Total ankle replacement in association with hindfoot fusion

Abstract

We report the clinical and radiological outcome of total ankle replacement performed in conjunction with hindfoot fusion or in isolation. Between May 2003 and June 2008, 60 ankles were treated with total ankle replacement with either subtalar or triple fusion, and the results were compared with a control group of 288 ankles treated with total ankle replacement alone. After the mean follow-up of 39.5 months (12 to 73), the ankles with hindfoot fusion showed significant improvement in the mean visual analogue score for pain (p < 0.001), the mean American Orthopaedic Foot and Ankle Society score (p < 0.001), and the mean of a modified version of this score (p < 0.001). The mean visual analogue pain score (p = 0.304) and mean modified American Orthopaedic Foot and Ankle Society score (p = 0.119) were not significantly different between the hindfoot fusion and the control groups. However, the hindfoot fusion group had a significantly lower mean range of movement (p = 0.009) and a higher rate of posterior focal osteolysis (p = 0.04). Both groups showed various complications (p = 0.131) and failure occurring at a similar rate (p = 0.685). Subtalar or triple fusion is feasible and has minimal adverse effects on ankles treated with total ankle replacement up to midterm follow-up. The clinical outcome of total ankle replacement when combined with hindfoot fusion is comparable to that of ankle replacement alone. Thus, hindfoot fusion should be performed in conjunction with total ankle replacement when indicated.

Outcomes After Total Ankle Replacement in Association With Ipsilateral Hindfoot Arthrodesis

“…In contrast to the prior study by Kim et al, 16 however, overall outcome, pain relief, and implant survivorship was inferior to that of isolated TAR.…”

“…7,9,16,19,22 Furthermore, any compromise of the vascularity of the talus could lead to early component subsidence and malposition. 16 Finally, there is no consensus as to the timing of these procedures, either staged or synchronous, or whether triple arthrodeses confer a greater risk of adverse events than less complete hindfoot fusions. 16 One series has shown that at midterm follow-up, hindfoot fusion in association with ipsilateral TAR has minimal adverse effects with clinical and radiographic outcomes similar to that of primary TAR alone.…”

“…16 Finally, there is no consensus as to the timing of these procedures, either staged or synchronous, or whether triple arthrodeses confer a greater risk of adverse events than less complete hindfoot fusions. 16 One series has shown that at midterm follow-up, hindfoot fusion in association with ipsilateral TAR has minimal adverse effects with clinical and radiographic outcomes similar to that of primary TAR alone. 16 This investigation, however, used components not available in the United States.…”

“…16 One series has shown that at midterm follow-up, hindfoot fusion in association with ipsilateral TAR has minimal adverse effects with clinical and radiographic outcomes similar to that of primary TAR alone. 16 This investigation, however, used components not available in the United States. There are currently no published series evaluating the outcome of implants in this setting that include prostheses available in the United States.…”

How Do Hindfoot Fusions Affect Ankle Biomechanics: A Cadaver Model

“…Although successful subtalar joint arthrodesis provides pain relief, resultant alterations in ankle biomechanics need to be considered carefully given the possibility that this procedure may predispose the remaining hindfoot and ankle to accelerated degenerative changes [8,19,21,23,25]. The clinical association among subtalar joint arthrodesis, double (subtalar and talonavicular), and triple (subtalar, talonavicular, and calcaneocuboid) arthrodeses with progressive ankle degeneration is evident in medium-to long-term clinical studies [13,18,24].…”