulation of the ankle.

 


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  		Fig. 3-B: Fig. 3-B Lateral radiograph showing that the two-component total ankle replacement involved minimal bone resection of the talus, which helps to maintain bone stock.

 
Pyevich et al. 13 reported the results of 100 semiconstrained Agility total ankle replacements. Forty-five were performed for posttraumatic arthritis; twenty-six, for rheumatoid arthritis; and twenty-six, for osteoarthritis. At the time of intermediate follow-up, at a mean of 4.8 years, 55% of the patients remained pain-free and the average range of motion was 36°. Radiographically, 24% of the components were found to have migrated, and 6% of the patients had undergone a revision procedure. Delayed union and nonunion of the syndesmosis were associated with an increased prevalence of lysis surrounding the tibial component ( Fig. 4 ). Patients with posttraumatic arthritis reported significantly more pain at the time of follow-up than did those with primary or rheumatoid arthritis (p < 0.05).



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  		Fig. 4: Osteolysis surrounding the tibial component of a two-component total ankle replacement. In the series by Pyevich et al. 13 , ballooning lysis around the tibial component was observed in eighteen (64%) of twenty-eight ankles with a nonunion of the syndesmosis and in seventeen (28%) of sixty-one ankles with a solid fusion of the syndesmosis.

 
Despite the early encouraging results of replacement with the Agility prosthesis, migration of the prosthesis as noted on radiographs has raised concerns 13 . Successful fusion of the syndesmosis is essential for stability of the tibial component, and this has prompted use of a low-profile distal fibular plate with the syndesmosis screws placed through the plate 134 as a means of enhancing fixation and consolidation of the syndesmosis ( Figs. 3-A and 3-B ). Conversion of a three-bone ankle joint to a two-bone joint does require greater bone resection than does use of the more anatomic designs 12 . The incongruent configuration of this prosthesis necessitates the use of a talar component that is smaller than the natural talus, and this may lead to increased contact stress at the talar component-bone interface. In addition, the mismatch between the talar and tibial components may increase transmission of shear forces to the metal-polyethylene and metal-bone interfaces. This point was demonstrated by Michelson et al., who analyzed ankle motion in loaded cadaveric limbs, both in the intact state and with an implanted unconstrained Irvine total ankle replacement 135 . They found that the average sagittal motion of the prosthetic ankle was similar to that of the intact cadaveric ankle, but normal ankle motion was not restored by the unconstrained prosthesis. In the normal ankle, dorsiflexion-plantar flexion is a coupled motion: the talus rotates in the transverse plane as it flexes and extends in the sagittal plane (biplanar joint mechanics). The two motions are coupled, meaning that the magnitude of rotation is the same through the arc of dorsiflexion and plantar flexion; the rotations are just in opposite directions. In the incongruent prosthetic ankle, the direction and magnitude of rotation differed significantly through the arc of dorsiflexion and plantar flexion (p < 0.05), creating hysteresis in the curve of coupled axial plane motion. The authors theorized that this uncoupled rotation of the talar implant increases contact stresses and could account for premature failure of the arthroplasty.

Three-Component Design
The three-component implants have a more anatomic design and require less bone resection than the two-component designs. There are two metal components: the superior component consists of a flat tibial tray, and the inferior component is an anatomically designed talar dome that sits on top of a resurfaced talar body. Both have a porous backing and rely on biologic fixation (osseous ingrowth). A mobile polyethylene bearing sits between the two metal components, with a flat articulation at the tibial interface and a circular articulation with a central groove at the talar interface. The superior tibiotalar articulation is completely resurfaced on both the tibial and the talar side. On either side, a hemiarthroplasty is performed by leaving the articular surfaces of the medial and lateral malleoli intact and resurfacing only the corresponding articular surfaces of the talus ( Figs. 5-A and 5-B ).



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  		Fig. 5-A: Fig. 5-A Anteroposterior radiograph of a three-component total ankle replacement. There is minimal bone resection of the tibia and talus. The medial and lateral articulations of the ankle are replaced only on the talar side (hemiarthroplasties). The polyethylene consists of a mobile bearing insert ranging in thickness from 6 to 10 mm.

