Review Article Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes
Abstract Mitchell Bernstein, MD, FRCSC Ankle distraction is an alternative to ankle arthrodesis or total ankle Jay Reidler, MD, MPH arthroplasty in younger patients with arthritis. Ankle distraction involves the use of external fixation to mechanically unload the ankle Austin Fragomen, MD joint, which allows for stable, congruent range of motion in the setting S. Robert Rozbruch, MD of decreased mechanical loading, potentially promoting cartilage repair. Adjunct surgical procedures are frequently done to address lower-extremity malalignment, ankle equinus contractures, and impinging tibiotalar osteophytes. Patients can bear full weight during the treatment course. The distraction frame frequently uses a hinge, and patients are encouraged to do daily range-of-motion exercises. Although the initial goal of the procedure is to delay arthrodesis, many patients achieve lasting clinical benefits, obviating the need for total ankle arthroplasty or fusion. Complications associated with external fixation are common, and patients should be counseled that clinical improvements occur slowly and often are not achieved until at least 1 year after frame removal.
nkle osteoarthritis is generally ambulation do occur.5 Unlike fusion, Aa progressive condition, most TAA does not affect range of motion commonly the result of high-energy (ROM); however, its use in young tibial plafond fractures, bimalleolar active patients may be contra- ankle fractures, recurrent ankle insta- indicated because of wear, failure, bility, and neuropathy.1-3 Lower- and subsequent revisions.6 extremity posttraumatic arthritis has In contrast to the aims of TAA and an estimated cost of $12 billion ankle fusion, the aim of distraction annually in the United States.4 It is arthroplasty is to optimize the body’s From the Department of Orthopaedic often disabling, predominantly regenerative capacity and the func- Surgery, Loyola University Chicago 7,8 Stritch School of Medicine, Chicago, affects young, active persons, and has tion of the diseased joint. An IL (Dr. Bernstein), the Department of a negative effect on quality-of-life external fixator is used to mechan- Orthopaedics, Johns Hopkins measures that is comparable to that ically unload the ankle to relieve University, Baltimore, MD of hip and knee arthritis.1 The pain, preserve ROM, and potentially (Dr. Reidler), and the Department of Orthopaedic Surgery, Hospital for mainstay of surgical treatment of delay or even partially reverse the Special Surgery, Cornell University, advanced ankle arthritis has tradi- effects of arthritis (Figure 1). The New York, NY (Dr. Fragomen and tionally included ankle arthrodesis or surgeon should be aware of this Dr. Rozbruch). total ankle arthroplasty (TAA). treatment option, as well as its J Am Acad Orthop Surg 2016;0:1-11 Ankle arthrodesis reliably provides indications, outcomes, and potential DOI: 10.5435/JAAOS-D-14-00077 pain relief. However, loss of ankle adverse effects for ankle arthritis. motion, increased stress at adjacent Recent short- and intermediate-term Copyright 2016 by the American Academy of Orthopaedic Surgeons. joints that leads to degeneration, and evidence suggests that distraction increased energy expenditure with arthroplasty may be a viable surgical
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Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes
18,19 Figure 1 ability to withstand up to 5.5 times with a circular fixator. The body weight during ambulation concept of the hinge is based on the depends on a stable relationship theory that the talar dome is a frus- among the bony and ligamentous tum of a cone with its apex medially structures of the distal tibia, fibula, directed. and talus.11 The tibial plafond has a Articular cartilage, or hyaline car- central ridge oriented in the sagittal tilage, lacks blood supply, nerve plane that is complementary to a innervation, and lymphatic drainage. concavity on the talar dome. The It receives nutrition and expels waste relationship between the distal fib- via diffusion and imbibition. Its high ula, tibiotalar joint, and the medial tensile strength and elasticity func- malleolus is maintained by the stout tion to withstand high loads, protect ligaments that make up the ankle subchondral bone, and decrease syndesmosis. friction between the two opposing Ankle distraction frame mounted on One study demonstrated that even surfaces. Hyaline cartilage is primar- an extremity model demonstrating our a 1-mm displacement of the talus in ily composed of type II collagen, current assembly method. The red the ankle mortise generates a 42% water, and chondrocytes. Chon- (circular) and blue (U-shaped) rings are secured with 6-mm decrease in available joint contact drocytes, which produce enzymes, hydroxyapatite-coated half pins and area.12 Consequently, the remaining proteins, and collagen, are responsi- 1.8-mm bayonet Kirschner wires to cartilage is exposed to compressive ble for the normal and pathologic the tibia and foot, respectively. The forces over a smaller surface area, state of the articular surface.20,21 hinge (red arrow) is aligned with the Inman axis. The acute and gradual potentially leading to degeneration Chondrocytes are metabolically distraction is achieved with