Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

doi:10.21203/rs.2.17170/v1

Download PDF

Research article

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

https://doi.org/10.21203/rs.2.17170/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 14 Jan, 2020

Read the published version in BMC Musculoskeletal Disorders →

You are reading this older preprint version

Read the latest preprint version →

Background Advanced to end-stage ankle osteoarthritis in highly active older individuals has traditionally been treated using tibiotalar arthrodesis. Tibiotalar arthrodesis is possible to have high levels of pain-free function, however there is loss of ankle joint movement and a risk of arthrosis of adjacent joints in the future. Distraction arthroplasty is a simple method with a possibility of the joint cartilage repair but current results are mixed with reports of patients with better pain scores and some without any improvement. Distal tibial osteotomy (DTO) without fibular osteotomy, a type of joint preservation surgery, has garnered attention in recent years, However, as far as we know, there are no reports on DTO with joint distraction using a circular external fixator. The purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator on ankle osteoarthritis.

Materials and Methods A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed. Then angled osteotomy and correction of the distal tibia were performed. After ankle conditions improved, the stabilization of the ankle joint was performed. An external fixator was used in all patients. In addition, joint distraction of about 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery.

Results Antero-posterior mortise angle during weight-bearing, lateral mortise angle during weight-bearing, and talar tilt angle and anterior translation of the talus in ankle stress radiography significantly improved (P < 0.05). In addition, signal changes in magnetic resonance imaging (MRI) improved in all patients. Visual Analogue Scale (VAS ) and The American Orthopaedic Foot & Ankle Society (AOFAS) scores also improved significantly (P < 0.05). No severe complications were observed.

Conclusion DTO with joint distraction may be useful for older patients with a high physical activity level as joint preserving surgery for medial ankle osteoarthritis.

Orthopedic Surgery

distal tibial osteotomy

medial ankle arthritis

joint distraction

circular external fixator

To date, ankle arthrodesis or total ankle arthroplasty has been performed in patients with progressive or end-stage ankle osteoarthritis. With the advent of the super-aged society and an increased number of older patients with a high physical activity level, joint preserving surgery has become a treatment option.

Surgical treatment of ankle osteoarthritis varies depending on the stage. For patients with stage II and IIIa ankle osteoarthritis, low tibial osteotomy (LTO) for alignment correction of the surface of the lower end of the tibia is indicated〔1〕〔2〕〔3〕〔4〕〔5〕. For patients with end-stage (stages IIIB and IV) arthropathy, total ankle arthroplasty or ankle arthrodesis is generally indicated〔6〕〔7〕〔8〕〔9〕.For patients with stage III or IV arthropathy, distraction arthroplasty is indicated〔10〕〔11〕〔12〕〔13〕〔14〕. In patients, especially younger patients, with post-traumatic osteoarthritis, distraction arthroplasty with an external fixator is performed. There is a report showing that DTO, a type of joint preserving surgery, which allows patients to reacquire ankle stability and achieve weight-bearing with a site where healthy cartilage remains, is indicated for stage II-IIIB arthropathy. However, as far as we know, there are no reports on DTO with joint distraction using a circular external fixator. The purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator on ankle osteoarthritis.

Twenty-one patients with medial ankle osteoarthritis (4 stage IIIA patients, 17 stage IIIB patients according to the Takakura classification) who underwent DTO with joint distraction using a circular external fixator and a ≥2-year follow-up were included in the study. The patients consisted of 17 patients with ankle osteoarthritis, 2 patients with ankle rheumatoid arthritis, 1 patient with post-traumatic ankle osteoarthritis,　and 1 patient with polio-related ankle osteoarthritis.

The patients consisted of 7 males and 14 females with a mean age of 68.2 years (range, 60–80 years). The mean period with an external fixator was 89.2 days (range, 80–128 days). The mean follow-up period was 3.2 years (range, 2–9 years).

