Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in hindfoot ling2015

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C OPYRIGHT Ó 2015
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Investigating the Relationship Between
Ankle Arthrodesis and Adjacent-Joint
Arthritis in the Hindfoot
A Systematic Review
Jeffrey S. Ling, MBBS, FRACS(Orth), Niall A. Smyth, MD, Ethan J. Fraser, MD, MaCalus V. Hogan, MD,
Christine M. Seaworth, MD, Keir A. Ross, MD, and John G. Kennedy, MD, FRCS(Orth)
Investigation performed at the Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY
Background: Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with endstage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are
conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint
arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting
that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically
review the available literature to determine if there is sufficient evidence to support either hypothesis.
Methods: A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total
of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted,
including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis
radiographs and medical records were available for analysis.
Results: The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gaitanalysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there
was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical
outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular
and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints
and patient symptoms was not established in a number of the clinical studies reviewed.
Conclusions: There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or
whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings
and clinical presentation in this cohort of patients has not been conclusively demonstrated.
Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor
reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or
more exchanges between the author(s) and copyeditors.
A
nkle arthrodesis has long been regarded as a reliable treatment for end-stage ankle arthritis1,2. The general principles
of alleviating pain and restoring function have remained
unchanged for over a century, and modern techniques yield good
results with a low complication rate3-8. A major reported risk of
ankle arthrodesis is adjacent-joint degeneration, with many
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one
or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to
influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the
online version of the article.
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TABLE I Biomechanical and Gait-Analysis Studies
Authors
Study Focus
Study Details
Study Findings
34
Effect of tibiotalar joint arthrodesis
on adjacent tarsal joint pressure in
a cadaver model
12 cadaver feet loaded axially on
varying uphill inclines from 0° to
30°, with pressure and contact
area measured in talonavicular,
subtalar, and calcaneocuboid joints
Significant increase in pressure in
talonavicular and calcaneocuboid
joints on 10° (p < 0.001) and 20°
(p = 0.002) inclines
30
Gait analysis and functional
outcomes following ankle
arthrodesis for isolated ankle
arthritis
Retrospective study; n = 26; mean
follow-up, 44 months
Significant (p < 0.05) decrease in
motion in all 3 planes of hindfoot
and midfoot in stance and swing.
Decrease in cadence and stride
length
31
Effect of tibiotalar arthrodesis
on foot kinematics and ground
reaction force progression during
walking
N = 9, three-dimensional gait
analysis performed, comparison
with a matched control group
Earlier forward displacement of
ground reaction force, ground
reaction force more posterior at
heel-off, increased stress on
midfoot during stance
Kinematic changes after arthrodesis
and total replacement of the ankle.
Part 1: range of motion. Part 2:
movement transfer
6 cadaver legs; axial load, 200 N;
motion sensors on all contiguous
bones; moments applied in coronal
and sagittal planes and rotation;
intact/fused/total ankle
arthroplasty states tested
Motion substantially decreased in
all planes in the fused ankle, tibial
rotation and foot inversion/eversion
increased with dorsiflexion/plantar
flexion of foot
Plantar pressure distribution after
tibiotalar arthrodesis
Plantar pressures measured in
20 patients at mean of 2 yr after
arthrodesis and compared with
other side
Plantar pressure largely unaffected
in most areas of foot
Jung et al.
Thomas et al.
Beyaert et al.
32,33
Valderrabano et al.
29
Schuh et al.
studies demonstrating an increased prevalence of arthritis of the
ipsilateral hindfoot and midfoot after ankle arthrodesis3,9-23. This
finding is thought to be due to altered biomechanics, with increased motion and wear through the subtalar and tarsal joints
compensating for the loss of ankle motion9,10. As a result of this
thinking and the quest for a reliable motion-preserving alternative, substantial efforts have been made to develop and improve total ankle replacements. While recent studies have shown
an improvement in outcomes following ankle replacement, arthrodesis continues to be the most widely employed surgical
treatment for end-stage ankle arthritis24-27.
