SLR - April 2013 - Brant McCartan
References: Townshend, David; Di Silvestro, Matthew; Krause, Fabian; Penner, Murray; Younger, Alastair; Glazebrook, Mark; Wing, Kevin. Arthroscopic Versus Open Ankle Arthrodesis: A Multicenter Comparative Case Series. J Bone Joint Surg AM. 2013; 95-A: 98-102.
Scientific Literature Review
Reviewed by: Brant McCartan, DPM
Residency Program: Beth Israel Deaconess Medical Center/Harvard Medical School
Podiatric Relevance:
Ankle arthritis is debilitating and severely impacts the quality of life of our patient population. Despite the advances in equipment and implants, as well as increase in surgeons' experience with total ankle replacement (TAR), arthrodesis remains the procedure of choice among many surgeons and produces time-tested, predictable results. Just as TAR is challenging arthrodesis as the gold standard in treatment for ankle arthritis, so is the means of fusing the ankle, particularly with a renewed trend towards minimally invasive surgery. Couple this with the constant pressure of decreasing operating room time and duration of hospital stay, arthroscopic ankle fusion may have already surpassed open arthrodesis as the gold standard.
Methods:
Two groups of 30 patients who received ankle arthrodesis were evaluated based on patient reported clinical outcome, morbidity, and length of hospital stay. One group underwent an open fibula sparing arthrodesis by a single surgeon, while the other group was performed via arthroscopy by three different surgeons. Both groups underwent the same postoperative course consisting of six weeks cast immobilization followed by transition to weight bearing in a CAM walker the following six weeks. The primary outcome measure was the change in Ankle Osteoarthritis Scale (AOS) from preoperatively to two-years post-procedure. The secondary outcomes evaluated were the Short Form-36 (SF-36) health survey, radiographic alignment, operative time, and length of hospital stay.
Results:
The average age and BMI were 54.7 (open) and 59.4 (arthroscopic), and 29.6 (open) and 27.4 (arthroscopic), respectively. There was a significant difference in AOS score favoring the arthroscopic group at both one and two years. There was no difference in SF-36 PCS scores at two years. The hospital stay was significantly shorter in the arthroscopic group (2.5 compared to 3.7 days in the open group). The mean tourniquet time was 107 minutes in the open group and 99 minutes in the arthrodesis group. In both groups the coronal alignment improved: Nice degrees to four degrees in the open group and eight degrees to two degrees in the arthroscopic group. In each group there was one non-union and one case of delayed wound-healing. In the arthroscopic group, there were two cases of hardware removal as a result of symptomatic implants. In the open group, two patients were not available for follow-up and a third was deceased.
Conclusions:
The gold standard should always be questioned with evidence-based research. There is little Level-III or better research comparing open versus arthroscopic ankle arthrodesis. The three studies referenced in this paper all favor an arthroscopic approach finding shorter time to fusion, less morbidity, shorter operative times and shorter hospital stays. The authors of this study candidly admit that they have completely abandoned the open technique and now perform fusions as an outpatient procedure. Previous debate may support the open technique as the only option for severe deformities. However, in this paper there were coronal plane deformities over 30 degrees in each group. Also, Gougoulias et al published a study comparing patients with a coronal plane deformity <15 degrees to those with a deformity >15 degrees (up to 45 degrees) with similar outcomes. There still need to be prospective studies on this topic, but the current literature supports arthroscopic ankle arthrodesis.