Total ankle replacement in patients with haemophilic arthropathy: primary arthroplasty and conversion of painful ankle arthrodesis to arthroplasty.

INTRODUCTION: There are two general surgical approaches for operative treatment of end-stage haemophilic ankle arthropathy: ankle arthrodesis and total ankle replacement (TAR). AIM: The aim of this study was to determine intraoperative and postoperative complications and evaluate the mid-term clinical and radiographic outcomes of TAR in patients with haemophilic arthropathy. METHODS: Fourteen patients with a mean age of 51.4 ± 10.2 years (range = 32.9-63.7) were treated for end-stage haemophilic ankle arthropathy. Nine procedures were primary arthroplasties, five procedures were conversions of painful ankle arthrodesis to TAR. The mean duration of follow-up was 5.8 ± 2.3 years (range = 2.0-9.2). Component stability and alignment was assessed with weight-bearing radiographs. Clinical assessment was performed. RESULTS: One patient sustained an intraoperative medial malleolar fracture. In two patients, delayed wound healing was observed. In one patient, open arthrolysis was performed due to painful arthrofibrosis. Both components were neutrally aligned. Visual analogue scale (VAS) significantly decreased from 8.5 ± 0.9 (range = 8-10) to 1.3 ± 1.6 (range = 0-6). Significant functional improvement including range of motion (ROM) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was observed. The summarized components of the SF-36 physical and mental outcomes score significantly improved at the latest follow-up. Complication rates and clinical/radiographic outcomes were comparable in patients with primary TAR and conversion of ankle arthrodesis to TAR. CONCLUSION: The mid-term results following TAR or a conversion procedure in patients with haemophilic arthropathy are encouraging. However, for postoperative success, access to an experienced, multidisciplinary team including a haematologist is mandatory.

[Supramalleolar osteotomy in asymmetric ankle osteoarthritis : Short-term clinical and radiographic results]. / Supramalleolare Osteotomie bei asymmetrischer Arthrose des oberen Sprunggelenks : Kurzfristige klinische und radiologische Ergebnisse.

BACKGROUND: The main indication for the supramalleolar osteotomy is asymmetric ankle osteoarthritis with concomitant supramalleolar valgus or varus deformity. The aim of this prospective study was to analyze short-term clinical and radiographic outcomes in patients with asymmetric ankle osteoarthritis. METHODS: A total of 16 patients with asymmetric ankle osteoarthritis and concomitant supramalleolar deformity - 7 patients with valgus deformity, 9 patients with varus deformity - were treated. Intraoperative and postoperative complications were recorded and analyzed. The clinical and radiographic outcomes were assessed after a mean follow-up of 3.6 ± 1.1 years. RESULTS: In 10 of 16 patients, removal of hardware was performed. The AOFAS hindfoot score increased significantly after surgery. All categories of the SF-36 score showed significant improvement. The average range of motion also increased significantly. Radiographic assessment showed neutral hindfoot alignment at the latest follow-up. The postoperative clinical outcomes were comparable in both patient groups. The time until complete osseous union was significantly longer in patients with opening wedge osteotomy. CONCLUSION: This prospective study demonstrated encouraging short-term results in patients with asymmetric ankle osteoarthritis who underwent supramalleolar osteotomy. In progressive ankle osteoarthritis, joint-nonpreserving treatment options including total ankle replacement or ankle arthrodesis should be discussed.

[Aseptic loosening of total ankle replacement : One-stage revision ankle arthroplasty]. / Aseptische Lockerung einer OSG­Endoprothese : Einzeitiger Prothesenwechsel.

OBJECTIVE: To revise one or both loosened prosthesis components, to achieve postoperative pain relief, and preserve ankle range of motion. INDICATIONS: Aseptic loosening of the tibial and/or talar ankle prosthesis components without substantial bone defect of the tibial or talar bone stock. CONTRAINDICATIONS: General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g. Charcot arthropathy), substantial nonreconstructable osseous defects with or without cysts on the tibial and/or talar side, non-compliance, patients with primary total ankle replacement (TAR) using intramedullary fixation (stem fixation), patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking, unrealistic patient expectations, patients with high activity in sports. SURGICAL TECHNIQUE: Exposure of the ankle joint using the previous incision (anterior or lateral transfibular approach). Mobilization and removal of loosened prosthesis component. Careful debridement of bone stock at bone-prosthesis interface. Determination of prosthesis component size. Implantation of definitive prosthesis components. Wound closure in layers. POSTOPERATIVE MANAGEMENT: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts at postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated gradually. RESULTS: Between January 2007 and December 2012 a one-stage revision TAR was performed in 14 patients with a mean age of 52.7 ± 12.0 years (29.8-70.5 years). The indication for revision surgery was aseptic loosening of one or both prosthesis components. The mean time between the initial TAR and revision surgery was 5.9 ± 2.9 years (2.0-11.5 years). In 2 patients a tibiotalocalcaneal arthrodesis was performed due to painful aseptic loosening of revision TAR. In all patients a significant pain relief was observed.

[Dwyer osteotomy : Lateral sliding osteotomy of calcaneus]. / Dwyer-Osteotomie : Laterale Verschiebeosteotomie des Kalkaneus.

OBJECTIVE: To correct the underlying inframalleolar varus deformity and to restore physiologic biomechanics of the hindfoot. INDICATIONS: Neurologic, posttraumatic, congenital, and idiopathic cavovarus deformity. In patients with end-stage ankle osteoarthritis with varus heel malposition as additional single-stage procedure complementing total ankle replacement. Severe peroneal tendinopathy with concomitant cavovarus deformity. CONTRAINDICATIONS: General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g., Charcot arthropathy), end-stage osteoarthritis of the subtalar joint, severely reduced bone quality, high age, insulin-dependent diabetes mellitus, smoking. SURGICAL TECHNIQUE: The lateral calcaneus cortex is exposed using a lateral incision. The osteotomy is performed through an oscillating saw. The posterior osteotomy fragment is manually mobilized and shifted laterally. If needed, a laterally based wedge can be removed and/or the osteotomy fragment can be translated cranially. The osteotomy is stabilized with two cannulated screws, followed by wound closure. POSTOPERATIVE MANAGEMENT: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated step by step. RESULTS: Between January 2009 and June 2013, a Dwyer osteotomy was performed in 31 patients with a mean age of 45.7 ± 16.3 years (range 21.5-77.4 years). All patients had a substantial inframalleolar cavovarus deformity with preoperative moment arm of the calcaneus of -17.9 ± 3.3 mm (range -22.5 to -10.5 mm), which has been improved significantly to 1.6 ± 5.9 mm (range -16.9 to 9.9 mm). Significant pain relief from 6.3 ± 1.9 (range 4-10) to 1.1 ± 1.1 (range 0-4) using the visual analogue scale was observed. The American Orthopaedic Foot and Ankle Society score significantly improved from 33.1 ± 14.2 (range 10-60) to 78.0 ± 10.5 (range 55-95).