clockwise and arthritis. controlled via the surrounding rotations of the square nuts (red The orientation of the ankle joint, mechanical environment and thus, arrowhead), which are attached to the as described by a line perpendicular can upregulate the synthesis of deg- tibial ring. Range-of-motion exercises occur with unlocking the connection to the diaphysis of the tibia, is in slight radative cytokines, increasing cata- between the two rings (yellow arrow). valgus. Named the lateral distal tibial bolic enzymes in the local milieu—a Gradual dorsiflexion of the ankle, in angle, it measures on average 89° concept referred to as mechanoelec- the setting of chronic ankle equinus, is (range, 86º to 92°). The axis of the trochemical events.22 achieved by gradually increasing the distance between the square nut ankle joint is created through the Arthritis in the ankle is most often (yellow arrow) and the proximal end of relationship between, and the geo- secondary, usually resulting from the rod. (Copyright Mitchell Bernstein, metric constraints of, the talar dome, trauma.2,3 The energy dissipated MD, FRCSC, Chicago, IL.) tibial plafond, and the lateral and through the articular surface and the medial malleoli.13 The traditionally ensuing inflammatory response is option with the use of appropriate accepted theory, proposed in the thought to be critical in post- 23,24 patient selection criteria.9,10 1950s, suggests that the ankle rotates traumatic arthritis. It has been with one-degree of freedom about an demonstrated that the inflammation axis (ie, the Inman axis) that lies resulting from the energy loss causes Anatomy and between the tips of the medial and the production of dysfunctional Biomechanics of the Ankle lateral malleoli.14-16 This axis is the cellular elements and chondrocyte Joint basis for total ankle prosthesis apoptosis.25 In the subacute phase, designs17 and forms the basis on articular cartilage changes its com- The ankle is a highly constrained and which the hinge is built when dis- position, increasing its water con- congruent weight-bearing joint. Its traction arthroplasty is performed tent and decreasing its proteoglycan
Dr. Bernstein or an immediate family member serves as a paid consultant to NuVasive, Smith & Nephew, and DuPuy Synthes and serves as a board member, owner, officer, or committee member of the Limb Lengthening Reconstruction Society. Dr. Fragomen or an immediate family member has received royalties from Small Bone Innovations; is a member of a speakers’ bureau, or has made paid presentations on behalf of Smith & Nephew; and serves as a paid consultant to Smith & Nephew and DePuy Synthes. Dr. Rozbruch or an immediate family member has received royalties from Small Bone Innovations and Smith & Nephew; is a member of a speakers’ bureau, or has made paid presentations on behalf of Smith & Nephew; serves as a paid consultant to Small Bone Innovations and Smith & Nephew; and serves as a board member, owner, officer, or committee member of the Limb Lengthening Reconstruction Society. Neither Dr. Reidler nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.
2 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Mitchell Bernstein, MD, FRCSC, et al concentration. Furthermore, type II and has recalcitrant pain in the setting distraction, the etiology of ankle collagen is weakened by a combina- of a congruent joint with preserved arthritis is critical. A history of injury tion of decreased production by motion of .20°.33 Relative contra- or repetitive instability is therefore chondrocytes and increased concen- indications include complex regional carefully elucidated. tration of proinflammatory cytokines. pain syndrome, inflammatory ar- The physical examination begins To restore normal homeostasis, thritides, previous infection, neuro- with an assessment to identify any deeper layers containing “resting” pathic joint, and older age with low ipsilateral (or contralateral) extrem- chondrocytes proliferate to increase functional demands. Patients with a ity malalignment, such as tibial mal- anabolic activities. The exact cellu- painful stiff ankle (ie, ,20° of union, knee hyperextension, or tibia lar mechanisms, signaling mole- motion) are less likely to do well with vara. The patient is screened for limb cules, genetic factors, and the role of distraction because the procedure length inequality by comparing the mechanical influences currently are does not reliably increase ROM, and heights of the iliac crests. Dynamic not fully understood. thus, these patients may be better extremity instability, malalignment, As the catabolic processes over- candidates for arthrodesis or TAA.10 and foot progression angle are whelm resident chondrocytes, “full- Extra-articular deformity, located determined by observing the patient thickness” chondral involvement in the hindfoot or distal tibia, is not a ambulate. A focused assessment of ensues, exposing subchondral bone. contraindication if the deformity is the ankle and foot, including stability Healing is possible, albeit unpre- addressed concurrently.34 Patients and ROM testing, completes the dictably. This spontaneous healing with marked intra-articular defor- physical examination. occurs in part because of the release mity or a flat-top talus, however, are No routine laboratory tests are of growth