Long-term results after triple arthrodesis: Influence of alignment on ankle osteoarthritis and clinical outcome
Introduction
Medical conditions such as neuromuscular diseases, posttraumatic conditions, rheumatoid arthritis, congenital and flat foot deformities can be the cause of a painful, deformed and/or unstable hindfoot. Due to deformity and pain, disability evolves and consequently the quality of life reduces. Triple arthrodesis, conjoining the talocalcaneal, talonavicular and calcaneocuboid joints, is known as a salvage procedure to restore the form of the hindfoot and reduce pain [1]. Although patient satisfaction is high after a triple arthrodesis, the procedure has a disadvantage, it can lead to degenerative changes of the ankle joint in the long-term [2], [3].
The development of osteoarthritis (OA) of the ankle joint is possibly a result of abnormal stresses placed on the ankle and midfoot joints due to the absence of tarsal movements [3], [4]. After the performance of an arthrodesis, the peak pressure in the ankle joint increases; this might cause an overload of pressure on the joint and consequently results in osteoarthritis [5]. Correct shape and alignment of the foot is pursued to obtain the most natural position of the hindfoot and thus provide optimal pressure distribution in the adjacent joints. However, triple arthrodesis is a technically difficult procedure and correction of the alignment of a sometimes severely deformed foot might not always be as successful as intended. Persistent malalignment after operative correction might cause aggravation of OA in the long-term.
Previously, our group presented the short- and midterm results of patients after triple arthrodesis [6], [7]. It was noted that a certain degree of OA of the ankle joint was already present due to the underlying pathology and/or deformity prior to surgery. Interestingly, it seemed that patients with a valgus position of the ankle more often had aggravation of OA seven years after surgery. Although the results were not statistically significant, it was suggested that aggravation of OA was related to malalignment. Therefore, the aim of the present study was to determine whether the geometry of the foot aggravates OA of the ankle joint 15 years after triple arthrodesis. In addition, the clinical outcome was evaluated and we examined whether this was related to malalignment. We hypothesised that if malalignment persists after operative correction, this will lead to aggravation of OA in the ankle joint in the long-term.
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Patients
This study was a follow-up of a previous prospective study investigating the results of triple arthrodesis performed between 1999 and 2002 at the St. Maartenskliniek Nijmegen, The Netherlands [6], [7]. A total of 81 patients who underwent 93 fusions were initially included in the study. In 2003, the short-term results were evaluated in 75 patients, including 87 fusions. Subsequently, in 2008, the midterm results were assessed in 48 patients including 55 feet. Patients who completed the midterm
Results
Thirty-eight of the 48 patients, who completed the midterm follow-up, visited the hospital between November 2015 and June 2016 to participate in the present study. Ten patients were lost-to-follow-up because they passed away (n = 3), withdrew their consent (n = 3), were unattainable (n = 3) or were not able to visit the hospital (n = 1). There were three failures. One patient with rheumatoid arthritis underwent an ankle arthroplasty due to ankle OA grade 4 and progressive pain. The two other patients
Discussion
In the present study good clinical results were found 15 years after surgery in patients who underwent a triple arthrodesis. Patients remain satisfied after the procedure and the pain is significantly reduced. Examining Fig. 3, one might argue that there is a slight tendency towards an increase in disability over time, however this is not significant. This is not surprising as most of the patients included are patients with a progressive neuromuscular disease (CMT). The majority of patients
Conclusion
Malalignment, as defined in the present study, did not result in a significantly higher grade of ankle OA in the long-term. What might cause the increase in ankle OA of the treated patients in the long-term is still unknown. Nevertheless, clinical results are still satisfying 15 years postoperatively. Taking the long-term results into account, triple arthrodesis is a salvage procedure in patients with a painful and deformed hindfoot, resulting in a clinically beneficial outcome even 15 years
Conflict of interest
The authors declare that they have no proprietary, financial, professional, or other personal competing interests of any nature or kind.
Funding
The institution received funding from Anna Fonds to pay for staff and materials. Anna Fonds had no role in the design or conduct of the study, the collection, management, analyses and interpretation of the data, or the preparation and review of the manuscript.
References (16)
- et al.
Risk of osteoarthritis secondary to partial or total arthrodesis of the subtalar and midtarsal joints after a minimum follow-up of 10 years
Orthop Traumatol Surg Res
(2014) - et al.
Triple arthrodesis of the hindfoot, a short term prospective outcome study
Foot Ankle Surg
(2006) - et al.
Does osteoarthritis of the ankle joint progress after triple arthrodesis? A midterm prospective outcome study
Foot Ankle Surg
(2016) - et al.
The effect of hindfoot realignment in triple arthrodesis
J Foot Ankle Surg
(2009) - et al.
Foot Build Registration System (FBRS) to evaluate foot posture: a reliability study with healthy subjects and patients with Charcot-Marie-Tooth disease
Foot Ankle Surg
(2009) - et al.
Flexible cavovarus feet in Charcot-Marie-Tooth disease treated with first ray proximal dorsiflexion osteotomy combined with soft tissue surgery: a short-term to mid-term outcome study
Foot Ankle Surg
(2010) - et al.
Triple arthrodesis: twenty-five and forty-four-year average follow-up of the same patients
J Bone Jt Surg Am
(1999) - et al.
Triple arthrodesis: a critical long-term review
J Bone Jt Surg
(1986)
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