Chaklin Ural Scientific Research Institute of Traumatology and Orthopedics, Ekaterinburg, Russia

 

Treatment of diseases and consequences of ankle joint (AJ) injuries is one of the most actual problems of modern orthopedics. Treatment of AJ osteoarthrosis is a significant problem for specialists. The number of such patients has been increasing constantly [1]. AJ takes third place according to the frequency of arthrosis development (9-25 %), conceding only to hip and knee joints [2, 3]. The most frequent causes of AJ arthrosis are severe injury to its anatomic structures – internal and external malleolus, tibia, ankle bone, and rheumatoid diseases [1, 2]. In the days of endoprosthetics advancement the issue of treatment of AJ arthrosis is one of the most difficult and least solved. The main method of osteoarthrosis treatment is conservative one [2, 4]. However, possibilities of conservative treatment are very limited in case of AJ arthrosis of degenerative dystrophic or traumatic etiology with evident pain syndrome and joint contracture [3].

Conventionally, AJ arthrodesis is the gold standard of surgical treatment for patients with severe deforming osteoarthrosis, which allows removing pain syndrome and giving proper results [5, 6, 7]. However, because of changes in foot and extremity biomechanics, walking dynamics alters and claudication develops frequently. The lost function of AJ is undertaken by other foot joints, and it results in rapid fretting and progressing arthrosis [5, 7, 8]. Patients with AJ osteoarthrosis at the background of rheumatoid diseases are in worst position because of their limited compensatory abilities. Decreasing total volume of movements increases stress load upon remaining foot joints and the tibia, with decreasing positive effect of arthrodesis and even leading to tibial fracture [9]. At the present time orthopedists demonstrate their great interest to treatment of AJ osteoarthrosis. For this category of patients endoprosthetics is a modern alternative to arthrodesis [5, 8, 10, 11].

Objective – to assess the short term outcomes of AJ endoprosthetics in osteoarthrosis.

 

MATERIALS AND METHODS

The patients were included into the study after their consent in concordance to Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects 2000 and the Rules for Clinical Practice in Russian Federation confirmed by the Order of Healthcare Ministry of Russian Federation from 19.06.2003, #266. The study protocol was approved by the local ethic committee of Chaklin Ural Scientific Research Institute of Traumatology and Orthopedics, #28, 31.01.2014.

32 operations for deforming AJ osteoarthrosis were performed for 31 included patients (for one patient bilateral endoprosthetics was performed). There were 9 men and 22 women. The age was 26-76 (mean age of 51). Most patients were working age persons (68 %). 23 patients requested assistance because of posttraumatic AJ osteoarthrosis. Injury age was from 1 till 11 years. 8 patients suffered from rheumatoid arthritis. In most patients with posttraumatic osteoarthrosis the treatment of primary injury was associated with errors: in 11 cases plaster immobilization was used in presence of indications to surgery, in 5 – technical errors of osteosynthesis. Among them 11 persons had AJ arthrosis, which developed as result of malunions of distal tibial epimetaphys and ankles. In 2 patients talocalcanean joint ankylosis developed after arthrodesis.

On admission all patients’ main complaints were apparent intractable pain, crackling and limited motions in AJ, disorders in lower extremity support ability, claudication.

During objective examination one could observe AJ edema, increasing AJ circumference, hypotrophy of leg and foot muscles. The joint motions were significantly limited: in most patients (n = 23) the amplitude of active motions varied from 5 to 20 degrees. One could observe evident disorders in lower extremity support ability because of pain syndrome: all patients limped, 8 patients used a cane, 7 patients did not use available AJ motions.

Plain and functional X-ray identified AJ deformations of different degrees, narrowing joint space, ankle bone block applanation, boundary osteophytes of different degrees and incidence, as well as decreased amplitude of motions in AJ. CT study found single cysts in ankle bone region mostly. X-ray picture corresponded to osteoarthrosis of stages II-III according to N.S. Kosinskaya. The patients with rheumatoid arthritis had arthrosis of foot adjacent joints, longitudinal and transverse platypodia.

For 28 patients AJ endoprosthetics with Mobility total endoprosthesis (DePuy) was performed, for 2 – Hintegra (NewDeal). One year after surgery, one patient received other AJ endoprosthetics with Hintegra total endoprosthesis (NewDeal). Healing by first intention was in all patients. In postsurgical period brace immobilization was performed for 4 weeks.

After completing AJ fixation the course of 3 week complex conservative treatment was performed for muscular system strengthening and removing presurgical contracture. During this period the partial load to treated limb was recommended. In the end of rehabilitation course the full load was permitted. After treatment the patients received recommendations for continuation of curative exercises and limiting significant physical load.

The duration of postsurgical follow-up varied from 3 months to 3 years. For 6 patients (19 %) the information about outcomes is available for 3-6 months after surgery. For period of 6-12 months the outcomes are available for 31 % of the patients, in half of the patients (50 %) the outcomes are available for 1-3 years after endoprosthetics. During the analysis of treatment outcomes the disease history and the data of clinical and X-ray examination were considered.

 

RESULTS

The treatment outcomes were evaluated with consideration of motion range in AJ, presence of pain syndrome and supporting ability of the limb.

