The Journal of Foot & Ankle Surgery 59 (2020) 1019−1031 Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org ACFAS Clinical Consensus Statement Consensus Statement of the American College of Foot and Ankle Surgeons: Diagnosis and Treatment of Ankle Arthritis Naohiro Shibuya, DPM, MS, FACFAS1, Jeffery E. McAlister, DPM, FACFAS2, Mark A. Prissel, DPM, FACFAS3, Jason A. Piraino, DPM, MS, FACFAS4, Robert M. Joseph, DPM, PhD, FACFAS5, Michael H. Theodoulou, DPM, FACFAS6, Daniel C. Jupiter, PhD7 1 Professor, College of Medicine, Texas A&M University, Temple, TX 2 Podiatrist, Arcadia Orthopedics and Sports Medicine, Phoenix, AZ 3 Faculty, Advanced Foot and Ankle Reconstruction Fellowship Program, Orthopedic Foot and Ankle Center, Worthington, OH 4 Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, University of Florida Health, Gainesville, FL 5 Chairman, Department of Podiatric Medicine & Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University, North Chicago, IL 6 Chief, Division of Podiatric Surgery, Cambridge Health Alliance, Instructor of Surgery, Harvard Medical School, Cambridge, MA 7 Associate Professor, Department of Preventive Medicine and Community, Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX Executive Summary S15: Open arthrodesis is a viable option for treatment of ankle arthritis. The American College of Foot and Ankle Surgeons has developed a S16: Arthroscopic arthrodesis is a viable option for treatment of consensus statement on diagnosis and treatment of ankle arthritis. A ankle arthritis. modified Delphi method was sed in an attempt to develop consensus S17: Total ankle arthroplasty is a viable option for treatment of on a series of 18 statements using the best available evidence, clinical ankle arthritis. experience, and educated judgment. S18: Amputation may be a viable option for the treatment of com- The panel reached consensus that the following statements were plex ankle issues when previous salvage attempts have failed. “ ” appropriate : The panel did not find any of the statements “inappropriate.” S1: It is clinically relevant to determine causes and types of ankle The panel did not find any of the statements “neither appropriate arthritis. nor inappropriate.” S2: Assessment of instability and alignment are important in the The panel was unable to reach consensus on the following state- management of ankle arthritis. ments: S3: Plain weightbearing x-ray images of the ankle should be exam- S6: Physical therapy may be a useful option for treatment of ankle ined before the use of advanced imaging. arthritis. S4: Advanced imaging such as an magnetic resonance imaging or S8: Cast immobilization is a viable option for treatment of ankle computerized tomography scans is useful for working up a arthritis. patient with ankle arthritis. S10: Intra-articular nonsteroidal injection is a viable option for S5: A multimodal approach is important for pharmacological man- treatment of ankle arthritis. agement of painful ankle arthritis. S12: Resurfacing articular surfaces with biologics/scaffolds is a via- S7: Bracing with an ankle/foot orthosis is an effective conservative ble option for treatment of ankle arthritis. treatment option for ankle arthritis. S13: Arthroscopic debridement is a viable option for treatment of S9: Intra-articular corticosteroid injection is a viable option for ankle arthritis. treatment of ankle arthritis. S14: Arthrodiastasis is a viable option for treatment of early ankle S11: Periarticular ankle realignment osteotomy may relieve the arthritis. symptoms of ankle arthritis. Clinical consensus statements (CCSs) reflect information synthe- sized by an organized group of experts based on the best available evi- Financial Disclosure: None reported. dence, expert opinions, and to some degree, uncertainties and minority Conflict of Interest: None reported. viewpoints. A CCS is not meant to establish clinical practice guidelines, Address correspondence to: Dr. Naohiro Shibuya, Texas A&M University, College of systematic evidence reviews, or recommendations. A CCS should assist Medicine, Health Science Center, 1901 Veterans Memorial Dr., Temple, TX 76502, United States. in promoting discussion on relevant topics, as opposed to providing E-mail address: [email protected] (N. Shibuya). definitive answers. Adherence to consensus statements will not ensure 1067-2516/$ - see front matter Published by Elsevier Inc. on behalf of the American College of Foot and Ankle Surgeons. https://doi.org/10.1053/j.jfas.2019.10.007 1020 N. Shibuya et al. / The Journal of Foot & Ankle Surgery 59 (2020) 1019−1031 successful treatment in every clinical situation, and individual clinicians better physical function (11). Most