Sports and Recreation Activity of Varus and Valgus Ankle Osteoarthritis Before and After Realignment Surgery

FOOT &ANKLE INTERNATIONAL Copyright 2008 by the American Orthopaedic Foot & Ankle Society DOI: 10.3113/FAI.2008.0985 Sports and Recreation Activity of Varus and Valgus Ankle Osteoarthritis Before and After Realignment Surgery Geert Pagenstert, MD; André Leumann, MD; Beat Hintermann, MD; Victor Valderrabano, MD, PhD Liestal, Switzerland ABSTRACT Background: Realignment-surgery to unload ankle osteoarthritis (OA) has been proposed as treatment alternative for varus and valgus ankle OA. Sports activity after this procedure has not been analyzed. Realignment-surgery increases sports activity. Sports activity correlates with ankle pain, function, and alignment, but does not influence revision rate. Materials and Methods: Prospective case series of 35 consecutive patients with post-traumatic varus or valgus ankle OA limited to half tibiotalar joint surface were treated by OA unloading realignmentsurgery. Distal tibia osteotomy was used in all cases; additional osteotomies, tendon, ligament procedures in 92% of cases. Main Outcome Measurements: Pain (visual-analogue-scale; VAS), ankle range-of-motion (ROM); function (American- Orthopaedic-Foot-and-Ankle-Society (AOFAS) ankle-score; Swiss-symptom-related-Ankle-Activity-Scale (SAAS); Sports- Frequency-Score (SFS), OA and tibiotalar-alignment-grade (Takakura-Score), and revision surgery. Mean followup was 5 years. Results: Mean values from preoperative to followup: VAS decreased (p = 0.0001) 4 points; ankle ROM increased (p = 0.001) 5 degrees; AOFAS-Score increased (p = 0.0001) 46 points; SAAS increased (p = 0.0001) 42 points; SFS increased (p = 0.02) 0.5 grades; Takakura-score decreased (p = 0.0001) 1.0 grades. Revision surgery was performed in 10 cases (29%). Three of these were revised to ankle arthroplasty. At followup, SAAS correlated with VAS, AOFAS score, Takakura score, and not with ROM or SFS. SFS did not correlate with other variables. Patients needing revision surgery had a higher (p = 0.003) SFS than patients who needed no revision. Conclusion: Realignment-surgery increased sports activity of ankle 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 work was supported by the Swiss National Funds No. 3200BO-120631. Corresponding Author: Geert Pagenstert, MD University of Basel, Kantonsspital Liestal Orthopedic Surgery Rheinstrasse 26 Liestal, 4410 Switzerland E-mail: geert.pagenstert@ksli.ch For information on prices and availability of reprints, call 410-494-4994 x226 985 OA patients. Improved ankle pain and function correlated with ability to perform activity without symptoms; however, sports frequency had no correlation to patients symptoms but showed higher revision rate. Level of Evidence: II, Prospective Comparative Study INTRODUCTION Surgical treatment of symptomatic ankle osteoarthritis (OA) is controversial, particularly in asymmetric (varus and valgus) ankle OA in which joint cartilage is partially preserved. These patients are typically in their active middle ages since trauma at a younger age is the predominant etiology of ankle OA (70 to 80%). 26,33 The main sources of controversy for their treatment are long life expectancy and high activity demands of these patients who continue to workandplaysports. 8,32 Ankle fusion may enable a higher activity level, but degeneration of neighboring joints occurs in 44% to 50% after an average of 7 to 8 years 17,28 and in 100% after 20 years. 7,12 Although total ankle arthroplasty (TAR) may preserve the neighboring joints from overload and wear, 16 it allows only a certain amount of deformity correction, ligament balance, and activity level. 8,32 In case of TAR-failure, loss of bone stock may complicate revision arthroplasty and fusion 14,25 to an extent that even below-knee amputation may be needed. 8,23 Realignment surgery has been reported as an alternative treatment in asymmetric ankle OA patients to unload the degenerated joint area. 6,20,24,26,27 Takakura and colleagues 26 reported on the restoration of the degenerated ankle joint space. In four of 18 patients following unloading distal tibial osteotomy for varus ankle OA, activities such as running and jumping had become possible. 26 Recently we reported about our consecutive case series of 35 patients with unilateral varus or valgus ankle OA treated with unloading realignment surgery including distal tibial osteotomies, calcaneal osteotomies and soft tissue tendon and ligament reconstructions. 20 After a mean of 5 years, we found that reduction of pain correlated well with