Several studies have supported the concept that ankle arthrodesis causes adjacent-joint arthritis in the hindfoot. Coester
et al.11 and Fuchs et al.10 reported degenerative changes in the
Chopart and subtalar joints following ankle arthrodesis, implicating ankle arthrodesis as the direct cause. Both of those studies
have been quoted widely because they included long-term followup (mean, twenty-two years [range, twelve to forty-four years] and
twenty-three years [range, twenty to thirty-three years], respectively). More recently, however, this implication was challenged by
Sheridan et al.28, who argued that those studies may be flawed in
their analysis and that there may be other factors influencing
adjacent-joint arthritis. Specifically, Sheridan et al.28 noted that
many patients undergoing ankle arthrodesis have preexisting
degenerative changes in the adjacent joints prior to surgery.
Biomechanical and gait-analysis evidence is also conflicting. Schuh et al.29 showed a compensatory increase in motion in
the talonavicular, calcaneocuboid, and subtalar joints following
ankle arthrodesis, whereas Thomas et al.30 showed a decrease in
motion in these joints. Furthermore, the effect of increased or
decreased movement in the adjacent joints following ankle arthrodesis appears to be equivocal.
Because of the disparity in evidence with regard to progression of adjacent-joint degenerative arthritis, no consensus
has been reached on the basis of empirical data. In this context,
the aim of the present study was to systematically review the
available English-language literature to determine if there is
sufficient evidence to support either hypothesis.
Materials and Methods
Literature Search
he terms “(ankle arthrodesis OR ankle fusion OR tibiotalar fusion OR tibiotalar arthrodesis) AND (osteoarthritis OR arthritis OR osteoarthrosis OR
degenerative joint disease OR OA or DJD) AND (subtalar OR calcaneocuboid
OR talonavicular OR chopart OR transverse tarsal)” were used to search the
PubMed/MEDLINE and EMBASE electronic databases (1974 to present) in
January 2013. In addition, the references of the included studies were reviewed in
order to ensure that no relevant publications were excluded.
T
Inclusion Criteria
Studies were considered for inclusion if they (1) were published in the Englishlanguage literature, (2) assessed the clinical or biomechanical outcomes following ankle arthrodesis, (3) involved biomechanical and gait analyses that
were performed with use of a multi-segment foot model, (4) evaluated the
radiographic appearance of the subtalar, talonavicular, or calcaneocuboid joint,
(5) evaluated the prevalence of subsequent adjacent-joint arthritis following the
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primary procedure, and (6) were published in a peer-reviewed journal. Studies
that exclusively focused on patients with inflammatory arthritis as the etiology
for ankle disease were excluded. The literature search was performed by two of
the authors, and all of the authors independently reviewed the search results.
The title and abstract of all search results were assessed, and studies that were
identified for possible inclusion received a full-text review. Authors agreed on
the studies that met the inclusion criteria (Fig. 1).
Data Extraction
A standardized data sheet was prepared, and all authors extracted the relevant
information, including research methodology, postoperative outcomes in the
adjacent joints of the foot, and whether pre-arthrodesis radiographs and
medical records were available for analysis. Postoperative outcomes that were
recorded included adjacent-joint symptoms, the existence or exacerbation of
arthritis in adjacent joints, the rates of reoperation and adjacent-joint arthrodesis, and any effects on motion of adjacent joints.
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and abstracts, 405 studies were excluded because they did not
meet the inclusion criteria. Thirty-eight studies were considered
for full-text review, of which fourteen were excluded as they
evaluated inflammatory arthritis exclusively, did not provide
data on the adjacent joints, were review articles, or were gaitanalysis studies performed with use of a single-segment model
(Fig. 1). Twenty-four studies were determined to be eligible for
inclusion overall, including eighteen clinical studies, five biomechanical studies, and one gait-analysis study. Three of the latter
six studies also provided clinical data.
No external funds were received in support of this study.
Gait-Analysis Study (Table I)
Only one study assessed gait following ankle arthrodesis with
use of a multi-segment model30. The study demonstrated a significant decrease in motion of hindfoot and forefoot joints, in all
planes and in all phases of stance and swing, compared with the
contralateral, unfused side.
Results
ollowing the removal of duplicates, the literature search
yielded 443 relevant publications. After a review of the titles
Biomechanical Studies (Table I)
Five biomechanical studies investigated motion and pressure
changes after ankle arthrodesis. Schuh et al.29 evaluated plantar
Source of Funding
F
Fig. 1
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram for included studies for review.
