Abstract
Research Type:
Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies
Introduction/Purpose:
Ankle arthritis, often post-traumatic or rheumatologic, is traditionally managed with arthrodesis, but its drawbacks include adjacent joint arthrosis, persistent pain, and suboptimal outcomes. While ankle fusion is effective for select patients, alternatives are essential for managing end-stage arthritis. Total ankle arthroplasty (TAA) offers improved mobility and pain relief with complication rates comparable to arthrodesis. Conversion from ankle fusion to TAA, first described by Greisberg in 2004, shows promising outcomes, including better functionality, despite challenges like malleolar fractures and arthrofibrosis. Our meta-analysis synthesizes data on patient outcomes, surgical techniques, and complications to provide evidence-based insights, guiding treatment strategies for end-stage ankle arthritis and advancing patient care.
Methods:
A systematic review was conducted following PRISMA guidelines. Online databases including Google Scholar, Cochrane Library, and PubMed were searched using terms such as "ankle replacement," "ankle arthrodesis," and "takedown total," tailored for each database. Studies from 2004 to July 2024 were screened for eligibility by the authors. Inclusion criteria required discussion of implants, joint arthrodesis, surgical protocols, complications, and outcome measures like AOFAS and VAS pain scores. Excluded were non-peer-reviewed, cadaveric, or duplicate studies. Data were extracted and analyzed for AOFAS and VAS scores, patient satisfaction, and complications such as fractures, tendon injuries, and treatment failures. Heterogeneity was assessed using I² and chi-square tests, with random- or fixed-effects models applied accordingly. Subgroup and sensitivity analyses were conducted, and publication bias was evaluated with funnel plots and Egger’s test using Stata version 18.5.
Results:
Five studies showed significant postoperative improvements in AOFAS scores, with a mean increase of 35.6 points (95% CI: 29.4–41.84). Heterogeneity was high (I² = 73.2%, p = 0.005), with larger gains post-2010 (40.6 vs. 32.5 points). Sensitivity analysis confirmed stable results, with no publication bias. Four studies reported significant pain reduction post-TAR (mean difference: -14.3 points, 95% CI: -19.0 to -9.6), influenced by implant type and follow-up duration, with non-Hintegra implants performing better. Patient satisfaction was 88% across five studies, with no heterogeneity. Complications included intraoperative fractures (13%), delayed wound healing (11%), symptomatic arthrofibrosis (11%), and failure rates (10%), with variability tied to publication year.
Conclusion:
Ankle fusions are generally effective but may lead to complications like adjacent joint arthritis, painful nonunion, and malalignment. Transitioning failed fusions to total ankle replacement (TAA) offers improved outcomes, with pain reduced by 14.3 points on the VAS scale and AOFAS scores increasing by 35.5 points. Satisfaction rates were high (88%), highlighting the procedure’s potential for enhancing quality of life. Complications include intraoperative fractures (13%), wound healing issues (11%), and symptomatic arthrofibrosis (11%). Advanced techniques and implants have improved outcomes over time. While demanding, fusion takedown to TAA is a promising option for select patients, requiring expertise and meticulous planning.