The Mobility (DePuy International) is a three-component, cobalt chrome, uncemented design. Over an 18-month period 100 ankles, with end-stage arthritis and less than 20 degree valgus or varus deformity, were replaced. There were 95 patients (70 OA, 25 RA) with average age of 65 years (41-95). Five had bilateral replacements. Follow-up was 30 months (24 to 48). Average score on VAS pain line improved from 8.8 to 1.8. The average AOFAS pain score improved from 3 to 33. Average AOFAS function score improved from 31 to 48. Four patients were disappointed because pain relief was poor. Four ankles have undergone further surgery. One ankle was converted to fusion for recurrent deformity. One ankle required repeated washout for infection at six months but remains clinically and radiologically satisfactory 2 years later. One ankle required exchange of UHMWP insert at 4 weeks because of a technical error. One ankle required fixation of an ununited intraoperative medial malleolar fracture and subsequently developed ‘edge loading’, namely radiographs showed that a gap had opened up between the articular surfaces on the lateral side of the joint. The radiographs of 3 other ankles also showed ‘edge loading’. Two of these patients were symptom free but one wore a brace to control symptoms of instability. Radiographs showed bony incorporation in all surviving ankles. This was always complete around the tibial stem and under the talar component. However in 15 ankles there was a small non-progressive area of lucency adjacent to the tibial plate.Patients
Results
There were 106 men and 94 women (mean age 65 years; 22 - 85). 69 patients had inflammatory arthritis and 131 osteo-arthritis. 27 patients (13 B-P, 14 STAR) had a pre-operative varus/valgus deformity greater than or equal to 20 degrees. Mean follow-up was 48 months (36-72). Ten patients had died from unrelated cause with satisfactory final outcome assessment. Thirteen ankles (4 STAR, 9 B-P) required revision surgery. The causes of failure were: early deep infection (1 STAR), recurrent deformity (1 STAR, 4BP) aseptic loosening (1STAR, 4 BP), implant failure (1STAR, 1 BP). Six revised ankles (5BP, 1STAR) had pre-operative varus/valgus deformity of 20 degrees or more. AOFAS score for pain improved from 0 to 35 and for function from 30 to 43. There was no difference between the two groups. Pre-operative range of movement was predictive of the final range of movement. Radiographic assessment showed that 30 patients (17BP, 13 STAR) had recurrent deformity (edge loading) as shown by the UHMWPE insert no longer articulating congruently with the metallic components. 14 ankles (8BP, 6 STAR) from this group had pre-operative deformity of 20 degrees or more.Methods
Results
Twenty-four replacements were performed in 19 patients (13 female: 6 male), with average age of 33 years (18-40). All had severe polyarticular rheumatoid arthritis. Pre-operatively 12 ankles had no angular deformity, 9 were in valgus and 3 in varus. All had associated hindfoot disease. Some of these patients are part of two larger studies of the Scandinavian Total Ankle Replacement (STAR) and the Buechel-Pappas (BP) replacement. In this group there were 20 STAR and 4 BP replacements. Average follow-up was 62 months (36 to 120). Twenty-one replacements had good pain relief and function. The AOFAS hindfoot score for pain improved from 0 to 36 (max 40) and for function from 25 to 35 (max 60). Three have failed. One ankle had a 25-degree valgus deformity pre-operatively and this recurred and caused failure at 11 months. The second failed at 34 months due to aseptic loosening of the talar component. Both of these were converted to tibio-talo-calcaneal fusions with an intra-medullary nail. The third failure had never provided satisfactory pain relief in spite of appearing satisfactory on clinical and radiological examination. Exploratory surgery was carried out at 36 months but failed to produce an improvement and at 61 months the decision was made to revise the replacement to a fusion. However, due to concurrent health problems, this has not yet been done. We offer replacement to patients with severe polyarticular rheumatoid disease especially if there is a stiff but well aligned hindfoot. In the light of increased experience, we now consider valgus or varus deformity of greater than 20 degrees to be a contra-indication to replacement. This is because the deformity tends to recur leading to pain, loosening and failure.
