Aims. Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens. Patients and Methods. MEDLINE, Web of Science, Embase, and Scopus databases were searched for studies reporting outcomes following ankle arthrodesis, in which standardized postoperative rehabilitation regimens were employed. Eligible studies were grouped according to duration of postoperative nonweightbearing: zero to one weeks (group A), two to three weeks (group B), four to five weeks (group C), or six weeks or more (group D). Outcome data were pooled and compared between groups. Outcomes analyzed included union rates, time to union, clinical scores, and complication rates. Results. A total of 60 studies (2426 ankles) were included. Mean union rates for groups A to D were 93.2%, 95.5%, 93.0%, and 93.0%, respectively. Mean time to union was 10.4 weeks, 14.5 weeks, 12.4 weeks, and 14.4 weeks for groups A to D, respectively. Mean complication rates were 22.3%, 23.0%, 27.1%, and 28.7% for groups A to D, respectively. Reporting of outcome scores was insufficient to conduct meaningful analysis. Conclusion. Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative nonweightbearing, although the existing literature is insufficient to make definitive conclusions. Cite this article: Bone Joint J 2019;101-B:1256–1262

Aims. Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. Methods. We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function. Results. The union rate for Group A was 81% (17/21) while it was 84.6% (33/39) for Group B. All the nonunions in Group A underwent revision with an open technique and achieved 100% union. Mean duration of IRF was 71.5 days (59 to 82) in Group A and 69 days (64.8 to 77.7) in Group B. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was similar in both groups. The postoperative hospital stay was shorter in Group A (21 days (SD 8)) than Group B (28 days (SD 9)). In the latter Group there were more problems with wound healing and greater requirement for antibiotic treatment. The mean operating time was 40 minutes (SD 9) in Group A compared to 80 minutes (SD 13) in Group B. Recurrence of infection occurred in 19% (4/21) and 15.5% (6/39) for Group A and Group B respectively. Conclusion. We found CAA using an IRF to be an effective method for ankle arthrodesis in infected neuropathic foot and ankle cases and afforded comparable results to open methods. Due to its great advantages, Ilizarov method of CAA should always be considered for neuropathic ankles in suitable patients. Cite this article: Bone Joint J 2020;102-B(4):470–477

Introduction. Arthroscopic ankle fusion is an effective treatment for end stage ankle arthritis. It reliably improves pain but at the expense of ankle motion. Development of adjacent degenerative joint disease in the foot is thought to be a consequence of ankle fusion due to altered biomechanics. However, it has been reported to be present on pre-operative radiographs in many patients. There is very little evidence reporting the long-term outcomes of patients undergoing arthroscopic ankle fusion and particularly those requiring secondary procedures for adjacent joint disease. Material and methods. We reviewed the operative records of 149 patients who had undergone arthroscopic ankle fusion under the care of two consultant foot and ankle surgeons between 2002 and 2006. We contacted patients by telephone to determine whether they had required further investigation or surgery on the same foot after their index procedure. Secondary outcome measures included a Manchester Oxford Foot Questionnaire (MOQFQ) score and a patient satisfaction score. Results. 149 patients underwent 151 arthroscopic ankle fusions. Nine had died or developed dementia and 30 patients had incomplete hospital records leaving 111 available for follow-up with a response rate of 55% (65 ankles). The average time to follow-up was 12.0 years (9.5–16.6 years). 14 patients (22%) had undergone a secondary procedure including injections on the foot or ankle of the same side as the index procedure. Four of these procedures were arthrodeses and three of these were of the subtalar joint. Mean MOQFQ score was 18.0 (0–55). Overall 83% (54) patients were very satisfied or satisfied with their ankle fusion. Conclusions. Arthroscopic ankle arthrodesis results in high patient satisfaction rates at long-term follow-up. The number of patients requiring a secondary procedure due to ongoing pain and adjacent degenerative joint disease in their foot following ankle arthrodesis is low

We describe a surgical technique for ankle arthrodesis using an anterior approach to the ankle and internal fixation with an anteriorly-placed AO T plate. A total of 33 patients who had ankle arthrodeses have been followed retrospectively. Thirty-one (94%) of the ankles fused although two patients developed tibial stress fractures. Four patients had a superficial infection which did not prevent union. The surgical technique is simple, easily reproducible and gives excellent clinical results with a high rate of union

Aims

The surgical management of ankle arthritis with tibiotalar arthrodesis is known to alter gait, as compared with normal ankles. The purpose of this study was to assess post-operative gait function with gait before arthrodesis.

