Abstract
Background: Ankle arthrodesis is considered
by many to be the standard operative treatment for end-stage ankle arthritis;
however, the long-term effect of ankle arthrodesis on other lower-extremity
joints remains largely unknown. The purpose of this study was to perform
a clinical and radiographic review to determine the effect of ankle
arthrodesis on the development of osteoarthritis in other lower-extremity joints.
Methods: Twenty-three patients who had had an isolated ankle
arthrodesis for the treatment of painful post-traumatic arthritis
of the ankle were followed for a mean of twenty-two years (range,
twelve to forty-four years) after the operation. Each completed standardized,
self-reported outcome questionnaires (the Foot Function Index, Western
Ontario and McMaster University Osteoarthritis Index [WOMAC], and
Short Form-36 [SF-36]), was examined clinically by two of the investigators,
and underwent complete radiographic examination of the knee, ankle,
and foot bilaterally. The radiographic grade of osteoarthritis was
determined for each joint, and the levels of overall activity limitation,
pain, and disability were determined for each patient from the clinical
findings and questionnaire information.
Results: Osteoarthritis of the ipsilateral subtalar
(p < 0.0001), talonavicular (p < 0.0001), calcaneocuboid (p < 0.0001),
naviculocuneiform (p = 0.0012), tarsometatarsal (p = 0.0009), and
first metatarsophalangeal joints (p = 0.0012) was consistently more severe
than the osteoarthritis of those joints on the contralateral side.
Osteoarthritis did not develop more frequently in the ipsilateral
knee or lesser metatarsophalangeal joints than it did on the contralateral
side. Significant differences between the two sides were found with
regard to overall activity limitation (p < 0.0001), pain (p < 0.0001),
and disability (p < 0.0001), with the involved side consistently
more symptomatic.
Conclusions: To our knowledge, the present series
represents the longest follow-up study of ankle arthrodesis to date. Our
cohort of patients all had isolated post-traumatic ankle arthritis,
and each underwent a successful isolated ankle arthrodesis. At a
mean of twenty-two years, the majority of the patients had substantial,
and accelerated, arthritic changes in the ipsilateral foot but not
the knee. They were often limited functionally by foot pain. Although
ankle arthrodesis may provide good early relief of pain, it is associated
with premature deterioration of other joints of the foot and eventual
arthritis, pain, and dysfunction.
Symptomatic osteoarthritis of the ankle is a difficult clinical
problem. Treatment options include the use of walking aids, orthotic
devices, intra-articular steroids, open rather than arthroscopic
d�bridement, periarticular osteotomy, and arthroplasty-all of which
have provided inconsistent relief. Although ankle arthroplasty has
been used to treat such patients, variable results have been reported and
the traditional operative treatment for ankle osteoarthritis has
been tibiotalar arthrodesis1-3.
However, little has been reported on the long-term effects of ankle
arthrodesis on other lower-extremity joints. It is clear that arthrodesis
of other major lower-extremity joints is associated with painful, premature
degenerative arthritis of contiguous joints4,5.
The lack of knowledge of the long-term effects of ankle arthrodesis
limits the ability of physicians to counsel their patients appropriately
when they are faced with the decision of whether to undergo this procedure.
Many reports have suggested that ankle arthrodesis reliably provides
a painless, plantigrade, stable foot. Since 1879, when Albert first
described arthrodesis of the ankle6,
more than thirty different techniques have been described. In series
ranging in size from twelve to 101 patients, rates of successful
primary fusion of 80% to 100% have been reported7-14.
Similarly, in series ranging in size from five to sixty-two patients,
pain relief has generally followed fusion, with reported rates of
substantial pain relief ranging from 80% to 100% after successful fusion8,11,12,15-18. However, reports based
on a mean duration of follow-up of eight to twelve years have shown
that some patients eventually become limited by pain and degenerative
changes elsewhere in the foot7,10,12.