factors from exposed felt to be poor candidates for ankle required. Infectious markers, such as marrow spaces.26 The resultant local distraction. Asymmetric arthritis of white blood cell count and erythrocyte inflammatory response recruits plu- the ankle is not a contraindication sedimentation rate and C-reactive ripotent mesenchymal stem cells, for ankle distraction. For example, protein level, are ordered when active which, depending on the local envi- patients with varus deformity at the infection is suspected or needs to be ronment, can be manipulated to distal tibia and asymmetric joint ruled out. develop fibrocartilage.27-30 This is wear on the medial side may benefit Radiographic evaluation includes one potential pathway that distrac- from a supramalleolar osteotomy, AP,lateral,andmortiseweight- tion arthroplasty and adjunct pro- with correction of the varus defor- bearing views of the ankle (Figure 2). cedures may use to exploit the mity and ankle distraction to offload Radiographs of the tibia and/or formation of hyaline cartilage.31 the diseased segment. Finally, ante- a standing hindfoot alignment For younger patients with rior joint space narrowing associated (Saltzman) view of the foot are ob- posttraumatic lesions, a durable, with impinging anterior osteophytes tained in the case of pathology and/or joint-sparing solution is desirable. should be identified. In these malalignment. CT scans of the ankle Concurrently addressing all pathol- patients, arthroscopic or open de- are not routinely ordered. MRI is used ogy, including equinus contracture, ti- compression, possibly in conjunction when osteochondral lesions need to be biotalar osteophytes, supramalleolar with gastrocnemius recession, delineated or in the case of nonosseous or hindfoot malalignment, and insta- should be considered. pathology (eg, lateral ankle ligament bility, is central to treatment. Cartilage The success of ankle distraction is pathology, posterior tibial tendinosis). regeneration is more reliable when it predicated on a thorough history, The ankle radiographs are also occurs in the setting of a congruent, physical examination, and ancillary used to measure the weight-bearing stable limb in anatomic alignment.19,32 tests. Our evaluation includes a review preoperative joint space in prepara- of patients’ reasons for consultation tion for the required increase of 5 mm and their perception of their disability during distraction to effectively Distraction Arthroplasty in addition to the basic elements of a unload the ankle joint.10,35 The thorough patient history: the location presence of subchondral sclerosis The success of ankle distraction and quality of the pain, aggravating and subchondral cysts are noted. In depends on proper patient selection and alleviating factors, subjective addition, the ankle joint should be and appropriate management of description of instability, previous scrutinized for asymmetric wear. expectations. The ideal candidate for nonsurgical and surgical treatments, This wear should be correlated to an ankle distraction arthroplasty is a and other musculoskeletal com- associated deformity. For example, if motivated patient who seeks an plaints. Because inflammatory arthri- the medial aspect of the ankle joint alternative to ankle fusion or TAA tides are relative contraindications to demonstrates arthritis with relative
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Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes
Figure 2
Preoperative AP (A) and lateral (B) standing radiographs of the ankle joint in a 53-year-old woman with posttraumatic arthritis. Subchondral sclerosis and cysts, as well as decreased joint space are noted. Mild flattening of the talar dome is evident anteriorly on the lateral radiograph. AP (C) and lateral (D) standing radiographs obtained immediately postoperatively after distraction arthroplasty and osteophyte excision. Note the 1-inch calibration ball to measure the joint space E, Photograph of the patient wearing the frame. AP (F) and lateral (G) standing radiographs of the ankle joint demonstrating joint space and remodeling of the joint at an 18-month follow-up visit. (Copyright Mitchell Bernstein, MD, FRCSC, Chicago, IL.) preservation of the lateral joint and Judet36 described a technique using those of normal hyaline cartilage.36 the patient has a posttraumatic varus external fixation to mechanically Aldegheri et al37 reported on the deformity with an apex at the distal separate opposing joint surfaces to use of a hinged distractor for hip tibial metaphysis, joint distraction in allow “for fibrous tissue between arthritis in 80 patients. Based on addition to a supramalleolar osteot- theboneends.” Their histologic goodresultsachievedin46patients omy may be indicated. analysis of regenerated tissue in at a minimum follow-up of 5 years, dogs was done after the tibiotarsal the authors concluded that radio- joints were devoid of articular graphic results do not always cor- History of the Procedure cartilage and distracted for 30 days relate with clinical outcomes. with a 4- to 8-mm gap. At 1 year, Patients aged .45 years with or In 1978, seeking alternatives to they reported metaplastic changes without inflammatory arthritis had TAA for joint arthritis, Judet and in the joint surface resembling uniformly poor results.
