Review Question - QID 212921

The best surgical treatment in the setting of avascular necrosis of the talus is tibiotalar arthrodesis.

End-stage ankle arthritis that had failed nonoperative treatments can be most reliably treated with total ankle arthroplasty (TAA) or ankle arthrodesis. Contraindications to TAA include those with an insensate foot, active ankle infection, Charcot arthropathy, severe deformity, osteonecrosis of the talus, or soft tissue compromise. Of note, a patient with a prior history of infection should be strongly considered for arthrodesis rather than TAA given high risk of periprosthetic joint infection. Although ankle arthrodesis has long been the gold standard for end-stage ankle arthritis it is not without many shortcomings including ipsilateral foot and limb joint arthritis due to loss of motion across the tibiotalar joint. When selecting patients for TAA understanding the above contraindications and counseling patients on the risks and benefits of arthrodesis versus arthroplasty is of utmost importance.

Daniels et al. reviewed 321 patients who underwent either ankle arthroplasty or arthrodesis between 2001 and 2007. They found patients who underwent arthrodesis were younger, more likely to be diabetic, more likely to smoke, and less likely to have inflammatory arthritis. They found major complications were 7% for arthrodesis and 19% for arthroplasty with both groups demonstrating significant improvement in outcomes scoring. They conclude outcomes were similar in both arthrodesis and arthroplasty groups with a higher rate of complications and reoperation in the arthroplasty group.

Glazebrook et al. reviewed all articles reporting complications and failures of total ankle arthroplasty (TAA). They found 20 studies that met their inclusion criteria with a failure rate between 1.3 and 32.3% and an overall mean complication rate of 12.4% at 64 months. They proposed a classification scheme of post-operative TAA complications ranging from high-grade to low-grade. They conclude this classification system is useful in prognosticating outcomes and may help drive postoperative care.

Figures A and B show an AP and lateral of the ankle with tibiotalar arthritis. Figure C shows an MRI of the left ankle with talar avascular necrosis.

Incorrect Answers:
Answer 1: Repeat arthroscopic irrigation and debridement is not indicated as based on aspiration there is no active infection
Answer 3: Ankle arthroplasty is contraindicated in the setting of talus avascular necrosis
Answer 4: Supramalleolar osteotomy is only indicated in coronal plane deformity greater than 10 degrees with only mild or moderate joint arthritis
Answer 5: Triple arthrodesis is indicated for painful fixed adult flatfoot deformities.