Orthopedics: Foot and Ankle Surgery Matthew S Austin, Gregg R Klein, David I Pedowitz
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Total Ankle Arthroplasty in Young Patients

World Clin Orthoped. 2015;2(1):10-21.
*David N Garras MD,
Department of Orthopedic Surgery, Midwest Orthopedic Consultants, Oak Lawn, Illinois, USA
Christopher E Gross MD,
Department of Orthopaedic Surgery, Medical University of South Carolina Charleston, South Carolina, USA
David I Pedowitz MS MD
Department of Orthopaedic Surgery, Thomas Jefferson University Hospital Rothman Institute, Philadelphia, Pennsylvania, USA

ABSTRACT

Since the majority of posttraumatic arthritis is burdened by patients younger than 50 years, long-term solutions in decreasing pain and improving function are of particular concern. While arthrodesis is still considered as the gold standard to treat patients with ankle arthritis who fail conservative management, arthroplasty is becoming a more attractive option given limitations of arthrodesis. This article serves to discuss the current state of literature regarding age and the results of total ankle arthroplasty (TAA) in the younger (<50 years old) population.
 
INTRODUCTION
Ankle arthritis is a debilitating condition that is primarily related to prior trauma.1 It contributes to the disability of millions of Americans, yet it is still 9 times less common than arthritis in the hip and knee joint.2-4 The tibiotalar joint has remarkable resilience to primary osteoarthritis (OA) and aging and may be related to its inherent bony and ligamentous stability, biomechanics, biology, and unique biochemical milieu.5 Ankle arthritis primarily affects the elderly population, but for the young who develop arthritis, they may develop significant debilitation. Interestingly, patients with end-stage ankle and hip arthritis have similar mental and physical disability scores, which are two standard deviations below the normal population.6 Similarly, patients with ankle arthritis perceive the degree of physical impairment equivalent to those with congestive heart failure or end-stage renal dysfunction.7
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2 The primary cause of ankle arthritis is overwhelmingly trauma-related.1,8,9 In at least 70% of patients treated with Kellgren-Lawrence grade 3 and 4 ankle arthritis, secondary ankle OA was related to rotational ankle fractures (37%) and recurrent ankle instability (15%). Only 7% of patients were diagnosed with primary ankle OA. The next most common cause is inflammatory arthropathies, such as rheumatoid arthritis (12%) followed by infection, osteonecrosis, gout, hemophilia or neuropathic arthropathy. Saltzman et al. noted that patients who developed ankle arthritis did so at a relatively younger age than those with hip or knee arthritis.1
Conservative therapies for ankle arthritis are numerous and include non-steroidal anti-inflammatory drugs (NSAIDs), activity modification, ice, corticosteroid or viscosupplementation intra-articular injections, bracing, and foot wear modification (rocker bottom shoe, solid ankle cushion heel). When conservative therapy fails, joint-sparing surgical procedures are often considered that include arthroscopic debridement, distraction arthroplasty, osteochondral autografts transplantation surger (OATS) procedure, autologous cartilage implant transplantation/autologous chondrocyte implantation (AIC), and tibial osteotomies. Large talar or bipolar allografts may also be considered (Table 1).
Historically, ankle arthrodesis has been considered as the surgical gold standard for ankle arthritis that has failed conservative management. This is partly due to its consistent and reproducible results in restoring functionality and decreasing pain and also partly due to the disappointingly high rates of complications associated with first-generation total ankle replacement (TAR) systems in the 1970s.8 These systems were associated with high rates of osteolysis, component loosening, tibial and talar bone loss, and wound complications.10-13 Arthrodesis, however, is not exempted from undesirable long-term consequences. Other hindfoot and tarsal joints must compensate for the loss of tibiotalar motion and may develop adjacent joint degeneration.14-16 Buchner et al. reported that the subtalar joint in patients followed for an average of 9.3 years had a 47% rate of moderate-to-severe arthritis rate with a 54% decrease in tarsal mobility as compared to the contralateral side.143
Table 1   Treatment Strategies for Ankle Arthritis
Conservative
Joint-sparing
Joint-sacrificing
  • NSAIDs
  • Activity modification
  • Ice
  • Intra-articular injections
  • Foot wear modification
  • Bracing
  • Arthroscopic debridement
  • Distraction arthroplasty
  • OATS
  • ACI
  • Tibial osteotomy
  • Allograft replacement
  • Tibiotalar arthrodesis
  • Ankle arthroplasty
NSAIDs, non-steroidal anti-inflammatory drugs; OATS, osteochondral autografts transplantation surgey; ACI, autologous cartilage implant transplantation/autologous chondrocyte implantation.
Fuchs et al. reported that in patients at least 20 years status postankle arthrodesis, 50% reported significant limitations in their activities of daily living (ADL) due to arthritis in the subtalar, talonavicular, calcaneocuboid, and midfoot joints.15 These long-term results are particularly relevant to the younger patients with tibiotalar arthritis.
Third-generation ankle arthroplasty systems have made significant strides in improving the biomaterials and mechanical design of modern total ankle arthroplasty (TAA). Such improvements include attention to coronal plane stability, retaining ligamentous support, and anatomic balancing. Recent meta-analyses and prospective controlled trials have suggested that modern ankle arthroplasty offers similar pain relief and perhaps better function than ankle arthrodesis.17,18 Given these promising results, ankle replacement may be an attractive option for younger patients who will need to maximize the use of ankle and foot joints for many future decades.
 
