Keywords
ankle - arthroplasty - osteoarthritis - replacement - sport
Introduction
Ankle osteoarthritis (OA) incidence is significantly lower than knee and hip arthritis.[1] It is mostly posttraumatic (65–80% of the cases), and this may explain a different
epidemiology with a younger population affected.[2] Historically, design issues are related to early failures of total ankle replacement
(TAR) rather than patient age or high-impact activities. Furthermore, it has been
showed that TAR is a high demanding surgery with a long learning curve. This may contribute
to raise the rate of failures in small cohorts, rather than patient age and high-impact
activities. In the past, ankle arthrodesis was considered the first surgical treatment
for end-stage arthritis of the ankle. However, during the years, some important disadvantages
related to this surgery became clear: compensatory overload, gait change, high rates
of nonunion, long rehabilitation period, and eventual development of adjacent joint
OA.[3] These led to a new increasing interest in TAR, inducing important development in
implants design and materials.
Mobile-bearing implants represented a revolutionary and successful step forward in
Europe. With their consistent use, it has been clarified that primary implant stability
should be the main focus of the surgeon rather than any cement fixation. Kofoed and
Lundberg-Jensen[4] evaluated early generation cemented and uncemented mobile-bearing TAR and concluded
that the results of TAR were equivalent in patients younger and older than 50 years,
pointing out cement fixation as a major reason for failures rather than patient age
or high-impact activities. Recently, some authors proposed TAR as the gold standard
treatment for ankle OA, even in young and active patients. Demetracopoulos et al[5] claimed comparable results with TAR in younger (<55 years) and older patients (>70
years) at early follow-up. The incidences of complications and the revision rate were
similar between the two groups. However, the authors did not describe physical activities
allowed for these patients. There is still a controversy regarding whether patients
who underwent TAR can participate in sport and recreational activities.[6]
Today, there is a new trend toward better results in terms of quality of life, and
physical and athletic ability after TAR than after tibiotalar arthrodesis.[7]
The aim of this study was to analyze sports activity before and after TAR. The hypothesis
of the study was that sports activity of patients affected by ankle OA increases after
TAR.
Methods
This study is a retrospective review of 76 patients who were treated with Hintegra
total ankle prosthesis (Newdeal, Lyon, France; Integra LifeSciences, Plainsboro, New
Jersey, United States) between May 2011 and October 2014. All patients were followed
up 12 months after surgery. The indications for symptomatic end-stage ankle OA were
posttraumatic OA (70 patients), revision surgery of an osteochondral lesion procedure
failure (one patient), posterior tibial tendon dysfunction (PTTD) stage IV according
to the Bluman–Myerson[8] classification (one patient), drop foot (one patient), and rheumatoid arthritis
(three patients).
All patients, except for those with the rheumatoid arthritis and drop foot, had prior
ankle surgeries: patients with posttraumatic OA previously had fixation of fractures
and, in a few cases, removal of internal fixation, the patient with osteochondral
lesion underwent two arthroscopic treatments performed by other surgeons, and the
patient with PTTD was previously treated with subtalar and talonavicular arthrodesis.
All TAR procedures were performed by one of the coauthors according to the technique
by Barg et al[9]: an anterior ankle approach of 10 to 12 cm length was made. The retinaculum was
dissected along the lateral border of the anterior tibial tendon, avoiding the neurovascular
bundle that runs behind the long extensor hallucis tendon ([Fig. 1]).
Fig. 1 Anterior ankle approach for total ankle replacement.
Patients were evaluated preoperatively and 12 months after surgery. Pain and function
were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle
and hindfoot score, the visual analog scale (VAS) pain score, and the 12-Item Short
Form Health Survey (SF-12) – physical component summary (PCS) and mental component
summary (MCS). Furthermore, the patients were radiologically examined preoperatively
and at follow-up using standard weight-bearing radiographs (anteroposterior and lateral
views)[10] and the Saltzman alignment view[11] ([Fig. 2]).
Fig. 2 Painful end-stage varus osteoarthritis of the left ankle in a 54-year-old man. Preoperative
standard weight-bearing X-rays in (A) anteroposterior and (B) lateral views. (C) Saltzman alignment view shows a significant varus malalignment of the heel. Postoperative
radiographs in (D) anteroposterior, (E) lateral, and (F) Saltzman alignment view show a significant correction of the malalignment of the
heel.