We could not find information on the longer-term results of arthrodesis
with respect to the likelihood of the development of pain, functional
limitation, and degenerative changes in other joints of the ipsilateral
foot and knee.
We performed this retrospective clinical and radiographic review
to assess the clinical outcomes of ankle arthrodesis over a long
period of time. We performed a radiographic assessment of the degree of
osteoarthritis of other joints (foot and knee) of both extremities
to determine its influence, if any, on the patient's overall activity
level, pain, and disability.
The present study was performed with approval of our institution's
Human Subjects Review Board, and all participants signed an approved
informed-consent form.
A manual search through medical records revealed 447 patients
who had undergone any type of arthrodesis between January 1951 and
December 1966 at our institution. A computer-generated search identified
an additional 150 patients who had undergone a foot arthrodesis
or an ankle arthrodesis, or both, between January 1967 and December
1978, and 142 patients who had undergone an ankle arthrodesis during
the period between January 1979 and May 1997. These 739 charts were
reviewed to identify patients who had undergone an isolated tibiotalar
arthrodesis for the treatment of post-traumatic or primary ankle
osteoarthritis more than ten years prior to 1997. Exclusion criteria
included another arthrodesis of the midfoot or hindfoot, rheumatoid arthritis,
poliomyelitis, congenital deformity, and a Charcot joint. Fifty-five
patients treated at our institution who met the criteria were included
in the study. An additional nine patients who met the same criteria
were identified and included after a computer-generated search from
the local community hospital, Mercy Hospital of Iowa City.
Patients were located through medical-record identification information
and the state Department of Motor Vehicles registry, and by contract
with a private search service (Choice Point, McLean, Virginia).
Of the sixty-four available patients, forty-eight (75%) were located
and sixteen were lost to follow-up. Of the forty-eight patients,
thirteen had died, four had had a below-the-knee amputation because
of intractable infection related to the arthrodesis and other procedures,
two had had an additional midfoot arthrodesis, five declined to participate,
and one completed the questionnaires but would not return for radiographic
or clinical evaluation. The remaining twenty-three patients (eleven
men and twelve women), all of whom had had a diagnosis of post-traumatic
osteoarthritis at the time of the arthrodesis and none of whom were known
to have arthritis of other foot joints, were included in the study.
The mean age at the time of the operation was forty-one years (range,
twelve to seventy years), and the mean age at the time of the latest
follow-up examination was sixty-four years (range, thirty-eight
to eighty-nine years). The mean duration of follow-up was twenty-two
years (range, twelve to forty-four years). Information on surgical technique
and postoperative immobilization was obtained from the charts.
Preoperatively, the etiology of the ankle arthritis in all of
the patients was considered to be post-traumatic. The mechanisms
of injury included a fall from a height (ten patients), an automobile
accident (six), a motorcycle accident (two), chronic recurrent ankle
sprain (two), a lawn-mower injury (one), an auger injury (one),
and a tractor rollover (one).
The mean time from the injury to the arthrodesis was thirty-one
months (range, one to ninety-six months). Information on the findings
of physical examination prior to the ankle arthrodesis was varied.
A limited range of motion of the ankle was noted in fourteen patients.
Subtalar motion was reported to be good in four patients and decreased in
five patients.
Of the twenty-three patients who had a comprehensive examination
at the time of the latest follow-up, eleven had had internal fixation
and twelve had had external fixation. Of those with external fixation, five
had the Charnley type and seven had pins placed through the calcaneus.
In terms of postoperative management, the mean time to weight-bearing was
eight and one-half weeks (range, two to sixteen weeks) and the mean
duration of immobilization was four and one-half months (range,
one and one-half to eleven months).
Clinical Evaluation
At the time of the latest follow-up, all subjects were personally
interviewed about pain and overall function of the lower extremities
and they had a complete physical examination of the lower extremities bilaterally
to determine gait; knee and hindfoot alignment; range of motion
of the knees, ankles, and subtalar joints; neurovascular status;
and presence or absence of tenderness and swelling. Two reviewers
assessed each patient clinically. The contralateral extremity was
used as a control.