986 PAGENSTERT ET AL. Foot & Ankle International/Vol. 29, No. 10/October 2008 Table 1: Surgical Procedures and Complications for Single, Double, and Tripple Varus/Valgus Ankle Osteoarthritis Variable Single Varus / Valgus Ankle OA Double Varus / Valgus Ankle OA Triple Varus / Valgus Ankle OA Surgical procedures (mean, range) 2.2 ±.8 a 3.7 ±.8 a 4.8 ± 1.0 a Low tibia osteotomy 1 21 6 8 Calcaneus correction 2 0 6 6 Tendon procedure 3 0 0 5 Mid-/Forefoot correction 4 0 0 5 Ligament procedure 5 5 3 7 Cartilage procedure 6 13 4 5 Fibula osteotomy 7 7 4 4 Complications, number of ankles (%) 6 (29%) 3 (50%) 2 (25%) Total ankle replacement 0 2 1 Nonunion fixation 1 1 0 Redo realignment surgery 0 1 1 Wound healing problems 1 0 1 Implant removal 5 0 2 1 Medial or lateral open or closed wedge distal tibia osteotomy; 2 Medial or lateral sliding calcaneus osteotomy, subtalar corrective fusion, sinus tarsi screw = arthroereisis; 3 Achilles tendon lengthening, posterior tibial tendon repair, augmentation with flexor digitorum longus transfer, peroneus brevis repair, peroneus longus to brevis transfer; 4 Flexion or extension osteotomy of the first metatarsal or cuneiform bone, corrective fusion of the first tarsometatarsal joint, lateral lengthening osteotomy of the calcaneus; 5 Lateral ankle ligament repair and augmentation with plantaris tendon autograft, antero-medial ankle ligament repair, spring ligament repair, medial ligament release; 6 Cartilage debridement, microfracturing, retrograde drilling of subchondral cysts with grafting, autologous osteochondral transplantation (Mosaik-plasty) from knee to talus; 7 Fibula lengthening or shortening osteotomy; a Significant difference between subgroups p < 0.05. walking ability, the functional portion of the AOFAS ankle score, and improved tibiotalar alignment (Takakura ankle OA and alignment score. 27 ) One-third of our patients were pain-free. 20 Whether it is a pure salvage procedure limited to control pain for patients with activities of daily living or if sporting activities can be resumed, remains unclear. The present study evaluated overall sports frequency and sporting types of those previously reported patients 20 treated by realignment surgery for asymmetric ankle OA. We hypothesized that realignment surgery increases sports activity in patients with asymmetric ankle OA, sports activity correlates with ankle pain, function and alignment and that sports activity does not influence revision rate. MATERIALS AND METHODS Thirty-five consecutive patients (nine women, 26 men) with asymmetric posttraumatic ankle OA were included in a prospective study for ankle realignment surgery between 1996 and 2003. The average age at surgery was 43 (range, 26 to 68) years. The average body mass was 80.3 (range, 54 to 125) kg, and the average body mass index was 25.4 (range, 18 to 33) kg/m 2. The mean followup was 5 (range, 3 to 10.5) years. No patient was lost to followup. All patients agreed to participate through signed written consent in accordance with the World Medical Association Declaration of Helsinki. The study s inclusion criteria were: unilateral ankle joint degeneration limited to less than half of the joint surface (verified by arthroscopy or arthrotomy). Exclusion criteria were: co-morbidities limiting daily activity (i.e. cardiac insufficiency, adiposity, etc.) or noncompliance with the postoperative protocol (i.e. drug abuse, debility, etc.); combined deformity or degeneration of the ankle with knee or hip joints. The aim of surgical reconstruction was to realign the hindfoot and to obtain anatomic ankle joint alignment in the frontal plane by shifting the load axis from the degenerated part of the ankle to the preserved part. The heel contact point (end of load axis) was transferred from the concave side of the deformity to the convex side to unload the diseased joint area. In the sagittal plane, the aim of realignment was to shift the rotational center of the ankle (lateral talar process) under the anatomic axis of the tibia. The procedure included osteotomies of the distal tibia and additionally procedures depending on stage of the arthritic deformity (Table 1). Stage I varus or valgus ankle arthritis (single varus/valgus) The foot and ankle deformity was primarily limited to the ankle joint narrowing and/or tilt. Sufficient translation of the heel and consequently the load axis was achieved by low tibial closing or opening wedge osteotomy alone. 