The disability associated with end-stage ankle arthritis. Arthroscopic Versus Open Ankle Arthrodesis: A Multicenter Comparative Case Series

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1 98 COPYRIGHT Ó 2013 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Arthroscopic Versus Open Ankle Arthroesis: A Multicenter Comparative Case Series Davi Townshen, MBBS, FRCS(Orth), Matthew Di Silvestro, MSc, MD, FRCSC, Fabian Krause, MD, Murray Penner, MD, FRCSC, Alastair Younger, MBChB, FRCSC, Mark Glazebrook, MSc, PhD, MD, FRCSC, Dip Sports Me, an Kevin Wing, MD, FRCSC Investigation performe at St Paul s Hospital, Vancouver, British Columbia, an Halifax Infirmary, Halifax, Nova Scotia, Canaa Backgroun: Ankle arthroesis results in measurable improvements in terms of pain an function in patients with enstage ankle arthritis. Arthroscopic ankle arthroesis has gaine increasing popularity, with reports of shorter hospital stays, shorter time to soli fusion, an equivalent union rates when compare with open arthroesis. However, there remains a lack of high-quality prospective ata. Methos: We evaluate the results of open an arthroscopic ankle arthroesis in a comparative case series of patients who were manage at two institutions an followe for two years. The primary outcome was the Ankle Osteoarthritis Scale score, an seconary outcomes inclue the Short Form-36 physical an mental component scores, the length of hospital stay, an raiographic alignment. There were thirty patients in each group. Results: Both groups showe significant improvement in the Ankle Osteoarthritis Scale score an the Short Form-36 physical component score at one an two years. There was significantly greater improvement in the Ankle Osteoarthritis Scale score at one year an two years an shorter hospital stay in the arthroscopic arthroesis group. Complications, surgical time, an raiographic alignment were similar between the two groups. Conclusions: Open an arthroscopic ankle arthroesis were associate with significant improvement in terms of pain an function as measure with the Ankle Osteoarthritis Scale score. Arthroscopic arthroesis resulte in a shorter hospital stay an showe better outcomes at one an two years. Level of Evience: Therapeutic Level III. See Instructions for Authors for a complete escription of levels of evience. Disclosure: One or more of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of an aspect of this work. In aition, one or more of the authors, or his or her institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. No author has ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. The isability associate with en-stage ankle arthritis is substantial, causing pain an severe limitation of function 1,2. Open ankle arthroesis traitionally has been the preferre surgical metho to treat ankle arthritis, proviing patients with less pain an improve function 3. Since its first escription in , arthroscopic ankle arthroesis has gaine increasing popularity. Improve instrumentation an greater experience have prouce encouraging results, with most recent stuies emonstrating shorter hospital stays an reuce time to soli fusion while maintaining fusion rates equivalent to those associate with open techniques 5-7. An arthroscopic approach also extens the scope of ankle arthroesis to inclue patients with compromise ajacent soft tissue who may be consiere to have a relative contrainication to an open proceure. The purpose of the present stuy was to compare patientreporte clinical outcome, morbiity, an length of hospital stay between two cohorts of patients who were manage with either an This article was chosen to appear electronically on December 12, 2012, in avance of publication in a regularly scheule issue. A commentary by Eric Giza, MD, is linke to the online version of this article at jbjs.org. J Bone Joint Surg Am. 2013;95:

2 99 open or an arthroscopic arthroesis for the treatment of en-stage ankle arthritis. Materials an Methos This was a comparative case series. Institutional review boar approval was grante from all participating sites, an informe consent was obtaine from all stuy participants. Patients unergoing ankle fusion at two institutions were invite to participate in the stuy, which forme part of the ongoing Canaian Orthopaeic Foot an Ankle Society (COFAS) stuy on the clinical outcomes of arthroesis or total ankle replacement. Subjects were inclue if they were over eighteen years of age an presente with isolate en-stage ankle arthritis (COFAS types 1 an 2) 8. Patients with ongoing infection, previous ankle or hinfoot fusions, or previous ankle arthroplasty were exclue. Patients with arthritis in the triple joint complex (subtalar, talonavicular, or calcaneocuboi joint) or substantial