Pre- and postoperative activity level was determined using the University of California
at Los Angeles (UCLA) activity scale.[12] The UCLA scale is based on the patient's ranking of her/his level of physical activity.
The score ranges from 1 to 10. The patient had to indicate her/his most appropriate
activity level, with level 1 defined as “no physical activity, dependent on others”
and level 10 defined as “regular participation in impact sports.”[13]
[14]
All data were expressed as mean and standard deviation. Statistical analysis was performed
with MATLAB statistical toolbox version 2008 (MathWorks, Natick, Massachusetts, United
States). Paired Student's t-test was used to compare baseline and follow-up values. P-values less than 0.05 were considered statistically significant.
Results
A total of 76 patients were included in this review. Patients were mainly males (44/76;
58%), were 56 years old on average (range: 22.3–79.6 years) at the time of surgery,
and were treated with Hintegra prosthesis (Allegra Orthopaedics, Lane Cove West, NSW,
Australia) with an anterior approach.
Forty right and 36 left TARs were performed. The prosthesis components sizes were
mismatched (talus component size smaller than tibial component size) in 32 patients.
Nineteen patients underwent the following concurrent operative procedure at the time
of TAR: Achilles tendon lengthening (seven patients), realignment calcaneal osteotomy
(three patients), and subtalar arthrodesis (three patients). Ligament balancing was
performed as required through an isolated deltoid release (one patient), a medial
malleolar lengthening osteotomy (three patients), and a combination of medial malleolar
lengthening osteotomy, fibular shortening osteotomy, and peroneus longus to brevis
transfer (two patients).
At 12 months postoperatively, there was a statistically significant increase in AOFAS
scores from 32.8 ± 12.7 preoperatively to 72.6 ± 13.3 (p < 0.001), in SF-12 PCS from 34.3 ± 5.1 preoperatively to 45.4 ± 6.4 (p < 0.001), and in the SF-12 MCS from 39.8 ± 7.5 preoperatively to 51.4 ± 6.1 (p < 0.001). In addition, there was also a statistically significant decrease in the
VAS pain score from 8.7 ± 1.6 preoperatively to 2.2 ± 1.6 (p < 0.001). The UCLA activity levels increased significantly from 2.4 ± 0.8 to 6.3
± 2.3 (p < 0.001) ([Table 1]).
Table 1
UCLA score
|
Pre-Operative
|
|
|
Arthritic Condition
|
Post- TAR
|
|
UCLA Score
|
%
|
N° of Pts
|
%
|
N° of Pts
|
|
1
|
5,3
|
4
|
0
|
0
|
|
2
|
61,8
|
47
|
7,9
|
6
|
|
3
|
23,7
|
18
|
7,9
|
6
|
|
4
|
6,6
|
5
|
6,6
|
5
|
|
5
|
2,6
|
2
|
9,2
|
7
|
|
6
|
0
|
0
|
17,1
|
13
|
|
7
|
0
|
0
|
14,5
|
11
|
|
8
|
0
|
0
|
18,4
|
14
|
|
9
|
0
|
0
|
14,5
|
11
|
|
10
|
0
|
0
|
3,9
|
3
|
|
Total
|
100
|
76
|
100
|
76
|
|
Mean UCLA Score
|
2,4
|
|
6,3
|
Before surgery, 11.7% of the patients were active in sports; after surgery, this percentage
rose to 49.4%. The most frequent sports activities were jogging, dancing, biking,
and skiing; a fraction of patients (n = 14) participated in impact sports such as jogging (13 patients) and martial arts
(1 patient) in spite of adverse medical advice ([Table 2]).