20,27 (A calcaneal medial or lateral displacement osteotomy could

Foot & Ankle International/Vol. 29, No. 10/October 2008 SPORTS AFTER REALIGNMENT OF ANKLE OA 987 have been used in Stage I instead of the low tibial osteotomy. However, these patients were not included in the current study). Stage II varus or valgus ankle arthritis (double varus/valgus) The partial ankle joint degeneration was combined with significantly more heel varus or valgus than stage I which was impossible to correct with the low tibial osteotomy alone. Low tibial and calcaneal displacement osteotomies were used to establish alignment and unload ankle joint OA. 20,24 Stage III varus or valgus ankle arthritis (triple varus/valgus) The partial ankle OA was combined with a significant torsional deformity of the whole foot (i.e., pes cavovarus or pes planovalgus contributing to excessive hindfoot deformity). In such cases the second surgical step was not the calcaneus displacement osteotomy but rather the cavovarus or planovalgus deformities were corrected after low tibial osteotomy. 20,24 However, a calcaneus displacement osteotomy was used in conjunction with tendon transfers, first ray osteotomies/fusion and other established procedures to realign pes cavovarus and pes planovalgus deformities. Beside these three main steps of realignment surgery, there were three crucial sidesteps, independent of the above given three stages of ankle OA deformity: 1. The fibula needed special attention in valgus ankle OA. The fibula serves as a buttress for the talus, thus development of valgus ankle OA was found after shortening and external-rotation malunion after lateral malleolar fracture. 20 A CT scan was helpful to evaluate the congruence of the syndesmosis. With significant shortening, external-rotation, and syndesmotic incongruity, osteotomy of the fibula and reduction of the syndesmosis were indicated. In varus ankle OA, the role of the fibula was less clear. We shortened the fibula since it may have hindered talus reduction in the mortise. 20 2. Ankle instability has a crucial impact on the development of ankle OA 13,19 and was addressed by repair (and augmentation if needed) of the ligaments to gain absolute ankle stability. 20 Deltoid insufficiency was seen with advanced valgus deformity and was a contraindication for joint preserving surgical procedures. 13 Ankle fusion was performed, instead. In some varus ankle OA cases, the deltoid was found contracted and shortened, hindering reduction of the talus in the mortise. In such cases, a partial deltoid ligament release was indicated. 20 We now perform the deltoid release with a medial malleolar osteotomy to preserve the vascular supply in the deltoid to the talus. 3. Large subchondral cystic lesions (more than 1 cm) were considered potential sources of pain and retrograde drilling and grafting was done. Osteophytes restricting ankle motion were removed. Excessive osteophyte debridement was not done because subsequent destabilization of the ankle was possible. 2 Circumscribed cartilage defects were debrided and treated by microfracturing. Complex resurfacing procedures with osteochondral plugs, matrix and cell transplants have only been performed once since the value of chondral surgery is not currently clear. Chondral surgery was considered ineffective without proper mechanical realignment. The number of procedures of the presented cohort is listed in Table 2. The surgical procedures and their algorithm used in this patient cohort have been described in detail in our previous study. 