Residual pain due to soft-tissue impingement after uncomplicated total ankle replacement

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1 FOOT AND ANKLE Residual pain due to soft-tissue impingement after uncomplicated total ankle replacement B. S. Kim, W. J. Choi, J. Kim, J. W. Lee From Yonsei University College of Medicine, Seoul, Korea We report the incidence and intensity of persistent pain in patients with an otherwise uncomplicated total ankle replacement (TAR). Arthroscopic debridement was performed in selected cases and the clinical outcome was analysed. Among 120 uncomplicated TARs, there was persistent pain with a mean visual analogue scale (VAS) of 2.7 (0 to 8). The intensity of pain decreased in 115 ankles (95.8%). Exercise or walking for more than 30 minutes was the most common aggravating factor (62 ankles, 68.1%). The character of the pain was most commonly described as dull (50 ankles, 54.9%) and located on the medial aspect of the joint (43 ankles, 47.3%). A total of seven ankles (5.8%) underwent subsequent arthroscopy. These patients had local symptoms and a VAS for pain 7 on exertion. Impingement with fibrosis and synovitis was confirmed. After debridement, the median VAS decreased from 7 to 3 and six patients were satisfied. The median VAS for pain and the American Orthopaedic Foot and Ankle Society score of the ankles after debridement was similar to that of the uncomplicated TARs (p = and p = 0.066, respectively). Although TAR reduces the intensity of pain, residual pain is not infrequent even in otherwise uncomplicated TARs and soft-tissue impingement is the possible cause. Cite this article: Bone Joint J 2013;95-B: B. S. Kim, MD, Orthopaedic Surgeon, Assistant Professor Inha University Graduate School of Medicine, Department of Orthopaedic Surgery, 7-206, 3-ga, Sinheungdong, Jung-gu, Incheon , Korea. W. J. Choi, MD, Orthopaedic Surgeon, Assistant Professor J. W. Lee, MD, PhD, Orthopaedic Surgeon, Professor Yonsei University College of Medicine, Department of Orthopaedic Surgery, 50 Yonsei-ro, Seodaemun-gu, Seoul , Korea. J. Kim, MD, Orthopaedic Surgeon Busan Veterance Hospital, Department of Orthopaedic Surgery, 420, Baegyang-daero, Sasang-gu, Busan , Korea. Correspondence should be sent to Professor J. W. Lee; ljwos@yuhs.ac 2013 The British Editorial Society of Bone & Joint Surgery doi: / x.95b $2.00 Bone Joint J 2013;95-B: Received 3 November 2012; Accepted after revision 12 December 2012 The results following total ankle replacement (TAR) have improved over the past ten years. 1-8 However, unlike after total knee or hip replacement, most patients experience some degree of persistent pain after TAR. 9 There are various causes of pain after TAR. If it is due to an obvious complication such as loosening, dislocation, osteolysis or infection, it has the potential to be solved by revision. Minor complications due to technical errors such as nerve injury or stress concentration due to malalignment, can also cause pain, but the incidence of these will be reduced with experience. 10 However, some pain often occurs following uncomplicated TAR that simply cannot be explained. This study aims to analyse the prevalence, character and intensity of residual pain after uncomplicated TAR. We also report the clinical outcomes of arthroscopic debridement in patients with soft-tissue impingement after TAR. Patients and Methods A total of 137 primary TARs were performed in 122 patients in our institution between September 2004 and July Of these, five ankles underwent revision or conversion to arthrodesis due to infection or aseptic loosening; they were considered failures and excluded from the study. A further 12 ankles underwent revision due to dislocation of the polyethylene bearing (four), progressive or large (diameter > 1 cm) osteolysis with a stable implant (six), and malalignment (two), and these were also excluded. The remaining 120 uncomplicated TARs (107 patients) were included in an analysis of residual pain. The mean age of the patients was 63.9 years (33 to 84). The Hintegra (Newdeal SA, Lyon, France) system was used in all cases. All operations were performed by the senior author (JWL). TAR was performed through a standard approach, 11,12 with various associated ligamentous and bony procedures to balance the ankle and correct associated deformities when indicated. 