Review Question - QID 214141

This patient has end-stage isolated tibiotalar that has failed conservative treatment with a high demand occupation. Treatment with a tibiotalar arthrodesis through a direct anterior or arthroscopic approach would enable later conversion to a total ankle arthroplasty if the patient becomes a candidate.

Ankle arthritis is typically post-traumatic and occurs less frequently than hip and knee arthritic. Conservative treatment involves ankle gauntlet bracing, physical therapy, corticosteroid injections, and NSAIDs. Operative treatment consists of ankle fusion to total ankle arthroplasty (TAA). Young and active patients with physically demanding occupations are not good candidates for TAA due to high stresses placed on the prosthesis and the bone-prosthesis interface, which has lead to increased failure rates. This patient's risk of complications are too high given his age and physical demands of job thereby making fusion a better option.
Elderly and low-demand patients are ideal candidates for TAA due to increased wear and failure rates in younger, active patients. Arthrodesis can later be converted to TAA, but there can be increased wound complications following the conversion if the arthrodesis was performed through a transfibular or medial malleolar osteotomy approach. Arthroscopic arthrodesis is another option in patients with less than 15° of coronal plane deformity for later conversion to TAA.

Duan et al. performed a retrospective study of 68 patients with primary osteoarthritis, posttraumatic arthritis, and rheumatoid arthritis with less than 15° of coronal plane deformity treated with arthroscopic ankle arthrodesis. They reported a 100% fusion rate without the need for bone grafting and no deep space infections, deep vein thrombosis, or revision surgeries. The authors concluded that arthroscopic arthrodesis provides an effective alternative to open ankle arthrodesis.

Hendrickx et al. performed a retrospective study of 66 patients that underwent tibiotalar arthrodesis through a two-incision and three screw technique. They reported a 91% fusion rate with six patients requiring rearthrodesis and 91% of patients being satisfied with their clinical result. They concluded that the two-incision and three-screw technique for tibiotalar arthrodesis is an effective treatment of ankle osteoarthritis at nine years post-op.

Kim et al. performed a meta-analysis of ten studies comparing TAA versus ankle arthrodesis for the treatment of end-stage ankle arthritis. They reported no significant differences in AOFAS and SF-36 scores between the two groups, but a significantly higher risk of major reoperation and surgical complication with TAA. They concluded that both TAA and arthrodesis are effective treatment options for ankle arthritis, but the risk of reoperation and surgical complications must be weighed in treatment decisions.

Figures A and B are the AP and lateral radiographs of the right ankle with isolated tibiotalar arthritis and no significant coronal plane deformity.

Incorrect answers:
Answer 1: The patient has failed conservative treatment thus far. An additional corticosteroid injection would not provide significant benefit for the patient.
Answer 2: The patient does not have clinical or radiographic subtalar arthritis. Performing an arthrodesis that includes the subtalar joint is not appropriate.
Answer 3: The patient is relatively young with a high demand occupation. A TAA would perform poorly in this patient.
Answer 4: Performing a tibiotalar arthrodesis through a medial malleolar osteotomy or transfibular approach would prevent later conversion to a total ankle arthroplasty if the patient becomes a candidate in the future.