20 The following clinical variables were prospectively documented by three observers: 1) pain, measured by a visual analogue scale (VAS; 1 = no pain and 10 = maximal pain imaginable); 2) ankle dorsiflexion and plantarflexion range of motion (ROM) measured under fluoroscopy; 3) inversion and eversion ROM measured as percentage of the contralateral side; 4) ankle joint stability, tested with the anterior drawer test, inversion and eversion talar tilt test, and in doubtful cases with stress X-rays; 5) clinical hindfoot alignment, measured with a goniometer in the standing position looking from posterior to the heel. Normal values were set at an average 5 degrees ± 4 degrees valgus 21 ;6) the AOFAS ankle score 15, addressing pain, alignment, and function [minimal points (pts): 0; maximal pts: 100; 40 pts for pain, 10 pts for hindfoot alignment, and 50 pts for function (10 pts for activity of daily living and recreation, 14 pts for ankle and subtalar ROM, 8 pts for ankle stability, and 18 pts for walking ability)]. 5 Frequency of sports activity (sport hours per week) and symptoms with work and/or sports activity were documented. These data were used to create the Symptom-related Ankle Activity Scale (SAAS) and the Sports Frequency Score 31 (SFS, Table 2) If sports activity and/or frequency were correlated with outcome or complications, in depth analysis of activity was considered. The SAAS utilizes the defined activity levels 0 to 10 of the established Tegner Activity Score, 29 which has been used for assessment of work, sports, and recreational activity after knee injuries. We added information about symptoms with the defined activity level of Tegner. 29 With increasing level, the Tegner Score increases in work and sports demands. For the cohort of this manuscript, the upper five Tegner levels have been combined because differentiation within professional sports activity (Tegner 6 to 10) is not necessary to adequately evaluate activity after ankle OA surgery. The same applies to the evaluation of sports frequency. We used a score which was previously used to evaluate activity after ankle replacement. 31 This score is practical for recreational sports activity levels with a frequency between 0 and greater than 5 hours sports activity per week. Higher sports frequency was pooled in the highest SFS level.

988 PAGENSTERT ET AL. Foot & Ankle International/Vol. 29, No. 10/October 2008 Table 2: Sports frequency score and ankle activity scale Preoperative (n = 35) Followup (n = 35) Sports Frequency Score (SFS) 35 % Absolute % Absolute 0 = no sport 42.9 15 20 7 1 = recreational 1 sports, <1 hour/week 14.3 5 11.4 4 2 = recreational sports, 1 5 hours/week 11.4 4 34.3 12 (2 x TAR) 3 = recreational sports, >5 hours/week 31.4 11 34.3 12 (1 x TAR) 4 = competetive 2 sports, >5 hours/week 0 0 0 0 Symptom related Ankle Activity Scale (SAAS) % Absolute % Absolute 0 = no ADL, disabled 3 by ankle (Tegner 5 0) 14.3 5 0 0 20 = symptoms 4 with ADL, not disabled; sedentary work and 45.7 16 8.6 3 walking on even ground possible (Tegner 1) 40 = no symptoms with ADL; light work (e.g. nursing), 37.1 13 8.6 3 (2 TAR) swimming, walking on uneven ground possible (Tegner 2 and 3) 60 = no symptoms with light work; moderate work (e.g. truck 2.9 1 34.3 12 (1 TAR) driving, heavy domestic work), recreational jogging, skiing, cycling possible (Tegner 4) 80 = no symptoms with moderate work; strenuous work (e.g. 0 0 40 14 building, forestry), jogging on uneven ground, competitive cycling, skiing possible (Tegner 5) 100 = no symptoms with strenuous work, all recreational and competitive sports possible (e.g. soccer) (Tegner 6 to 10) 0 0 8.6 3 ADL, activity of daily living; TAR, total ankle replacement; n, number of patients; 1 sports for fitness without intention to win; 2 competetive sports with the primary intention to win, college- or professional sports; 3 needs aid from a person to walk to a store and carry home groceries; 4 swelling, pain, giving way of any intensity; 5 Tegner Activity Score. Grading of ankle OA was performed on weightbearing radiographs according to Takakura. 