A Staged Approach to Combined Extra-articular Limb Deformity Correction and Total Ankle Arthroplasty for End-Stage Ankle Arthritis

Abstract

Background: Patients presenting with end-stage ankle osteoarthritis (OA) in the setting of a concomitant extra-articular limb deformity pose a challenging problem that has not yet been described in the literature. We describe a case series of patients treated with external and internal fixation techniques followed by total ankle arthroplasty (TAA) in a staged approach to treat this complex presentation. Methods: Eight patients with limb deformity and end-stage ankle OA who underwent staged deformity correction and TAA from 2016 to 2019 at our institution were retrospectively identified. Average age was 58.5 (range, 49-68) years, with an average follow-up of 2.6 (range, 0.8-4.2) years. All patients underwent limb reconstruction with either tibial osteotomy with a circular frame (n=6) or intramedullary nail (n=2). Limb deformities consisted of the following: posttraumatic tibial malunion (2), limb length discrepancy (1), acquired tibial deformity (1), genu varum (2), or genu valgum (2). Radiographic parameters were assessed pre- and postoperatively on 51-inch standing and ankle radiographs: limb length discrepancy (LLD), genu varum/valgum deformity, recurvatum deformity, mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, anterior distal tibial angle, and tibiotalar alignment. Pre- and postoperative patient-reported outcomes were assessed using 2 metrics, the Limb Deformity–Scoliosis Research Society (LD-SRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Intensity, Pain Interference, Global Physical Function, and Global Mental Function). Results: Following staged limb deformity correction and TAA, all patients achieved correction of LLD and angular deformities of the lower limb, along with restoration of normal alignment of the ankle joint. There was significant mean improvement in all patient-reported LD-SRS and PROMIS domains, except for LD-SRS mental health. LD-SRS function improved from 2.6 (±0.7) to 4.6 (±0.2), P = .008; pain improved from 2.9 (±0.9) to 4.8 (±0.2), P = .012; self-image improved from 2.9 (±0.4) to 4.7 (±0.3), P < .001; and total LD-SRS improved from 3.3 (±0.4) to 4.8 (±0.2), P = .002. Average satisfaction was 4.9 (±0.3). PROMIS physical function improved from 32.3 (±6.8) to 51.3 (±5.3), P = .008; pain interference improved from 66.0 (±9.1) to 41.3 (±6.2), P = .004; pain intensity improved from 60.0 (±13.3) to 33.1 (±5.3), P = .007; global physical health improved from 39.3 (±6.8) to 60.7 (±5.1), P = .002; global mental health improved from 54.8 (±5.9) to 65.6 (±2.8), P = .007. There was one incidence of pin site infection and one reoperation. Conclusion: Deformity correction with either external frame or intramedullary nail fixation followed by TAA in a staged approach was a viable surgical option in the treatment of end-stage ankle OA with concurrent extra-articular limb deformity. This unique approach was capable of achieving deformity correction with improved patient-reported outcomes, minimal complications, and good patient satisfaction. Level of Evidence: Level IV, retrospective case series.

Two-Year Revision Rates in Total Ankle Replacement Versus Ankle Arthrodesis

“…However, new data indicate that younger age (<50 years) should no longer be considered a contraindication for TAR 16 . Furthermore, patients with gross deformities were initially advised against TAR, but recent studies indicate that these patients can also benefit from TAR [17][18][19] . Increased patient demand to retain ankle movement and expanding indications can explain why the number of TAR procedures in California and New York State has equaled that of AA.…”

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

“…There have been reports describing staged total ankle arthroplasty techniques for correction of limb deformity in patients with ankle osteoarthritis [6] , [7] . However, this report describes a case of ankle osteoarthritis and tibial malalignment after distal tibial osteotomy in which one-stage corrective tibial osteotomy and ankle arthrodesis with an anterolateral plate via a transfibular approach was successful.…”

“…Rotational and angular deformities of the tibia can drive malalignment at the ankle joint, leading to shear stresses within the articular cartilage and altered contact pressures [5] . This asymmetric mechanical loading due to tibial deformity contributes to an increased risk of progression of osteoarthritis [6] . When ankle osteoarthritis is accompanied by limb deformity, it is reasonable to correct the more proximal deformity by first performing tibial osteotomy with an internal fixation method such as an intramedullary nail or external fixator, followed by total ankle arthroplasty in a staged manner to drive distal alignment [6] , [7] .…”

“…This asymmetric mechanical loading due to tibial deformity contributes to an increased risk of progression of osteoarthritis [6] . When ankle osteoarthritis is accompanied by limb deformity, it is reasonable to correct the more proximal deformity by first performing tibial osteotomy with an internal fixation method such as an intramedullary nail or external fixator, followed by total ankle arthroplasty in a staged manner to drive distal alignment [6] , [7] . However, to our knowledge, there has been no description of a one-stage operative approach for osteoarthritis of the ankle with concomitant limb deformity after distal tibial osteotomy.…”

Personalized total knee arthroplasty in patients with extra-articular deformities

“…Regarding the ankle, for example, deformities, especially in the tibia, can lead to changes in contact pressure and shear stresses. If associated with symptoms, the deformities require correction before addressing the ankle surgically ( 39 , 40 ). In such cases, osteotomy to resolve symptoms on the adjacent joint is advised.…”