Self-Reported Questionnaires
Twenty-four patients completed a Foot Function Index and a slightly
shortened version of the Hip and Knee Registry Preoperative Patient
Form. They also completed a slightly shortened version of the Hip
and Knee Registry Postoperative Patient Form, answering all questions
with regard to the "Patient Self-Assessment of Medical Conditions"
and filling out the SF-36 health survey. In addition, they completed
a full Western Ontario and McMaster University Osteoarthritis Index
(WOMAC); however, the questions referring to the hips were eliminated. The
patients answered all general questions except the last two, which
concerned the status of the hip or knee at that time compared with
the status at the last time that the patient filled out the form,
and the patient's level of satisfaction with the joint replacement.
The Foot Function Index is a validated and reliable visual analog
scale for measuring activity limitation, pain, and disability19,20. The Hip and Knee Registry Preoperative
Patient Form shares components with the WOMAC and the SF-36. The
WOMAC is a disease-specific, health-related, quality-of-life measure.
The scale was designed to be used in clinical trials for assessing patients
with osteoarthritis of the hips and knees21. The SF-36 is a generic
health profile. Derived from the Rand Health Insurance long form,
it measures health in seven dimensions (physical functioning, role
limitations, social functioning, bodily pain, mental health, vitality,
and general health perceptions). Its test-retest reliability, internal
consistency, responsiveness, construct validity, discriminant validity,
and convergent validity have all been supported21.
These instruments were utilized to determine each respondent's activity
limitations, pain, and disability, and the interaction of each of
these factors with the radiographic and clinical findings. Three
additional questions were posed to the subjects about their overall
satisfaction with the results of the operation.
Radiographic Examination
Radiographs made at the time of the arthrodesis were available
for only one patient (Fig. 1-AFigs. 1-A, Fig. 1-B, Fig. 1-C, Fig. 1-D, Fig. 1-E, Fig. 1-F, Fig. 1-G, Fig. 1-H, Fig. 1-I, and Fig. 1-J). However,
the records of fourteen patients had a description of radiographic
findings of ankle osteoarthritis and either no mention of the other joints
(twelve patients) or specific mention that other joints had no radiographic
evidence of osteoarthritis (two patients). Three patients had evidence
of osteonecrosis of the talus as well as degenerative joint disease
of the ankle on preoperative radiographs.
At the time of the latest follow-up, the patients underwent a
comprehensive radiographic examination that included (1) bilateral
standing anteroposterior radiographs of the foot, (2) bilateral
standing mortise radiographs of the ankle, (3) bilateral standing
lateral radiographs of the foot and ankle, (4) bilateral standing
anteroposterior radiographs of the knee, (5) bilateral standing
lateral radiographs of the knee, (6) bilateral standing hindfoot
alignment radiographs, and (7) bilateral Broden radiographs22. One patient agreed to only two
radiographs (a lateral standing radiograph of the foot and ankle
and a hindfoot alignment radiograph, both on the ipsilateral side).
Two reviewers measured the position of the fusion and graded the
osteoarthritis seen on each radiograph according to the system of Kellgren
and Moore23 (Table ITable I). These
measurements were performed simultaneously, and consensus was obtained
for each one. We separately evaluated and graded the degenerative
changes in the patellofemoral, medial knee, lateral knee, subtalar,
talonavicular, calcaneocuboid, naviculocuneiform, tarsometatarsal,
first metatarsophalangeal, and lesser metatarsophalangeal joints.
Some of the radiographs did not demonstrate a joint well enough
to be graded: the calcaneocuboid joint could not be seen well enough
on the radiographs of two patients; the naviculocuneiform joint,
on the radiographs of two; the first metatarsophalangeal joint,
on the radiographs of two; one of the tarsometatarsal joints, on
the radiographs of one; and the lesser metatarsophalangeal joints,
on the radiographs of two.