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TABLE II Clinical Studies on Adjacent-Joint Arthritis: Imaging Findings and Correlation with Symptoms*
Adjacent-Joint Arthritis After Arthrodesis
Clinical Study
Radiographic Evidence
13
Strasser and Turner
37% subtalar joint
33% subtalar joint,
37% talonavicular joint,
45.5% calcaneocuboid
joint
No correlation
NR
35% subtalar joint, 18%
talonavicular joint†
30% subtalar joint,
19% talonavicular joint
NR
NR
43% subtalar joint (high
grade)‡
37% subtalar joint
10% symptomatic
NR
24% subtalar joint†
NR
50% symptomatic
NR
47% moderate-severe
osteoarthritis
33% overall
Subtalar osteoarthritis
correlated with poorer
outcomes
Adjacent-joint
motion reduced
91% subtalar joint, 56%
talonavicular joint, 22%
calcaneocuboid joint‡
NR
Correlation between
poorer Kellgren-Lawrence
grade and outcome
Subtalar joint
motion decreased
NR
32.5% subtalar joint,
12% talonavicular
joint
14% subtalar joint
osteoarthritis symptomatic
Adjacent-joint
movement increased
88% subtalar joint‡
NR
Correlation reported
NR
Mean subtalar KellgrenLawrence grade, >3†
Yes
Subtalar arthritis
correlated with poorer
outcomes
Adjacent-joint
movement reduced
37
59% tarsal joints‡
NR
No correlation
Variable change in
adjacent-joint motion
35
44% overall‡
27% progressed overall
NR
Motion same as
contralateral side
62% subtalar stiffness
NR
Not correlated
NR
NR
NR
Not significantly
correlated
Increased adjacentjoint motion
50% Chopart joint, 36%
subtalar joint‡
Some progression
Poor correlation with
symptoms
NR
;24% subtalar joint‡
10.4% subtalar joint
30% symptomatic
NR
42% subtalar joint‡
29% subtalar joint
NR
NR
NR
No progression
Tarsal joint arthritis
correlated with poorer
outcomes
Reduced movement
15
16
Winson et al.
17
Kopp et al.
18
Buchner and Sabo
11
Coester et al.
9
Takakura et al.
19
Trouillier et al.
10
Fuchs et al.
Jackson and Glasgow
21
Boobbyer
36
Sealey et al.
22
Morrey and Wiedeman
23
3
Aaron
20
Schaap et al.
56%
Loss of Motion
91% subtalar joint, 77%
talonavicular joint†
Zwipp et al.
Hallock
Correlation with Symptoms
100% subtalar joint
14
Hendrickx et al.
Abdo and Wasilewski
Progression
NR
*NR = not reported. †Preoperative. ‡Postoperative.
pressure distribution in the foot after ankle arthrodesis and
showed a moderate increase in pressure in the lateral aspect of the
midfoot region in stance phase, but they did not indicate whether
the increase was significant. They otherwise found that ankle
arthrodesis did not affect the plantar pressure distribution in
most regions of the foot. Beyaert et al.31 found an earlier forward
displacement of the ground reaction force. Valderrabano et al.32,33
assessed the kinematic changes after ankle arthrodesis in six cadaver specimens and found that the range of motion decreased in
all three planes, with inversion and eversion of the foot decreasing
slightly and with tibial rotation decreasing markedly. In addition,
the authors noted that tibial rotation and foot inversion and
eversion increased significantly with dorsiflexion and plantar
flexion of the foot.
Most recently, Jung et al.34 studied pressure changes in the
talonavicular, calcaneocuboid, and subtalar joints in feet that were
loaded axially after ankle arthrodesis on varying uphill inclines
from 0° to 30°. They found a significant increase in pressure in the
talonavicular and calcaneocuboid joints between intact and fused
ankles on 10° (p < 0.001) and 20° (p = 0.002) inclines.
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Clinical Studies (Table II)
Study Quality and Design
All eighteen clinical studies were retrospective reviews. Of the 675
patients who were included in those studies, 56.4% were male and
43.6% were female. The mean age of the patients was fifty-two years.
The mean duration of follow-up for each individual study ranged
from two to twenty-three years, with an overall mean of 7.9 years.
Etiology of Ankle Arthritis
Seventeen studies (94%) evaluated the etiology of arthritis in the
patient population. Of these, two included a homogeneous cohort consisting of patients with posttraumatic arthritis11,18. All of
the other studies either did not include information on etiology
or included a heterogeneous cohort consisting of patients with
etiologies such as posttraumatic osteoarthritis (82.3%), primary
arthropathy (9.3%), inflammatory arthropathy (4.6%), neuropathic arthropathy (2.7%), and hemophilic arthropathy (1.1%).
