Open Versus Arthroscopic Ankle Arthrodesis: Which is Superior?

Point

Sharing evidence from the literature and their own experience, the authors contend that broader applications and an ability to address larger deformities are among the characteristics that make an open approach to ankle arthrodesis a better option in many cases.

By Joshua Wolfe, DPM, MHA, AACFAS, Ryan T. Scott, DPM, FACFAS

Surgical treatment of ankle arthritis has been an ever-progressing discussion point within the foot and ankle community. This has become even more prevalent with the increasing improvements in technology and adaptation of total ankle arthroplasty for the management of end-stage arthritis of the ankle. Ankle arthrodesis has long been a cornerstone procedure for managing ankle arthritis, chronic instability, deformity correction, and other pathologies.¹ Understanding the proper indications and contraindications for these procedures is crucial to ensuring quality, consistent surgical outcomes.

Open approach versus arthroscopic ankle arthrodesis remains a highly debated topic. The literature has shown that ankle arthrodesis, whether open or arthroscopic, improves patient American Orthopaedic Foot and Ankle Society (AOFAS) scores (44.0 to 78.9 and 36.1 to 68.9, respectively) and visual analog scale (VAS) pain scores 0.4 and 1.0 at 24 months postoperatively.² Ankle arthrodesis alters gait biomechanics and contributes to adjacent joint arthritis, regardless of open or arthroscopic arthrodesis.³

What Does the Literature Say About Open Ankle Arthrodesis?

Open ankle arthrodesis is a valuable procedure with various approaches that allow for a wide range of indications. Fusion rates have historically ranged in the open arthrodesis group to between 75 and 100 percent.^4-10 Surgeons primarily perform open ankle arthrodesis through anterior, mini-anterior, lateral, posterior, or a combination of these approaches. The anterior approach is the utilitarian approach, which allows sparing of the fibula for potential future procedures. This is the same approach used in total ankle arthroplasty.

Preservation of the talonavicular joint remains critical to preservation of overall pedal mobility.³ Consideration will be given to operative approaches involving stage II progressive collapsing foot deformity where dysfunction of the peritalar complex only involves the posterior tibial tendon. Bluman and team advised a classification that includes four stages of progressive deformity.⁶

The mini-anterior approach allows for anteromedial and anterolateral incisional approaches, which mimics that of the traditional arthroscopic portals but similarly allows for an open approach with full visualization and utilization of traditional joint preparation techniques. The lateral approach requires fibular resection, which one can later use for autograft or as an onlay technique. The onlay technique allows for the possibility of total ankle arthroplasty as a revision option, although this is not a primary consideration. The onlay technique acts as a strut to provide additional support/stability to the fusion construct. Lastly, the posterior approach for ankle arthrodesis is a final technique in cases with contraindication to anterior or lateral approaches. For example, patients with a history of incisional complications with these approaches (infection, skin grafts/flaps), multiple revision surgeries, or deformity that would lead to excessive soft tissue tension.

The literature does show that there are varying complication rates based on approach. The lowest complication rate is in the anterior ankle approach with 14 percent, the lateral approach at 16 percent, and the combined lateral/anterior approach at 31 percent.¹⁰ Similarly, fixation plays a role in complication rates as well. Screw fixation historically has a complication rate of 18 percent, and screw and plate fixation at 9 percent. In addition, the open approach allows for effective bone grafting and/or biologic augmentation. Although still possible with the arthroscopic approach, it is not as easily afforded. The literature shows that bone grafting may not be necessary in low-risk patients. However, benefits are certainly afforded to those in the higher risk category.¹⁰ The variability in open ankle arthrodesis techniques allows for a broader range of indications and allows surgeons to effectively treat deformity and complex lower extremity pathologies. This is not necessarily true of the arthroscopic approach.

What Does Open Arthrodesis Offer That Arthroscopic Does Not?

Open arthrodesis has long been the standard for ankle arthrodesis compared to the arthroscopic approach. Open ankle arthrodesis stands out as a better alternative for several indications. The most obvious benefit is that of deformity correction. Arthroscopic arthrodesis is limited in the ability to correct significant deformity.

