Short-Term Outcome of Surgical Arthrodiastasis of The Ankle with Ilizarov Frame in a Cohort of Children and Young People with Juvenile Idiopathic Arthritis

SLR - December 2019 - Kristina Sikar

References: Gavin Cleary, Clare Pain, Liza McCann, Kamran Mahmood, Steven Brookes-Fazakerley, Simon Robinson, Roger Walton, Alan Highcock, Caren Landes, Nik Barnes, Ian Roberts and Leroy James. Short-Term Outcome of Surgical Arthrodiastasis of The Ankle with Ilizarov Frame in a Cohort of Children and Young People with Juvenile Idiopathic Arthritis. Rheumatology Advances in Practice 2019.;0:1-8.

Scientific Literature Review

Reviewed By: Kristina Sikar, DPM
Residency Program: Cambridge Health Alliance – Cambridge, MA

Podiatric Relevance: Despite medical advances in the treatment of juvenile idiopathic arthritis, including DMARDs and biologic therapies, articular damage remains a devastating complication of this destructive joint disease. In children and young patients, preservation of the anatomical and pain-free ankle joint function for as long as possible is highly desirable and of most importance. This study reports a short-term outcome of the first non-joint-sacrificing approach to this situation, including arthrodiastasis of the ankle with an Ilizarov frame in a cohort of children and young patients with juvenile idiopathic arthritis. This study aims to investigate the efficacy of ankle arthrodiastasis in end-stage of juvenile idiopathic arthritis, including pain, measures of function and survivorship of the procedure.

Methods: This is a Level IV study with retrospective analysis of demographics, disease pre-surgical treatment, and prospective review of patient- and clinician-reported outcome measures. This study includes nine ankles in eight patients who underwent ankle joint arthrodiastasis between 2009 and 2013 at Alder Hey Children's Hospital, Liverpool, UK. The surgical procedure included the application of the TrueLok Ring Fixation System. The tibiotalar joint was distracted by approximately 5 millimeter as previously assessed intra-operatively via fluoroscopy. Post-operatively, full weight-bearing was allowed. The external fixator was removed after three months. The patient-reported outcomes were assessed using a 10 centimeter visual analog scale of pain, Oxford Ankle Foot Questionnaire-Child (OxAFQ-C) and Oxford Ankle Foot Questionnaire-Parent (OxAFQ-P) for subjective patient functional scoring. The AOFAS ankle-hindfoot scale was used to provide a combined subjective and objective score.

Results: All patients had radiological evidence of increased joint space post-operatively. All patients improved their AOFAS score at 12-months post-frame removal. Both OxAFQs scores demonstrated statistically significant improvements at 12-months post-frame removal. The pain scores were improved immediately post-frame removal by 54 percent; at six months post-frame removal by 56 percent and were statistically significant, and at 12-months, pain score deteriorated, but there was still a 29 percent improvement compared to pre-operative pain levels. The mean duration of pain improvement post-operatively was 11 months. Six of nine children (67 percent) reported they were satisfied with the procedure and would do it again. Eight of nine parents (89 percent) said they were satisfied and would have their child undergo the procedure again.  

Conclusions: Despite the advancement in the medical treatment of juvenile idiopathic arthritis, end-stage joint arthritis remains a challenging complication. A load-bearing joint, such as ankle joint, is particularly susceptible to destructive forces. This study was able to demonstrate that arthrodiastasis using an Ilizarov frame is a safe and well-tolerated joint-preserving technique that provides short-term improvement in patient disease outcome measures, including pain. Such improved outcomes post-arthrodiastasis are the result of the restoration of anatomical positioning of the ankle joint. Unfortunately, arthrodiastasis alone is not a definitive treatment of end-stage joint arthritis, given the pathogenesis of this destructive disease. Persistent inflammation of the synovium eventually leads to erosive changes that may destroy cartilage. Without regeneration of cartilage, arthrodiastasis will remain a temporary solution that will delay, but not eliminate the need for further joint-sacrificing procedures.