SLR - April 2017 - Timothy A. Graeser
Reference: Desai SJ, Glazebrook M, Penner MJ, Wing KJ, Younger AS, Pinsker E, Daniels TR. Quality of Life in Bilateral vs. Unilateral End-Stage Ankle Arthritis and Outcomes of Bilateral vs. Unilateral Total Ankle Replacement. J Bone Joint Surg Am. 2017 Jan. 2017;99:133–140Reviewed By: Timothy A. Graeser, DPM
Residency Program: KentuckyOne Health
Scientific Literature Review
Podiatric Relevance: There is limited existing literature on the preoperative function and treatment outcomes of end-stage bilateral ankle arthritis. As total ankle replacement (TAR) technologies have improved, their utilization has increased across more patient populations. The study examined unilateral vs. bilateral TAR due to the preferred treatment methodology for the study authors leaning heavily toward TAR. While previous studies on the treatment of end-stage bilateral ankle arthritis have indicated that bilateral ankle fusion is a viable option, this study examined the outcomes of unilateral versus staged bilateral TAR.
Methods: This retrospective cohort study examined 159 patients with either bilateral (53 patients) or unilateral (106 patients) end-stage ankle arthritis identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. The overall average age of patients in the cohort was 62 years old, and fifty-five percent were male. Preoperative health-related quality of life (HRQoL) was evaluated using both Short Form-36 (SF-36) and American Academy of Orthopaedic Surgeons Foot and Ankle Module. Midterm follow-up included revision and reoperation rates, HRQoL evaluation and implant survival. Minimum follow-up was two years across all groups.
Results: A total of 106 patients who received unilateral and 37 patients who were treated using staged bilateral total ankle replacements were evaluated. Comparison of preoperative and postoperative physical component summary (PCS) scores between the unilateral and bilateral groups showed patients in the unilateral group had higher preoperative PCS scores (32.4 vs 26.1) and similar postoperative scores (40.4 vs 39.5). Six of the patients in each group required revision ankle implant surgery during the follow-up period. Mean survival time in the unilateral group was 9.2 years and 10.9 years in the bilateral group.
Conclusions: Postoperative scores were similar between both groups, in spite of the bilateral group having worse debility preoperatively. Some potentially confounding factors include the higher percentage of patients in the bilateral group with diagnosed systemic conditions, such as rheumatoid arthritis, hemophilia and hemochromatosis. While the systemic effects of these conditions could contribute to the lower preoperative SF-36 scores, the similar postoperative SF-36 scores between groups would seem to indicate that the bilateral end-stage ankle arthritis was the major contributing factor. The authors conclude bilateral TAR in the setting of bilateral end-stage ankle arthritis appears to offer similar postoperative outcomes when compared to unilateral TAR, in spite of worse preoperative function. A prospective study with a larger patient cohort and long-term follow-up would be beneficial in determining the application of these findings to the general population.