Open arthrodesis offers a wider range of instrumentation and joint preparation and fixation techniques to allow for improved outcomes with deformity correction. The open approach allows for a stable construct utilizing plate technology with screws. 

Additionally, the primary contributor to ankle arthritis is post-traumatic arthritis (78 percent), followed by secondary osteoarthritis (13 percent) and primary osteoarthritis (9 percent).¹¹ In the scenario of retained hardware from the index procedure, hardware removal may also warrant consideration when selecting the surgical approach.

The literature has documented arthroscopic ankle arthrodesis’ association with decreased operative times, blood loss, hospital length of stay, and postoperative pain scores. These studies do not consider preoperative deformity or the learning curve associated with this technique.¹² Moreover, the arthroscopic approach to arthrodesis does have support within the literature. One should note that revision ankle arthrodesis primarily takes place through an open approach. The literature also recommends that those who perform arthroscopic arthrodesis be proficient in open arthrodesis as failure of the arthroscopic approach or intraoperative complications will require an intraoperative transition to an open approach.¹²

Concluding Thoughts

Open versus arthroscopic ankle arthrodesis remains a prominent discussion point in the literature. Ultimately, a surgeon performing arthroscopic ankle arthrodesis must be comfortable performing this procedure through the open approach if unforeseen intraoperative obstacles require conversion to the open approach. The utility of the open approach affords the surgeon the ability to address more significant deformities. It is the authors’ opinion that surgeons should be comfortable with both techniques to more effectively address the needs of their patients based on their respective comorbidities and the indications/contraindications associated with this.  

Dr. Wolfe is a Fellow at the CORE Institute Advanced Foot and Ankle Reconstruction Fellowship in Phoenix, AZ.

Dr. Scott is an Attending Surgeon and the Fellowship Director at the CORE Institute Advanced Foot and Ankle Reconstruction Fellowship in Phoenix, AZ.

Counterpoint

Here the author contends that with proper indications and technique, an arthroscopic approach can be a consistent and reliable pathway to ankle fusion. Citing evidence from the literature, she also points out that improvements in the learning curve and advancements in instrumentation make arthroscopic ankle arthrodesis an increasingly appealing option.

By Jamie L. Dermatis, DPM

Ankle arthrodesis is the traditional treatment for end-stage osteoarthritis in cases unresponsive to conservative efforts.¹ End-stage osteoarthritis is a degenerative process associated with severe pain and loss of function, negatively impacting quality of life. While ankle arthritis can be primary, most cases are post-traumatic in etiology, often affecting young patients.² Despite increasing utilization of total ankle replacement, ankle arthrodesis remains the gold standard surgical treatment for end-stage osteoarthritis due to its safety and reliability.^3-5 Although open ankle arthrodesis has historically been the more common surgical option, arthroscopic ankle arthrodesis (AAA) has gained popularity over the last few decades, proving to have its advantages.^4,6

Since its first report in 1983,⁷ use and indications for arthroscopic ankle arthrodesis have increased as surgeons improved their skills. Typically, surgeons reserved this procedure for patients with minimal ankle joint deformity (less than 15 degrees in the coronal plane),⁸ however, experienced surgeons note successful outcomes in larger deformities.^1,4,9 The minimally invasive procedure is preferrable for patients more susceptible to wound-related complications, including those with immunosuppression, diabetes, and rheumatoid arthritis.^10,11 Owing to its small stab incisions and minimal dissection, an arthroscopic approach to ankle fusion is beneficial in patients with excessive scarring from previous surgeries or skin grafting.¹²

Key Aspects of the Procedural Technique

While an anterior approach is more common, some studies suggest that posterior arthroscopic ankle fusions may provide better fusion rates.¹³ Often, surgeons use a thigh tourniquet and noninvasive distraction while insufflating the ankle using normal saline or Ringer’s lactate. Standard anteromedial and anterolateral portals facilitate an anterior approach, before using a 2.7 or 4.0 mm 30-degree arthroscope. Debridement of the soft tissues occurs with a shaver in the anterior joint, and in some cases, anterior osteophyte removal is necessary to allow for complete visualization. Next, a burr and curettes help remove the talar and tibial cartilage. Often, the surgeon only clears the lateral gutter enough to allow compression of the joint and reduce the deformity, but several surgeons recommend removing the entire articular surface of the lateral gutter.^11,14,15 The subchondral bone is then scaled using an osteotome and drill. If desired, one may place a demineralized bone matrix or platelet-rich plasma in the fusion site.