eformity requiring corrective osteotomies or arthroeses beyon the ankle joint (COFAS types 3 an 4) were also exclue. A compute tomographic (CT) scan was routinely use to assess triple joint arthritis. For the purposes of the stuy, patients with concomitant ipsilateral hinfoot arthritis were only inclue if the ankle pathology alone require surgical intervention. All arthroeses were performe by orthopaeic surgeons who were engage in a full-time foot an ankle practice. Open arthroeses were performe at one site by a single surgeon through an anatomic transfibular approach with use of a fibular sparing Z-osteotomy, as previously escribe 9. Arthroscopic arthroeses were performe by one of three surgeons at a secon site. Arthroscopy was performe with use of noninvasive istraction an anteromeial an anterolateral portals. Aequate inflow was achieve with use of a 2.9-mm arthroscope within a 4.0-mm fenestrate cannula or a 4.0-mm arthroscope with a 5.5-mm fenestrate cannula an a pump with 30 mm Hg of inflow pressure at the iscretion of the surgeon. One surgeon frequently ae a posteromeial portal. After the removal of articular cartilage, the subchonral bone was prepare with use of a 2-mm rill an osteotome or high-spee burr. Osseous contours were preserve an fusion sites were stabilize with use of two or three compression screws at the iscretion of the surgeon. Only one of the three surgeons routinely ebrie the lateral gutter an place a screw from the fibula into the talus. Postoperatively, patients were manage with immobilization of the ankle in a cast or cast boot, were kept non-weight-bearing for the first six weeks, an were allowe to procee to full weight-bearing uring the secon six weeks. The primary outcome measure in the present stuy was the change in the Ankle Osteoarthritis Scale (AOS) score from baseline to twenty-four months postoperatively. The AOS is a reliable, valiate, visual analog-base, iseasespecific, self-aministere outcomes instrument that is esigne specifically to measure isability an pain resulting from ankle osteoarthritis 10. Both the pain an isability components were use to calculate the total score. The score ranges from 0 to 100, with a lower score inicating more normal function. The minimum clinically important ifference for the AOS score is not known. Demographic ata were collecte preoperatively. Seconary outcome measures also inclue the Short Form-36 (SF-36) health survey 11, raiographic alignment, operative time, an length of hospital stay. Data were collecte an anteroposterior an lateral raiographs were mae at baseline an at the twelve an twenty-four-month visits. Complete raiographs were available for ata analysis for twenty-seven subjects in the open arthroesis group an twenty-seven subjects in the arthroscopic arthroesis group. Sagittal alignment was measure as the angle between the anatomical axis of the tibia an the long axis of the talus as viewe on a lateral raiograph. Coronal alignment was measure as the angle between the anatomical axis of the tibia an the proximal talar subchonral surface as viewe on an anteroposterior raiograph. The eviation from neutral was measure, but the varus or valgus irection was not recore. We believe that the magnitue of the coronal plane eformity was important for the purposes of this stuy but that the varus or valgus irection was not. Source of Funing The atabase was fune by the St. Paul s Hospital Founation, which i not play any role in the investigation. Statistical Analysis The primary objective of the present stuy was to compare the open an arthroscopic treatment groups in terms of the magnitue of change in the AOS score from baseline to twenty-four-months postoperatively. In the analysis, the change in the AOS score between baseline an the twenty-four-month followup visit was calculate for each patient. The treatment effect was assesse by comparing the average change in score between the two treatment groups with use of a linear regression moel. In particular, the change in the AOS score was the response variable an the treatment group was consiere as the primary interest variable in the moel. The analysis was ajuste for sex an TABLE I Demographic Characteristics Open Arthroesis Arthroscopic Arthroesis Number of patients Age at time of surgery* (yr) 54.7 ± ± 10.6 BMI* 29.6 ± ± 3.7 Male:female ratio (no. of patients) 11:19 20:10 Coronal plane alignment 9 (0 to 36 ) 8 (0 to 30 ) Sagittal plane alignment 20 (5 to 36 ) 21 (10 to 30 ) Diagnosis (no. of patients) Posttraumatic 4 23 Primary osteoarthritis 19 4 Inflammatory arthritis 4 1 Hemophilia 0 1 Osteonecrosis 2 0 Poliomyelitis 1 0 Flat foot 0 1 *The values are given as the mean an the stanar eviation. The values are given as the mean, with the range in parentheses.