On the standing lateral radiographs of the ankle and the foot,
we determined the tibiotalar angle (the angle subtended by the longitudinal
axes of the tibia and the talus) and the tibiotalar translation (anterior
translation of the head of the talus in front of the anterior border
of the tibia). On the hindfoot alignment radiographs, we measured
the tibiocalcaneal angle (the angle subtended by the longitudinal axes
of the tibia and the calcaneus) and the calcaneal-tibial displacement
(the distance between the central longitudinal axis of the tibia
and the inferior surface of the calcaneus as previously described)22.
Statistical Analysis
Before we performed the study, a power analysis was done to determine
adequate sample size. The presence of radiographically proven subtalar
arthritis (grade 4 or 5, according to the system of Kellgren and
Moore) was considered the primary outcome variable. With use of
a one-tailed McNemar chi-square test with the level of significance
at 0.05 with 90% power, and assuming a difference in the prevalence
of subtalar osteoarthritis consisting of 50% on the affected side
compared with 5% on the nonaffected side, a sample size of twenty
subjects was determined to be sufficient.
Paired t tests and one-tailed McNemar chi-square tests comparing
the results on the ipsilateral side with those on the control, contralateral
side were used to determine the significance of the findings. Spearman
and Kendall-tau-b correlation coefficients were used to determine
significant relationships between variables. A p value of less than
0.05 was considered significant.
Findings on Clinical Examination
Most (twenty-two [96%]) of the twenty-three patients had a slight-to-moderate
limp. Clinical hindfoot alignment on the ipsilateral side varied: nine
patients (39%) had varus alignment, eight (35%) had valgus alignment,
and six (26%) had neutral alignment. Alignment of the contralateral hindfoot
was neutral in twenty-one patients (91%) and valgus in two. The
ranges of motion of ipsilateral and contralateral knees were comparable.
Most (twenty [87%]) of the patients had full and painless motion
of the uninvolved ankle. The ipsilateral subtalar range of motion
was decreased in every patient, with no motion in nine (39%), 10%
to 50% of the range of motion on the contralateral side in thirteen
(57%), and 70% of the motion on the contralateral side in one patient.
All patients had intact neurovascular function. Eleven patients
(48%) had tenderness and swelling in the hindfoot and nine (39%),
in the midfoot.
The majority (fifteen [65%]) of the patients did not use any
supports for walking. Six patients (26%) used a cane, and two (9%)
used a walker or assistance from another person for support.
Questionnaire Results
There was more severe overall activity limitation on the ipsilateral
side than on the contralateral side (mean, 27 compared with 10 points;
p < 0.0001). There was also more overall foot pain (mean, 38 compared
with 11 points; p < 0.0001) and more overall foot disability
(mean, 47 compared with 15 points; p < 0.0001) (Table IITable II).
Self-reported responses to direct queries from the examiner about
pain in the subtalar and midfoot regions revealed significantly
more pain on the ipsilateral side than on the contralateral side
(p = 0.0002).
As the degree of dependence on walking aids increased, the overall
activity limitation (r = 0.66, p = 0.0004), foot pain (r = 0.57,
p = 0.004), and foot disability (r = 0.70, p = 0.0002) all increased.
Pain did not differ significantly between the ipsilateral and
the contralateral knee. The ratings on the WOMAC osteoarthritis
scale provided by twenty-four patients indicated that sixteen (67%)
had difficulty climbing stairs and twelve (50%) had difficulty standing
upright because of the knee. The patients who reported that the
knee caused difficulty with stair-climbing and standing also tended to
have more foot problems. As the difficulty with stair-climbing increased,
the overall activity limitation (r = 0.57, p = 0.004), foot pain
(r = 0.49, p = 0.01), and foot disability (r = 0.65, p = 0.001)
also increased. As the subjects' reported difficulty with standing
upright increased, the overall activity limitation (r = 0.51, p
= 0.01), foot pain (r = 0.67, p = 0.0004), and foot disability (r
= 0.72, p < 0.0001) increased as well.