Effect on Range of Motion in Adjacent Joints
Varying results were reported with regard to the clinical outcomes
in the adjacent joints following ankle arthrodesis. Abdo and
Wasilewski35 evaluated thirty patients at a mean of seven years
after ankle arthrodesis and found no difference in tarsal movement compared with the contralateral side. In contrast, Sealey
et al.36 and Takakura et al.9 demonstrated a compensatory increase
in motion in the adjacent hindfoot joints, with the latter study9
showing that the mean subtalar range of motion increased by 4.1°.
Jackson and Glasgow37 showed that tarsal joint mobility increased
in 27% of patients, stayed the same in 40%, and decreased in 33%
when the contralateral side was used as a control. Overall, four
studies showed a decrease in adjacent-joint motion whereas two
studies showed an increase and one study showed variable change
in adjacent-joint motion. The remaining studies did not include
information on adjacent-joint motion after arthrodesis.
Prevalence of Arthritic Changes in Adjacent Joints
Many studies evaluated the postoperative prevalence of arthritis in
the joints of the foot, with the subtalar joint being more frequently
affected than either the talonavicular or calcaneocuboid joint3,9-23,38.
The reported prevalence of subtalar joint arthritis ranged from
24% to 100%, whereas the reported prevalence of arthritis in
the talonavicular and calcaneocuboid joints ranged from 18%
to 77%. The talonavicular joint was more frequently affected than
the calcaneocuboid joint. Coester et al.11, after a mean duration of
follow-up of twenty-three years, showed that the majority of
patients in their cohort had moderate to severe restriction in
subtalar range of motion and half had tenderness and/or swelling
in the hindfoot and midfoot. Fuchs et al.10, after a mean duration
of follow-up of twenty-two years, showed that their cohort of
eighteen patients had mean osteoarthritis scores of 2.3 and 3.1 for
the talonavicular and subtalar joints, respectively, according to
the radiographic grading system of Kellgren and Lawrence39.
Preexisting Adjacent-Joint Arthritis
Five (28%) of the eighteen studies13-16,23 provided the preoperative
prevalence of adjacent-joint arthritis. Hallock23 reported on forty-
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eight patients at a mean of four years after arthrodesis. After this
relatively short duration of follow-up, only five patients (10.4%)
showed progression of adjacent-joint arthritis, with four patients
developing arthritis in the subtalar joint and one patient developing arthritis in the talonavicular joint. The authors did not
report on the calcaneocuboid joint. In addition, six patients had
preexisting arthritis in the subtalar joint and three had preexisting
arthritis in the talonavicular joint. The authors did not comment
on whether the arthritis progressed in these patients. Aaron3, at a
mean of three years after ankle arthrodesis, reported progression
to a more severe grading of subtalar arthritis in 29% of the cohort
but did not mention the preoperative prevalence of subtalar arthritis. In addition, in the most recent publications13,14, almost all
patients undergoing ankle arthrodesis had some degree of subtalar
arthritis on preoperative radiographs. Despite this high prevalence
of subtalar disease, subtalar arthritis progressed in only thirty-one
(34.4%) of ninety patients. The overall prevalence of preexisting
arthritis is not clear given the paucity of studies evaluating the
preoperative prevalence of adjacent-joint arthritis.
Association of Arthritis with Patient Symptoms
Although a high prevalence of postoperative radiographic arthritis
was reported, this finding often correlated poorly with clinical
symptoms10,13,14,21,22,35. Overall, an association between radiographic
adjacent-joint arthritis and patient symptoms was seen in six
(33%) of the eighteen included studies. Furthermore, within those
studies, a mean of 24% of patients had symptoms associated with
adjacent-joint arthritis. Hendrickx et al.14 reported that the degree
of radiographic arthritis in these joints failed to correlate with visual
analog scale (VAS) pain scores. In addition, Strasser and Turner13
found that 44% of patients with subtalar arthritis were asymptomatic. Boobbyer21 found that reduced motion in the subtalar joint
did not seem to affect the clinical result and concluded that deterioration in function due to adjacent-joint disease was not a frequent observation. Morrey and Wiedeman22 reported that 82% of
their patients with radiographic arthritis in the Chopart joint were
asymptomatic, whereas 87% of patients with no radiographic evidence of Chopart joint arthritis were asymptomatic. The studies
with the longest durations of follow-up demonstrated conflicting
findings. Coester et al.11 reported that pain, swelling, and activity
limitation correlated significantly with the Kellgren and Lawrence
grade for arthritis in the talonavicular and calcaneocuboid joints at
a mean of twenty-two years of follow-up. In contrast, Fuchs et al.10
found no correlation between radiographic results and Short
Form-36 (SF-36) scores and no correlation between the functional Olerud-Molander ankle score40 and radiographic scores for
the midtarsal joints at a mean of twenty-three years of follow-up.