2,11 The indications for subsequent arthroscopy included swelling, tenderness and pain on exertion and no evident cause on plain radiographs. Arthroscopy was undertaken with the patient in a supine position and a tourniquet applied to the upper thigh. Non-invasive ankle distraction (6.8 kg, 15 lb) was applied using a harness. A 2.7 mm, 30 -angled arthroscope was introduced in turn through the standard anteromedial and anterolateral portals. Soft-tissue 378 THE BONE & JOINT JOURNAL

2 RESIDUAL PAIN DUE TO SOFT-TISSUE IMPINGEMENT AFTER UNCOMPLICATED TOTAL ANKLE REPLACEMENT Change in pain VAS Ankles (n) Ankles (n) VAS for pain Fig. 2 Fig. 1 Bar chart showing distribution of the change in pain (visual analogue score, VAS) after total ankle replacement. Bar chart showing distribution of the residual pain intensity at last follow-up after total ankle replacement impingement was characterised by hypertrophic synovial and scar tissue at the site of the pain. Debridement was performed using a power shaver and in patients with associated bony impingement, the osteophytes were removed using an arthroscopic punch. All the patients were evaluated pre-operatively, and at two and six weeks, three and six months, one year and yearly thereafter. Clinical evaluation included a recording of pain on a visual analogue scale (VAS, ranging from 0 to 10), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, 13 the range of movement (ROM) and satisfaction. A provocation factor for the most pain was recorded. Pain on the VAS was subdivided into: 1) starting pain (the amount of pain when starting to walk), 2) stress pain (the amount of pain during exercise or when walking for > 30 minutes), 3) resting pain and 4) night pain. The location and the character of the pain was recorded. The pain was described as dull, stabbing, neurological or pulsating. Statistical analysis. This was carried out using SPSS v19.0 (SPSS Inc., Chicago, Illinois). In order to evaluate the changes before and after surgery, a paired t-test was used. The clinical outcome after arthroscopic debridement in seven patients was compared with that of those with an uncomplicated TAR (n = 113). Due to the small number of patients who underwent arthroscopic debridement, non-parametric tests were performed to compare their outcome with those with uncomplicated surgery. A Wilcoxon rank sum test or Mann-Whitney test was used for continuous variables. Results The mean follow-up was 40 months (14 to 84). For all 120 patients the mean VAS decreased from 7.1 (5 to 10) pre-operatively to 2.7 (0 to 8) at final follow-up (p < 0.001). The mean AOFAS ankle and hindfoot score increased from 59.3 (21 to 89) to 83.0 (49 to 100) (p < 0.001). Pain decreased in 115 ankles (95.8%), did not change in four (3.3%), and slightly increased in one (0.8%) (Fig. 1). A total of 29 ankles (24.2%) were completely pain-free at final follow-up (Fig. 2). In the 91 ankles (75.8%) with residual pain, the mean VAS was 3.5 (1 to 8): its intensity was minimal (VAS 1 to 2) in 27 (22.5%), mild (VAS 3 to 4) in 39 (32.5%), moderate (VAS 5 to 6) in 22 (18.3%), and moderate to severe (VAS 7 to 8) in three (2.5%). None complained of severe pain (VAS > 8) (Table I). Pain was most commonly located on the medial aspect of the ankle (43, 47.3%), followed by pain in the whole joint (23, 25.3%), on the lateral aspect (11, 12.1%), anterior aspect (seven, 7.7%), posterior aspect (four, 4.4%), and over the sinus tarsi in three ankles (3.3%). Among the 66 ankles with pain medially or in the whole joint, 27 (40.9%) had undergone a medial ligament releasing procedure during TAR. Of 54 ankles in which a medial ligament releasing procedure was performed, 27 (50%) had pain medially or in the whole joint while the other half did not (Table