Surgical methods

An external fixator was used in all patients. First, ankle arthroscopy is performed. Then, after synovectomy, a microfracture procedure is performed under arthroscopy. Then, osteotomy is performed to make an opening from the medial side of the distal tibia toward the tibiofibular joint. An opening is made in the tibia in the varus and valgus directions until instability in the frontal fluoroscopy image disappears to perform correction (Figure 1 A, B). Further correction is performed in the anteroposterior direction until instability in the lateral fluoroscopy image disappears (Figure 1 C, D). Then, an ipsilateral iliac bone is transplanted into the opening. In patients who had less than 10 degrees of ankle dorsiflexion even after opening-wedge correction osteotomy, Vulpius-type achilles tendon lengthening techniques were added. During fixation using a circular external fixator, fixation of foot ring (for the calcaneus) and joint distraction of about 5.8 mm were also performed (Figure 2 A, B)〔13〕.If the radiographic joint space of on a X-ray of an ankle undergoing distraction arthroplasty shows a minimum of 5.8mm of distraction gap, then there will be no contact between joint surfaces during full weight-bearing. All patients were allowed full weight-bearing walking immediately after surgery. Patients treated with joint distraction performed articulation while wearing an external fixator, which not only increases the range of motion (ROM) but also promotes the regeneration of good articular surface and the maturation and regeneration of fibrocartilage.

Evaluations:

Static parameters: pre- and postoperative X-ray images; antero-posterior (AP) mortise angle during weight-bearing, medio-lateral (ML) mortise angle during weight-bearing (Figure 3), dynamic parameters: Pre- and postoperative radiography measurements of manual mortise stress ankle stress were available for all patients preoperatively. Both lateral and mortise stress radiographs were taken at the final follow-up visit. Tibiotalar tilt was measured on the mortise stress view of the ankle. Anterior displacement of the talus with respect to the tibia was assessed on the lateral stress radiograph. varus instability: talar tilt angle Mortise radiograph stress test. The amount of talar tilt, measured as the angle (in degrees) between the superior surface of the talus and the tibial plafond, was assessed using a mortise radiograph of the ankle. Maximal manual pressure was used to exert an inversion/varus force across the ankle joint. anterior instability: anterior translation of the talus (the distance between the posterior edge of the tibia articular surface and the posterior edge of the trochlea of talus) Lateral radiograph stress test. Radiographic anterior translation of the talus was assessed by measuring the nearest distance from the posterior edge of the distal tibial plafond to the posterior edge of the joint surface on the talar dome. Maximal manual pressure was used to exert anterior translation of the talus (Figure 3). Rate of improvement in pre and post-operative MRI signal changes (Figure 3). The MRI was performed on a 1.5 tesla machine. T1-weighted sequences was utilized to assess the signal changes.

Rate of adjacent joint arthritis. Pre- and postoperative visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scale.

For statistical analysis, the unpaired Student’s t-test was used to compare and evaluate the before surgery and after surgery. P<0.05 was considered significant.

(Table 1)

Imaging evaluation:

AP mortise angle during weight-bearing: Preoperative values of 80.5 ° improved to post-operative values of 98.0 °; ML mortise angle during weight-bearing: Preoperative values of 76.0 ° improved to post-operative values of 85.0 °; talar tilt angle in ankle stress radiography: Preoperative values of 19.5 ° improved to post-operative values of 3.0 °; anterior translation of the talus: Preoperative values of 27 mm improved to post-operative values of 2.6 mm.

MRI signal changes: All patients showed improvement: disappearance of preoperative signal changes (n = 9) and reduction in signal change area (n = 12).

In X-ray, no patients had arthropathic changes in peripheral joints.

Clinical evaluation:

ROM was preserved with the pre- and postoperative. VAS also improved from preoperative mean of 9.1 points　to post-operative mean of 1.6 points. AOFAS score: AOFAS also improved from preoperative mean of 35.5 points to post-operative mean of 88.4 points. No patient had skin disorder that requires additional surgery.