4 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Mitchell Bernstein, MD, FRCSC, et al
increase in protoeglycan synthesis, were better (P , 0.004) than those Mechanism of Action recruitment of mesenchymal stems obtained at 1-year follow-up. cells, and optimization of the Although poorly understood, sev- The exact mechanism of action for mechanical environment.22,31,45 Fur- eral studies support the process of distraction arthroplasty is unknown; thermore, an improvement is seen in ankle joint remodeling after frame however, it is based on the belief that the density of the subchondral bone removal.10,40,46,47 The restoration the biologic aspects of cartilage with a decrease in sclerosis.40 This of preinjury ankle architecture and regeneration are most likely to occur subchondral change may improve the mechanics is thought to be instru- in a mechanically unloaded, well- biomechanical environment of the mental for prolonged benefit. The aligned limb.38,39 The stiffness of arthritic joint. In addition, resorption notion that improvements may the circular ring fixator may allow of subchondral cysts and improve- occur over 12 to 24 months sub- for sufficient stress shielding at the ment in edema may contribute to the sequent to frame removal should ankle joint to allow subchondral clinical improvement that we have be considered when counseling bone remodeling, which has been observed. patients in their recovery period. shown to be of clinical benefit.40 In 2008, Paley et al48 published However, this phenomenon, and its their results on a modified distraction clinical correlation to pain relief, is Outcomes frame that was being used in Europe. still controversial. Motion during distraction was In addition, weight bearing, sta- In 1995, van Valburg et al44 pub- stressed, and an anatomically located — bility, and motion crucial for pro- lished a preliminary retrospective hinge based on the Inman axis — moting durable articular cartilage study on the use of ankle distraction became the foundation of the frame. are possible for an extended period in 11 patients with severe post- Adjunctive procedures, such as os- 41-43 in the external fixator. traumatic arthritis scheduled for teophyte resection, gastrocnemius- 43 van Valburg et al measured intra- ankle arthrodesis. The patient soleus complex recession, and articular hydrostatic pressure dur- cohort was relatively young (mean extremity realignment with osteot- ing distraction by inserting a age, 35 years). An Ilizarov distrac- omy, were also done to maximize pressure-sensitive catheter into the tion apparatus was used for a mean clinical outcomes.48 Nine males and ankle. Recordings demonstrated of 15 weeks. Their technique, which 14 females were available for ret- intra-articular pressure fluctuations, has since been slightly modified, rospective chart review after a mean and the authors suggested that these consisted of ensuring a post- 17 weeks with external fixation. fluctuations combined with the operative distraction gap of 5 mm Preoperative and postoperative absence of mechanical stress were and the addition of hinges between ankle motion was 28° and 27°, instrumental in articular cartilage 6 and 12 weeks postoperatively. At respectively. At a mean follow-up of 43-45 repair. They theorized that the a mean follow-up of 20 months 64 months (range, 24 to 157 intermittent fluid flow inside the (range,10to60months),all months), 77% patients reported joint caused by pressure fluctuations patients reported a decrease in pain, ambulation for pleasure, and 33% effectively mimics normal physio- and five patients (45%) reported a reported an ability to run. Radio- logic processes in the absence of complete resolution of pain.44 Six graphic analysis revealed that the load and shear and that this pro- patients (55%) had increased ROM, joint space after frame removal did motes cartilage repair. In a study of and five (50%) had radiographic not remain distracted, although this knee arthritis (induced by anterior evidence of increased tibiotalar joint did not affect clinical results. The cruciate ligament resection) in a space. Encouraged by their results, authors claimed that the purpose canine model, van Valburg et al31 the authors published a prospective of articular cartilage repair was observed that, in addition to the study with a minimum 2-year to “seal cartilage cracks and intermittent fluid flow caused by follow-up.46 The study included 17 defects,”48 which was supported by an articulated knee hinge on the patients (mean age, 39.6 years) who an MRI study of three patients who Ilizarov device, a change occurred in underwent annual evaluations for were treated with ankle distrac- the proteoglycan metabolism that functional ability, mobility, and tion.49 Of note, 33% were not sat- resembled the nonarthritic control pain scores. Ankle distraction failed isfied with the outcome of the knee. in four patients, who ultimately procedure. Treatment failed in two Factors that have been associated proceeded with arthrodesis. Of the patients (11%); one patient under- with cartilage repair include a decrease remaining 13 patients, clinical out- went ankle fusion and another in joint reactive forces (shear), an come scores at 2-year follow-up underwent TAA.48
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Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes
Table 1 Summary of Outcomes and Adverse Events From Studies on Distraction Arthroplasty No. of Study Patients Follow-upa Agea (yr) Outcomes Adverse Events