Table 2
Recommendations of sports activities
|
Recommended
|
Possible
|
Not recommended
|
|
Aerobic activity
|
Cross-country skiing
|
Basketball
|
|
Cycling
|
Sailing
|
Beach volleyball
|
|
Dancing
|
Alpine skiing
|
Climbing
|
|
Golf
|
Tennis
|
Horseback riding
|
|
Hiking or nordic walking
|
Hunting
|
Ice hockey
|
|
Swimming
|
|
Ice skating and skating
|
|
|
Jogging
|
|
|
Martial arts
|
|
|
Mountain biking
|
|
|
Paragliding and skydiving
|
|
|
Rugby
|
|
|
Soccer
|
|
|
Volleyball
|
|
|
Water ski
|
|
|
Windsurfing
|
Discussion
Ankle OA has a deeply different epidemiology from hip and knee. These may be related
to biomechanics reasons[15]: the loading area of the ankle is approximately one-third smaller than the corresponding
ones for knee or hip[16]; the thinner (1–2 mm) cartilage layer of the ankle offer a far more resilient tissue
than those of the other joints.[17] Posttraumatic changes are the main reasons for developing ankle OA (∼65–80%).
Ankle trauma is more likely to affect younger population. This can also explain a
younger population for ankle OA, which usually affect higher demanding patients if
compared with hip and knee. In this respect, as a consequence of the impressive progress
achieved in ankle prosthesis designs and clinical outcome following TAR, ankle arthrodesis
is no longer the standard treatment for end-stage ankle OA.[18]
In our study, patient's recovery and joint restoration in terms of balance and movement
suggest that TAR may be considered the golden standard at least for highly active
patients. This statement finds a confirmation in our UCLA scale results. The UCLA
activity score is described as a valid instrument for assessment of activity levels
in patients undergoing total joint arthroplasties[13]: we detected a significant increase in UCLA activity levels from 2.4 to 6.3.
The most frequent sports activities were jogging, dancing, biking, and skiing; a group
of patients[14] participated in impact sports such as jogging[13] and martial arts[1] in spite of adverse medical advice.
Despite of our early results, high-impact sports activities may increase polyethylene
wear[19] and the incidence of the fracture of polyethylene[20] at a long-term follow-up. In addition, young age, high body mass index, and poor
bone quality are additional risk factors that led orthopaedic surgeons to remain more
cautious and restrictive.[6]
Nevertheless, the first clinical study on sport and recreation activities in patients
who underwent TAR published in 2006 found that the rate of sports participation increased
from 36% preoperatively to 56% postoperatively.[21] Furthermore, some authors pointed out that patients active in sports were not at
higher risk for failure compared with other groups[18]; Naal et al reported that neither sports participation nor activity levels were
identified as risk factors for development of periprosthetic radiolucencies.[14]
A critical factor in sport activities is the ankle range motion. Although the major
advantages of TAR versus ankle arthrodesis is the preservation of ankle mobility,
there is still no consensus whether patients with TAR have better results in sport
activities than patients with ankle fusion. In fact, Schuh et al[22] revealed no significant difference between these two groups concerning activity
levels, participation in sports activities, and UCLA and AOFAS scores. Anyway, the
patients after ankle arthrodesis significantly decreased their activities. It may
be related to the loss of movement due to the degenerative changes in the ipsilateral,
tarsometatarsal, and subtalar joints.[23]
[24]
[25]
Recently, Flavin et al[26] demonstrated that patients with TAR showed higher speed during walk. In fact, the
restored functionality of the ankle allowed a comparatively increased stride length
and faster cadence, as well as more normalized first and second rockers at the gait
analysis.
Bonnin et al[27] in their retrospective series of 140 mobile-bearing ankle arthroplasties showed
that TAR improved the quality of life and that return to recreational activities was
generally possible but the return to impact sport was rarely possible. As our results
suggest, less pain and better range of motion can encourage patients to increase their
participation in sports (including high impact ones) and recreation activities, but
this observation should be checked at a longer follow-up.
Although TAR has become an increasingly popular procedure to treat symptomatic and
recalcitrant ankle arthritis, orthopaedic surgeons have little guidance concerning
physical activity and sport participation recommendations following this procedure.
Our results suggest, though preliminary, that TAR is possibly a better choice with
respect to arthrodesis, at least for highly active individuals. This consideration
comes from both patients' perception and, more objectively, the reduced stress imposed
by TAR to the nearest joints with respect to OA.
To date, further studies on the durability and complications of prostheses, as well
as patient activity and return to specific sports and activities after surgery, are
needed to reach a unique guideline based on stronger levels of evidence.