 


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  		Fig. 5-B: Fig. 5-B Lateral radiograph demonstrating proper orientation of the tibial and talar components. The tibial implant is surrounded by sclerosis, as it is in many of these total ankle replacements, a reaction that may help to prevent subsidence of the component.

 
The three-component design allows for flexion and extension at the talar-meniscal interface with rotation and sliding at the tibiomeniscal interface. Advantages of this design are improved congruency, multiplanar motion, and minimal bone resection. Disadvantages are the potential for dislocation of the mobile bearing, persistent pain at the medial and lateral articulations, and the necessity for a tight implant fit to prevent instability of the mobile bearing. A tight fit can lead to abnormal strains on the ankle ligaments and also prevent sufficient rotational motion at the tibiomeniscal interface, both of which can increase the forces being transferred to the implant-bone interface 12 .

Kofoed and Lundberg-Jensen 14 reviewed the status of 100 cemented and uncemented Scandinavian total ankle replacements (STAR; Waldemar Link, Hamburg, Germany) implanted between 1981 and 1996. The goal was to compare prosthetic survivorship between patients younger than fifty and those fifty years of age or older. The duration of follow-up ranged from one to fifteen years, with an average of six years. The implant survival rate was 75% in the younger group (median age, forty-six years) and 80.6% in the older patients (median age, sixty-three years). The difference was not significant (p > 0.05). The authors concluded that the Scandinavian prosthesis was a viable option for patients younger than fifty years of age.

The results of a seven-year multicenter study of 131 uncemented Scandinavian prostheses implanted between 1990 and 1996 were discussed at the First International Congress of Ankle Arthroplasty in Copenhagen on June 20 and 21, 1997 136 . The study involved six institutions in six European countries and included sixty-eight ankles with rheumatoid arthritis and sixty-three with osteoarthritis. The functional status was assessed with the Kofoed ankle score system. The minimum duration of follow-up was one year, and the average duration was twenty-six months. The overall failure rate was 10%, and all of the failures occurred within two years after the surgery. Although preliminary, the results were promising as long as the implant did not fail in the first two years. Early failure was attributed to technical errors and reflected the steep learning curve of total ankle arthroplasty.

Patient Selection
Initially, the indications for the first generation of ankle arthroplasties were broad and included patients of all ages and diagnoses. These indications rapidly narrowed 121,130,137-139 because of the poor intermediate-term results and high complication rates. The clinical indications for and the efficacy of the second-generation arthroplasties have yet to be determined. The general principles of arthroplasty in lower-extremity joints such as the hip and knee should be applied to the ankle. Determination of the clinical indications for ankle arthroplasty should be influenced by (1) the results of intermediate and long-term follow-up studies, (2) comparison of results with those of other treatment options (i.e., arthrodesis), and (3) the feasibility of salvage after failure. At present, total ankle arthroplasty should be performed in a young active patient with symptomatic arthritis only if there is no other reasonable alternative 140,141 .

The contraindications are better defined; they include active or recent infection, neuropathic joint disease (Charcot arthropathy), osteonecrosis of the talus, severe malalignment, vascular impairment, a compromised soft-tissue envelope, severe joint laxity, and neurological dysfunction of the lower limb.

Complications
Ankle arthroplasty has numerous complications other than loosening of the implant. The most common are delayed wound-healing, skin necrosis, and deep infection. In many patients, ankle arthritis is a result of previous trauma with a compromised soft-tissue envelope or is the result of systemic disease such as an inflammatory arthropathy associated with long-term corticosteroid use.

The following requirements must be met or at least considered for optimal results.

1. Meticulous attention must be paid to the soft tissues and careful closure of the extensor retinaculum to maintain its function as a protective layer 141 .

2. Attention must be given to alignment of the limb and foot. A full-length radiograph helps to identify major malalignment of the lower limb. On occasion, deformities at the hip or knee may need to be addressed first. Malalignment of the distal part of the tibia of >10° may require a supramalleolar osteotomy prior to the ankle arthroplasty 141 . If the implant is not oriented parallel to the ground, asymmetric loading will occur, leading to early failure.

