JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Rhys Thomas, Tim R. Daniels, and Kim Parker
Gait Analysis and Functional Outcomes Following Ankle Arthrodesis for Isolated Ankle Arthritis
J Bone Joint Surg Am 2006; 88: 526-535 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr. Daniels responds to Dr. Jones
Tim R. Daniels, M.D., FRCSC   (21 March 2006)
[Read Letter to the Editor] Does ankle fusion cause foot arthritis?
Gary S. Jones, M.D.   (13 March 2006)

Dr. Daniels responds to Dr. Jones 21 March 2006
Previous Letter to the Editor Top
Tim R. Daniels, M.D., FRCSC,
Orthopaedic Surgeon
Associate Professor, University of Toronto, CANADA

Send letter to journal:
Re: Dr. Daniels responds to Dr. Jones

danielst{at}smh.toronto.on.ca Tim R. Daniels, M.D., FRCSC

I thanks Dr. Jones for his letter. Please note that the conclusion of our paper was that ankle fusion neither normalizes function nor does it create disability. However, all the patients in our study felt that they were better off after the ankle fusion.

Comparing one handicapped group to another does not help determine the short-comings of a treatment intervention. As orthopaedic surgeons our ultimate goal should be to normalize function; it is my personal belief that this can only be achieved by preserving motion.

The reason for our strict inclusion criteria was to make the two groups as comparable as possible. Those patients that had substantial ipsilateral arthritis requiring surgical fusion were excluded. Please note that our radiographic follow-up focused on progression of ipsilateral hindfoot arthritis. I agree with Dr. Jones that the natural history of the ipsilateral hindfoot joints in the presence of ankle arthritis is unknown - this area requires further study. However, I would caution against advising patients that ‘the progression of ipsilateral hindfoot arthritis is due to the pre-existing disease’ – to date this conclusion is based on anecdotal information.
Does ankle fusion cause foot arthritis? 13 March 2006
Next Letter to the Editor Top
Gary S. Jones, M.D.,
Orthopaedic Surgeon
Concord Orthopaedics, P.A., Concord, NH

Send letter to journal:
Re: Does ankle fusion cause foot arthritis?

gary.jones{at}concordortho.com Gary S. Jones, M.D.

To The Editor:

I disagree with the conclusion of the authors that ankle fusion “creates disability with regard to foot and ankle function.” This is a statement oft repeated in the orthopaedic literature that sounds reasonable but must be challenged.

Comparing patients with ankle arthritis to a normal patient with regard to the development of mid and hindfoot arthritis or gait analysis is not a fair comparison. Patients with even “isolated” ankle arthritis due to trauma or primary arthritis when viewed retrospectively, cannot be said to have normal subtalar or midfoot joints. This is true for the present study as well as the retrospective study of Said, et.al.(1) These patients have often had internal or external fixation and/or had prolonged casting. In addition, after trauma, though the radiological injury may be limited to the ankle, there are often unrecognized subtalar or midfoot injuries. In my twenty-seven years of othopaedic practice, it is rare to see a patient with debilitating ankle arthritis who has normal subtalar motion.

A proper study of this question would require the comparison of patients with ankle arthritis who were not treated with fusion with those who were. Or perhaps it would be helpful to do a prospective study of patients with ankle fusion compared to patients with total ankle with regard to development of arthritis in the hindfoot and midfoot.

I have no quarrel with the concept that patients with ankle fusion have more impairment than normal. However, we don’t operate on normal ankles. The cogent point for our patients is that well done fusions reduce disability. While I do tell my patients that they may later be troubled with arthritis in the foot, even to the point of requiring further surgery (rare), I believe this is most often due to preexisting disease. I choose to emphasize that we are making a bad situation much better.

References:

1. Said E, Hunka L, Siller TN. Where ankle fusion stands today. J Bone Joint Surg Br. 1978;60:211-4.