There are various options of surgical treatment of ankle osteoarthritis. We should perform optimal treatment considering patient characteristics thoroughly.　Total ankle arthroplasty for patients with progressive or end-stage ankle osteoarthritis is well indicated for bilateral patients and patients with degeneration of adjacent joints. However, total ankle arthroplasty is contraindicated for patients with infectious ankle osteoarthritis or severe deformity with ≥15° varus and valgus deformity of ankle joint. In addition, it is not appropriate for patients with a high physical activity level (e.g., sports and farming) even if they are ≥60 years of age〔15〕. Ankle arthrodesis shows stable long-term outcomes and is effective in pain reduction. However, it has disadvantages such as the loss of the ankle ROM and adjacent joint disorder. In countries like Japan, where people do not wear shoes and sit on the floor in the house, patient satisfaction of ankle arthroplasty is relatively low〔7〕〔9〕.　It has been reported that LTO is osteotomy that performs valgus correction of the alignment and outward shift of the weight-bearing line with good outcomes reported in patients with stage I-IIIA ankle osteoarthritis. LTO, which is extra-articular osteotomy surgery, is contraindicated for patients with ankle joint instability and may require additional surgery such as ligament reconstruction〔1〕〔16〕〔17〕.Distraction arthroplasty includes cell mobilization from bone marrow in the talus and tibial mortise (a microfracture procedure or drilling) and requires patients treated with joint distraction to perform articulation while wearing an external fixator that allows for increased ROM. Joint traction for an appropriate period of time prevents damage to the regenerated tissue, and articulation promotes maturation of the regenerated tissue〔15〕〔18〕.

In this study, we combined DTO and distraction arthroplasty. There are some reports showing that DTO is effective in older patients with a high physical activity level because the treatment preserves the ROM〔19〕〔20〕. There is also a study in which DTO was successfully performed in stage IIIB arthropathy patients with ankle joint instability. The merits of DTO, compared with arthrodesis, are that it preserves joint function and reduces pain. Another merit of DTO is that it has less influence on peripheral joints, which often cause problems in fixation. No patients in this study had adjacent joint disorder.

DTO is similar to LTO in that it corrects alignment. The merit of DTO, compared to LTO, is that it improves ankle joint stability by angled osteotomy of the proximal tibial attachment site of the anterior tibiofibular ligament and valgus correction〔20〕. DTO can narrow the lateral mortise. DTO with joint distraction using a circular external fixator may also be beneficial to cartilage〔10〕〔21〕.

Because long-term non-weight-bearing leads to reduced walking ability in older patients, walking with a circular external fixator with strong fixation immediately after surgery may greatly benefit the patients. In addition, mechanical stimulation by weight-bearing may have additional effects.

By pre- and postoperative X-ray evaluation of joint space narrowing, it is possible to visualize postoperative improvements (Figure 4). Furthermore, MRI evaluation allows us to confirm improvements when preoperative signal changes was reduced or disappeared after surgery.

On the other hand, DTO using a plate requires 1 to 2 months of non-weight-bearing period〔19〕〔20〕.Caution is required when the amount of correction is high due to high burden on soft tissue.

This study has some limitations. First, patients may find the use of a circular external fixator uncomfortable. However, one of the major reasons that no patients in this study had a deep infection or soft tissue trouble that requires additional surgery may be that the surgery does not require plate fixation. In most patients, improvement of talus instability without ligament reconstruction requires relatively large opening (i.e., about 20 mm) of the osteotomy site. A relatively large opening (about 20 mm) of the medial ankle substantially increases the tension of the medial soft tissue.

In treatment of patients with ankle osteoarthritis, it is important to choose the best surgical method considering patient age and physical activity level. In the future, with increased number of older ankle osteoarthritis patients with a high physical activity level, DTO with distraction arthroplasty using a circular external fixator may become a treatment option.

DTO with joint distraction may be useful for young patients as well as older patients with a high physical activity level as joint preserving surgery for medial ankle osteoarthritis.