CLINICAL EVALUATION
Common presenting symptoms of patients with ankle arthritis include pain and stiffness associated with activity. Patients with rheumatoid arthritis will complain of chronic mid- and hindfoot pain. In evaluating these patients, the surgeon must first obtain a thorough history from the patient, which includes any remote history of trauma, chronic ankle instability, autoimmunity, and if any operative intervention has been undertaken about the ankle. The onset, duration, quality, and severity of the symptoms must be established. The physical examination must concentrate on range of motion about the ankle and subtalar joints along with a gait analysis.
Radiographic analysis of the patient must include weight-bearing views of the foot and ankle along with a hindfoot alignment or long axial view.19 These views will help visualize adjacent joint degenerative changes or misalignment which needs to be taken into consideration for preoperative planning. Computed tomography or magnetic resonance imaging may be supplemental to evaluate the degree of bone loss, osteonecrosis, or subchondral cyst formation.
The TAA indications are expanding, as the technology matures. Traditionally, the ideal candidate for a TAR was over 60 years old, under 200 lbs with low-impact daily activities, minimal ankle/hindfoot deformity, and no adjacent soft-tissue pathology.20 Now, absolute indications only include those with sufficient tibial and talar bone stock to support a prosthesis. Absolute contraindications include active, insufficient bone stock, Charcot arthropathy, vascular insufficiency, and absence of neuromuscular function of the lower extremity.20 Successful results and survivorship for ankle arthroplasty is dependent on preoperative planning, surgical technique, and anatomic balancing.4
 
Age
 
The Controversy
Mean ages for TAA have been in the range of 50 and 60 years old.21 Age has never been an absolute contraindication since there has never been an expert consensus on the appropriate age to consider a TAR. Recent data with a mobile-bearing TAR system shows a probability of implant survival of 70.7% at 10 years and 45.6% at 14 years with 38% of patients undergoing a revision of at least one component at 12.4 years.22 Given this new data, patients under the age of 50 years old will likely undergo some type of revision procedure in relation to their ankle replacement.
Patients who cannot undergo component revision for a failed TAR pose a unique challenge to surgeons. These patients have substantial bone loss, gross instability of the ankle, and frequently a compromised soft-tissue envelope. With the relative lack of revision implants, salvage is the only practical option and can be achieved only through conversion of the TAR to tibiotalar or tibiotalocalcaneal fusion with a structural allograft or, in some cases, even transtibial amputation. While these are theoretical risks, many surgeons base their decisions on whether to operate on a patient under 50 years based on data gathered 20 years ago with older generation implants.
 