27 Grade 0: parallel joint, no tibiotalar tilt and no signs of arthritis; Grade 1: parallel joint, no tibiotalar tilt but signs of subchondral sclerosis or osteophyte formation; Grade 2: tibiotalar tilt (varus or valgus alignment) without subchondral bone contact; Grade 3: tibiotalar tilt (varus or valgus alignment) with subchondral bone contact; and Grade 4: total joint degeneration with total subchondral bone contact. At followup, all but six of the patients were clinically and radiographically evaluated by three observers according to the preoperative protocol. Six patients living in foreign countries did not return for the last followup. Therefore, the AOFAS ankle score questionnaire, 15 SAAS and SFS 31 were completed by telephone and the clinical evaluation, standing clinical photographs, and weight bearing radiographs of the foot and ankle were performed by their family physicians and were sent for evaluation. Followup assessment included complications and the need for revision surgery. We considered the surgery a failure if recurrent symptoms led to fusion or total ankle replacement. The preoperative and followup data for single, double and triple varus and valgus ankle OA were compared to determine the effect of various anatomic abnormalities on selected objective and subjective variables. Statistical tests included chi-square and Student s paired and unpaired t- tests, with alpha level less than. 05 selected for significance. There was no significant difference found between the single, double, and triple ankle OA for multiple comparisons, including demographic, preoperative and followup outcome variables (Table 3). The data were therefore combined for the analysis of outcome in 32 ankles (35 ankles minus three failures).mkolmogorov-smirnov normality test was used for Gaussian distribution testing of all study variables. For significance testing, paired Student s t-test was used to compare pre- and postoperative clinical and radiographic variables of each patient (hypothesis 1). Pearson s test was performed for correlation analysis of postoperative sports activity (SFS; SAAS) with postoperative clinical and radiographic variables (ankle ROM; functional AOFAS ankle score and sub-scores; Takakura ankle OA and alignment score; hypothesis 2). Unpaired Student s t-test was used for significance testing of SFS and SAAS of patients who

Foot & Ankle International/Vol. 29, No. 10/October 2008 SPORTS AFTER REALIGNMENT OF ANKLE OA 989 Table 3: Reported sports activities Preoperative Followup Type of Sports Activity % Absolute % Absolute Hiking 25.7 9 37.1 13 (1 TAR) Biking 40 14 65.7 23 (3 TAR) Swimming 28.6 10 45.7 16 (1 TAR) Aerobics /Fitness 11.4 4 22.9 8 (1 TAR) Downhill skiing 20 7 25.7 9 Golfing 8.6 3 11.4 4 Skating 5.7 2 2.9 1 Tennis 8.6 3 5.7 2 Jogging 5.7 2 0 0 Material arts 2.9 1 0 0 Handball 2.9 1 0 0 Soccer 5.7 2 2.9 1 Marathon 2.9 1 2.9 1 TAR, total ankle replacement. Table 4: Variables preoperative and at last followup Preoperative Followup Variable Mean ± SD Range Mean ± SD Range p Pain (visual analogue scale: range, 1 10) 7 ± 1.6 4 10 2.7 ± 1.6 1 6 0.0001 AOFAS walking ability (0 18 points) 6.1 ± 4.7 0 16 16.4 ± 1.9 12 18 0.0001 Ankle dorsi plus plantarflexion ROM ( ) 32.8 ± 14 5 60 37.7 ± 9.4 20 55 0.001 Ankle stability (yes/no) 22/13 32/0 AOFAS ROM and stability (0 22 points) 15.1 ± 4.5 8 22 20.1 ± 2.5 15 22 0.0001 Takakura OA and alignment score (0 4) 2.3 ± 0.6 1 3 1.3 ± 0.5 1 2 0.0001 AOFAS ankle score (0 100 points) 38.5 ± 17.2 10 67 85.4 ± 12.4 52 100 0.0001 Sports Activity Level (0 4) 1.3 ± 1.4 0 3 1.8 ± 1.2 0 3 0.02 Ankle Activity Scale (0 100 points) 25.7 ± 15 0 60 68.1 ± 21 20 100 0.0001 SD, standard deviation; p, p-value, significance was set at p < 0.05; ROM, range of motion; OA, osteoarthritis. needed revision surgery versus no revision surgery; before surgery and at last followup (hypothesis 3). The level of statistical significance was set at α = 0.05. All data were analyzed using SPSS (Version 11.0 for Windows, SPSS Inc, Chicago, IL). RESULTS After the realignment surgery, the patients were able to perform significantly a higher activity level without swelling, giving way or pain at the ankle (SAAS, p = 0.0001). The time of sports activity per week increased significantly from preoperative to last followup (SFS, p = 0.02) and SAAS scale after realignment surgery (hypothesis 1). Types of sports activities after realignment surgery were basically low joint-stress activities, but jumping and running activities were reported as well (Table 4). The rate of sports inactivity (no sports activity per week) decreased from 43% before surgery to 20% at followup (Table 2). Compared to preoperatively, all clinical and radiographic variables improved significantly at followup (Table 5). Sports frequency in hours per week (SFS) showed no correlation (r = 0.34, p = 0.054) with the Symptom-related Ankle Activity Scale (SAAS) (Table 6). Whereas the