Aims

A multicentre, randomized, clinician-led, pragmatic, parallel-group orthopaedic trial of two surgical procedures was set up to obtain high-quality evidence of effectiveness. However, the trial faced recruitment challenges and struggled to maintain recruitment rates over 30%, although this is not unusual for surgical trials. We conducted a qualitative study with the aim of gathering information about recruitment practices to identify barriers to patient consent and participation to an orthopaedic trial.

Aims

The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique.

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)).

Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion.

These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief.

Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited.

Cite this article: Bone Joint J 2013;95-B:371–7.

One assumed function of Total Ankle Replacement (TAR) is that by maintaining ankle joint motion we can protect the other hind foot joints from further degredation. 1. However, there is no work to our knowledge that compares hindfoot outcomes between TAR and arthrodesis. Sokolowski et al. found that 68% of TAR patients had no radiological progression of subtalar arthritis after TAR, and 4% went on to fusion. 2. However, no evaluation of the other hindfoot joints was made and no comparison made to other treatment. We performed a retrospective review of all patients at our centre who had had a TAR or ankle arthrodesis since 2002. Case notes and imaging were reviewed and all instances of hindfoot treatment (injections or surgical procedures) noted. Patients were excluded who had no documentation, were followed up at other hospitals, had prior hindfoot fusion, or were having staged surgeries at the time of index treatment. Chi squared analysis was used to compare the cohorts. 214 arthrodesis cases and 302 TAR were eligible. The average age was 57. Average time to follow up was 13 years (4–21). At the time of abstract submission 107 sets of notes had been reviewed fully. Full analysis will be performed by conference. 14% of TAR patients went on to have further procedures to the hindfoot joints while 35% of arthrodesis patients had further procedures (p=0.014). There was also a significant difference in the number of patients progressing to fusion of a further hindfoot joint between groups (TAR- 4%, arthrodesis- 20%, p=0.01). These data suggest that TAR are protective of symptomatic change of hindfoot joints. Patients with TAR had fewer hindfoot fusions than those with arthrodesis and also fewer procedures of any form, including injections

Background. Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods. A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm. 2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results. Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion. Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages

Background. The ability to return to physical activity is an important indicator of surgical success for end-stage ankle arthritis. There is paucity of literature comparing outcomes between surgical procedures. This study aimed to compare outcomes for physical activity and return to function between total ankle replacement (TAR) and ankle arthrodesis (AA) at 1-year follow-up. Methods. This was a single-centre prospective follow-up study. Patients who underwent TAR (n=33) or AA (n=25) between 2022–2023 completed questionnaires on FAOS scores (Pain, Symptoms, ADL and QOL domains), International Physical Activity Questionnaire (IPAQ), satisfaction scores and return to work/driving. IPAQ physical activities were compared across domains of work, transportation, domestic and leisure activities. Results. AA patients were younger (59.1 vs. 65.8). The AA group had better average FAOS scores for pain, symptoms, ADL, and QOL compared to TAR (51.2 vs. 29.2; 40.6 vs. 67.8, 46.8 vs. 66.4, 31.3 vs. 48.3) (p=0.526), but the TAR group reported higher overall satisfaction (77% vs. 66.6%). Earliest return to work was reported at 2 weeks (TAR) vs. 3 weeks (AA) group and driving at 3 weeks (TAR) vs. 4 weeks (AA). More TAR patients returned to vigorous (25%) and moderate (17.6%) physical activity versus AA (0% and 0%). For transport, 4 AA patients vs. 12 TAR patients returned to this activity. AA patients travelled 30 minutes to 2 hours per week, while TAR patients travelled 30 minutes to 5 hours. For household activities, 15.7% of TAR patients reported vigorous activity versus 0% in AA. AA patients spent less time on average leisure walking (1.25 hrs vs. 2 hrs), and more time sitting per day (9.2 hrs vs. 5.9 hrs). Conclusion. The TAR group demonstrated earlier return to work, driving, and higher levels of physical activity compared to AA patients at 1-year follow-up, despite the AA group having better FAOS scores