3 100 TABLE II Group Comparison Open Arthroesis* Arthroscopic Arthroesis* P Value Tourniquet time (min) 107 ± ± Length of hospital stay () 3.7 ± ± AOS score (points) One year 33.5 ± ± Two years 29.2 ± ± SF-36 score (points) PCS One year 37.9 ± ± Two years 38.2 ± ± MCS One year 51.3 ± ± Two years 52.2 ± ± *The values are given as the mean an the stanar eviation. preoperative coronal plane alignment as possible confouning variables. We also explore the treatment effect on the change in the AOS score from baseline to twelve months an from twelve to twenty-four months with use of the same analysis approach. We repeate the aforementione analysis for the two seconary outcomes, physical component score (PCS) an mental component score (MCS) of the SF-36. All p values were reporte as two-sie in this report. The level of significance was set at p Results There were thirty open an thirty arthroscopic arthroeses. In the open arthroesis group, the mean age (an stanar eviation) was 54.7 ± 11.5 years, the mean boy mass inex (BMI) was 29.6 ± 5.9, an the sex istribution was eleven males an nineteen females. In the arthroscopic group, the mean age was 59.4 ± 10.6 years, the mean BMI was 27.4 ± 3.7, an the sex istribution was twenty males an ten females. In the open arthroesis group, the mean coronal plane alignment was 9 (range, 0 to 36 ) an the mean sagittal plane alignment was 20 (range, 5 to 36 ). In the arthroscopic arthroesis group, the mean coronal plane alignment was 8 (range, 0 to 30 ) an the mean sagittal plane alignment was 21 (range, 10 to 30 ). The preoperative coronal an sagittal alignment between the two groups were similar. The emographic ata an preoperative iagnoses are liste in Table I. Fifty-five of the original sixty patients were available for the twenty-four month follow-up. One patient in each group ha a revision for the treatment of a symptomatic nonunion before twenty-four months. In the open arthroesis group, an aitional three patients were not available (two ha been lost to follow-up an one ha ie). Both open an arthroscopic groups emonstrate a significant improvement in AOS scores from baseline to twelve months (p < 0.01) an from baseline to twenty-four months (p < 0.01). Table II shows a comparison of the results in both groups. There was a significant ifference in the AOS score between the two groups in favor of the arthroscopic group at both one year (p = 0.01) an two years (p = 0.05) (Fig. 1). The ifference between the groups was not statistically influence by sex or coronal plane alignmentatanytimepointintheregressionanalysis. The analysis of the improvement in SF-36 PCS scores emonstrate no ifference between the groups at two years (mean improvement, 8.12 ± in the open group an ± in the arthroscopic group; p = 0.26) but showe a significantifferencebetweenthegroupsatoneyear(meanimprovement, 6.32 ± in the open arthroesis group an ± 9.85 in the arthroscopic arthroesis group; p = 0.01) (Fig. 2). The SF-36 MCS scores at one year an at two years were similar between the two groups. The hospital stay was significantly shorter for the arthroscopic arthroesis group than for the open arthroesis group (2.5 compare with 3.7 ays; p = 0.05). The mean tourniquet time was 107 minutes for the open arthroesis group an ninety-nine minutes for the arthroscopic arthroesis group. Fig. 1 Line graph showing the change in the AOS score.