Marijnissen 111 2 yr minimum 42.7 6 9.8 Pain and disability scores 48 patients (44%) had et al9 decreased from 67% and subsequent arthrodesis 68% to 38% and 36%, respectively, at 2 yr Tellisi et al10 23 30.5 mo 43 (16–73) Decrease in pain in 91% of Pin-site infection in all patients; 2 (12–60 mo) patients of 23 patients (9%) went on to arthrodesis Saltzman 29 2 yr Fixed: 42.4 Better pain improvement in 19 of 29 patients (66%) had et al32 (18–53) motion group at 2 yr; both recurrent pin-site infections; 2 of Motion: 42.7 groups better at 2 yr than 29 patients (7%) had (27–59) baseline osteomyelitis. 8 of 29 patients (28%) had nerve injury of medial calcaneal branch of the tibial nerve and deep peroneal nerve; 1 of 29 patients (3%) had deep vein thrombosis Intema et al40 26 2 yr 41 6 9 Decrease in AOS pain and Not reported disability scores; correlation with subchondral bone remodeling and clinical improvement Ploegmakers 22 10 yr 37 6 11 Decrease in pain scores from 6 of 22 patients (27%) had et al47 (7–15 yr) 78% to 30%; increase in arthrodesis; 1 of 22 patients function scores from 20% to (5%) had complex regional pain 73% syndrome van Valburg 11 20 wk 35 (20–70) Pain decreased in all patients Not reported et al44 (10–60 wk) 5 patients pain free van Valburg 17 2 yr 40 (17–55) Decrease in physical, 4 of 17 patients (24%) had et al46 functional, and pain disability arthrodesis; 4 of 17 patients (24%) scores at 2 yrs (P , 0.003) had broken Kirschner wires Paley et al48 23 64 mo (24– 45 (17–62) 71% of patients ambulating for 17 of 23 patients (74%) had pin- 157 mo) pleasure; 33% can run, 22% site infection; 1 of 23 patients using assistive devices; 11% (4%) had arthrodesis; 1 of 23 with severe limitations patients (4%) had total ankle arthroplasty; 10 of 23 patients (43%) returned to operating room for unplanned procedure Nguyen 36 8.3 yr (6.1– Fixed: 42.4 AOS score ,43; age at time of 16 of 36 patients (45%) failed et al50 10.5 yr) (18–53) distraction, and fixed versus treatment; 8 of 16 patients (50%) Motion: 42.7 motion ankle distraction had ankle fusion, 5 of 16 patients (27–59) predictive of failure at 2 yr (31%) had total ankle postoperatively arthroplasty Marijnissen 57 2.8 yr (2.5– 44 (18–65) Decrease in pain scores by 38% 16 of 57 patients (28%) had pin- et al51 3.1 yr) (P , 0.0001); 69% increase in site infections; 8 of 57 patients function (P , 0.0001); increase (14%) had broken Kirschner in clinical condition by 120% wires (P , 0.0001)
AOS = Ankle Osteoarthritis Scale a The values are given as the mean with the range in parentheses. Copyright Mitchell Bernstein, MD, FRCSC, Chicago, IL.
A hinge allows for ROM during addition, while hinge distraction in ation, histologic proof of hyaline rehabilitation, but ROM will not likely animals supports robust and dura- cartilage regeneration in humans increase after frame removal.10,32 In ble articular-like cartilage regener- is lacking.8,31 In a prospective
6 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Mitchell Bernstein, MD, FRCSC, et al randomized controlled trial, pain.46 Similar rates of failure were approach, respectively. An arthrot- Saltzman et al32 compared 36 reported by Marijnissen et al51 and omy is used to remove impinging patients who underwent distraction Ploegmakers et al47 (24% and 27%, anterior osteophytes. A supra- arthroplasty with or without a respectively), who reported that malleolar osteotomy is added to hinge. Two years after frame clinical recurrence of pain 1 year correct concomitant coronal or sag- removal, clinical scores were better after frame removal was the reason ittal malalignment.19,34 This pro- in the hinge group, although ankle for ankle arthrodesis.51 Marijnissen cedure requires placement of an motion was similar in both groups. et al9 recently updated their clinical additional circular ring at the However, in a subsequent report on results with data from a 12-year proximal tibia, with the distraction the same cohort with longer follow- follow-up, noting a 44% rate of tibial ring closer to the ankle joint up, the authors reported that conversion to ankle arthrodesis. In (Figure 3). The supramalleolar os- patients without a hinge had the same study, Cox regression teotomy begins with the patient in a improved outcomes.50 The authors analysis revealed that female sex was supine position on a radiolucent could only speculate on the reason predictive of failure, whereas pre- table. A bump is placed under the for the contradictory results, and operative ankle motion permitting ipsilateral buttock to ensure the limb further research on the benefit of a distraction was protective.9 Nguyen is in neutral rotation (ie, patella hinge is necessary. In a retrospec- et al50 reported on their cohort of 36 facing upward). tive study of 23 patients with patients who underwent ankle dis- In addition to mechanical distrac- hinged distraction arthroplasty, traction for end-stage osteoarthritis. tion, we prefer to inject bone marrow Tellisi et al10 reported that all At a mean follow-up of 8.3 years, 29 autograft concentrate (BMAC) from patients in the hinge group had patients (81%) were available for the ipsilateral iliac crest as described severe posttraumatic arthritis and follow-up. Treatment failed in 13 by Hernigou et al.52 An aspirate of were being considered for ankle patients (45%), requiring either 60 mL of marrow yields approxi- arthrodesis. At a mean follow-up of ankle fusion or TAA. The authors mately 7 mL of BMAC. This aspirate 30.5 months (range, 12 to 60 months), reported that age, Ankle Osteoar- contains pluripotent stem cells, no patient demonstrated