Introduction. Primary ankle arthroplasty (TAR) is increasingly used to treat end-stage ankle arthritis. Reported revision rates of TAR vary from 8.5% to 11.1% at 9 years. Revision surgery remains technically challenging with options ranging from simple joint debridement to tibio-talar-calcaneal fusion. The efficacy of these procedures remains unclear and there is no consensus on optimal revision options. Methods. A retrospective cohort study was performed of all patients undergoing surgery for a failed primary TAR at the Nuffield Orthopaedic Centre (2004–2021). TAR failure was determined by clinical assessment, serial radiographs and CT scans. Primary outcome measures included type and time of index surgery post TAR. Secondary outcomes included frequency of re-operations, post-operative complications, patient reported outcomes and union rate (for revision arthrodesis procedures). Results. 70 failed TARs in 69 patients (35M:34F, mean 65.7 years, s.d.=11.6) underwent re-operation a mean of 6.24 years (range 1–30) post primary. In total, 107 operations were performed including revision fusion (n=50), revision arthroplasty (n=14), bearing exchange (n=9) and joint clearance (n=9). The overall revision fusion union rate was 73.5% over a mean of 12.5 months (s.d.=7.6). 16/23 (69.6%) Tibio-Talo-Calcaneal and 9/12 (75%) ankle fusions (previous subtalar/triple fusion) using a hindfoot nail united over a mean 11.4 months (s.d.=6.0) and 15 months (s.d.=9.48) respectively. Only 64% of ankle fusions using screws alone united (mean=10.6 months, s.d.=8.14). The average post-operative MOXFQ score was 28.3 (s.d.=19.3). 73% said the operation improved their function and would recommend it to a friend/family member. Conclusion. Despite low post-operative MOXFQ scores, over 70% of patients were satisfied with re-operation for a failed TAR. Over 26% of all TAR revision fusions fail to unite with the highest non-union rates observed post ankle arthrodesis with screws alone (36.4%)

Background. Ankle arthrodesis results in significantly improved pain and function for patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity with reports of shorter hospital stays, time to union and equivalent union rates to open arthrodesis. However, there remains a lack of good quality prospective data. Methods. We report a prospective comparative clinical study comparing open and arthroscopic ankle arthrodesis at two institutions with two-year follow-up. The primary outcome was the Ankle Osteoarthritis Scale and secondary outcomes included the SF-36, hospital stay and radiographic alignment. A power calculation was performed. There were 30 patients in each group. Results. Both groups showed a significant improvement in AOS and physical component score (PCS) of the SF-36 at one and two years. There was a significantly greater improvement in AOS scores at one year and two years and shorter hospital stay in the arthroscopic group. There was no significant difference in complications, surgical time or radiographic alignment. Conclusions. Open and Arthroscopic Ankle arthrodesis demonstrate a significant improvement in pain and function as measured by the AOS. Arthroscopic arthrodesis showed improved outcomes at one and two years and a shorter hospital stay

Background. Total ankle replacement (TAR) design has evolved greatly in recent years and offers a reasonable alternative to ankle arthrodesis in a select patient population with end-stage arthritis. Originator series’ report good longevity and excellent patient reported outcomes (PROMs). We report our outcomes in an independent, non-inventor cohort. Method. We collected prospective data on consecutive patients undergoing total ankle replacement between April 2008 and March 2012, under the care of one Consultant Orthopaedic surgeon. The primary outcome measure was time to revision. Secondary outcomes measures included American Orthopaedic Foot and Ankle Society (AOFAS) scores, Visual Analogue Score (VAS) for pain, and complications. Results. 70 patients underwent TAR with a mean follow-up of 64 months (39–86). Three patients underwent revision of TAR to ankle arthrodesis, two for aseptic loosening and one for infection, equating to survivorship of 96%. Three patients sustained intra-operative fractures, one of the lateral malleolus and two of the medial malleolus. The patient who sustained the lateral malleolus fracture later went on to develop aseptic loosening requiring revision. One patient developed a late stress fracture of the medial malleolus. Two patients underwent open exploration, grafting of bone cysts and fixation for ongoing pain at a mean time of 4.5 years following the primary TAR. At the most recent review all patients reported improved AOFAS scores from 39.55 (21–52) to 82.10 (57–100) and VAS from 9.11 (6–10) to 1.79 (0–6) respectively. Conclusions. Longevity of the Zenith TAR in our non-inventor series is comparable to that of originator outcomes. Fractures are a recognized complication of TAR and when affecting the medial malleolus, do not appear to have an adverse effect on outcome. We feel that TAR offers an effective alternative solution to ankle arthrodesis with satisfactory relief of pain whilst preserving movement at the ankle joint