We aim to assess the outcome of ankle arthrodesis performed for painful osteoarthritis in the presence of a coronal plane deformity of 20 degrees or more. To our knowledge this is the first reported series of such a cohort of patients. We have a consecutive and complete series of 24 patients with 26 ankle arthrodeses which were all performed for painful osteoarthritis in the presence of large coronal plane deformity. These patients have a minimum of twelve months clinical follow-up. The results showed a low non-union rate of 8% (2 ankles). These have subsequently been re-fused satisfactorily, and are excluded from further analysis. The results of the remaining 24 ankles, which united primarily, show that patients were very pleased with the outcome of their surgery. AOFAS scores were used to measure pain and function, both pre-operatively and post-operatively. These scores showed large improvements for both pain and function, and had a high statistical significance (p<0.0001). All patients improved in their walking distance and many patients reduced their need for walking aids. Stair climbing ability was also improved in some patients. It is recognised that an ankle arthrodesis usually relieves pain but does not result in a normal gait and full function. We feel that the high level of patient satisfaction in this series was due to the combination of deformity correction, restoring a functional foot position, and achieving a painless ankle. Arthroplasty of the ankle is a good procedure for relief of pain and restoration of function. However, in the presence of a large coronal plane deformity, ankle arthroplasty is known to fare badly with early failure. Therefore for patients with painful osteoarthritis and a coronal plane deformity of 20 degrees or more, we recommend ankle arthrodesis as the procedure of choice.
Arthritis in the ankle causes considerable malalignment in the anteroposterior plane. The DTL is not affected by the destruction of the tibiotalar joint and is independent of slight variations in the positioning of the foot and radiological magnification.
Radiographs of 200 cases of TAR were reviewed. The anterior and posterior outlines of the talus could not be seen in all cases (e.g. preoperative talonavicular fusion). As a result 49 cases of inflammatory arthritis (49 of 119) and 6 of osteoarthritis (6 of 81) could not be assessed.
There was a lesser tendency for subluxation in the inflammatory group of patients although the body of the talus itself was more deformed. The average preoperative value was ‘36.1’ and the post operative value was ‘38.9’.
Patients undergoing total hip replacement (THR) often require further orthopaedic surgery including other primary lower limb joint replacements and revision surgery in their lifetime. We analysed the 10-year data of 552 patients who underwent primary total hip replacement between April 1991 and March 1992 at our institute. Data were available for all patients before the index operation. 77% of patients attended their 5-year review and 67% attended their 10-year review. 233 (42%) had had or subsequently had the opposite hip replaced. 30 patients (5%) had a knee replaced and 19 (3%) had both knees replaced. 4.4% underwent revision surgery.
whether ankle replacements were capable of maintaining a normal gait and whether ankle replacements were superior to arthrodeses in maintaining a normal gait pattern.
There were a mixture of patients with osteoarthritis and rheumatoid arthritis. We also looked at the ‘normal’ side of the patients with unilateral surgery.
Between 1993 and 1999, 119 total ankle arthroplasties (TAA) in 106 patients were performed. The prosthetic design in all cases was the Scandinavian Total Ankle Replacement (STAR). All patients have been reviewed annually. Eight arthroplasties have been revised (see table for reasons for revision). Twenty-four TAA were satisfactory at last review (4–87 months) in 19 patients who died. Annual review continues for 87 TAA. When last seen the average follow up was 72 months (48–123). The cumulative survival for all 119 TAA is 92% (see figure below).
Patients undergoing total hip replacement (THR) often require further orthopaedic surgery including other primary lower limb joint replacements and revision surgery in their lifetime. We analysed the 10-year data of 552 patients who underwent primary total hip replacement between April 1991 and March 1992 at our institute. Data was available for all patients before the index operation. 77% of patients attended their 5-year review and 67% attended their 10-year review. 233 (42%) had had or subsequently had the opposite hip replaced. 30 patients (5%) had a knee replaced and 19 (3%) had both knees replaced. 4.4% underwent revision surgery. Concluding, nearly half the total number of these patients will in due course require the opposite hip replaced. 13% will need another major joint surgery (ie revision or TKR). At £6138 for a primary THR and £8500 for revision THR, and the cost of radiographs (£60) and follow-up appointment (£60), the approximate cost implications on a conservative estimate are 13 million pounds. For a single surgeon undertaking 40 THRs in a single year the cost would be approximately £900,000. In addition, the surgeon in 10 years practice would create enough work to last him the rest of his working lifetime. These factors including cost implications and human resource requirements will have significant influence on future planning of health care trusts.
We have reviewed 31 consecutive patients, aged 65 years or more, after surgical decompression for degenerative lumbar spinal stenosis. The average follow-up was 42 months. Assessment included a standard questionnaire, a pain diagram which was completed by the patient, and clinical and radiological examination. Patients were considered in three groups; degenerative spondylolisthesis (19), lateral recess stenosis (5), and central-mixed stenosis (7). The indication for surgery was leg pain: no patient had an operation for back pain alone. Fusion was never performed. Overall, 64% of the patients had an excellent result, 17% a good result and 19% a poor result. We conclude that the long-term outcome of decompressive surgery in the elderly is good; it does not differ from that reported for younger patients.