990 PAGENSTERT ET AL. Foot & Ankle International/Vol. 29, No. 10/October 2008 Table 5: Correlation of sports activity and frequency with variables at followup Variables Function Alignment Sports Frequency Score Pain Ankle ROM (DF+PF ) AOFAS subscore walking ability AOFAS ankle score Takakura score Ankle Activity Scale r= 0.34 r= 0.7 r= 0.11 r= 0.79 r= 0.8 r = 0.4 p= 0.054 p= 0.0001 a p= 0.5 p= 0.0001 a p= 0.0001 a p= 0.02 a Pain r = 0.15 p= 0.42 a Ankle ROM (DF+PF ) r = 0.06 r = 0.18 p= 0.7 p = 0.3 AOFAS* subscore walking ability r= 0.39 r = 0.76 r = 0.3 p= 0.03 a p = 0.0001 a p = 0.1 AOFAS ankle score r= 0.25 r = 0.83 r = 0.23 p= 0.1 p = 0.0001 a p = 0.2 Takakura score r= 0.01 r = 0.5 r = 0.14 r = 0.42 r = 0.57 p= 0.9 p = 0.004 a p = 0.5 p = 0.02 a p = 0.001 a American Orthopaedic Foot and Ankle Society ankle score 13 ; Takakura ankle osteoarthritis and alignment score 26 ;ROM= range of motion; DF+PF = sum of ankle dorsi- and plantarflexion; VAS = visual analogue scale; p = significance was set p < 0.05; r = Pearson s correlation; a significant correlation p < 0.05. symptom related activity scale correlated with the clinical and radiological variables, the sports frequency score was not correlated (hypothesis 2; Table 6). However, the followup sports frequency of each individual (SFS) correlated with their preoperative frequency (SFS) (r = 0.54, p = 0.001). Ten ankles (29%) were absolutely pain-free (VAS 1), 18 ankles (51%) had mild pain (VAS 2 to 4), and four ankles (11%) had moderate pain (VAS 5 to 7) at last followup. Three ankles (9%) developed severe pain (VAS 8 to 10) after the realignment surgery and were revised to TAR after 12, 22, and 24 months, respectively. Overall, ten ankles (29%) had to be revised after primary realignment surgery including the three TAR mentioned above (Table 1). The other seven ankles (20%) were revised successfully. In seven additional patients (20%), the hardware caused discomfort and was removed 9 to 15 months after surgery. SFS at followup was significantly higher (p = 0.003) in patients who needed revision than in patients who needed no revision (hypothesis 3; Figure 1). The preoperative SAAS was significantly higher (p = 0.0001) in patients who did not need revision surgery than in patients who needed revision surgery (Figure 1). No correlation was found between complications or revision surgery and number of surgical procedures performed to realign the ankle, fixation material used, closing or opening wedge tibial osteotomy, and ankle joint alignment at the time of surgery (each p > 0.05). DISCUSSION Physical activity in sports and work challenges ankle fusion and TAR patients. Whereas fusion may allow greater physical activity in work and sports, long-term studies have reported a 100% OA rate after 20 years in adjacent foot joints in patients. Compensatory overuse was thought to be the reason. 8,32 In contrast, TAR may protect the adjacent joints from overload and degeneration. 16 However, high activity with TAR is contraindicated because of the elevated risk of early failure. 8,32 Currently realignment surgery to unload the partially degenerated ankle joint area has been proposed as a possible treatment alternative. 6,20,24,26,27 Realignment surgery may potentially allow physical activity without the adverse effect of adjacent joint overload. Whether realignment surgery can permit sporting activity or can only control pain during activities of daily living is unclear. Participation in sports and recreation activities after realignment surgery had not been analyzed previously. In general, reports about realignment surgery for ankle OA are rare and judged as a procedure to postpone TAR or ankle fusion. Takakura et al. reported two case series with eighteen 27 and nine 26 patients with progressive varus deformity with medial ankle OA treated by supramalleolar realignment osteotomies. Outcome scores increased significantly. However, in the frontal plane, the degenerated part of the tilted (varus/valgus) tibiotalar joint was stretched out to a parallel appearance. Despite a decrease in ankle ROM