II). The pain was described as dull in 50 ankles (54.9%), stabbing/sharp in 27 (29.7%), neurological in ten (11.0%), and pulsating in four (4.4%). Aggravating factors included exercise or long distance walking (62 ankles, 68.1%), when starting to walk (20, 22.0%), unknown causes (seven, 7.7%), and at night (two, 2.2%). The distribution of the pain intensity during specific circumstances are shown in Figure 3. In the seven patients who underwent subsequent arthroscopy, the findings were of scar tissue and associated synovitis causing impingement anteriorly and in both medial and lateral gutters (Fig. 4). Histology confirmed synovial hyperplasia with capillary ingrowth without the evidence of polyethylene debris. Osteophytes caused impingement in VOL. 95-B, No. 3, MARCH 2013

3 380 B. S. KIM, W. J. CHOI, J. KIM, J. W. LEE Table I. Summary of papers that presented the degree of pain after total ankle replacement Author/s Prosthesis Ankles (n) Mean follow-up (mths) (range) Residual pain Kopp et al 9 Agility (26 to 64) None: 16 (40%) Mild/occasional: 21 (52.5%) Moderate/daily: 3 (7.5%) Severe/almost always present: 0 San Giovanni et al 14 Buechel-Pappas (60 to 146.4) None: 21 (75%) Mild: 6 (21%) Moderate: 1 (4%) Severe: 0 Bonnin et al 20 Salto (24 to 68) None/minimal: 72 (77%) Mild: 12 (13%) Severe: 7 (8%) Totally disabled: 2 (2%) Valderrabano et al 19 Hintegra (24 to 48) None (VAS 0): 105 (69%) Moderate (VAS 1 to 5): 47 (31%) Severe: 0 Valderrabano et al 18 STAR (28.8 to 74.4) None: 37 (54%) Mild (VAS 0 to 7): 30 (46%) Hintermann et al 12 Hintegra (12 to 36) None: 83 (68%) Moderate (VAS 0 to 10): 37 (30%) Severe & unsatisfactory (VAS > 6): 2 (2%) Current study Hintegra (14 to 84) None (VAS 0): 29 (24.2%) Minimal (VAS 1 to 2): 27 (22.5%) Mild (VAS 3 to 4): 39 (32.5%) Moderate (VAS 5 to 6): 22 (18.3%) Moderate to severe (VAS 7 to 8): 3 (2.5%) Severe (VAS 9 to 10): 0 Table II. Details of the additional medial ligament releasing procedure and radiological findings in the patients with and without medial or whole joint pain Medial/ whole joint pain Present (n = 66) Absent (n = 54) p-value Medial ligament releasing procedure (n, %) Performed 27 (40.9) 27 (50.0) Not performed 39 (59.1) 27 (50.0) Mean (SD) post-operative α angle ( ) * 87.8 (2.1) 87.3 (1.9) * α angle: the angle on the anteroposterior view, between the longitudinal axis of the tibia and the articulating surface of the tibial component 12 chi-squared test two-sample t-test two patients. After debridement, the median VAS for pain decreased from 7 (7 to 10) to 3 (1 to 6) (p < 0.001), and all patients were satisfied except one who had associated neurological symptoms. When the final outcomes between the arthroscopic debridement and the uncomplicated TAR groups were compared, no differences were found regarding the median VAS, AOFAS score or the range of movement (p = 0.148) (Table III). Discussion Favourable mid-term and long-term results following TAR have been reported. 1,4,8,14 Most authors report an improvement in function and decreased pain. 1,4,15-17 However, less pain does not represent resolution of pain and this should not be overlooked. It is important, both for the patients and for the surgeons, to understand that some residual pain is to be expected. THE BONE & JOINT JOURNAL

4 RESIDUAL PAIN DUE TO SOFT-TISSUE IMPINGEMENT AFTER UNCOMPLICATED TOTAL ANKLE REPLACEMENT Night pain Resting pain Starting pain Stress pain Ankles (n) VAS for pain Fig. 3 Bar chart showing the distribution of the pain intensity during specific circumstances. Fig. 4a Fig. 4b Arthroscopic images showing a) thick fibrosis in the anterior aspect of the ankle prosthesis and b) after arthroscopic debridement. Kopp et al 9 reported that 40% of their patients (40 ankles in 38 patients) were pain-free after TAR. Higher rates of pain relief ranging from 54% to 75% have been reported. 