a change in thritis Scale score, and the presence which are injected into the ankle ankle motion. At the latest follow-up, of a hinge to allow ankle ROM were joint. We inject this percutaneously 21 of 23 patients (91%) reported predictors of failure at 2 years.50 at the end of the case, after the acute improvedpain,and17patients(74%) Finally, it is important to note distraction has been performed. We had notable improvement in Ameri- that published results primarily routinely administer this aspirate as can Foot and Ankle Society scores. analyze patients with severe ankle part of the ankle distraction pro- The initial enthusiasm for ankle arthritis who otherwise would be cedure. Although clinical evidence is distraction focused on the ability to considered candidates for arthrod- lacking, compelling basic science and delay arthrodesis or TAA. Propo- esis (Table 1). Selection of patients animal studies support the use of nents of distraction arthroplasty with moderate arthritis could lead BMAC to augment the cartilage cite several advantages, including to improved long-term outcomes. regeneration.8,29,53-55 the minimally invasive nature of Further research is necessary. The application of the ankle dis- the procedure, no required internal traction frame begins by choosing a fixation, and no interference with tibial ring that allows for two finger- future reconstructive efforts.10 How- Authors’ Preferred Surgical breadths of space circumferentially ever, studies of ankle arthrodesis and Technique between the skin and the ring. The TAA after distraction arthroplasty medial malleolus and the anterior are lacking. The patient’s history and physical and posteromedial border of the Nevertheless, clinical failures in the examination, as well as the results of distal tibia are marked. The prox- form of ankle fusion or TAA do occur appropriate imaging studies will imal ring is secured with two 6-mm following distraction.9,10,46,50 As dictate which, if any, adjunct surgi- hydroxyapatite-coated pins.56,57 The noted, van Valburg et al46 reported cal treatments are required before first pin is placed approximately 6 on 17 patients with a mean age of the circular frame is mounted to the cm proximal to the medial malleolus 39.6 years who were treated with leg. Ankle equinus contracture with directly anterior in the tibial crest fixed ankle joint distraction. Four a positive Silfverskiöld test is treated using a 4.8-mm drill bit. The pin is patients (24%) required ankle fusion with a gastrocnemius Strayer or placed perpendicular to the shaft within 1 year postoperatively Vulpius recession through a postero- of the tibia and secured to the because of the recurrence of severe medial or direct posterior surgical ring with a three-hole cube. Before
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Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes
Figure 3
Preoperative AP (A) and lateral (B) standing radiographs of the ankle joint in a 62-year-old woman who sustained a closed right distal tibia fracture in a skiing accident. Note the decreased joint space, subchondral sclerosis, cysts, and anterior ankle osteophytes. Lateral translation, recurvatum, and anterior subluxation of the talus also are evident. Supramalleolar osteotomy was performed to correct extremity malalignment, and ankle distraction arthroplasty was done in conjunction with arthrotomy, excision of tibiotalar osteophytes, microfracture of the talar dome and tibial plafond, and gastrocnemius-soleus complex recession. C, Intraoperative fluoroscopic image demonstrating bone marrow aspirate injection into the ankle joint. D, Clinical photograph of the lower extremity after frame application. Note the additional ring and struts used to correct supramalleolar malalignment. Lateral (E) and AP (F) radiographs of the ankle joint at 6 months postoperatively. Reduction of the tibiotalar joint and restoration of coronal and sagittal alignment have been achieved. Joint space is increased on weight-bearing radiographs. Clinical examination demonstrated 10° of dorsiflexion and 25° of plantar flexion. (Copyright Mitchell Bernstein, MD, FRCSC, Chicago, IL.) final tightening, intraoperative fluo- the axis of the tibial shaft. Universal of the lateral malleolus and exiting at roscopy is used to confirm that the hinges are then applied in line with a the tip of the medial malleolus, in a ring is positioned perpendicular to Kirschner wire, inserted from the tip posterolateral-to-anteromedial
8 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Mitchell Bernstein, MD, FRCSC, et al
18 direction (Figure 4). This approx- the use of the frame in distraction for Figure 4 imates the Inman axis. A footplate is at least 8 weeks, and no added secured 1 inch proximal and parallel benefit has been seen beyond 12 to the plantar aspect of the foot. A weeks.8,31 We prefer to use the frame locking rod connects the footplate to for 12 weeks. the proximal adjustable ring, which In addition to distraction, the allows for gradual dorsiflexion to senior authors (A.T.F., S.R.R.) cur- correct equinus contractures. The rently inject autologous bone mar- ring is unlocked four times daily row aspirate into the ankle joint and for ROM exercises (15 repetitions/ routinely affect microfracture. session). Typically, the ankle is Although the mechanism of action acutely distracted 3 mm in the of hyaline cartilage regeneration operating room by turning the remains elusive, and clinical data square nuts on the proximal ring. are lacking, we feel that these Acute distraction beyond that is