3. Attention must be paid to substantial hindfoot deformities. A hindfoot alignment radiographic view helps to identify varus or valgus deformities of the hindfoot 142 . These must be corrected with osteotomies or arthrodeses in association with the arthroplasty.

4. Ankle dorsiflexion must be carefully assessed after the arthroplasty. If the foot is not capable of 5° of dorsiflexion, Achilles tendon lengthening is required. The range of ankle dorsiflexion must be assessed with the knee in extension and the hindfoot in neutral (i.e., with the calcaneus aligned with the tibia) 141 .

5. Attention must be given to ligament imbalance of the ankle. This must be assessed and addressed at the time of the arthroplasty, particularly when there is a history of long-standing varus or valgus deformities at the ankle and/or subtalar joints.

Salvage
Salvage of a total ankle arthroplasty that has failed and/or become complicated by infection is a tremendous challenge. Failure is likely to be associated with loss of bone stock, malalignment, wound breakdown, infection, or a combination of these problems 141 ( Figs. 2-A and 2-B ). First and foremost, the component should be removed and the infection, if present, eradicated. Then there is a choice of three treatment options: revision arthroplasty, arthrodesis, or below-the-knee amputation 88,143,144 . Arthrodesis may be the only option after implant removal, particularly when the bone stock is not sufficient to support a new prosthesis. The goals of arthrodesis are to maintain and restore limb length and to correct malalignment. A variety of internal and external fixation techniques may be utilized, and bone graft may be required to restore limb length 89,143,144 . Salvage procedures are associated with a high risk of failure and morbidity. Very little information on revision arthroplasty is currently available.

Future Trends in Total Ankle Replacement
Intermediate clinical results of the second-generation arthroplasties are promising. However, the unique physiological and mechanical characteristics of the ankle joint remain a challenge. Both the clinician and the scientist face a daunting task when considering treatment alternatives other than an arthrodesis for end-stage ankle arthritis and/or deformity. The ankle joint is the primary articulation responsible for the transmission of forces from the ground to the remainder of the lower extremity. It accepts two to three times the forces experienced by the hip or the knee but has only one-third the surface area to dissipate the load. Moreover, there is far less bone stock available for implantation of a prosthesis in the ankle than in the hip or knee. Stability of an ankle implant is paramount for its success; however, given the large forces distributed through the ankle joint during gait, it is difficult to obtain and maintain ligamentous support once it has been lost. Salvaging a failed ankle arthroplasty will continue to be difficult because of the sparse soft-tissue envelope and limited bone stock. There will be clinical scenarios in which an ankle arthrodesis provides a more predictable outcome or an ankle arthroplasty is contraindicated. Several questions remain to be answered: (1) Will the functional outcomes of total ankle arthroplasty surpass those of ankle arthrodesis? (2) Will the motion attained following total ankle arthroplasty protect the ipsilateral subtalar joint complex from arthritis? (3) What will be the survival rates of the newer ankle replacements? The challenge in the future will be to clearly define the indications and contraindications for total ankle replacement.


   Overview
Top
 Introduction
 Pathophysiology and Epidemiology...
 Nonoperative Treatment
 Operative Treatment
 Overview
References
 
Surgical management of symptomatic ankle arthritis, particularly in a young, active individual with posttraumatic arthritis, is a challenge. The difficulty in choosing between arthrodesis and arthroplasty remains, and the current literature provides little to clarify the situation. The intermediate results of second-generation total ankle arthroplasties have been substantially better than the results of the first-generation replacements. It is noteworthy that objective analysis of first-generation arthroplasties 17,131 has helped to predict their eventual short-term failure. The clinical effectiveness of second-generation arthroplasties is yet to be determined and will depend on how the functional long-term results compare with those of arthrodesis. Future studies with an emphasis on objective analysis of early clinical results should define and delineate the role of total ankle arthroplasty.


   References
Top
 Introduction
 Pathophysiology and Epidemiology...
 Nonoperative Treatment
 Operative Treatment
 Overview
 References
 

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