A comparison of adjacent joint arthrodesis rate in arthroscopic and open technique of ankle arthrodesis: A database analysis. Khushdeep Vig, Ethan J. Fraser, Payal Desai, Christopher D. Murawski, Ian Savage-Elliott, John G. Kennedy Foot and Ankle Department, Hospital for Special Surgery New York, NY
Disclosure The authors have no financial conflicts to disclose
Introduction Arthrodesis is the gold standard for end stage ankle arthrosis not responsive to therapy 9, and is often preferred to arthroplasty in more active populations. 1-3,10 Most of the recent case series comparing arthroscopic and open ankle arthrodesis show that the arthroscopic technique results in the following in compared to open technique 4-6. shorter hospital stays less blood loss less morbidity reduced time to union
Introduction Complication of ankle arthrodesis: adjacent joint arthritis. Open ankle arthrodesis is associated with substantial arthritic change and deficits in functional outcome in the ipsilateral foot 7-8. Retrospective studies show this sequale of adjacent joint arthrosis is associated with both techniques 11. The purpose of the current study was to evaluate and compare trends in ankle arthrodesis procedures (arthroscopic and open), as well as to analyze the rate of patients undergoing subsequent adjacent joint arthrodesis procedures in the United States (U.S.).
Methods A PearlDiver Patient Record Database analysis (2005-2011) PearlDiver is Health Insurance Portability and Accountability Act compliant national database compiled from a collection of the Medicare MEDPAR dataset and the United Healthcare Orthopedic Dataset (UHC) Patient type underwent ankle arthrodesis (arthroscopic or open), subsequent midfoot or hindfoot procedures (e.g. midtarsal fusion, pantalar fusion, subtalar fusion) Search performed by searching Current Procedural Codes (CPT).
Results The yearly incidence of open ankle arthrodesis significantly increased by 27.1% when comparing 2007 to 2010 (P <.05) and was most commonly performed in 2010 with 0.44 cases per 10,000 people (Figure 2). 0.5 0.4 Incidence of Arthroscopic and Open Arthrodesis by Year Incidence 0.3 0.2 0.1 Open Arthroscopic 0 2007 2008 2009 2010 2011 Year
Results 5.1 % (431/8474) received subsequent arthrodesis (mid-foot, hind-foot) index ankle fusion (open or arthroscopic). 93% (401/431) index procedure open arthrodesis 7.0% (30/431) index procedure arthroscopic arthrodesis (p=<0.001) 3.5% (297/8474) received subsequent subtalar arthrodesis 95% (282/297) index procedure open arthrodesis 5.0% (15/297) ) index procedure arthroscopic arthrodesis (p=<0.001)
Results Percentage of Subsequent Adjacent Joint Arthrodesis of the Subtalar Joint and Midfoot/Hindfoot after Index Arthroscopic or Open Arthrodesis 100% 5.00% 7.00% 90% 80% 70% 60% Percentage 50% 40% 95.00% 93.00% Arthroscopic Open 30% 20% 10% 0% Subtalar Arthrodesis Midfoot/Hindfoot Fusion Subsequent Adjacent Joint Procedure
Results Index arthroscopic arthrodesis were less likely to have a subsequent mid-foot and or hind-foot arthrodesis compared to index open ankle arthrodesis OR=0.46; 95%CI: 0.32-0.67; P<0.0001). Index arthroscopic arthrodesis were less likely to go on to have a subtalar arthrodesis than index open ankle arthrodesis (OR: 0.33; 95%CI: 0.19-0.56; P<.0001).
Discussion 5.1% of arthrodesis patients underwent a subsequent fusion of the mid-foot and/or hindfoot within a 7 year period. The arthroscopic technique was associated with a lower rate and lower odds ratio of adjacent joint arthrodesis, specifically of the subtalar joint Previous studies have suggested that the relationship between adjacent joint deterioration and ankle joint fusion is inevitable 12 or may not be a causative one 11.
Discussion Adjacent joint damage due to: Increased motion in adjacent joints Abnormal chronic loading of other joints 8 Biological advantages of arthroscopic procedure: minimum degree of soft-tissue envelope disruption reduce the degree of permanent functional impairment of the joints and soft tissues adjacent to the arthrodesis site. rapid activation of the bone-healing cascade leading earlier functional improvement 6.
Conclusion While open ankle arthrodesis is more commonly performed than arthroscopic arthrodesis, it is associated with a higher rate of subsequent adjacent joint arthrodesis. The factors that may potentiate these subsequent procedures should be further investigated.
References 1. Bauer G, Kinzl L. Arthrodesen Des Oberen Sprunggelenks. Orthopa de 1996;25:158 65. 2. Mann RA, Van Maanen JW, Wapner K, Martin J. Ankle fusion. Clin Orthop (Am) 1991;268:49 55. 3. Albert, E.: Zur resektion des Kniegelenkes. Wien. Med. Press, 20:705, 1879. 1. 4. O Brien TS, Hart TS, Shereff MJ, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis: a comparative study. Foot Ankle Int 1999;20:368-74.2. 5. Myerson MS, Quill G. Ankle arthrodesis: a comparison of an arthroscopic and an open method of treatment. Clin Orthop 1991;268:84-95. 6. Townshend D., Di Silvestro M., Krause F. Arthroscopic versus open ankle arthrodesis: A multicenter comparative case series. J Bone Joint Surg Am. 2013;95:98 102. 7. Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle. A study of adjacent joints. J Bone Joint Surg Br. 2003;85:994 8. 8. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83-A:219 28. 9. Gougoulias NE, Agathangelidis FG, Parsons SW. Arthroscopic ankle arthrodesis. Foot Ankle Int. 2007;28:695 706 344 10. Cameron, Scott E., and Patricia Ullrich. "Arthroscopic arthrodesis of the ankle joint." Arthroscopy: The Journal of Arthroscopic & Related Surgery 16.1 (2000): 21-26. 11. Sheridan, B. D., et al. "Ankle arthrodesis and its relationship to ipsilateral arthritis of the hind-and mid-foot." Journal of Bone & Joint Surgery, British Volume 88.2 (2006): 206-207 12. Fuentes-Sanz, Adela, et al. "Clinical outcome and gait analysis of ankle arthrodesis." Foot & Ankle International 33.10 (2012): 819-827