The SF-36 results for the twenty-four patients revealed that
most of them were limited secondary to their general health perceptions
with regard to their participation in vigorous activities (twenty-three
patients [96%]) and walking more than 1 mile (1.6 km) (twenty patients
[83%]). The findings on the SF-36 correlated with those on the Foot
Function Index. As patients became more limited with regard to their
participation in vigorous activities, their scores for overall activity
limitation (r = 0.60, p = 0.002) and foot disability (r = 0.54,
p = 0.007) increased. Similarly, as patients became more limited
with regard to their ability to walk more than 1 mile, their scores
for overall activity limitation (r = 0.56, p = 0.004) and foot disability
(r = 0.56, p = 0.004) increased.
Three additional questions, with regard to overall satisfaction
with the outcome of the operation, were posed to the subjects. The
answers revealed that sixteen (67%) of the twenty-four patients
were happy with the overall outcome of the ankle arthrodesis, twenty-one
(88%) said that they would have the ankle arthrodesis again under
the same circumstances, and twenty-two (92%) stated that they would
recommend an ankle arthrodesis to a friend who had the same degree
of arthritis and symptoms in the ankle as they had had prior to
the operation.
Radiographic Findings
The radiographic grade of osteoarthritis, according to the system
of Kellgren and Moore23, was consistently
higher for each joint of the ipsilateral foot than it was for the
same joint of the contralateral foot (Table IITable II). Additionally, the numbers
of subjects with moderate or severe osteoarthritis (as opposed to
doubtful or minimal arthritis) of the joints of the ipsilateral
foot were consistently greater than the numbers with such involvement
of the joints of the contralateral foot (Table IIITable III).
The subtalar, calcaneocuboid, talonavicular, tarsometatarsal, naviculocuneiform,
and first metatarsophalangeal joints on the ipsilateral side all revealed
a significantly increased level of osteoarthritis compared with
those joints on the contralateral side (p < 0.01). There was
no difference with respect to the level of osteoarthritis between
the lesser metatarsophalangeal, lateral knee, medial knee, and patellofemoral
joints on the ipsilateral side and those joints on the contralateral
side.
The joints in the ipsilateral extremity that were significantly
more degenerated included, in rank order from the most involved
to the least involved, the subtalar (p < 0.0001), talonavicular
(p < 0.0001), tarsometatarsal (p = 0.0009), naviculocuneiform
(p = 0.0012), calcaneocuboid (p < 0.0001), and first metatarsophalangeal
joints (p = 0.0012) (Table IITable II). On the involved side,
twenty-one of twenty-three subtalar, thirteen of twenty-three talonavicular,
five of twenty-one calcaneocuboid, seven of twenty-one naviculocuneiform,
nine of twenty-two tarsometatarsal, and seven of twenty-one first
metatarsophalangeal joints had moderate or severe osteoarthritis (Table IIITable III).
The prevalence of moderate or severe osteoarthritis of the subtalar
joint was not found to be higher for the patients who had had external
fixation placed across the subtalar joint than it was for those who
had not had such fixation.
The mean and median tibiotalar angles on the fused side, measured
on a standing lateral radiograph of the foot and ankle, were both
114° (range, 98° to 141°), while the mean and median tibiotalar
angle on the contralateral side were both 110° (range, 96° to 131°);
the difference was significant (p = 0.007). The mean and median
tibiotalar translations (anterior displacement of the talus under
the tibia), measured on a standing lateral radiograph, were 25 and 24
mm (range, 11 to 43 mm), respectively, on the ipsilateral side,
which were not significantly different from the mean and median
translations of 21 mm each (range, 13 to 27 mm) on the contralateral side.