adjunctive procedures may opti- discouraged to avoid neurologic mize the local healing environment. traction injury; acute correction of equinus contracture is avoided for the same reason. Once normal post- Complications operative plantar sensation is con- firmed, an additional 2 mm of The most common complication distraction is usually done on post- associated with ankle distraction ar- AP fluoroscopic image of the ankle operative day 1 and another 1 mm on throplasty is a superficial pin-site demonstrating insertion of a postoperative day 2. At the 2-week infection, which typically resolves Kirschner wire to approximate the clinic visit, another 1 to 2 mm of dis- with a course of oral antibiotics. The Inman axis during application of an ankle distraction frame. The wire is traction is done. Fluoroscopy is used to reported incidence ranges from 14% inserted from the tip of the lateral confirm that a congruent distraction to 100%.10,32,48,50,51,58 Osteomyeli- malleolus aiming toward the distal gap exists on the AP and lateral views. tis that requires hospital admission aspect of the medial malleolus in a Postoperatively, the patient is al- and intravenous antibiotics is less posterolateral-to-anteromedial direction. (Copyright Mitchell lowed full weight bearing as toler- common, with a reported incidence Bernstein, MD, FRCSC, Chicago, IL.) ated, with crutches. The neutral of 1.2% to 5.5%.32,48,51 Pin break- position (ie, ankle dorsiflexion) is age does occur, usually in the mid- marked on the hinge, and the physical foot because of the motion-induced are educated preoperatively and in therapist teaches the patient how to cyclic fatigue of the Kirschner wire. the hospital before discharge regard- unlock the hinge and do active- Likely underreported, the estimated ing the appropriate use of their assisted ROM exercises with a foot incidence is 14% to 24% in two external fixation device. We recom- strap. Once patients are comfortable, studies of 74 patients.51,58 Typically, mend daily pin-site care using a they are encouraged to ambulate with this breakage occurs at the junction solution of 50% normal saline and the frame’s hinge unlocked. Any of the wire connection onto the ring 50% hydrogen peroxide applied with residual distraction beyond what and therefore is rectified by modi- sterile cotton-tipped swabs. To pro- was done in the operating room is fying the connection of the wire- tect the soft tissues, each group of undertaken by the physician in the fixation bolt closer to the skin. pins should be wrapped with 2-inch hospital or 2 weeks later at the first Complications are best avoided cotton gauze. clinical visit. We typically do not with stringent and consistent patient A thorough knowledge of cross- distract .3 mm acutely. Based on a selection, meticulous surgical tech- sectional anatomy in the lower recent biomechanical study, a rela- nique, and close clinical follow-up. extremity is required to avoid inad- tive increase of 5 mm of joint space Patients should be screened at the vertent perforation or incarceration should be obtained relative to the initial clinical visit for the inability to of neurovascular structures. Specifi- preoperative standing radiograph to comply with postoperative regimens. cally, when placing the tibial ring, ensure that the articular surfaces of Educational level, ability to take time the tibialis anterior tendon and the tibial plafond and talar body do off work, living situation, and the anterior neurovascular bundle are at not come in contact during weight availability of supportive family and/ risk of injury. The surgeon should bearing.35 Animal models support or friends are determined. Patients have access to new, sharp 4.8-mm
Month 2016, Vol 0, No 0 9
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes bits to drill pilot holes for the 6-mm composition of the resultant gener- derived mesenchymal cell transplantation. J half pins in each case. This pre- ated tissue is needed. Bone Joint Surg Br 2005;87(5):721-729. caution avoids thermal damage to 9. Marijnissen AC, Hoekstra MC, Pré BC, et al: Patient characteristics as predictors of bone, premature loosening, and pin- clinical outcome of distraction in treatment site infection. The foot ring is applied References of severe ankle osteoarthritis. J Orthop Res with care taken to avoid the medial 2014;32(1):96-101. Evidence-based Medicine: Levels of neurovascular structures. However, 10. Tellisi N, Fragomen AT, Kleinman D, evidence are described in the table of O’Malley MJ, Rozbruch SR: Joint in our experience, patients report contents. In this article, references 1, preservation of the osteoarthritic ankle heel numbness, which can be attrib- using distraction arthroplasty. Foot Ankle 9, 32, and 57 are level I studies. uted to medial calcaneal branch Int 2009;30(4):318-325. Reference 51 and 55 are level II nerve irritation from the crossed 11. Stauffer RN, Chao EY, Brewster RC: Force studies. References 5, 6, 11, and 33 hindfoot wires. These symptoms and motion analysis of the normal, are level III studies. References 2-4, diseased, and prosthetic ankle joint. Clin should not be mistaken for plantar Orthop Relat Res 1977;127:189-196. 7, 10, 17, 18, 24, 34, 37, 39, 40, 44, numbness at the forefoot consistent 46-50, and 53 are level IV studies. 