Open Versus Arthroscopic Ankle Arthrodesis in High-Risk Patients: A Comparative Study

SLR - January 2022 - Lant Abernathy

Reference: Martinelli N, Bianchi A, Raggi G, Parrini MM, Cerbone V, Sansone V. Open Versus Arthroscopic Ankle Arthrodesis in High-Risk Patients: A Comparative Study. Int Orthop. 2021 Oct 6. Epub ahead of print.

Level of Evidence: 4

Scientific Literature Review

Reviewed By: Lant Abernathy, DPM
Residency Program: Inova Fairfax Medical Campus – Falls Church, VA

Podiatric Relevance: Ankle osteoarthritis (AO) is a debilitating condition that can cause pain, decrease mobility, and decrease quality of life. Ankle arthrodesis (AA) has been the gold standard of care, and can be performed open or arthroscopic with each approach having advantages and disadvantages. Literature has shown that comparison between these two approaches favors arthroscopic arthrodesis due to fewer complication rates, faster union times, and shorter recovery time. The goal of this study was to compare arthroscopic versus open AA in patients with risk factors that might potentially increase their risk of non-union.

Methods: Patients underwent AA for AO secondary to degenerative, post-traumatic, rheumatoid arthritis (RA), or talar avascular necrosis (AVN). Two groups were separated into arthroscopic and open with 21 and 23, respectively. Risk factors were defined as the following: smoking, history of rheumatoid arthritis, previous ankle infection/intervention, psychiatric illness, Diabetes mellitus (DM), body mass index greater than 30, and age over 60. Inclusion criteria consisted of patients older than 18 years, isolated AO with a neutral hindfoot, at least two risk factors previously described, and follow-up of at least one year. The arthroscopic procedure was performed through conventional ankle portals with debridement of hypertrophic synovium visualization followed by denudement of cartilage using a combination of arthroscopic burrs and curettes. The open procedure was performed via anterior, lateral with transfibular takedown, or a combination of the two approaches. Both groups were fixated using two transmalleolar cannulated screws, with some cases utilizing additional fixation including supplemental screws, plates, or staples. Primary outcomes included radiographic union at six months and secondary outcomes included American Orthopaedic Foot and Ankle Score (AOFAS), Foot Function Index (FFI), visual analog scale (VAS), complication rates, operative time and re-operation rates.

Results: Radiographic union was observed in both groups in the open (15/23) and the arthroscopic (19/21) groups, showing favor to the arthroscopic group with statistical significance, but no difference was shown in average time to union. AOFAS, FFI, and VAS scores in all groups had statistically significant improvement post-operatively with only VAS score showing statistical significance between groups with preference to the arthroscopic group. Complication rate and follow up time were higher in the open group, with statistical significance, and longer operating time in the arthroscopic group was noted, but was not found to be significant. Re-operation rate was comparable between the two groups.

Conclusions: Clinically both groups showed vast improvements in pain and functional scores post-operatively. However, there was a statistically significant difference in union rates with the arthroscopic group proving superior. Open AA continues to prove a reliable approach as documented in the literature. However, in the presence of risk factors that could potentially lead to higher complication rates, arthroscopic AA offers an alternative approach. Therefore, it is imperative that the foot and ankle surgeon be familiar with both techniques to optimize patient outcomes through patient selection.