Review Question - QID 211770

The best candidate for ankle arthrodesis of the patients listed in this scenario is the young laborer that places high demand and stress on the ankle.

Ankle arthrodesis is a common procedure performed open or arthroscopically that can address end-stage ankle arthritis with the goal of attaining a plantigrade foot allowing pain-free activities of daily living. Good candidates for ankle arthrodesis include, but are not limited to young laborers and patients with inflammatory arthritis or other comorbidities. The recommended position of the ankle at the time of arthrodesis is neutral dorsiflexion, slight external rotation and approximately 5° of valgus alignment. The average bony union rate is around 90% and the procedure has shown reliable relief of pain. However, some longer-term studies have indicated high rates of adjacent joint arthritis.

Raikin et al. retrospectively reviewed epidemiologic trends of total ankle replacement (TAR) and ankle arthrodesis (AA). They found that both TAR and AA increased yearly after 2006. TAR patients tended to be older, while those undergoing AA were more likely to have comorbidities like obesity or diabetes. They note that while TAR is becoming more common and its indications are expanding, AA is still performed much more frequently.

Krause et al. discussed how surgeons should decide between TAR and AA for their patients. They argue that AA produces reliable pain relief, but they question long-term results given the reports of adjacent joint arthritis and hindfoot pain. On the contrary, they note TAR preserves motion at the ankle joint, theoretically avoiding adjacent joint arthritis. This being said, indications for AA may be more expansive given the higher risk of complications and failure with TAR. They concluded that the entire foot, as well as patient comorbidities, must be evaluated in order to choose the most appropriate surgical option to optimize long-term outcomes.

Incorrect Answers:
Answer 1: This young patient with a large OCD lesion will likely benefit from joint and cartilage preservation procedures prior to undergoing ankle arthrodesis. Their slight tibiotalar malalignment is not, on its own, an indication for ankle arthrodesis.
Answer 3: In a patient who has post-traumatic arthritis and wants to return to hiking postoperatively, total ankle arthroplasty would be more appropriate.
Answer 4: In a patient with tibiotalar arthritis with a prior contralateral ankle arthrodesis, total ankle arthroplasty should be considered before bilateral arthrodesis is performed given the negative effect of bilateral ankle arthrodesis has on gait.
Answer 5: This patient has significant vascular compromise which may affect incision and arthrodesis healing, making them a less optimal fusion candidate.