SLR - February 2024 - Rollins
Title: Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled TrialReference: Goldberg AJ, Chowdhury K, et al. Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial. Ann Intern Med. 2022 Dec;175(12):1648-1657. doi: 10.7326/M22-2058. Epub 2022 Nov 15. Erratum in: Ann Intern Med. 2023 Feb;176(2):288. PMID: 36375147.
Level of Evidence: Level 1
Scientific Literature Review
Reviewed by: Austin Rollins, DPM, PGY-3
Residency Program: Creighton University School of Medicine – Phoenix; Phoenix, Arizona
Podiatric Relevance: Ankle osteoarthritis has been shown to cause significant pain and affect quality of life. Ankle arthrodesis was traditionally considered the gold standard for surgical management of end stage ankle osteoarthritis. There has been advancement of total ankle arthroplasty technology over the last two decades. Both treatment options have been shown to resolve pain associated with end stage ankle arthritis. Before this investigation, there was a lack of randomized control trials comparing complications and patient reported outcomes of the two treatment modalities.
Method: Patients included all with end-stage ankle osteoarthritis, aged 50 to 85 years. The study period ranged from March 2015 to January 2019 in the United Kingdom. An independent web-based randomization service (Sealed Envelope) was used. Total ankle replacement (TAR) surgeons used both 2-component, fixed-bearing and 3-component, mobile-bearing implants. Ankle fusion (AF) was done using either arthroscopic-assisted or open AF. The primary outcome was gauged by the Manchester–Oxford Foot Questionnaire (MOXFQ). Total range of motion from the tibia to the floor was recorded. Follow up was performed for 52 weeks.
Results: A total of 281 patients were randomly assigned to each group. Patients undergoing AF were more likely to be diabetic (11% vs. 7%) and obese (10% vs. 6%) than the TAR group. There were greater levels of preoperative deformity in the TAR group than in the AF group. The MOXFQ pain and social interaction domains were improved in both groups at 52 weeks, and there was no clinical or statistically significant difference between TAR and AF. Total range of motion in those with TAR improved at 52 weeks and decreased in AF patients. There were 20 wound complications 19 (13%) patients in the TAR group compared with 8 (6%) in the AF group, 8 nerve injuries in 6 (4%) patients in the TAR group compared with 1 (<1%) in the AF group and 13 thromboembolic events reported in 11 patients (3%) in the TAR group and 7 (5%) in AF group. The symptomatic nonunion rate of the AF group was 7%.
Conclusion: Clinical MOXFQ scores did not indicate superiority to either treatment group. The risk of adverse events was similar in both groups but were differentiated by the type of adverse event. The TAR group showed a higher rate of wound problems and nerve injury while the AF group showed a high incidence of thromboembolic events and the risk of nonunion. This study demonstrates that short outcomes to be comparable in both groups which may be helpful in preoperative discussions with patients.