DTO: Distal tibial osteotomy

MRI: Magnetic resonance imaging

VAS: Visual Analogue Scale

AOFAS: The American Orthopaedic Foot & Ankle Society

ROM: Range of motion

AP: Antero-posterior

ML: Medio-lateral

LTO: low tibial osteotomy

Ethics declarations

Ethics approval and consent to participate

All participants received prior information about the study before providing their written informed consent in accordance with the declaration of Helsinki. The study was approved by the ethical committee of Akita University Hospital (registration number 1970).

Consent for Publication

Written informed consent was obtained from the patients for publication of this research and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

All authors declare that they have no competing interests.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Authors’ contributions

KN performed the surgery. MN helped with surgery and helped to draft the manuscript. TK, HS, HK and SC assisted with surgery. HT and YS helped draft the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

Takakura Y, Tanaka Y, Kumai T, Tamai S: Low tibial osteotomy for osteoarthritis of the ankle. J Bone Joint Surg (Br) 1995, 77-B:50–54. doi: 10.1302/0301-620X.77B1.7822395.

2. Zhao H, Liang X, Li Y , Yu G, Niu W, Zhang Y. The role of fibular for supramalleolar osteotomy in treatment of varus ankle arthritis: a biomechanical and clinical study. Orthop Surg Res. 2016, 11(1):127.

3. Lee WC: Extraarticular supramalleolar osteotomy for managing varus ankle osteoarthritis, alternatives for osteotomy: how and why? Foot Ankle Clin, 2016, 21: 27–35.

4. Guo CJ, Li XC, Hu M, Xu Y, Xu XY: Realignment Surgery for Malunited Ankle Fracture. Orthop Surg. 2017, 9(1):49-53. doi: 10.1111/os.12312. Epub 2017 Mar 9.

5. Guo C, Liu Z, Xu Y, Li X, Zhu Y, Xu X: Supramalleolar Osteotomy Combined With an Intra-articular Osteotomy for the Reconstruction of Malunited Medial Impacted Ankle Foot AnkleInt. 2018, 39(12):1457-1463. doi: 10.1177/1071100718795309. Epub 2018 Sep 6.

6. Usuelli FG, Maccario C, Indino C, Manzi L, Gross CE. Tibial slope in total ankle arthroplasty: Anterior or lateral approach. Foot Ankle Surg.2017; 23(2):84-88. doi: 10.1016/j.fas.2016.10.001. Epub 2016 Nov 9.

7. Ebalard M, Le henaff G, Sigonney G, Lopes R, Kerhousse G, Brilhault J, Huten D. Risk of osteoarthritis secondary to partial or total arthrodesis of the subtalar and midtarsal joint after a minimum follow-up of 10 years. Ortho Traumatol Surg Res. 2014;100(4):231–237. doi: 10.1016/j.otsr.2014.03.003.

8. Boobbyer GN. The long-term results of ankle arthrodesis. Acta Orthop Scand. 1981; 52(1):107–110. doi: 10.3109/17453678108991769.

9. Chalayon O, Wang B, Blankenhorn B, Javckson JB, 3rd, Beals T, Nickisch F, Saltzman CL. Factors affecting the outcomes of uncomplicated primary open ankle arthrodesis. Foot Ankle Int. 2015; 36(10):1170–1179. doi: 10.1177/1071100715587045.

10. Van Valburg AA, van Roermund PM, Lammens J, et al. Can Ilizarov joint distraction delay the need for an arthrodesis of　the ankle? A preliminary report. J Bone Joint Surg Br. 1995;77-B(5): 720-725.

11. Van Valburg AA, van Roermund PM, Marijnissen ACA, et al.　Joint distraction in treatment of osteoarthritis: a two-year followup　of the ankle. Osteoarthr Cartil. 1999; 7(5): 474-479.