The mean calcaneal-tibial displacement, measured on the hindfoot
alignment radiograph, was -1.5 mm (medially displaced 1.5 mm), with
a range of -28 mm (medially displaced) to +52 mm (laterally displaced),
on the ipsilateral side, and +0.5 mm (laterally displaced), with
a range of -14 (medially displaced) to +21 mm (laterally displaced),
on the contralateral side; the difference was not significant. Likewise,
the mean calcaneotibial angle on the hindfoot alignment radiograph
was 1º of valgus (range, 23º of varus to 26º of valgus) on the ipsilateral
side and 7º of valgus (range, 10º of varus to 22º of valgus) on
the contralateral side; the difference was not significant.
Correlations Between Foot Function Index and Kellgren
Radiographic Scores
The separate subsections of the Foot Function Index were used
to determine whether each domain was associated with the radiographic
findings. Activity limitation on the ipsilateral side correlated significantly
with the Kellgren grade of the ipsilateral talonavicular (r = 0.79,
p £ 0.0001), tarsometatarsal (r = 0.66, p = 0.0008), naviculocuneiform
(r = 0.47, p = 0.029), calcaneocuboid (r = 0.47, p = 0.03), and
patellofemoral (r = 0.46, p = 0.03) joints. Foot disability on the
ipsilateral side correlated significantly with the Kellgren grade
of the ipsilateral talonavicular (r = 0.59, p = 0.001) and tarsometatarsal
(r = 0.49, p = 0.02) joints. Foot pain on the ipsilateral side was
not significantly correlated with the Kellgren scores.
The patients in the current study all had isolated post-traumatic
arthritis of the ankle treated with an isolated ankle arthrodesis.
The relatively frequent occurrence of osteoarthritis in the foot
joints on the ispsilateral side but not on the contralateral side suggests
that, at a mean of twenty-two years after ankle arthrodesis, substantial
and accelerated deterioration of other foot joints is common. However, the
etiology of the deterioration is unknown. Our initial power analysis
indicated that this retrospective study of twenty-three patients
had sufficient power to enable us to make this conclusion.
To our knowledge, the present series represents the longest follow-up
study to date on ankle arthrodesis for the treatment of post-traumatic
osteoarthritis. In this study, we found radiographic signs of osteoarthritis
in many of the joints in the involved foot by a mean of twenty-two
years postoperatively. Likewise, overall pain was increased in the
involved foot, and function was limited because of the involved
foot. With the numbers available, these changes appeared to be independent
of operative technique, radiographic alignment, and age at the time
of the operation.
Two patients were excluded from the study because, after the
ankle arthrodesis, they had an arthrodesis of the ipsilateral midfoot.
These two patients presumably had substantial problems with function
and pain in the ipsilateral foot after ankle fusion. The exclusion
of these two patients may have modestly skewed the results in favor
of ankle arthrodesis.
Ankle arthrodeses have been performed for more than a century,
and our study is one of a long series of reports documenting potential
problems with the procedure. Hallock was one of the earliest investigators
to focus on diagnoses of post-traumatic osteoarthritis, and he reported
postoperative evidence of subtalar, cuneonavicular, and talonavicular osteoarthritis
after a mean duration of follow-up of 4.4 years24.
In a 7.5-year follow-up analysis of eighteen patients who predominantly
had post-traumatic osteoarthritis, Said et al. noted that sixteen
of them had stiff subtalar joints14.
Mazur et al., in an eight-year follow-up series of twelve patients,
found radiographic changes of osteoarthritis in the subtalar and
midtarsal joints in all of the patients12.
Five ankles were rated as minimally affected; five, as moderately
involved; and two, as severely affected. However, they also noted
that radiographic changes did not strongly correlate with symptoms.