Ankle positioning for arthroscopic ankle fusion is the same as the open technique: neutral position in the sagittal plane, 0 to 5 degrees of hindfoot valgus, and 5 to 10 degrees of external rotation. Joint fixation typically involves two to three 6.5 mm cannulated screws placed in various configurations based on surgeon preference. The postoperative course varies significantly, with many patients being discharged home on the day of surgery.¹⁶ Most surgeons recommend strict non-weight-bearing for 5 to 7 weeks,^12,16,17 however, Cannon and colleagues¹⁸ allowed patients without any peripheral neuropathy or preop talar collapse to fully weight-bear as tolerated immediately and found no adverse effects on their outcomes.

Understanding the Arthroscopic Advantages

Due to its minimally invasive technique, arthroscopic ankle arthrodesis offers advantages, including fewer complications, minimal limb length loss, diminished postop pain, shorter hospital stays, and decreased time to union.^19,20 Also, arthroscopic ankle fusion can yield reduced tourniquet times, operation duration, and blood loss.^4,6 Quayle and team²¹ observed a statistically significantly shorter procedure length in the arthroscopic group than in the open surgery group. Fewer complications in terms of infections and nerve injuries are due to the decreased disruption of the soft tissue and diminished risk of thrombosis given the shorter immobilization times.^20,22

In a comparative study, Martinelli and coworkers⁵ reported that the complication rate for arthroscopic ankle fusion was lower at 14.3 percent versus the open surgery at 48.3 percent. Furthermore, in contrast to open fusions which often implement planal resection of the joint, the arthroscopic pathway preserves the bony contour, resulting in minimal limb length loss and shape changes to the ankle.

This preservation of cancellous bone allows for significant stability and rigid internal fixation and is beneficial if a total ankle replacement is necessary in the future.^22,23

AAA has demonstrated reduced postop pain, leading to shorter hospital stays, reduced cost, and faster recovery.²⁴ In both a meta-analysis by Bai et al²⁵ and a study by Woo et al,²⁶ postoperative pain scores were significantly better for the arthroscopic groups than for the open surgery groups. Many surgeons perform arthroscopic ankle fusion as an outpatient procedure due to the decreased need to monitor and manage postoperative pain.^3,19,23 Several studies found shorter lengths of hospital stay after arthroscopic versus open ankle fusion^4,19,26 with an average hospitalization of 1 day for arthroscopic fusion patients and 3 days for those who underwent an open procedure.¹⁹ A shorter hospital stay not only decreases the risk of hospital-born infections but also results in substantial cost savings for patients.²⁴

Other clear advantages to arthroscopic over open techniques are a shorter time to fusion, higher fusion rates, and better patient outcomes. While open ankle fusions have an average fusion time of approximately 14 weeks,²⁰ many studies note time to fusion for arthroscopic ankle arthrodesis to be between about 9 and 12 weeks.^3,10,19 In a study of 39 arthroscopic fusions, the authors reported an average fusion time of 47 days.²³ Meanwhile, Martinelli and colleagues⁵ observed a higher fusion rate in the arthroscopic group (90.5 percent) compared to the open group (65.2 percent), which is similar to findings in other studies.^4,20,26-28 Theories for the improved fusion times and rates seen with AAA are based on limited periosteal stripping and preserved local blood supply.^20,21 This creates a more favorable environment for fusion to occur and allows more rapid activation of the bone-healing cascade, leading to more rapid bone fusion and functional improvements.⁴ Townsend and colleagues reported a quicker clinical improvement in patients who underwent AAA during early follow-up at 6 and 12 months; a finding attributed to less soft tissue dissection and less swelling.⁴ Given the reduced time to fusion, patients experience a faster rehabilitation and return to normal life.19,20 Multiple studies have shown better Ankle Osteoarthritis Scale (AOS) scores at the 1- and 2-year postoperative marks in patients treated with arthroscopic ankle fusion.^4,28-30 Dannawi and team⁹ reported good to excellent results in over 80 percent of arthroscopically fused patients using Mazur’s grading system, and Kats and coworkers³¹ obtained 100 percent good to excellent results (Morgan scale) in post-arthroscopic patients.