4 101 Fig. 2 Line graph showing the change in the SF-36 Physical Component Score. Therewasimprovementinanklealignmentinbothgroups. In the open arthroesis group, the mean postoperative coronal plane alignment was 4 (range, 1 to 12 ) anthemeanpostoperative sagittal plane alignment was 20 (range, 5 to 32 ). In the arthroscopic arthroesis group, the mean postoperative coronal plane alignment was 2 (range, 0 to 8 ) an the mean postoperative sagittal plane alignment was 20 (range, 10 to 35 ). In each group, there was one nonunion that successfully unite following revision surgery. There was one case of elaye woun-healing in each group, an there were two aitional surgical proceures for the removal of symptomatic implants in the arthroscopic arthroesis group. Discussion There are currently very few publishe clinical stuies comparing arthroscopic an open ankle arthroesis. A recent review of the literature on arthroscopic arthroesis ientifie only three stuies with Level-III evience (case control stuies, retrospective comparative stuies, or systematic reviews of Level-III evience) in support of arthroscopic ankle arthroesis 12.Myerson an Quill performe the first retrospective comparative stuy an note a similar fusion rate in both groups but reporte a shorter time to fusion in the arthroscopic arthroesis group 13.In a retrospective cohort stuy, O Brien et al. also emonstrate similar fusion rates an less morbiity, shorter operative times, an shorter hospital stays in the arthroscopic treatment group 14. Ogilvie-Harris et al. reporte prospectively collecte ata on nineteen arthroscopic arthroeses an emonstrate an average length of stay of only one ay 15. Fusion was achieve in eighteen patients, an sixteen patients reporte a goo or excellent outcome. However, the lack of a control group an the lack of a vali outcome measure prevent useful comparison with the stanar open technique. Our review of the English-language literature faile to ientify any other clinical stuies of arthroscopic ankle fusion that involve the use of a valiate outcome measure. In keeping with the stuies note above, we foun a low nonunion rate in both treatment groups an a significantly shorter hospital stay (ifference, 1.2 ays) in the arthroscopic treatment group. The egree of improvement in the AOS score was both greater an more rapi in the arthroscopic treatment group than in the open treatment group, with maximum improvement achieve by one year. The minimum egree of soft-tissue envelope isruption associate with arthroscopic arthroesis may reuce the egree of permanent functional impairment of the joints an soft tissues ajacent to the arthroesis site. It also appears to allow more rapi activation of the bonehealing cascae, leaing to more rapi bone healing an earlier functional improvement. Also, it is currently our stanar practice to perform arthroscopic ankle arthroesis as outpatient proceure. Previous authors have cautione against performing arthroscopic ankle arthroesis in the presence of a large coronal plane eformity 13,15,16. In the present series, both groups inclue coronal plane eformities of as large as 30 an 36. It has not been our experience that such coronal plane eformities are a contrainication to the arthroscopic technique. We have foun that, with increasing experience, larger coronal plane eformities can be manage. Careful preoperative assessment with weight-bearing ankle raiographs an CT scans (also necessary to investigate arthritis of ajacent joints, specifically, the subtalar joint) frequently emonstrates that large coronal plane eformities are the result of talar tilting within the ankle mortise, with little eformity in the actual tibia or talus. After arthroscopic ebriement, the surgeon can reposition the talus to eliminate the coronal malalignment without the nee for major bone resection or osteotomy. The use of arthroscopic arthroesis for larger coronal plane eformities was supporte by Gougoulias et al., who compare the outcomes of arthroscopic ankle arthroeses in patients with <15 eformity an >15 (up to 45 ) of eformity 17. The outcomes were similar, with goo results in 79% an 80% of the patients, respectively, an goo correction in both groups. In our stuy, there was no significant ifference between the groups with regar to preoperative alignment or eformity correction. The present stuy is limite by a lack of ranomization. Patients were not consecutive, an, in the initial perio, an open technique was use for some of the more ifficult cases at the center at which the arthroscopic proceures were performe. However, we woul like to point out that, after the initial perio following the introuction of the arthroscopic technique, the authors so strongly preferre the arthroscopic technique that they nearly completely abanone the open technique. The center where open arthroesis was performe was recruite to contribute patients to the