Optimizing Procedure Choice for End-Stage Ankle Arthritis

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At the 2023 Western Wisconsin Foot and Ankle Symposium, thought leaders discussed varying points of view on end-stage ankle degenerative joint disease (DJD), specifically total ankle replacement versus arthroscopic ankle arthrodesis. Podiatry Today had the chance to speak with the faculty about their respective sides of the debate.

What is the one most important thing you feel makes one approach superior to the other, and why?

Arthroscopic Ankle Fusion. Brian Burgess, DPM, FACFAS shared that his biggest take home point in this debate focused on the literature in terms of functional outcomes and patient satisfaction, demonstrating how most studies do not favor one treatment option over the other.

“Outcomes are very similar,” he said. “A lot of physicians have the opinion that ankle arthrodesis has a profound negative impact on an individual's ability to ambulate and their quality of life and this simply isn't true. Study after study has demonstrated that patients have significant improvement in terms of pain, function and quality of life and are overall satisfied with the procedure.”

While arthroscopic ankle arthrodesis is not a particularly new procedure, Dr. Burgess noted that most ankle fusions still take place via a traditional open approach.

“There are significant benefits to performing the arthrodesis arthroscopically, including higher fusion rates, fewer complications, less pain and overall cost,” he explained. “My hope is that we continue to push and train our residents and fellows on arthroscopic ankle arthrodesis so that they can use this approach to their patients' benefit.”

Total Ankle Replacement (TAR). Mark Prissel, DPM, FACFAS stated that both TAR and ankle arthrodesis have appropriate indications and warrant consideration for end-stage ankle arthritis.

“However, TAR provides a motion-sparing option, thus limiting abnormal mechanical stress onto the adjacent joints which may predispose (one to) an increased risk for advanced arthritis at the talonavicular and subtalar joints, where options other than further arthrodesis may be limited,” he added.

What do you most want DPMs to know about treating end-stage ankle DJD with each type of procedure?

Arthroscopic Ankle Fusion. The biggest misconception about arthroscopic ankle arthrodesis, said Dr. Burgess, is that it is going to be very difficult to get the arthroscopic camera in the joint for cartilage resection and joint preparation.

“Certainly there is a little bit of a learning curve with this approach, but a thorough joint prep can be performed arthroscopically with the added benefits of less soft tissue and vascular disruption from the joint,” he said.

He also points out that he finds that the overall cost of the procedure is less than ankle replacement and open ankle arthrodesis procedures, which often require postoperative admission. He explained this makes it attractive for those physicians who wish to mostly operate out of ambulatory surgery centers.

“Lastly, it is important to highlight that the arthroscopic-assisted procedure can be easily converted to a mini-open or even an open approach at any point in time by extending the portal sites,” shared Dr. Burgess. “The many benefits of performing this procedure arthroscopically, which has been shown in the literature, make it an attractive option worth trying.”

Total Ankle Replacement (TAR). Dr. Prissel noted that when considering TAR for the end-stage ankle arthritis candidate, patient selection is paramount. He added that this in turn relates to many factors including, but not limited to, bone quality, deformity, age, comorbidities, activity level, and others.

“Identifying concomitant deformities that may influence the predictability and success of the outcome is also critical, while understanding if these deformities should be managed in a staged or simultaneous manner.”

Dr. Burgess is the Fellowship Director of the Hinsdale Orthopaedics (IBJI) Foot and Ankle Fellowship in Illinois and a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Prissel is a Fellowship-trained foot and ankle surgeon and Managing Strategic Partner at the Orthopedic Foot and Ankle Center in Worthington, OH. He is a Fellow of the American College of Foot and Ankle Surgeons.

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