Age as a Prognostic Indicator
Many studies have implicated age as a risk factor for failure (as defined by need for a revision or salvage fusion),9,22-27 while others have stated that age does not affect the clinical outcomes.28-30 Furthermore, recent research has suggested that TAR performed in patients younger than 50 or 55 years may experience better functional outcome.31,32
 
Age as a Negative Prognostic Factor
Some of the earliest data on first-generation TAR showed that age was a predictor of postoperative complications. In a study of 102 ankle arthroplasties performed during a 4-year period, there was a 41% complication rate with impingement being the most common complication.27 The average patient age was 51 years old (range 21–77 years). The best results were seen in patients with posttraumatic arthropathy in patients over 60 years old and those with rheumatoid arthritis. Based on these results, Stauffer and Segal adamantly declared that arthroplasty should not be performed in patients younger than 60 years with posttraumatic arthritis. Patients with rheumatoid at all ages were considered operative candidates.
Kitaoka and Patzer reviewed 204 cemented Mayo TARs from 1974 to 1988.26 Their patient series had a 12% complication rate. The rate of failure (36%; defined 5 as the need to remove the implant) was influenced by the age of the patient. In the patients under 57 years old, 43% (39/91) were considered surgical failures. This value was significantly greater than the failure rate of 26% (18/69) for patients over 57 years old. They recommended that arthroplasty should not be considered in patients with either rheumatoid arthritis or OA of the ankle.
Multiple studies looked at how age is related to the STAR (Scandinavian Total Ankle Replacement, Small Bone Innovations) prosthesis.9,23,24 Henricson looked at the STAR prosthesis at two different time points.23,24 In an analysis of 531 arthroplasties performed between 1993 and 2005, the average age was 58 (±12) years old.24 The types of implants used were the STAR (318/531, 60%), HINTEGRA (Integra), and Buechal Pappas-type prostheses (AES and mobility). Lower age at the time of the index arthroplasty significantly increased the risk of revision. Similarly, when Henricson reported on 780 arthroplasties from the Swedish Ankle Registry,23 women below the age of 60 years with OA were at a higher risk of revision surgery. Age did not play a role in male or female patients with rheumatoid arthritis. The average age for these patients was 58 years (range 18–86 years).
Valderrabano et al.9 looked at a 3.7-year average follow-up of 65 patients with an average age of 56.1 years (range 22–85 years). No correlation was found between age and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, pain, periarticular ossification, and range of motion. These authors did see a correlation for young age and loosening of the components, bone lysis and the need for hindfoot arthrodesis. These three patients with TARs and an ipsilateral hindfoot fusion had a large amount of bone lysis at the tibia-component interface. Most recently, Brunner et al. looked at the long-term (11–15-year data) results of the STAR prosthesis.22 In a study of 62 TAR, with a patient mean age of 56.9 ± 13.9 years (range 22.3–84.5 years), the researchers noted a lower age at the time of implant led to an increased risk of revision.
Spirt et al.25 reviewed the survivorships for 303 total ankles along with complications. The 5-year implant survivorships for patients under and over 54 years were 74% and 89%, respectively. The younger cohort of patients had a 1.45-times greater risk for reoperation and a 2.65-times greater risk of prosthesis failure than patients over 54 years old.
Hurowitz et al.29 retrospectively reviewed 65 patients with arthroplasties performed between 1998 and 2002 with the agility TAR (DePuy, Warsaw, IN, USA) with the intent on looking at prognostic factors. The mean age at surgery was 54.5 years (range 28–77 years). Those with rheumatoid arthritis had a significantly lower rate of failure. The age of the patient did not predict failure in the posttraumatic group. However, the group noticed that in the primary OA cohort, age trended toward significance in predicting failure.
6
Similarly, Claridge et al.28 looked at 28 patients with agility TAR over 5 years. The AOFAS questionnaire was used for evaluation. The mean age at surgery was 68.5 years (range 41–81 years). They discovered that age did not affect the outcome. Similarly, Fevang33 looked at a cohort of 257 primary ankle replacement, 83% of which were STAR prostheses. The mean age at primary surgery was 58 years (range 18–85 years) for women and 60 years (range 31–89 years) for men. There was no significant influence on age, diagnosis, sex, or type of prosthesis.
In 100 consecutive cases of implanted mobile-bearing prosthesis followed prospectively for 15 years, Kofoed and Lundberg-Jensen specifically looked at age and clinical results;30 they split the cohort into patients younger and older than 50 years old. They found that age did not affect survivorship or risk for implant failure. They did report that in the first 8 years, the younger patients did have significantly lower mobility scores, which lowered the overall score which totaled pain, function, and mobility in years 3–6. The gain in total scores was the same in both groups.
There is no published literature to date that correlates a younger age with improved outcomes. However, a recent abstract presented at the 2013 meeting of the American Academy of Orthopaedic Surgeons (AAOS), Rodriguez-Pinto et al. reported on 159 patients followed for a mean of 41 months.32 They reported that the mean range of motion was significantly higher in patients younger than 50 years old (37.2° in <50 years vs. 33.9° in >50 years). Patients younger than 50 years old had a significant increase of 22.7° of motion compared to 17.6° in patients older than 50 years. The AOFAS hindfoot score was significantly greater in patients younger than 50 years old (93.5 in <50 years vs. 89.8 in >50 years). Patients younger than 50 years old also had a significant increase of 66.8 point in the AOFAS scale compared to 62.1° in patients older than 50 years. There was also a trend toward fewer minor complications in younger patients.
In a presentation at AOFAS 2013 Summer Meeting, Demetracopoulos et al.31 evaluated 395 ankles with an average follow-up of 3.7 years. They divided patients into three cohorts: (1) younger than 55 years, (2) 55–70 years, and (3) older than 70 years. Patients under the age of 55 years had a significantly greater increase in short form-36 (SF-36) vitality and AOFAS function subscales postoperatively. There was no statistical difference in the incidence of wound complications, reoperation, and revision among the three age groups. They concluded that outcomes of TAA in younger patients are similar to outcomes in the older patient at early-to-intermediate follow-up.
 