ankle arthritis (65% to 80%) is post- should make decisions based on all available clinical information and traumatic in nature (3,9,12), compared with <10% and <2% of knee and circumstances. hip arthritis, respectively (13). Therefore, those with ankle OA are typi- This CCS focuses on the general topic of diagnosis and treatment of cally younger than those with knee or hip arthritis (11,14), and this ankle arthritis, with the aim of addressing controversies in treatment may necessitate surgery earlier in life (15). options. Although the statements apply to many types of ankle arthriti- Although 37% to 53% of advanced or end-stage ankle OA patients des, our focus is mostly on noninflammatory arthritis, including pri- have had malleolar fractures (9,10,16), fracture of any rearfoot bones, mary and posttraumatic arthritis, unless specified in a given section of as well as sprains and lateral ankle ligament instability (17,18), can lead the CCS. to OA of the ankle. Deformity of the lower extremity often accompanies posttraumatic ankle OA, and therefore, the biomechanics of the joint Methods can be altered (9,19,20). Thus, being aware of the mechanism of injury and making assessments of surrounding osseous and soft tissue struc- A 7-member panel consisting of 6 foot and ankle surgeons and a biostatistician, who are all familiar with the topic of ankle arthritis, participated in 1 face-to-face meeting, tures other than the ankle itself are also important in clinical manage- several email dialogs, and 3 conference calls. The panel was tasked with developing a ment of ankle OA. Additionally, knowing whether the traumatic cause series of CCSs on the topic of ankle arthritis that may be controversial or misunderstood. is recent or distant can help in planning the course of treatment. It may Using our collective clinical experience during a face-to-face open discussion, we devel- also be important to determine what treatment was used previously. If oped a preliminary list of 25 specific statements covering the diagnosis and treatment of ankle arthritis. A preliminary literature search using Medline, EMBASE, Cochrane, and the treatment was conservative, the type and duration of the treatment CINAHL databases was conducted to assess availability of published research on each should be determined. If the past treatment was surgical, then what statement. Based on the results of these preliminary searches, some of the initial state- specifically was done and what, if any, complications occurred should fi ments were combined. A nal list of 18 of the original 25 statement/questions was be determined. retained for further discussion. A history of open fracture, which has a high risk of infection (21), or Consensus an open wound and/or surgical intervention should be reviewed thor- oughly with the patient. In addition, identifying whether the patient has any underlying medical issues such as neuropathy, vasculopathy, or A modified Delphi method was used to attain consensus among the a chronic pain syndrome is important to avoid short-term complica- members of the panel, who were asked to review and anonymously tions, such as infection and wound-healing complications, or ongoing rate the appropriateness of each statement. Rating was graded from 1 pain, if surgical intervention is indicated. (extremely inappropriate) to 9 (extremely appropriate) on a Likert scale Nontraumatic underlying deformity itself can cause arthritic (1). The results were summarized with basic descriptive statistics, changes in the ankle. Underlying causative long-term deformities such including an average, distribution of the scores, and outliers. The results as flat and cavus feet, for example, can cause arthritic changes in the were kept anonymous, and summary results were distributed back to ankle and often influence the surgical treatment plan. Observing mis- the panel members. After open discussion of these results, the state- alignment of the ankle or surrounding structures in motion and stand- ments were distributed for a second anonymous review by the same ing not only helps in clinical planning, but may also point to the cause panel members, and the answers were again analyzed using the same of the ankle arthritis (22). method. The new results were grouped from 1 to 3 (inappropriate), 4 to BMI is associated with OA, and it is also associated with a greater 6 (neither inappropriate nor appropriate), and 7 to 9 (appropriate). number of complications after total ankle arthroplasty (TAA) and ankle Although an attempt was made to reach consensus for all questions, it arthrodesis (AA) (23). A higher BMI exacerbates the already higher rates was not a requirement, and contrary opinions