Foot & Ankle International/Vol. 29, No. 10/October 2008 SPORTS AFTER REALIGNMENT OF ANKLE OA 991 A B C D Fig. 1: Sports Activity and Revision Surgery Sports Frequency Score (SFS) before surgery (A) and at last followup (B). Symptom-related Ankle Activity Scale (SAAS) before surgery (C) and at last followup (D). Box plots (Box = median and quartiles, whiskers = maximum and minimum). at a mean of about 7 years followup in each series, none of the patients had limitations of activities of daily living, and four patients were able to participate in sports activities (two patients were able to participate in school sports, two patients performed competitive basketball). Information about the ability to perform sports activity in relation to preoperative severity of ankle OA was not reported. 26,27 However, the present study supports the observation of Takakura et al. 26,27 that ankle ROM after ankle OA realignment surgery does not correlate with physical activity level or AOFAS ankle score at followup (Table 6). In addition, ankle fusion has been demonstrated in multiple studies to improve patients activity and other outcome parameters despite eliminating ankle ROM. 1,3,7,12 Therefore ROM of the ankle may have less influence on outcome than pain and instability, however, some ROM may be needed to protect the adjacent joints from overload. Cheng et al. 6 treated 18 patients with medial ankle OA with a supramalleolar osteotomy which they named pressure redistribution surgery. All variables improved after a mean of 4 years followup including ankle OA and alignment score, pain, function, outcome score, and ankle ROM as well. Sporting activities were not reported. Recently, Pagenstert et al. reported on 35 consecutive patients with varus or valgus ankle OA treated with unloading realignment surgery including distal tibial osteotomies, calcaneal osteotomies and soft tissue tendon and ligament reconstructions. 20 After a mean of 5 years the authors found that reduction of pain correlated well with walking ability, the functional part of the AOFAS ankle score, and tibiotalar alignment (Takakura ankle OA and alignment score 27 ). One-third of their patients were pain-free. However, the level of physical activity was not reported. Although the current literature is lacking data on sports activity after realignment surgery for varus or valgus ankle OA, the restoration of pain free sporting activity may be possible. 26,27 This hypothesis is supported by the present study as significant reduction of ankle pain, significant increase of walking ability, total AOFAS ankle score, 15 and frontal plane alignment (Takakura Score 27 ) all improved after realignment surgery. This improvement correlated with the symptom related ankle activity scale (SAAS) of the patients at followup (Table 6). However, sports frequency (SFS) did not correlate with AOFAS ankle score, SAAS, ankle ROM, and pain. We conclude that sports frequency is often a habit or lifestyle consciously chosen by the patient, despite potential occurrence of pain or reduced function during sports. This hypothesis is supported by the correlation of the SFS at followup with the SFS before surgery. While return to sports activity