12. Intema F, Thomas TP, Anderson DD, Elkins JM, Brown TD, Amendola A, Lafeber FP, Saltzman CL: Subchondral bone remodeling is related to clinical improvement after joint distraction in the treatment of ankle osteoarthritis. Osteoarthritis Cartilage. 2011, 19(6):668-675. doi: 10.1016/j.joca.2011.02.005. Epub 2011 Feb 1

13. Fragomen AT, McCoy TH, Meyers KN, Rozbruch SR: Minimum distraction gap: how much ankle joint space is enough in ankle distractionarthroplasty? HSS J. 2014, 10(1):6-12. doi: 10.1007/s11420-013-9359-3. Epub 2013 Sep 24.

14. Zhao H, Qu W, Li Y, Liang X, Ning N, Zhang Y, Hu D: Functional analysis of distraction arthroplasty in the treatment of ankle osteoarthritis. J Orthop Surg Res. 2017, 12(1):18. doi: 10.1186/s13018-017-0519-x.

15. Bernstein M, Reidler J, Fragomen A, Rozbruch SR: Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes. J Am Acad Orthop Surg.2017, 25(2):89-99. doi: 10.5435/JAAOS-D-14-00077.

16. Tanaka Y, Takakura Y, Hayasi K, Taniguti A, Kumai K, Sugimoto K. Low tibial osteotomy for varus-type osteoarthritis of the ankle. J Bone Joint Surg Br. 2006; 88-B:909–913. doi: 10.1302/0301-620X.88B7.17325.

17. Tanaka Y: The concept of ankle jointpreserving surgery: why does supramalleolar osteotomy work and how to decide when to do an osteotomy or joint Foot Ankle Clin. 2012. 17(4):545-53. doi: 10.1016/j.fcl.2012.08.003. Epub 2012 Sep 18. Review.

18. Nishino T, Chang F, Ishii T et al. Joint distraction and movement for repair of articular cartilage in a rabbit model with subsequent weight-bearing. J Bone Joint Surg Br. 2010; 92:1033-1040.

19. Ahn TK, Yi Y, Cho JH, Lee WC. A cohort study of patients undergoing distal tibial osteotomy without fibular osteotomy for medial ankle arthritis with mortise widening. J Bone Joint Surg Am.2015 Mar 4;97(5):381-8. doi: 10.2106/JBJS.M.01360.

20. Teramoto T, Harada S, Takaki M, Asahara T, Kato N, Takenaka N, Matsushita T, Makino Y, Tasiro K, Kazutaka O, Nishi Y, Kinugsa K. The Teramoto distal tibial oblique osteotomy (DTOO): surgical technique and applicability for ankle osteoarthritis with varus deformity. Strategies Trauma Limb Reconstr.2018;13(1):43-49.

21. Zhao HM, Liang XJ, Li Y, Ning N, Lu J: Supramalleolar osteotomywith distraction arthroplasty in treatment of varus ankle osteoarthritis with large talar tilt angle: a case report and literature review. J Foot Ankle 2017, 56(5):1125-1128. doi: 10.1053/j.jfas.2017.04.022. Epub 2017 May 27.

Due to technical limitations, the table could not be displayed here. Please see the supplementary files to access the table.

2019DTOTable.pptx

Download PDF

Journal Publication

published 14 Jan, 2020

Read the published version in BMC Musculoskeletal Disorders →

Editorial decision: Minor revision
20 Nov, 2019
Review #1 received at journal
17 Nov, 2019
Reviewer #2 agreed at journal
15 Nov, 2019
Review #2 received at journal
15 Nov, 2019
Reviewers invited by journal
14 Nov, 2019
Reviewer #1 agreed at journal
14 Nov, 2019
Editor assigned by journal
29 Oct, 2019
First submitted to journal
28 Oct, 2019
Submission checks completed at journal
28 Oct, 2019
Editor invited by journal
28 Oct, 2019

You are reading this older preprint version

Read the latest preprint version →

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Materials and Methods

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Table

Supplementary Files

Status:

Journal Publication

Version 1