Foot and Ankle Surgery 20 (2014) 1
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Editorial
Is ankle arthrodesis or total ankle replacement the better treatment for end stage arthrosis?
This is the question that has been asked for the last 40 years. A few papers have tried to come up with the answer studying the literature for the results of both treatments [1,2]. They have failed to give the answer. No one will conduct a study comparing hip and knee arhrodesis to total replacements. The reason is obvious in those cases. Arthrodesis of hips and knees carry a major negative functional loss. This may not be so in the ankle provided the subtalar joints are intact, without arthrosis, and well functioning. If a prospective randomized study should be conducted to answer whether ankle arthrodesis or total replacement is the better treatment, the result will depend on the period of follow-up. Replacements may deteriorate, and need revision, and subtalar arthrosis needing treatment may develop after arthrodesis. The results will also depend on who is performing the surgeries. Is the surgeons’ technique equally good performing arthrodesis and total replacement? and which kind of technique for arthrodesis should be included? The results of different techniques – arthroscopic or open with internal or external fixation – may differ as well as the population chosen for these methods. Which kind of total ankle replacement should be used as the standard or does that not matter? That answer will probably have to await the results of a European ankle replacement register based on UDI (Unique Device Identification). It is all a juggling with bananas and coconuts. What about patients’ conditions that should be excluded in the study: diabetes, smoking, subtalar arthrosis, psoriatric arthritis, talus necrosis, ankle angulations of >108, unstable ankles, neurological disorders, mental disorders, age under 40 and above 80 and so on? It will be very difficult to collect similar cohorts for comparison. Furthermore, how many patients will withdraw from the study when they are scheduled for arthrodesis? Even if a true comparison could be established for comparative groups of patients, how should we judge the results? Should ankle mobility be one parameter, and with what weight? If we only want the patients’ evaluation – what is it they want? Certainly freedom of pain, and a good function. While pain is an obvious parameter, patients cannot differentiate between function and
mobility [3] – unless they have an arthrodesis on one side and a total replacement on the opposite side. The closest judgement for a comparison was pragmatic and was conducted in USA. Using the same inclusion criteria several clinics performed the same total ankle replacement, while other clinics performed ankle arthrodesis [4]. The short-term results showed the same positive effect on pain reduction, but that function was better after total ankle replacement. It was a prospective study, but not randomized, and this was the weakness. The title question remains unanswered, but maybe the question was wrong. If a prospective randomized study in a well defined population showed a positive long-term result for one of the treatments – should we then give up the other option? In my opinion we must still judge patients individually giving them the choice of treatment after solid information about the pros and cons of ankle arthrodesis and ankle replacement in their particular case. Therefore the real question should be: ‘‘Which cases are best suited for ankle arthrodesis and which are best treated with ankle replacement’’. References [1] Haddad SL, Coetze JC, Estok R, et al. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis: a systematic review of the literature. J Bone Joint Surg Am 2007;89:1899–905. [2] Saltzmann CL, Kadoko RG, Suh JS. Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop 2010;2:1–7. [3] Lundberg-Jensen A, Kofoed H, Levi N. Visual analogue scoring and importance rating for ankle arthroplasy. Foot Ankle Surg 1998;4:163–6. [4] Saltzmann CL, Mann RA, Ahrens JE, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int 2009;30:579–96.
Hakon Kofoed MD Kysthospitalet, Skodsborg, Denmark E-mail address: [email protected] (H. Kofoed)
1268-7731/$ – see front matter ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.fas.2013.12.003
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Editorial
Is ankle arthrodesis or total ankle replacement the better treatment for end stage arthrosis?
This is the question that has been asked for the last 40 years. A few papers have tried to come up with the answer studying the literature for the results of both treatments [1,2]. They have failed to give the answer. No one will conduct a study comparing hip and knee arhrodesis to total replacements. The reason is obvious in those cases. Arthrodesis of hips and knees carry a major negative functional loss. This may not be so in the ankle provided the subtalar joints are intact, without arthrosis, and well functioning. If a prospective randomized study should be conducted to answer whether ankle arthrodesis or total replacement is the better treatment, the result will depend on the period of follow-up. Replacements may deteriorate, and need revision, and subtalar arthrosis needing treatment may develop after arthrodesis. The results will also depend on who is performing the surgeries. Is the surgeons’ technique equally good performing arthrodesis and total replacement? and which kind of technique for arthrodesis should be included? The results of different techniques – arthroscopic or open with internal or external fixation – may differ as well as the population chosen for these methods. Which kind of total ankle replacement should be used as the standard or does that not matter? That answer will probably have to await the results of a European ankle replacement register based on UDI (Unique Device Identification). It is all a juggling with bananas and coconuts. What about patients’ conditions that should be excluded in the study: diabetes, smoking, subtalar arthrosis, psoriatric arthritis, talus necrosis, ankle angulations of >108, unstable ankles, neurological disorders, mental disorders, age under 40 and above 80 and so on? It will be very difficult to collect similar cohorts for comparison. Furthermore, how many patients will withdraw from the study when they are scheduled for arthrodesis? Even if a true comparison could be established for comparative groups of patients, how should we judge the results? Should ankle mobility be one parameter, and with what weight? If we only want the patients’ evaluation – what is it they want? Certainly freedom of pain, and a good function. While pain is an obvious parameter, patients cannot differentiate between function and
mobility [3] – unless they have an arthrodesis on one side and a total replacement on the opposite side. The closest judgement for a comparison was pragmatic and was conducted in USA. Using the same inclusion criteria several clinics performed the same total ankle replacement, while other clinics performed ankle arthrodesis [4]. The short-term results showed the same positive effect on pain reduction, but that function was better after total ankle replacement. It was a prospective study, but not randomized, and this was the weakness. The title question remains unanswered, but maybe the question was wrong. If a prospective randomized study in a well defined population showed a positive long-term result for one of the treatments – should we then give up the other option? In my opinion we must still judge patients individually giving them the choice of treatment after solid information about the pros and cons of ankle arthrodesis and ankle replacement in their particular case. Therefore the real question should be: ‘‘Which cases are best suited for ankle arthrodesis and which are best treated with ankle replacement’’. References [1] Haddad SL, Coetze JC, Estok R, et al. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis: a systematic review of the literature. J Bone Joint Surg Am 2007;89:1899–905. [2] Saltzmann CL, Kadoko RG, Suh JS. Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop 2010;2:1–7. [3] Lundberg-Jensen A, Kofoed H, Levi N. Visual analogue scoring and importance rating for ankle arthroplasy. Foot Ankle Surg 1998;4:163–6. [4] Saltzmann CL, Mann RA, Ahrens JE, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int 2009;30:579–96.
Hakon Kofoed MD Kysthospitalet, Skodsborg, Denmark E-mail address: [email protected] (H. Kofoed)
1268-7731/$ – see front matter ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.fas.2013.12.003