Return to Sport
Four recent studies have looked at participation in sports and other recreation activities following TAA.34-37 These studies did not recommend specific activities 7 or caution against others, rather they discussed what activities the patients decided to return to following TAR.
Valderrabano et al. evaluated 152 mobile-bearing prostheses with an average age of 59.6 years (range 28–86).37 Prior to surgery, 36% of patients were active in sports; following surgery, 56% were active in sports (p <0.001). The patients involved in sports had significantly higher AOFAS hindfoot scores than those who did not participate in sports (88 vs. 79 points). Those engaged in sports were frequently involved with hiking, biking, and swimming.
Naal et al.35 assessed the pre- and postoperative University of California, Los Angeles (UCLA) Activity Scale and Activities Rating Scale in 155 TAR with a mean age of 59.8 years at a mean of 3.7 years follow-up. There were no differences found in the sports frequency, number of different sports, or participation in sports following the procedure. However, 65% of patients noted an improvement in their sports ability. Those who participated in sports were frequently involved with swimming, biking, and fitness/weight training. There were no associations with radiographic lucency at last follow-up and sports participation.
Bonnin et al.34 evaluated 179 mobile-bearing TAR arthroplasties in 170 patients with an average age of 60.9 years. Seventy-six percent of the patients considered their ankle “normal” or “nearly normal” with the majority of these patients returning to nonimpact sports or light recreational activities, such as cycling, swimming, gardening, dancing, and hiking. A 31.4% of patients indicated no limitation related to their ankle in any situation while 49% of patients reported no discomfort in ADL but experienced discomfort in recreational activities and sports.
Schuh et al.36 evaluated 41 patients (21 ankle arthrodesis/20 TAR) at 34.5 months. Pre- and postoperative participation in sports and recreational activities were assessed using the UCLA activity scale and AOFAS hindfoot score. No significant difference between the fusion or arthroplasty groups concerning activity levels, participation in sports activities, UCLA and AOFAS score were seen. After arthrodesis, the number of patients participating in sports decreased, but this change was not statistically significant.
 
CONCLUSION
With advances in our understanding of ankle biomechanics and implant design, ankle arthroplasty is an attractive option for patients with ankle arthritis who fail conservative management. Historically, age has been seen as an independent risk factor for increased revision and failure rates. More recent data with 3rd generation devices are challenging our notions of the appropriate age in which to implant a TAR. Long-term data are critical in identifying all prognostic factors relating to revision and failure rates.8
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