Background. Management of failed total ankle replacements (TAR) remains a difficult challenge. Ankle arthrodesis, revision TAR, debridement and amputation are all utilized as surgical options. The purpose of the study was to review a series of failed TAR surgically managed in our tertiary referral centre. Methods. A retrospective review of 18 consecutive failed TARs, either within or referred to our institution, which required surgical management were reviewed. The average age was 58.2 (range 25–77) with 11 males and 6 females. Results. The failed implants included eight Mobility TARs, five BOX TARs, four Salto Mobile TARs and one Biomet Ankle Replacement System. Reasons for failure of implant include aseptic loosening (8/18, 44%), talus collapse (3/18, 17%), poor function (3/18, 17%), heterotopic ossification (2/18, 11%), component migration (1/18, 6%) and infection (1/18, 11%). The average duration between index procedure and second procedure was 43 months (range 6–120). Five patients further required a third surgical procedure. Definitive surgical management included tibio-talar arthrodesis (7/18, 39%), revision TARs (5/18, 28%), debridement (4/18, 22%) and a below knee amputation (1/18, 6%). All the fusions subsequently went on to unite. Conclusions. The number of TARS being performed is increasing, so there is a need to successfully manage failed implants. Surgical options depend on the reason for implant failure, patient factors and surgical expertise. Salvage ankle arthrodesis remains favorable with high fusion rates. However revision TARs are evolving into a reliable treatment option. Further studies are required to directly compare these two modes of surgical management for failed primary TARS

Aims

This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

Aims. Few reports compare the contribution of the talonavicular articulation to overall range of movement in the sagittal plane after total ankle arthroplasty (TAA) and tibiotalar arthrodesis. The purpose of this study was to assess changes in ROM and functional outcomes following tibiotalar arthrodesis and TAA. Patients and Methods. Patients who underwent isolated tibiotalar arthrodesis or TAA with greater than two-year follow-up were enrolled in the study. Overall arc of movement and talonavicular movement in the sagittal plane were assessed with weight-bearing lateral maximum dorsiflexion and plantarflexion radiographs. All patients completed Short Form-12 version 2.0 questionnaires, visual analogue scale for pain (VAS) scores, and the Foot and Ankle Ability Measure (FAAM). Results. In all, 41 patients who underwent TAA and 27 patients who underwent tibiotalar arthrodesis were enrolled in the study. The mean total arc of movement was 34.2° (17.0° to 59.1°) with an average contribution from the talonavicular joint of 10.5° (1.2° to 28.8°) in the TAA cohort. The average total arc of movement was 24.3° (6.9° to 44.3°) with a mean contribution from the talonavicular joint of 22.8° (5.6° to 41.4°) in the arthrodesis cohort. A statistically significant difference was detected for both total sagittal plane movement (p = 0.00025), and for talonavicular motion (p < 0.0001). A statistically significant lower VAS score (p = 0.0096) and higher FAAM (p = 0.01, p = 0.019, respectively) was also detected in the TAA group. Conclusion. TAA preserves more anatomical movement, has better pain relief and better patient-perceived post-operative function compared with patients undergoing fusion. The relative increase of talonavicular movement in fusion patients may play a role in the outcomes compared with TAA and may predispose these patients to degenerative changes over time. Take home message: TAA preserves more anatomic sagittal plane motion and provides greater pain relief and better patient-perceived outcomes compared with ankle arthrodesis. Cite this article: Bone Joint J 2016;98-B:634–40