12. Ringleb SI, Udupa JK, Siegler S, et al: The with tibial nerve injury because the effect of ankle ligament damage and References 15, 19, and 38 are level V former should resolve, whereas the surgical reconstructions on the mechanics expert opinion. of the ankle and subtalar joints revealed by latter requires urgent release of dis- three-dimensional stress MRI. J Orthop Res traction and possible tarsal tunnel References printed in bold type are 2005;23(4):743-749. decompression. Posterior tibial those published within the past 5 13. Siegler S, Toy J, Seale D, Pedowitz D: The nerve neurapraxia often occurs with years. Clinical Biomechanics Award 2013 . presented by the International Society of larger, acute distraction ( 5 mm) in 1. Glazebrook M, Daniels T, Younger A, et al: Biomechanics: New observations on the patients with contracted postero- Comparison of health-related quality of life morphology of the talar dome and its medial soft tissues. between patients with end-stage ankle and relationship to ankle kinematics. Clin hip arthrosis. J Bone Joint Surg Am 2008; Biomech (Bristol, Avon) 2014;29(1):1-6. 90(3):499-505. 14. Barnett CH, Napier JR: The axis of rotation 2. Saltzman CL, Salamon ML, Blanchard GM, at the ankle joint in man: Its influence upon Summary et al: Epidemiology of ankle arthritis: Report the form of the talus and the mobility of the of a consecutive series of 639 patients from a fibula. J Anat 1952;86(1):1-9. tertiary orthopaedic center. Iowa Orthop J Ankle distraction arthroplasty is a 2005;25:44-46. 15. Close JR: Some applications of the surgical procedure whereby the functional anatomy of the ankle joint. J 3. Valderrabano V, Horisberger M, Russell I, Bone Joint Surg Am 1956;38(4):761-781. ankle joint is temporarily mechan- Dougall H, Hintermann B: Etiology of ’ ically unloaded with an external ankle osteoarthritis. Clin Orthop Relat Res 16. Inman VT: Inman s Joints of the Ankle,ed 2009;467(7):1800-1806. 2. Baltimore, MD, William and Wilkins, fixator and is performed in con- 1991. 4. Brown TD, Johnston RC, Saltzman CL, junction with osteophyte removal, 17. Hintermann B, Valderrabano V, Marsh JL, Buckwalter JA: Posttraumatic microfracture, soft-tissue release, Dereymaeker G, Dick W: The HINTEGRA osteoarthritis: A first estimate of incidence, ankle: Rationale and short-term results of and deformity correction, if neces- prevalence, and burden of disease. J Orthop 122 consecutive ankles. Clin Orthop Relat Trauma 2006;20(10):739-744. sary. Although robust clinical evi- Res 2004;424:57-68. dence is lacking, studies using 5. Thomas R, Daniels TR, Parker K: Gait 18. Inda DA, Blyakher A, O’Malley MJ, analysis and functional outcomes following animal models support the theory Rozbruch SR: Distraction arthroplasty for ankle arthrodesis for isolated ankle the ankle using the Ilizarov frame. Tech that the addition of mechanical un- arthritis. J Bone Joint Surg Am 2006;88(3): Foot Ankle Surg 2003;2(4)249-253. loading and alignment correction 526-535. 19. Rozbruch SR: Posttraumatic reconstruction improves the inherent ability of 6. Brunner S, Barg A, Knupp M, et al: The of the ankle using the Ilizarov method. HSS Scandinavian total ankle replacement: human cartilage repair to occur. J 2005;1(1):68-88. The goals of the procedure are to Long-term, eleven to fifteen-year, survivorship analysis of the prosthesis in 20. Millward-Sadler SJ, Salter DM: Integrin- provide pain relief, preserve seventy-two consecutive patients. J Bone dependent signal cascades in chondrocyte motion, and to generate hyaline Joint Surg Am 2013;95(8):711-718. mechanotransduction. Ann Biomed Eng 2004;32(3):435-446. cartilage or a durable hyaline-like 7. Wiegant K, van Roermund PM, Intema F, cartilaginous substance. Although et al: Sustained clinical and structural 21. Pulai JI, Chen H, Im HJ, et al: NF-kappa B benefit after joint distraction in the mediates the stimulation of cytokine and clinical studies have demonstrated treatment of severe knee osteoarthritis. chemokine expression by human articular good short- to intermediate-term Osteoarthritis Cartilage 2013;21(11): chondrocytes in response to fibronectin clinical outcomes, the mechanisms 1660-1667. fragments. J Immunol 2005;174(9): 5781-5788. for success and failure remain 8. Yanai T, Ishii T, Chang F, Ochiai N: Repair of large full-thickness articular cartilage 22. Mow VC, Wang CC, Hung CT: The unknown. Further clinical research defects in the rabbit: The effects of joint extracellular matrix, interstitial fluid and on this procedure and the histologic distraction and autologous bone-marrow- ions as a mechanical signal transducer in
10 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Mitchell Bernstein, MD, FRCSC, et al
articular cartilage. Osteoarthritis Cartilage 35. Fragomen AT, McCoy TH, Meyers KN, 47. Ploegmakers JJ, van Roermund PM, van 1999;7(1):41-58. Rozbruch SR: Minimum distraction gap: Melkebeek J, et al: Prolonged clinical benefit How much ankle joint space is enough in from joint distraction in the treatment of ’ 23. McKinley TO, Borrelli J Jr, D Lima DD, ankle distraction arthroplasty? HSS J 2014; ankle osteoarthritis. Osteoarthritis Cartilage Furman BD, Giannoudis PV: Basic science 10(1):6-12. 2005;13(7):582-588. of intra-articular fractures and posttraumatic osteoarthritis. J Orthop 36. Judet R, Judet T: The use of a hinge 48. Paley D, Lamm BM, Purohit RM, Specht SC: Trauma 2010;24(9):567-570. distraction apparatus after arthrolysis and Distraction arthroplasty of the ankle: How arthroplasty (author’s transl) [French]. Rev far can you stretch the indications? Foot 24. Haller JM, McFadden M, Kubiak EN, Chir Orthop Reparatrice Appar Mot 1978; Ankle Clin 2008;13(3):471-484, ix. 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Month 2016, Vol 0, No 0 11
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.