12,14,18,19 Bonnin et al 20 stated that 77% of their patients (93 ankles in 91 patients) had minimal or no pain. The reported incidence of pain after TAR is summarised in Table I. Most of these papers are from centres of excellence or from the designers of the implants. We found that only 24.2% (29 of 120 ankles) were completely pain-free after TAR; 22.5% had minimal, 32.5% mild, 18.3% moderate, and 2.5% had moderate to severe pain. As we have no association with any inventor groups, the higher incidence of residual pain in our patients may more closely represent the incidence of pain after TAR. We are a relatively large-volume centre with an experienced senior author having performed more than 180 TARs in the last nine years, the incidence of persistent pain after TAR performed by less experienced surgeons might be even higher. Most (61.6%) of the residual pain was on the medial aspect of the ankle. Kurup and Taylor 21 reported eight patients (23.5%) with medial impingement in 34 TARs. Of VOL. 95-B, No. 3, MARCH 2013

5 382 B. S. KIM, W. J. CHOI, J. KIM, J. W. LEE Table III. Clinical assessment (median, range) of the arthroscopic debridement and uncomplicated total ankle replacement (TAR) groups Outcome * Arthroscopic debridement (n = 7) Uncomplicated TAR (n = 113) p-value Visual analogue scale Initial (before primary TAR) 8 (6 to 8) 7 (5 to10) Pre-arthroscopy 7 (7 to 10) Final follow-up 3 (1 to 6) 3 (0 to 8) AOFAS score Initial 62 (40 to 70) 58 (21 to 72 ) Pre-arthroscopy 45 (22 to 65) Final follow-up 78 (59 to 97) 85 (49 to 100) Range of movement ( ) Initial 25 (20 to 30) 30 (0 to 70) Final follow-up 40 (35 to 50) 50 (15 to 70) * AOFAS, American Orthopaedic Foot and Ankle Society Mann-Whitney test those, four underwent revision, and the cause of pain was found to be bony and soft-tissue impingement in two and tibialis posterior tendinitis with degenerative tears in two. Barg et al 22 considered impingement, contracture of medial ligaments or eccentric loading due to malalignment to be the cause of medial pain after TAR. We found soft-tissue impingement to be the cause of pain medially or across the whole joint even in patients without malalignment. Subsequent arthroscopy in seven ankles revealed impingement anteriorly and in the medial and lateral gutters. Although arthroscopy was only undertaken in a few patients with a VAS 7, it can be concluded that synovitis or soft-tissue impingement is the cause of residual pain in an otherwise normal looking TAR. Also, undertaking a medial ligament releasing procedure to balance the ankle did not increase the incidence of pain felt medially or in the whole joint (Table II). In an attempt to avoid the subsequent development of impingement, we pay a special attention to avoid malposition of the prosthesis and to debride the bony spurs and fibrotic tissues in the gutters as clearly as possible. Most patients (68.1%) stated that exercise or walking for > 30 minutes was an aggravating factor causing pain. During such exercise, 64 patients (53.3%) had minimal to mild pain, while 24 (20.0%) had moderate pain and two had moderate to severe pain (Fig. 3). Starting to walk was the second most common (22.0%) aggravating factor. We recommend an exercise programme for such patients. Arthroscopic debridement successfully reduced the pain in seven ankles with painful impingement syndrome. Arthroscopy in patients with impingement after TAR has recently been described by Richardson et al 23 and also by Shirzad, Viens and DeOrio 24 who reported a good outcome in 11 patients. Unlike Shirzad et al 24 who did not distract the joint, we used distraction of 15 lb (approximately 6.8 kg) using a harness. Without associated complications, we recommend this form of treatment for patients with symptoms due to impingement after TAR. These results should be interpreted with caution. Firstly, the number of patients undergoing arthroscopic debridement was small. However, through non-parametric analysis, reduced pain and improved outcome equivalent to that of the uncomplicated group was observed. Secondly, the incidental associated taking of analgesic and anti-inflammatory medication could have affected the outcome. Analgesic medication is not used routinely after TAR. In conclusion, while