Reoperation Rates for Adjacent-Joint Arthrodesis
Of the eighteen clinical studies, four included patients who required further arthrodesis of the adjacent joints9,13,16,35. Of the
675 patients who were included in the eighteen studies, twelve
required further adjacent-joint arthrodesis. Nine patients underwent a subtalar arthrodesis, two patients underwent a triple arthrodesis, and one patient underwent a talonavicular arthrodesis.
One of the two patients who underwent a triple arthrodesis and
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the one patient who underwent a talonavicular arthrodesis
had an inflammatory arthropathy rather than a degenerative
pathology.
Because of the heterogeneity of the included studies, our
review of the literature did not allow us to correlate findings to
operative technique, alignment, or approach.
Discussion
nkle arthrodesis remains a commonly used procedure for
the treatment of end-stage ankle arthritis. Traditionally,
concerns have existed over the potential long-term risk of arthritis in the surrounding joints of the foot—in particular, the
talonavicular, calcaneocuboid, and subtalar joints. A paucity
of data exists to support this concern. The aim of the current
systematic review was to establish whether there are sufficient
data to provide evidence for this concern.
A
Gait-Analysis Studies
Only one of the available gait-analysis studies on the subject
involved the use of a multi-segment model30. That study demonstrated decreased motion in hindfoot and forefoot joints following ankle arthrodesis. However, there is conflicting evidence
in previous single-segment models, with one study showing increased motion in the adjacent joints and another showing
no change12,38. Those studies were not included in our review,
however, as single-segment models consider the foot as a rigid
segment and as such are flawed in their analysis of adjacent-joint
movement41. As a result of the paucity of evidence and limitations
of the gait-analysis models currently available, in addition to the
contrasting findings in previous studies, the effect of arthrodesis
of the ankle on adjacent-joint movement remains unclear.
Biomechanical Studies
Jung et al.34, using arthrodesed ankles in a cadaver model, showed
a significant increase in pressure in the talonavicular and calcaneocuboid joints on a 10° and a 20° incline as compared with the
unfused state. The authors concluded that this pressure increase in
dorsiflexion, simulating late stance phase, may be responsible for
the late degenerative changes in these joints after ankle arthrodesis. The concern related to that study, however, is that it used only
time-zero mechanical data, confounding the conclusions.
Schuh et al.29 showed increases in the lateral aspect of the
midfoot region during the stance phase of gait, but they did not
indicate whether the increases were significant. Ankle arthrodesis
was not shown to affect plantar pressure distribution in other
regions of the foot in their analysis. Beyaert et al.31 hypothesized
that the earlier forward displacement of ground reaction force
seen in their study would lead to high stress on the midtarsal
joints during stance phase. Valderrabano et al.32,33 found that
kinematic changes in the hindfoot after ankle arthrodesis may
not fully compensate for normal range of motion in all three
planes, leading to increased movement transfer, which the authors
postulated may be associated with overloading of the adjacent
joints. Overall, the biomechanical studies that were reviewed
revealed no consensus on whether ankle arthrodesis might cause
arthritis in adjacent joints.
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Clinical Studies
Fifteen of the eighteen clinical studies that were retrieved demonstrated radiographic evidence of adjacent-joint arthritis in the
foot following ankle arthrodesis3,9-11,13-19,22,23,35,37. However, there
are two caveats. First, radiographic arthritis does not correlate
strongly with symptoms and patients with adjacent-joint arthritis may even be asymptomatic despite high radiographic
scores10,13,14,21,22,35. Second, the development of arthritis in these
joints after ankle arthrodesis may be multifactorial and may not
be due to the arthrodesis alone. Sheridan et al.28 reported that
arthritis in these joints is often preexisting and is not necessarily
recorded. Sheridan et al.28 also demonstrated that the majority of
studies are retrospective and that radiographs made prior to the
ankle arthrodesis are frequently unavailable for analysis. Other
possibilities mentioned by those authors are that the abnormality that caused the ankle arthritis, such as the initial trauma
or inflammatory disease, may have caused disease in these adjacent joints. In addition, longstanding arthritis in the ankle and
alterations in hindfoot kinematics prior to the actual arthrodesis
may damage the surrounding joints.