992 PAGENSTERT ET AL. Foot & Ankle International/Vol. 29, No. 10/October 2008 is a reasonable parameter for assessment of outcome, 29 our data suggest that it is somewhat subjective and one could reasonably question the validity of using returning to sports as a primary endpoint. Noyes and co-workers 18 developed the Cincinnati knee rating system because of a lack of a scale combining knee symptoms and sports activity level. They criticized previous reports that judged outcome simply by reporting rates of return to sports activity. This rate may be improperly high because of joint abusers who continue to perform sports despite pain, giving way, and swelling because of financial or habitual reasons. 18 In contrast, reported sports rates may be artificially low since some patients may be able to perform sports without symptoms but choose not to do so because of other reasons (no time, graduation, family, etc.). In addition, judging results by reporting back to pre-injury sports level may give little information about their sports intensity. In addition outcome scores often combine data of physical examination and radiographic evaluation with a questionnaire of activity. 18 We found no activity outcome measurement which combined patient based assessment of ankle symptoms with basic physical activities of daily living up to the highest level of sports activity. Therefore the Symptom-related Ankle Activity Scale was created based on the established activity levels of Tegner. 29 Data exists regarding exercise recommendations for patients with hip and knee OA. 11,22 For ankle OA these recommendations are rare. 31 Vaderrabano and co-workers reported about sports activity before and after TAR and recommended low impact sports activities. 31 In their series, sports active patients had a significantly higher AOFAS ankle score after TAR than did sports inactive patients. The authors hypothesized that sports activity may reduce muscle atrophy and enhance neuromuscular control which may reduce dangerous peaks in joint reaction force during activities of daily living. They found no correlation between sports frequency with implant revision. 31 In a later clinical and electromyographic study, Valderrabano et al. demonstrated muscle regeneration in patients with ankle OA before and after TAR. 30,31 In general, there is consensus 11,22 and evidence 10 that strengthening exercise and aerobics can reduce pain and disability in patients with knee OA which may be true for the ankle as well. On the other hand, certain sports activities with increased joint impact have been associated with the development of OA. 4 In the revision group of our case series, the sports frequency (SFS) increased after surgery (Figure 1B) while the symptom related activity scale (SAAS) was similar in both groups (revision versus no revision at followup, Figure 1D). Looking at the preoperative situation, both groups performed a similar amount of sports per week (Figure 1A). However, patients who needed revision had a significantly lower symptom related activity scale (SAAS) than patients who needed no revision surgery (Figure 1C). This data suggest that even with specific ankle pain, giving way, and swelling, some individuals perform recreational sports on a regular basis. However, activity which causes ankle symptoms may have adverse effects on joint wear and implant tolerance which may counteract the beneficial effects of sports on muscle strength and proprioception. This could be partially responsible for the revision surgery needed in our case series. Therefore exercise which causes joint symptoms should be discouraged. Compared to other reports of realignment surgery for ankle OA (revision rate, 12.5% to 16%) 6,24 our revision rate of 29% (10 of 35 ankles) was higher. However, most of the other reports treated primary ankle OA whereas our cohort was composed of posttraumatic ankle OA patients with a scarred posttraumatic soft tissue envelope aggravating rehabilitation. However, compared to complications after ankle fusion, which range from 23% to 44%, 9,12 and ankle arthroplasty up to 28% 8,23 no difference in complications and revision rate were found. CONLUSION Realignment surgery for varus or valgus ankle OA improves the ability to perform sports activity by reducing pain and increasing the function of the ankle joint. Realignment surgery leads to an increased sports activity rate and level sometimes allowing high intensity sports like running and jumping. However, activity which causes joint symptoms should be discouraged because of the potentially higher risk for revision. REFERENCES 1. Ahlberg, A; Henricson, AS: Late results of ankle fusion. Acta Orthop Scand. February; 52(1):103 5, 1981. 2. 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