After endoprosthetics and realized course of conservative treatment the restoration of AJ motion range depended on contracture degree before surgery and disease etiology. So, in 9 patients with mild contracture on admission (amplitude > 50°) the AJ motion was achieved in full range after surgery. Non-significant postsurgical limited motions (amplitude > 40°) were found in more than a half of the patients (n = 17). This group included the patients with evident limitation of AJ motions before surgery. In 5 patients (15.6 %) with initial severe AJ contracture the limitation of motion range of middle degree was observed (motion range 20-40°). In 1 patient (3.1 %) with presurgical oscillating movements in the joint the initial severe AJ contracture was not removed because of apparent scar process.

One should note that in 7 patients with AJ osteoarthrosis as result of rheumatoid arthritis the joint motion range was fully achieved after endoprosthetics, and 1 patient had mild limited motion range. In these patients the joint function restoration completed faster – during 2-3 weeks. In the patients with posttraumatic arthrosis the AJ restoration period was extended, and the gradual increase in motion range was observed within 1.5-6 months after surgery, when the ablebodied patients worked during 3-4 months.

In all patients the pain syndrome in AJ was removed. The patients with periodical pain in the foot during walking had concurrent arthrosis of the talocalcanean joint of stage II or other foot joints. After conservative treatment the pain syndrome associated with adjacent joint arthrosis was jugulated.

In 29 patients the supporting ability of treated limb restored after 2 months after endoprosthetics, and 2 patients of retirement age walked using a cane, because of concurrent diseases.

Two months after surgery all patients of mental labour resumed their activity (n = 9). Despite of the recommendation for changing labor activity, 9 patients resumed their previous professional activity with long standing, but 3 patients changed heavy physical labor to work in simplified conditions. The non-working patients resumed their active life style after 2 months.

In one case of implantation of Mobility (DePuy) endoprosthesis the intrasurgical complication was identified – the internal malleolus fracture, which was treated with pin and wire osteosynthesis. In other case in the patient (age of 76) with concurrent disorders of bone mineral density after falling (6 months after AJ endoprosthetics) the internal malleolus fracture was diagnosed. The patient received conservative treatment according to his place of residence. However the identified complications did not influence the functional outcomes of treatment.  

The clinical case. The patient (female) K., age of 49, was admitted to Chaklin Ural Scientific Research Institute of Traumatology and Orthopedics after 11 years after the injury. The diagnosis was posttraumatic osteoarthrosis of left AJ of degree III, flexion-extension contracture of left AJ, arthrosis of the talocalcanean joint of the left foot of degree II (Fig. 1). The patient had persistent pain during load, soft tissue edema in the region of AJ, claudication, disordered supporting ability of the lower extremity. The patient received repeated conservative treatment, but without efficiency.

Figure 1

X-rays images of the ankle join by patient K. before surgery

During the examination the pastosity of the soft tissues in the region of lower third of the ankle and the foot, as well as pain during palpation were found at the level of AJ space. The motion range was 15°. The patient moved with full load, with laming in the bad leg. The AJ motions were absent because of pain. According to H. Kofoed life quality scale the result was 41 points. It corresponded to unsatisfactory result.

In the institute the patient received total AJ endoprosthetics with Mobility (DePuy) device (Fig. 2A). The brace fixation continued during 1 month. Later the complex restorative treatment was performed during 3 weeks.

Figure 2

X-rays images of the ankle join by patient K. after surgery: A – after implantation of Mobility DePuy prosthesis, B – one year after surgery 

       

During examination 2 months after surgery the AJ motion range was 35° (85-120°). The patient walked with full load, without pain, and later started her activity as kindergartner. One year after surgery the range of active and passive motions in AJ was full (Fig. 2B, 3). According to H. Kofoed scale the result was 96 points that corresponded to excellent grade.

 Figure 3

 

DISCUSSION

The performed analysis of AJ function restoration showed that AJ total endoprosthetics (in case of arthrosis) allowed removing pain syndrome and restoring supporting ability of lower extremity. The degree of restoration of postsurgical motion range in AJ is defined with arthrosis etiology and initial severity of concurrent contracture.

At the present time the great amount of AJ endoprosthesis exist. For Russia the common ones are Mobility (DePuy, Great Britain), and Hintegra (NewDeal, France), which are characterized with special features in component design. For improving outcomes of treatment of AJ arthrosis it is necessary to define indications for one or other type of prosthesis judging from patient’s complaints, his/her age, arthrosis etiology and outcomes of presurgical examination.

One should note that at the present time orthopedists and arthrologists rarely refer patients with AJ arthrosis to prosthetics. Often patients require late assistance in specialized facilities, when severe joint arthrosis is accompanied by evident instability and disarranged limb axis. Endoprosthetics and restoration of AJ function in such patients are difficult. It is necessary to note that for patients with bilateral AJ lesions (commonly, patients with rheumatoid diseases for which AJ arthrodesis is unacceptable because of biomechanics) AJ endoprosthetics is a method of choice. Besides, it was found that in patients with evident presurgical contracture the process of restoration of motion range after endoprosthetics is longer, and rehabilitation is to be performed not less than 3 months. The above mentioned facts demonstrate necessity of precise interrelation and continuance of management of such patients in injury care centers and polyclinics according to place of residence.

 

CONCLUSION

Therefore, it is appropriate to use total AJ endoprosthetics for restoration of limb function in osteoarthrosis independently of its etiology. Using this technique allows removing pain syndrome, saving and sometimes increasing motion range in AJ, restoring limb supporting ability, with improving life quality for such patients. All that gives evidence of efficiency of total endoprosthetics in treatment of AJ arthrosis and necessity of consideration of method of choice in patients with severe AJ arthrosis.