Of the eighteen clinical studies that were analyzed, five13-16,23
had the benefit of having pre-arthrodesis radiographs available
for analysis, with the majority of these studies being published
after 2005. In two of the eighteen studies13,14, almost all patients
undergoing ankle arthrodesis had some degree of adjacent-joint
arthritis on preoperative radiographs, which is consistent with
the findings of Sheridan et al.28. Despite this high prevalence of
preexisting arthritis, the severity of arthritis only progressed in
roughly one-third of the patients in each cohort. The conclusions
from those studies indicate that ipsilateral hindfoot and midfoot
arthritis is almost universally present in patients undergoing
ankle arthrodesis and that two-thirds of these patients will not
experience any progression of disease in these joints and therefore
presumably will remain asymptomatic.
When considering other treatment options, total ankle
replacement is an attractive alternative given the theoretical
benefit of motion preservation. However, because of the paucity
of long-term data, there is insufficient evidence to recommend
total ankle replacement over arthrodesis for all patients at this
time42.
The principal limitation of this systematic review is the
quality of the included publications. Long-term prospective
studies with a homogeneous cohort confined to patients with
posttraumatic and/or primary osteoarthritis as the etiology of
arthritis would be better designed to answer the titled premise.
Without knowledge of the state of the surrounding joints, the
position of the fusion, and the activity level of the patient, it is not
possible to draw conclusions about the likelihood of degenerative
change.
While many patients undergoing arthrodesis of the ankle
develop arthritis in surrounding joints, the cause is not clear from
the available studies in the literature. A prospective comparison
with baseline assessment of surrounding-joint arthritis is needed.
Moreover, radiographic evidence of arthritis is not always
clinically important, with patients often being asymptomatic
despite high radiographic scores for arthritis.
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Overview
iomechanically, there is no consensus on how ankle arthrodesis might contribute to the pathogenesis of adjacentjoint degeneration. Radiographic evidence of adjacent-joint
arthritis in the foot following ankle arthrodesis is seen in studies
with a mean duration of follow-up of two to twenty-three years.
There is only a weak correlation between radiographic evidence
of arthritis and the presence of symptoms in these joints.
Further prospective analysis of adjacent joints at baseline
and following arthrodesis may help to establish the effects of
arthrodesis on adjacent-joint arthritis. n
B
R E L AT I O N S H I P B E T W E E N A N K L E A R T H R O D E S I S A N D
A D J A C E N T -J O I N T A R T H R I T I S I N T H E H I N D F O O T
Niall A. Smyth, MD
Ethan J. Fraser, MD
Christine M. Seaworth, MD
Keir A. Ross, MD
John G. Kennedy, MD, FRCS(Orth)
Department of Foot and Ankle Surgery,
Hospital for Special Surgery,
523 East 72nd Street,
East River Professional Building,
5th Floor Room 507,
New York, NY 10021.
E-mail address for K.A. Ross: [email protected]
MaCalus V. Hogan, MD
Division of Foot and Ankle Surgery,
Department of Orthopaedic Surgery,
University of Pittsburgh School of Medicine,
3471 Fifth Avenue, Suite 911,
Pittsburgh, PA 15232
Jeffrey S. Ling, MBBS, FRACS(Orth)
Prince of Wales Hospital Clinical School,
UNSW, Sydney, NSW 2052, Australia
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TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
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A D J A C E N T -J O I N T A R T H R I T I S I N T H E H I N D F O O T
Update
This article was updated on April 2, 2015, because the degree and affiliation of the first author, Jeffrey S. Ling, were listed incorrectly.
The degree, which had previously read “MBBS, FRCS(Orth)” on pages 513 and 519, now reads “MBBS, FRACS(Orth).” The
mailing address, which had previously read “Department of Foot and Ankle Surgery, Hospital for Special Surgery, 523 East 72nd
Street, East River Professional Building, 5th Floor Room 507, New York, NY 10021” on page 519, now reads “Prince of Wales
Hospital Clinical School, UNSW, Sydney, NSW 2052, Australia.”
An erratum has been published: J Bone Joint Surg Am. 2015;97(9):e43.