most patients (95.8%, 115 of 120 ankles) had reduced pain following TAR, there is often some persistent pain after an otherwise apparently uncomplicated procedure. Understanding the incidence and amount of the persistent pain before choosing to have surgery can help patients to have more realistic expectations. Synovitis or soft-tissue impingement is a cause of persistent pain and benefit may be gained through arthroscopic debridement. Supplementary material A table detailing the seven patients who received arthroscopic debridement due to painful impingement is available alongside the electronic version of this article on our website No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by J. Scott and first-proof edited by D. Rowley. References 1. Wood PL, Prem H, Sutton C. Total ankle replacement: medium-term results in 200 Scandinavian total ankle replacements. J Bone Joint Surg [Br] 2008;90-B: Kim BS, Choi WJ, Kim YS, Lee JW. Total ankle replacement in moderate to severe varus deformity of the ankle. J Bone Joint Surg [Br] 2009;91-B: Kim BS, Knupp M, Zwicky L, Lee JW, Hintermann B. Total ankle replacement in association with hindfoot fusion: outcome and complications. J Bone Joint Surg [Br] 2010;92-B: Haddad SL, Coetzee 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-A: SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg [Am] 2007;89- A: THE BONE & JOINT JOURNAL

6 RESIDUAL PAIN DUE TO SOFT-TISSUE IMPINGEMENT AFTER UNCOMPLICATED TOTAL ANKLE REPLACEMENT Deorio JK, Easley ME. Total ankle arthroplasty. Instr Course Lect 2008;57: Saltzman 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: Easley ME, Adams SB Jr, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg [Am] 2011;93-A: Kopp FJ, Patel MM, Deland JT, O Malley MJ. Total ankle arthroplasty with the Agility prosthesis: clinical and radiographic evaluation. Foot Ankle Int 2006;27: Lee KB, Cho SG, Hur CI, Yoon TR. Perioperative complications of HINTEGRA total ankle replacement: our initial 50 cases. Foot Ankle Int 2008;29: Hintermann B. Total ankle arthroplasty: historical overview, current concepts, and future perspectives. New York: Springer, 2005: Hintermann B, Valderrabano V, Dereymaeker G, Dick W. The HINTEGRA ankle: rationale and short-term results of 122 consecutive ankles. Clin Orthop Relat Res 2004;424: Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the anklehindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15: San Giovanni TP, Keblish DJ, Thomas WH, Wilson MG. Eight-year results of a minimally constrained total ankle arthroplasty. Foot Ankle Int 2006;27: Wood PL, Sutton C, Mishra V, Suneja R. A randomised, controlled trial of two mobile-bearing total ankle replacements. J Bone Joint Surg [Br] 2009;91-B: Kofoed H, Sørensen TS. Ankle arthroplasty for rheumatoid arthritis and osteoarthritis: prospective long-term study of cemented replacements. J Bone Joint Surg [Br] 1998;80-B: Doets HC, Brand R, Nelissen RG. Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. J Bone Joint Surg [Am] 2006;88- A: Valderrabano V, Hintermann B, Dick W. Scandinavian total ankle replacement: a 3.7-year average followup of 65 patients. Clin Orthop Relat Res 2004;424: Valderrabano V, Pagenstert G, Horisberger M, Knupp M, Hintermann B. Sports and recreation activity of ankle arthritis patients before and after total ankle replacement. Am J Sports Med 2006;34: Bonnin M, Judet T, Colombier JA, et al. Midterm results of the Salto Total Ankle Prosthesis. Clin Orthop Relat Res 2004;424: Kurup HV, Taylor GR. Medial impingement after ankle replacement. Int Orthop 2008;32: Barg A, Suter T, Zwicky L, Knupp M, Hintermann B. Medial pain syndrome in patients with total ankle replacement. Orthopade 2011;40: (in German). 23. Richardson AB, Deorio JK, Parekh SG. Arthroscopic debridement: effective treatment for impingement after total ankle arthroplasty. Curr Rev Musculoskelet Med 2012;5: Shirzad K, Viens NA, DeOrio JK. Arthroscopic treatment of impingement after total ankle arthroplasty: technique tip. Foot Ankle Int 2011;32: VOL. 95-B, No. 3, MARCH 2013