Jackson and Glasgow, in a one to twenty-five-year follow-up study
of thirty-seven patients, found radiographic degenerative changes in
the tarsal joint of twenty-two patients and a stiff subtalar joint
in all thirty-seven25. In studies
with a mean duration of follow-up of ten years, Morgan et al.13 and Buck et al.10 described
the experience with ankle arthrodesis at the University of Michigan
and the Mayo Clinic, respectively. Morgan et al. reported a good
or excellent result in 90% of the ankles and suggested that the
results had not changed over the period of follow-up13. Buck et al. found that all nineteen
patients in their study had decreased subtalar motion and difficulty with
walking on uneven ground. Eight patients reported pain in the ankle;
nine, in the subtalar joint; and eight, in the midtarsal region;
however, no radiographic analysis of other joints was noted10.
Until the present series, the study with the longest duration
of follow-up was performed by Ahlberg and Henricson7. They evaluated thirty-one patients
with osteoarthritis and rheumatoid arthritis at a mean of 12.3 years.
Pain in the subtalar joint was noted in two-thirds of the patients.
Of the twenty-seven patients who were examined radiographically,
three (11%) had severe osteoarthritis of the subtalar joint; nine (33%),
moderate osteoarthritis of the subtalar joint; fourteen (52%), no
evidence of osteoarthritis of the subtalar joint; and one (4%),
ankylosis of the subtalar joint. Seventy-five percent of the patients needed
special footwear, and 84% had difficulty walking on uneven ground7.
The effects of an ankle arthrodesis on the motion of other major
lower-extremity joints have been studied in the gait-laboratory
setting. Mazur et al.12 and Waters
et al.26 found that ankle arthrodesis
did not appreciably alter hip and knee motion. Gait after an ankle
arthrodesis was thought to be 90% efficient in terms of measured
oxygen consumption26. While wearing
shoes, patients who had had an ankle arthrodesis showed excellent
gait characteristics, with lost ankle motion compensated for by ipsilateral
small-joint motion and altered motion within the foot on the contralateral
side12.
The increased stresses and functional demands placed on the joints
of the ipsilateral foot, secondary to the fused ankle, may result
in increased motion and abnormal chronic loading of other joints
of the foot, ultimately leading to the development of osteoarthritis.
Similar findings have been reported in association with other major
lower-extremity arthrodesis procedures4,5,26.
However, prolonged immobilization can also be implicated in the
etiology of the degeneration seen in ipsilateral foot joints. Similarly,
with the design of this retrospective study, we could not completely exclude
the possibility that the patients had sustained an injury to other
joints of the ipsilateral foot at the time of the initial injury
and that the resulting arthritic changes were inevitable, regardless
of the status of ankle motion.
Ankle arthrodesis continues to be a standard operative treatment
of severe post-traumatic ankle osteoarthritis. However, when counseling
patients with regard to the potential long-term effects and trade-offs
of ankle arthrodesis, it should be explained that if the patient
lives long enough he or she can expect the development of symptomatic osteoarthritis
in the other joints of the foot. Patients, and treating physicians,
should also expect overall pain and functional limitations to increase
over time. However, patients should be informed that most subjects
in our cohort who had this procedure were satisfied with the overall
outcome of the ankle arthrodesis, would choose the same treatment again,
and would recommend it to another patient in a similar situation.
