Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. Ankle Arthroplasty in Patients Younger and Older than 50 Years: A Prospective Series with Long-term Follow-up Outcome After Single Technique Ankle Arthrodesis in Patients With Rheumatoid Arthritis Prospective Controlled Trial of STAR Total Ankle Replacement versus Ankle Fusion: Initial Results Functional Evaluation of the Scandinavian Total Ankle Replacement Anterior ankle arthrodesis with cross-screw fixation. A dowel graft method used in 20 cases. Short-Term Results of Our First 49 Scandanavian Total Ankle Replacements (STAR) A retrospective study of posterior malleolus fractures Total ankle replacement. Early experiences with STAR prosthesis.
BACKGROUND Interest in mobile-bearing total ankle arthroplasty  has increased in recent years . However , to our knowledge , no study has focused exclusively on patients with the diagnosis of inflammatory joint disease or has provided a detailed analysis of the risk factors for failure . METHODS A prospect i ve observational study of the results of cementless mobile-bearing total ankle arthroplasty  in patients with inflammatory joint disease ( mainly rheumatoid arthritis ) was conducted at two centers . Ninety-three total ankle arthroplasties were performed . The LCS ( low contact stress ) prosthesis was used initially , in nineteen ankles , between 1988 and 1992 , and a modification of the LCS prosthesis , the Buechel-Pappas design , was used in seventy-four ankles between 1993 and 1999 . Clinical and radiographic follow-up was performed at yearly intervals . Three clinical scoring systems were used , and any complication was recorded throughout follow-up . Actuarial survival ( with revision as the end point ) , multivariate analysis , and a competing risk approach were used to describe the long-term outcome . RESULTS The clinical result at one year after surgery showed a significant improvement in the scores on all three scoring systems ( p < 0.05 ) . Ankle dorsiflexion ( mean , 7 degrees ) also improved significantly ( p < 0.05 ) compared with the preoperative state . The most frequent complication was a malleolar fracture , which occurred in twenty ankles . Only when it occurred in combination with a deformity in the frontal plane did this complication have an adverse effect on the end result . At a mean follow-up of eight years , seventeen patients ( twenty-one ankles ) had died and fifteen ankles had been revised because of aseptic loosening ( six ankles ) , primary or secondary axial deformity with edge-loading ( six ankles ) , deep infection ( two ankles ) , and a severe wound-healing problem ( one ankle ) , leaving fifty-seven ankles ( 61 % ) that were evaluated . The mean overall survival rate at eight years was 84 % . An increased failure rate was encountered in ankles with a preoperative deformity in the frontal plane of > 10 degrees ( p = 0.03 ) and in ankles in which an undersized tibial component had been implanted ( p = 0.02 ) . CONCLUSIONS Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used . Aseptic loosening and persistent deformity are the most important modes of failure One hundred consecutive cases treated with ankle arthroplasty for osteoarthritis ( OA ) or rheumatoid arthritis were followed prospect ively and annually for up to 15 years . Survivorship analysis was performed , with the endpoint being prosthesis revision or change to arthrodesis .  Patients who were younger than 50 years at the first implantation constituted one group ( group A , 30 ankles ) . The other group ( group B , 70 ankles ) consisted of patients aged 50 years or older at the first implantation . All patients were assessed clinical ly according to the Kofoed Ankle Score . The distribution of OA/rheumatoid arthritis in group A was 18/12 , and in group B it was 43/27 ( not significant ) . The median age in group A was 46 years ( range , 22–49 years ) , and in group B it was 63 years ( range , 51–83 years ) . In group A , one case was revised , and three cases were converted to  arthrodesis  after a median of 5 years ( range , 5–9 years ) . In group B , four cases were revised , and four cases were converted to  arthrodesis  after a median of 5.5 years ( range , 2–8 years ) . The results of cases with traumatic OA did not differ between groups A and B. It was concluded that the results of ankle arthroplasty were of equal quality in patients younger than 50 years and those who were older The established treatment for severe rheumatoid arthritis in the ankle is arthrodesis . Numerous reports in the literature describe outcomes in patients with degenerative and posttraumatic arthrosis and rheumatoid disease . This has led to results that are difficult to interpret . In addition , in the few studies that have evaluated patients with rheumatoid disease many techniques of arthrodesis are reported , further confounding assessment of one fusion method . One technique of 20 ankle fusions in patients with rheumatoid disease was evaluated . A modified Wagner arthrodesis was used through a transfibular approach using parallel compression screws . The scoring systems of Mazur et al , Moran et al , and the Short-Form-36 were used to evaluate the outcome . The mean time to followup was 3 years 10 months . Eighteen of 20 fusions obtained a solid talocrural union ( 90 % ) . No correlation was found between the scores of Mazur et al and Moran et al. Correlation was achieved between the scores for the Short Form-36 and Moran et al. The modified Wagner ankle arthrodesis is a simple , reliable , reproducible technique with a 90 % union rate . The value of the technique has been confirmed in patients with rheumatoid arthritis by evaluating the outcome using a scoring system that is vali date d and relevant to this population Background : Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades . The goal of the present study was to perform a prospect i ve evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis . We report the results of three separate cohorts of patients : a group of Sc and anavian Total Ankle Replacement ( STAR ) patients and a control group of ankle fusion patients ( the Pivotal Study Groups ) and another group of STAR total ankle patients ( Continued Access Group ) whose surgery was performed following the completion of enrollment in the Pivotal Study . Material s and Methods : The Pivotal Study design was a non-inferiority study using ankle fusion as the control . A non-r and omized multi-centered design with concurrent fusion controls was used . We report the initial perioperative findings up to 24 months following surgery . For an individual patient to be considered an overall success , all of the following criteria needed to be met : a ) a 40-point improvement in total Buechel-Pappas ankle score , b ) no device failures , revisions , or removals , c ) radiographic success , and d ) no major complications . In the Pivotal Study ( 9/00 to 12/01 ) , 158 ankle replacement and 66 arthrodesis procedures were performed ; in the Continued Access Study ( 4/02 to 10/06 ) , 448 ankle replacements were performed , of which 416 were at minimum 24 months post-surgery at time of the data base closure . Results : Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group . In the Continued Access Group , secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group . When the Pivotal Groups were compared , treatment efficacy was higher for the ankle replacement group due to improvement in functional scores . Pain relief was equivalent between fusion and replacement patients . The hypothesis of non-inferiority of ankle replacement was met for overall patient success . Conclusion : By 24 months , ankles treated with STAR ankle replacement ( in both the Pivotal and Continued Access Groups ) had better function and equivalent pain relief as ankles treated with fusion . Level of Evidence : II , Prospect i ve Controlled Comparative Surgical The purpose of this study was to evaluate the function of the ankle joint during walking before and after  Sc and inavian Total Ankle Replacement ( STAR ) . Nine patients ( six males and three females ) with an average age of 65 years , scheduled for unilateral total ankle replacement for osteoarthritis and rheumatoid arthritis , were evaluated both preoperatively and postoperatively in a gait analysis laboratory . Arthroplasty patients showed reduced range of motion at the ankle compared to normal controls . Postoperative arthroplasty subjects had significantly improved external ankle dorsiflexion moment , the moment that affects the plantarflexor muscles , when compared to their preoperative status . The moment in arthroplasty patients was increased , indicating improved function of the ankle joint We report a new method of ankle arthrodesis which combines an anterior approach with a dowel technique of bone grafting and screw fixation . In 20 ankles of 20 patients , ten with osteoarthritis , eight with rheumatoid arthritis and two others , we achieved 19 solid bony fusions  and one painless fibrous ankylosis . The average time to union was 12.5 weeks . Patient satisfaction was high and the functional results were as good as for other reported methods , with fewer complications Background : Forty-seven consecutive patients treated for ankle arthritis with a Sc and inavian total ankle replacement ( STAR ) by one surgeon were investigated retrospectively . Material s and Methods : A modification of