present stuy to provie a comparison group. We acknowlege that there was a ifference in sex istribution between the two groups. We are unaware of any publishe reports in the orthopaeic literature suggesting that this factor influences the outcome of ankle fusion surgery. Our regression analysis oes not suggest that the ifference in sex istribution affecte our primary outcome measure (the AOS score) or the seconary outcome measures. We further note the ifferences between the groups in terms of iagnosis, with the patients in the arthroscopic treatment group having primarily posttraumatic ankle arthritis an those in the open group having primarily iiopathic ankle arthritis. In the arthroscopic treatment group, many of the patients ha a history of multiple sprains or a simple remote ankle fracture an were therefore consiere to have

5 102 posttraumatic arthritis. We believe that the istinction between this etiology of multiple sprains an/or remote ankle fracture an iiopathic arthritis is subtle an unlikely to bias the stuy. In this comparative case series, we have shown that both open an arthroscopic ankle arthroeses were associate with goo clinical outcomes at two years postoperatively on the basis of a valiate outcome measure. The arthroscopic treatment group showe significantly improve AOS scores at both one an two years in comparison with the open group, with a more rapi rate of improvement, a shorter hospital stay, equivalent eformity correction, an an equivalent nonunion rate. n NOTE: The authors thank the foot an ankle research groups at St Paul s Hospital, Vancouver, an Halifax Infirmary, an Hubert Wong an Hong Qian for statistical assistance. Davi Townshen, MBBS, FRCS(Orth) Department of Orthopaeics, North Tynesie General Hospital, Rake Lane, North Shiels NE29 8NH, Unite Kingom. aress for D. Townshen: avetownshen@hotmail.com Matthew Di Silvestro, MSc, MD, FRCSC Queensway Carleton Hospital, Suite 220, 770 Broaway Avenue, Ottawa, ON K2A 3Z3, Canaa Fabian Krause, MD Department of Orthopaeic Surgery, Inselspital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerlan Murray Penner, MD, FRCSC Alastair Younger, MBChB, FRCSC Kevin Wing, MD, FRCSC Department of Orthopaeics, University of British Columbia, 1144 Burrar Street, 5th Floor, Vancouver, BC V6Z 2A4, Canaa Mark Glazebrook, MSc, PhD, MD, FRCSC, Dip Sports Me Queen Elizabeth II Health Sciences Center, Halifax Infirmary, 1796 Summer Street, Suite 4867, Halifax, NS, Canaa References 1. Agel J, Coetzee JC, Sangeorzan BJ, Roberts MM, Hansen ST Jr. Functional limitations of patients with en-stage ankle arthrosis. Foot Ankle Int Jul;26(7): Glazebrook M, Daniels T, Younger A, Foote CJ, Penner M, Wing K, Lau J, Leighton R, Dunbar M. Comparison of health-relate quality of life between patients with en-stage ankle an hip arthrosis. J Bone Joint Surg Am Mar;90(3): Haa SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermeiate an long-term outcomes of total ankle arthroplasty an ankle arthroesis. A systematic review of the literature. J Bone Joint Surg Am. 2007;89: Marcus RE, Balouras GM, Heiple KG. Ankle arthroesis by chevron fusion with internal fixation an bone-grafting. J Bone Joint Surg Am Jul;65(6): Nielsen KK, Line F, Jensen NC. The outcome of arthroscopic an open surgery ankle arthroesis: a comparative retrospective stuy on 107 patients. Foot Ankle Surg. 2008;14(3): Epub 2008 Mar Winson IG, Robinson DE, Allen PE. Arthroscopic ankle arthroesis. J Bone Joint Surg Br Mar;87(3): Ferkel RD, Hewitt M. Long-term results of arthroscopic ankle arthroesis. Foot Ankle Int Apr;26(4): Krause FG, Di Silvestro M, Penner MJ, Wing KJ, Glazebrook MA, Daniels TR, Lau JT, Stothers K, Younger AS. Inter- an intraobserver reliability of the COFAS enstage ankle arthritis classification system. Foot Ankle Int Feb;31(2): Glazebrook MA, Holen D, Mayich J, Mitchell M, Boy G. Fibular sparing Z-osteotomy technique for ankle arthroesis. Tech Foot Ankle Surg. 2009; 8(1): Domsic RT, Saltzman CL. Ankle osteoarthritis scale. Foot Ankle Int Jul;19(7): Beaton DE, Schemitsch E. Measures of health-relate quality of life an physical function. Clin Orthop Relat Res Aug;(413): Glazebrook MA, Ganapathy V, Brige MA, Stone JW, Allar JP. Evience-base inications for ankle arthroscopy. Arthroscopy Dec;25(12): Myerson MS, Quill G. Ankle arthroesis. A comparison of an arthroscopic an an open metho of treatment. Clin Orthop Relat Res Jul;(268): O Brien TS, Hart TS, Shereff MJ, Stone J, Johnson J. Open versus arthroscopic ankle arthroesis: a comparative stuy. Foot Ankle Int Jun; 20(6): Ogilvie-Harris DJ, Lieberman I, Fitsialos D. Arthroscopically assiste arthroesis for osteoarthrotic ankles. J Bone Joint Surg Am Aug;75(8): Stone JW. Arthroscopic ankle arthroesis. Foot Ankle Clin Jun; 11(2):361-8, vi-vii. 17. Gougoulias NE, Agathangeliis FG, Parsons SW. Arthroscopic ankle arthroesis. Foot Ankle Int Jun;28(6):