Introduction. Traditional treatment for end-stage ankle arthritis has been ankle arthrodesis, however ankle arthroplasty is becoming an accepted alternative. The Zenith Ankle (Corin, UK) is 3rd generation implant with a mobile bearing design. In the NJR 2016 report, the Zenith was the commonest ankle prosthesis implanted in the UK. However, compared to other ankle implants, there's little published data on its performance and survival. The aim of this study was to analyse outcome in a consecutive series from a non-designer centre. Method. We conducted a retrospective review of a consecutive series of 118 Zenith Ankle replacements implanted in our Unit (December 2010 to May 2016). Data was collected from our National Joint Registry entries, research databases, patient notes, PACS and PROMS. Results. Average age was 68.2 years (range 46–46 years; 75M:43F; 97 Osteoarthritis, 20 inflammatory arthritis, 1 haemophilia). Results show a 95.8% survivorship at average 3.5 years follow up (range 0.6–6.3 years). 5 patients (4.2%) required revision. Average pre- and post-op MOXFQ scores were 85.0/100 and 32/100 respectively with improvements in VAS from 7.0/10 to 3.6/10, with an average range of movement of 20.4 degrees. Overall satisfaction rate was 89%. There were 65 complications in 55 patients, but only 7.7% of these led to detrimental effects on the implant. The commonest were malleolar fracture (14.4%), wound problems (13.6%) and superficial infection (12.7%), medial gutter pain (10.2%). There were no cases of deep infection. Five patients required revision (all were revised to revision arthroplasty), for component loosening, or pain and stiffness. Conclusions. This is largest non-designer centre series examining the outcomes of the Zenith implant. Survival figures for this implant are comparable to NJR averages (6.8% revision at 5 years), with high levels of patient functional outcome and satisfaction. The data highlights the risks associated with this procedure

Background. Subtalar nonunion has a detrimental effect on patients' function, and pose a significant challenge for surgeons particularly in the setting of higher risk factors. Methods. We retrospectively analyzed a consecutive series of 49 subtalar nonunions between October 2001 and July 2013. Patient records and radiographs were reviewed for specific patient demographics and comorbidities, subsequent treatments, revision fusion rate, use of bone graft, complications, and clinical outcome. Results. Forty-nine patients with a mean age of 49 years (range 23–80) were included. Sixteen (32%) were heavy smokers (>1 pack per day) and five (10%) had diabetes. Forty one (84%) of the nonunions were symptomatic and underwent a revision procedure at a mean of 16 months (range 2.8 to 57) from the time of the primary arthrodesis. Four of these patients required a triple arthrodesis at the time of revision. Bone graft was used in all cases, and in 25 cases (61%) additional adjuvant orthobiologics. Thirty-two (78%) of the patients achieved a solid arthrodesis at a mean of 3.4 months (range 1.4 to 7.6). Patients who were diabetic and smokers as a group had a 68% rate of union. Of the nine nonunions following a revision arthrodesis, five were in the setting of a prior ankle arthrodesis, three were complicated by a deep infection, and one had no obvious risk factors. Four of the repeat nonunions elected to not undergo an additional procedure, two had a successful third attempt at arthrodesis, one had an additional nonunion followed by a successful fourth attempt at arthrodesis, one had a successful tibiotalocalcaneal arthrodesis, and one ultimately required a below-knee amputation. Discussion. Management of subtalar nonunions pose a significant challenge with a low rate of arthrodesis at 78% fusion rate, but which can be achieved with rigid fixation and utilization of bone graft and orthobiologics

The relationship between hindfoot and forefoot kinematics is an important factor in the planning of ankle arthrodesis and ankle arthroplasty surgery. As more severe ankle deformities are corrected, improved techniques are required to assess and plan hindfoot to forefoot balancing. Gait analysis has previously been reported in patients with ankle arthritis without deformity. This group of patients have reduced intersegment motion in all measured angles. We have looked at a small group of patients with hindfoot deformity and ankle arthritis awaiting fusion or replacement. Using the Oxford Foot Model we have assessed lower limb kinematics with a focus on hindfoot to forefoot relationships. The results of our pilot study are in variance to previous studies in that we have shown that in the presence of hindfoot/ankle deformity, the forefoot range of motion increases. We feel that these data may impact on surgical planning