the Foot Function Index ( FFI ) , which scores pain and task difficulties , was followed prospect ively . Patients were assessed clinical ly and radiologically . Failure was defined as revision of the prosthesis or arthrodesis for any reason . Results : In 47 patients ( 16 male , 31 female ) 49 total ankle replacements were carried out between May 1999 and June 2004 . Indication for surgery was end stage arthritis for rheumatoid arthritis in 29 cases , post-traumatic arthritis in 12 , osteoarthritis in five and arthritis secondary to degenerative flatfoot in three . Mean followup time was 28 ( 12 to 67 ) months . The modified FFI ( range , 0 to 100 , a high score meaning more pain and disability ) improved significantly from 59 before to 35 after surgery . The mean postoperative Kofoed ankle score was 68 . Sixteen procedures were complicated by fractures or temporary neurological damage . At the time of followup , 45 prostheses survived , while four replacements had failed . Radiological examination at followup showed radiolucent lines , osteolysis , and malposition of the components in 31 cases . Conclusion : Our results are comparable with those reported in the literature . The clinical outcome improved significantly . Due to aseptic and septic loosening , 8.2 % of the prosthesis failed Purpose In this retrospective study , we evaluated the treatment effect of  ankle joint fracture surgery involving the posterior malleolus , and discuss relevant factors influencing the occurrence of traumatic arthritis of the ankle joint . Methods A total of 102 cases of ankle joint fractures involving the posterior malleolus in five large-scale skeletal trauma centres in China , from January 2000 to July 2009 , were retrospectively analysed in terms of surgical treatment and complete follow-up . Ankle joint mobility , posterior malleolus fragment size , articular surface evenness , Ankle-Hindfoot Scale of the American Orthopedic Foot and Ankle Society ( AOFAS ) score , and imaging scale score for arthritis were recorded . The degree of fracture pain during rest , active movement , and weight-bearing walking , and satisfaction with treatment were evaluated using a visual analogue scale ( VAS ) . Results The average AOFAS score was 95.9 , excellence rate was 92.2 % , and average VAS scores for degree of fracture pain during rest , active movement , and weight-bearing walking were 0.15 , 0.31 , and 0.68 , respectively . Thirty-six cases showed arthritic manifestations . Ankle joint mobility along all directions on the injured side was lower than that on the unaffected side . There was no obvious difference in treatment effect between the fixed and unfixed posterior malleolus fragment groups for all and for fragment size of < 25 % ; between fixing the posterior malleolus fragment from front to back or from back to front ; or between elderly patients ( ≥60 years old ) and young patients ( < 60 years old ) . There was a distinct difference in the treatment effect between articular surface evenness and unevenness for all and for fragment size of ≥25 % . Conclusions For all 102 cases of ankle joint fracture involving the posterior malleolus , the treatment effect was satisfactory . Restoration of an even articular surface , especially when fragment size ≥25 % , should be attempted during treatment Early design s of Total Ankle Replacement ( TAR ) had a high failure rate . More recent experience with the 3-piece , meniscal bearing , total ankle replacement has been more promising . We report a review of the early results of our first 22 prostheses in 20 patients undergoing Sc and inavian Total Ankle Replacement ( STAR ) in Northern Irel and . There was a mean follow-up time of 26 months . Seventeen patients are pain-free at the ankle joint during normal daily activities . Two of the early cases have required revision surgery due to technical errors . Other complications have included malleolar fractures , poor wound healing and postoperative stiffness . These early results show high levels of patient satisfaction , and we are encouraged to continue with total ankle arthroplasty . There is a steep initial learning curve and use of TAR should be restricted to foot and ankle surgeons . ImagesFig 1Figs 2a and bFigs 2 c and
Regardless of the method ological limitations it can be concluded that both interventions show clinical improvement and in line with current literature neither procedure is superior to the other
Background While arthrodesis is the st and ard treatment of a severely arthritic ankle joint , total ankle arthroplasty has become a popular alternative .
This review provides clinical outcomes and complications of both interventions in patients with rheumatoid arthritis .