SLR - September 2020 - Yvonne Baumrucker
Reference: Herrera-Perez M, Alrashidi Y, Galhoum AE, Kahn TL, Valderrabano V, Barg A. Debridement and Hinged Motion Distraction Is Superior to Debridement Alone In Patients with Ankle Osteoarthritis: A Prospective Randomized Controlled Trial. Knee Surg Sports Traumatol Arthrosc. 2019;27(9):2802-2812. doi:10.1007/s00167-018-5156-3Scientific Literature Review
Reviewed By: Yvonne Baumrucker, DPM
Residency Program: Hoboken University Medical Center – Hoboken, NJ
Podiatric Relevance: The ankle joint is the most commonly affected joint by osteoarthritis specifically of the post-traumatic etiology. Many of these patients tend to be younger patients as compared to primary osteoarthritis which has a prevalence for an older patient population. Once conservative treatment options are exhausted, surgery becomes a very important next step. Surgical options for osteoarthritis of the ankle joint typically are either joint-destructive or joint-preserving procedures. In a younger patient with post-traumatic osteoarthritis, a joint-destructive procedure such as ankle arthrodesis or total ankle replacement (TAR) may not be a popular choice. The main joint-preserving procedure in literature is debridement of the ankle joint via arthroscopy. There is another procedure that is less researched: joint distraction arthroplasty (JDA). Joint distraction arthroplasty has been shown in the existing literature to be an appropriate treatment option in a select group of patients: younger population with post-traumatic osteoarthritis. This study aims to compare the complication rates and post-operative outcomes in patients undergoing ankle debridement alone versus ankle debridement and hinged JDA.
Methods: A Level 1 prospective randomized controlled study that included a total of 50 patients with post-traumatic ankle osteoarthritis who underwent ankle debridement alone (25 patients) or ankle debridement with hinged JDA (25 patients). The appropriate sample size for this study was calculated using a priori power analysis. The visual analog scale (VAS) and AOFAS hindfoot scale were used to determine and compare post-operative outcomes between the two groups. A Kaplan-Meir survival analysis was used to calculate the three-year and five-year survival rates, which was defined as an end result of the patient undergoing a joint-destroying procedure (ankle arthrodesis or TAR).
Results: Comparable outcomes included: significant pain relief, functional improvement, and improved quality of life at the 6-month follow up which all patients attended. At the three-year follow-up, 23 patients attended from the JDA group and 19 from the ankle debridement alone group. Both groups had significant worsening of pain and functional outcome. However, ankle debridement alone patients had significantly more pain than JDA patients at 3 years. The survival rates for the JDA group was 19 out of 25 (74 percent) at 3 years and 15 out of 25 (59 percent) at 5 years. The survival rates for ankle debridement alone were 12 out of 25 (49 percent) and nine out of 25 (34 percent) at 3 years. During the study’s follow-up, 26 major secondary procedures were performed. For the JDA group, six ankle arthrodeses and six TARs. For the ankle debridement alone group, 11 ankle arthrodeses and 3 TARs.
Conclusions: The study found that debridement and hinged JDA is superior to debridement alone in patients with post-traumatic ankle osteoarthritis related to secondary revision surgery. The limitations of this study included: small sample size, only using weight bearing radiographs for radiographic assessment, and short follow-up duration. Both treatment options showed progressive ankle degeneration after original surgery, but only the ankle debridement group showed degeneration at both 3- and 5-year follow-ups. Ankle debridement with JDA may be the better option for the younger patient population to delay further ankle joint degeneration and joint-destructive procedures.