Effectiveness and Safety of Ankle Arthrodesis Versus Arthroplasty. A Prospective Multicenter Study

SLR - November 2019 - Pulin U. Joshi

Reference: Norvell D, Ledoux W, Shofer J, Hansen S, Davitt J, Anderson, J, Bohay M, Coetzee C, Maskill J, Brage M, Houghton M, Sangoerzan B. Effectiveness and Safety of Ankle Arthrodesis Versus Arthroplasty. A Prospective Multicenter Study. J Bone Joint Surg Am. 2019;101:1485-94.

Scientific Literature Review

Reviewed By: Pulin U. Joshi, DPM
Residency Program: Ascension Wisconsin – Milwaukee, WI

Podiatric Relevance: This is a direct prospective comparison between ankle arthrodesis (AA) and newer modalities of treating osteoarthritis of the ankle which are total ankle replacements or arthroplasty (TAA). TAA has become much more popular in recent years with better equipment and more well-defined patient selection. AA has been the long time gold standard and the decision between the two is still a surgeon’s preference. Hopefully the results of this study can help a surgeon decide which modality they choose to go with when treating arthritis of the ankle.

Methods: Five hundred seventeen patients were screened from six sites between May 2012 and May 2015. All had unsuccessful nonoperative management of their ankle osteoarthritis. Baseline risk factors were gathered pre-operatively including demographics, ankle-specific, osteoarthritis severity according to the Kellgren-Lawrence grading scale, the Functional Comorbidity Index, and alcohol and tobacco use. Patients were included who were eligible for both procedures and were told neither intervention was considered “better”. All chose their treatment, 414 TAA and 103 AA. Their outcomes were measured at six, 12, 18, and 24 months including Foot and Ankle Ability Measure (FAAM), the Short Form-36, Physical and Mental Component Summary scores, the Chronic Pain Grade, and the FCI.

Results: At 24 months, the mean improvement in the FAAM ADL and SF-36 PCS scores was significantly greater for the TAA vs AA. Both had significant improvements in pain scores at all time scales with TAA having significant improvement of “worst pain” at 24 months. The most improvement in the majority of these factors occurred within the first six to 12 months with more modest improvement thereafter. In general, when adjusting for age, sex, BMI, and FCI, the 24-month treatment success rate was significantly higher for TAA vs AA (81 percent to 68 percent).

Conclusions: There are minimal studies directly comparing these two modalities of treatment in terms of functional scores and the right subgroup of the patient population for each. In this study, both groups experienced significant improvements in number of scores, the majority of which were in the six- to 12-month range. Although there were more ankle adverse events in the AA group, when adjusting for potential confounders, these differences were no longer significant. I believe that the pre-operative demographics obtained about each patient is invaluable in determining who is the right candidate for each, specifically their age, activity level, and BMI. With overall benefit gained from both treatments, the right patient for each treatment is the most crucial step when coming up with a plan in practice. AA has long been the gold standard with plenty of evidence backing it up but TAA has presented an exciting alternative in treatment for the right patient type. This study can serve as a road map in selecting the right procedure as well as predicting how the treatment will functionally improve patients' lives.