SLR - June 2015 - Khoa D. Nguyen(1)
Reference: Ling JS, Smyth JA, Fraser EJ, Hogan MV, Seaworth CM, Ross KA, Kennedy JG. Investigating the Relationship between Ankle Arthrodesis and Adjacent-Joint Arthritis in the Hindfoot. J Bone Joint Surg Am. 2015 March 18; 97(6): 513-20.Scientific Literature Review
Reviewed By: Khoa D. Nguyen, DPM
Residency Program: Morristown Medical Center
Podiatric Relevance: Ankle arthrodesis has been considered a standard and reliable treatment for end-stage ankle arthritis for over a century, especially with good results and low complication rates with modern techniques. One of the major risks that often involves in isolated ankle arthrodesis is adjacent-joint arthritis in the hind-foot. There are many conflicting views in the literature regarding the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies challenged the notion of post-operative adjacent-joint arthritis from ankle arthrodesis with data purporting preexisting hind-foot arthritis as well as inconclusive correlation between postoperative imaging findings and clinical presentation. The aim of this study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis.
Methods: The study design consists of literature search from PubMed/MEDLINE and EMBASE electronic databases from 1974 to 2013. Inclusion criteria for the review must (1) be published in the English language literature, (2) assess the clinical or biomechanical outcomes following ankle arthrodesis, (3) involve biomechanical and gait analyses that were performed with the use of a multi-segment foot model, (4) evaluate the radiographic appearance of the subtalar, talonavicular, or calcaneocuboid joint, (5) evaluate the prevalence of subsequent adjacent-joint arthritis following the primary fusion, and (6) be published in a peer-reviewed journal. A standardized data sheet was prepared to analyze postoperative outcomes such as adjacent-joint symptoms, the existence or exacerbation of arthritis in adjacent joints, the rates of reoperation and adjacent-joint arthrodesis, and any effects on motion of adjacent joints.
Results: Twenty-four studies were determined to be eligible for inclusion overall with eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The gait-analysis study demonstrated a significant decrease in motion of hindfoot and forefoot joints, in all planes and in all phases of stance and swing, compared with the contralateral, unfused side. The biomechanical studies demonstrated conflicting evidence; Schuh et al. showed a compensatory increase in motion in the talonavicular, calcaneocuboid, and subtalar joints following ankle arthrodesis, whereas Thomas et al. showed a decrease in motion in these joints. The clinical studies indicated that ipsilateral hindfoot and midfoot arthritis is universally present preoperatively in patients undergoing ankle arthrodesis but only one-third of the patients in each cohort actually had progression of arthritic severity and symptoms.
Conclusions: The authors concluded that the cause is still not clear from the available studies in the literature regarding the development of arthritis in surrounding joints after ankle arthrodesis and radiographic evidence of arthritis is not always clinically important because patients are often asymptomatic despite high radiographic scores for arthritis. The results remain inconclusive as to whether isolated ankle arthrodesis without preoperative adjacent joint arthritis could eventually lead to hindfoot and midfoot degenerative arthritis. Also, the position of the fusion could play a huge part in biomechanical adaptation, which this article did not address. It would be beneficial to have graded activity level in correlation with the AOFAS score over a certain period of time for postoperative evaluation consistency. Future studies should include prospective analysis of adjacent joints at baseline and follow the progression to help establish the effects of arthrodesis. Therefore during preoperative planning, patients should be fully aware that adjacent joints would potentially develop degeneration and arthritis on radiographic evaluation over time but could be asymptomatic and pain-free at the same time.