Helm R, and Stevens J: Long-term results of total ankle replacement. J Arthroplasty,1986.1: 271-7, 1271
1986
[PubMed]
Kofoed H, and Lundberg-Jensen A: Ankle arthroplasty in patients younger and older than
50 years: a prospective series with long-term follow-up. Foot Ankle Int,1999.20: 501-6, 20501
1999
[PubMed]
Saltzman CL : Total ankle arthroplasty: state of the art. Instr Course Lect,1999.48: 263-8, 48263
1999
[PubMed]
Callaghan JJ; Brand RA; and Pedersen DR: Hip arthrodesis. A long-term follow-up. J Bone Joint Surg Am,1985.67: 1328-35, 671328
1985
[PubMed]
Sponseller PD; McBeath AA; and Perpich M: Hip arthrodesis in young patients. A long-term follow-up
study. J Bone Joint Surg Am,1984.66: 853-9, 66853
1984
[PubMed]
Albert E: Zur Resektion des Kniegelenkes. Wien Med. Press,1879.20: 705-8, 20705
1879
Ahlberg A, and Henricson AS: Late results of ankle fusion. Acta Orthop Scand ,1981.52: 103-5, 52103
1981
[PubMed]
Bishop AT; Wood MB; and Sheetz KK: Arthrodesis of the ankle with a free vascularized autogenous
bone graft. Reconstruction of segmental loss of bone secondary to
osteomyelitis, tumor, or trauma. J Bone Joint Surg Am.,1995.77: 1867-75, 771867
1995
[PubMed]
Boobbyer GN: The long-term results of ankle arthrodesis. Acta Orthop Scand,1981.52: 107-10, 52107
1981
[PubMed]
Buck P; Morrey BF; and Chao EYS: The optimum position of arthrodesis of the ankle. A gait
study of the knee and ankle. J Bone Joint Surg Am,1987.69: 1052-62, 691052
1987
[PubMed]
Lynch AF; Bourne RB; and Rorabeck CH: The long-term results of ankle arthrodesis. J Bone Joint Surg Br,1988.70: 113-6, 70113
1988
[PubMed]
Mazur JM; Schwartz E; and Simon SR: Ankle arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg Am,1979.61: 964-75, 61964
1979
[PubMed]
Morgan CD; Henke JA; Bailey RW; and Kaufer H: Long-term results of tibiotalar arthrodesis. J Bone Joint Surg Am,1985.67: 546-9, 67546
1985
[PubMed]
Said E; Hunka L; and Siller TN: Where ankle fusion stands today. J Bone Joint Surg Br,1978.60: 211-4, 60211
1978
[PubMed]
Cheng YM; Lin SY; Tien YC; and Wu HS: Ankle arthrodesis. Kao Hsiung I Hsueh Ko Hsueh Tsi Chih. ,1993.9: 524-31, 9524
1993
Corso SJ, and Zimmer TJ: Technique and clinical evaluation of arthroscopic ankle
arthrodesis. Arthroscopy,1995.11: 585-90, 11585
1995
[PubMed]
Gruen GS, and Mears DC: Arthrodesis of the ankle and subtalar joints. Clin Orthop,1991.268: 15-20, 26815
1991
[PubMed]
Papa JA, and Myerson MS: Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic
osteoarthrosis of the ankle and hindfoot. J Bone Joint Surg Am,1992.74: 1042-9, 741042
1992
[PubMed]
Budiman-Mak E; Conrad KJ; and Roach KE: The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol,1991.44: 561-70, 44561
1991
[PubMed]
Saag KG; Saltzman CL; Brown CK; and Budiman-Mak E: The Foot Function Index for measuring rheumatoid arthritis
pain: evaluating side-to-side reliability. Foot Ankle Int,1996.17: 506-10, 17506
1996
[PubMed]
Saltzman CL; Mueller C; Zwior-Maron K; and Hoffman RD: A primer on lower extremity outcome measurement instruments. Iowa Orthop J,1998.18: 101-11, 18101
1998
[PubMed]
Saltzman CL, and el-Khoury GY: The hindfoot alignment view. Foot Ankle Int,1995.16: 572-6, 16572
1995
[PubMed]
Kellgren JH, and Moore R: Generalized osteoarthrosis and Heberden's nodes. Br Med J,1952.1: 181-7, 1181
1952
[PubMed]
Hallock H: Arthrodesis of the ankle joint for old, painful fractures. J Bone Joint Surg Am,1945.27: 49-58, 2749
1945
Jackson A, and Glasgow M: Tarsal hypermobility after ankle fusion-fact or fiction. J Bone Joint Surg Br,1979.61: 470-3, 61470
1979
[PubMed]
Waters RL; Barnes G; Husserl T; Silver L; and Liss R: Comparable energy expenditure after arthrodesis of the
hip and ankle. J Bone Joint Surg Am,1988.70: 1032-7, 701032
1988
[PubMed]