Balancing the Drawbacks of the Procedure

Limitations to arthroscopic ankle arthrodesis do exist and include the frequent need for prominent screw removal and the development of adjacent joint arthritis. Absolute contraindications for an arthroscopic approach include active infection, extensive avascular necrosis of the talus, Charcot arthropathy, and large bone defects.¹⁹ Several surgeons consider peripheral neuropathy a contraindication,²³ while others caution its use in patients with an increased body mass index and history of smoking.^16,17 Myerson and Quill²⁰ recommended that bone defects larger than one-third of the talar dome be addressed with an open procedure. Approximately 9 to 31 percent of patients undergo surgery to remove prominent screws following arthroscopic ankle fusion,^26,32 however, it is a simple outpatient procedure and does not typically lead to complications.

Adukia et al¹⁷ suggested using headless compression screws to allow burying the entire screw length into bone, but headless screws may produce less interfragmentary compression compared with headed screws.³² In addition, adjacent joint arthritis development is seen after both AAA and open fusions due to a compensatory increase in movement of the surrounding joints.^33,34 However, Yasui et al²⁷ found the incidence of adjacent joint arthrodesis to be higher at 5.6% in the open surgery cohort versus 2.6% in the arthroscopic surgery cohort, a statistically significant difference.   

Historically, ankle deformities with greater than 10 to 15 degrees of varus or valgus constitute a contraindication to ankle fusion arthroscopically;^4,10,25 however, the acceptable limit of deformity has progressively increased over time.^1,4,9 Dannawi and colleagues9 found comparable clinical outcomes and union rates between arthroscopically fused patients with less than 15 degrees of coronal plane deformity and those with more than 15 degrees of deformity. Gougoulias et al¹ reported similar outcomes, showing that deformities up to 45 degrees could be treated effectively with arthroscopic ankle fusion. Townshend and team⁴ successfully fused the ankles in patients with deformity up to 36 degrees arthroscopically, arguing that large coronal plane deformities are often secondary to talar tilting within the ankle mortise, with little deformity in the actual tibia or talus.

Final Thoughts

In conclusion, with the correct indications and proper surgical technique, arthroscopic ankle fusion consistently yields successful outcomes and provides a reliable alternative for the treatment of end-stage osteoarthritis. Although ankle arthrodesis is usually the best option in young and active patients, reduced postoperative complication rates, shorter times to fusion, and faster rehabilitation make it a beneficial choice for susceptible and elderly patients as well. While larger ankle deformities should be reserved for more experienced arthroscopic surgeons, advancements in techniques and instrumentation have eased the learning curve once required for this approach, enabling this minimally invasive procedure to be used more often.  

Dr. Dermatis is a medical writer in Virginia.

Point References

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2. Woo BJ, Lai MC, Ng S, Rikhraj IS, Koo K. Clinical outcomes comparing arthroscopic vs open ankle arthrodesis. Foot Ankle Surg. 2020;26(5):530-534.

3. Ling JS, Smyth NA, Fraser EJ, et al. Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review. J Bone Joint Surg. 2015;97(6):513-519.

4. Gordon D, Zicker R, Cullen N, Singh D. Open ankle arthrodeses via an anterior approach. Foot Ankle Int. 2013;34(3):386-391.

5. Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ. Ankle arthrodesis using internal screw fixation. Clin Orthop Rel Res. 1991;(268):21-28.

6. Firoozabadi R, Thuillier D, Benirschke S. Obtaining correct ankle alignment using intraoperative external fixation for ankle arthrodesis. J Foot Ankle Surg. 2017;56(2):242-246.

7. Morrey BF, Wiedeman Jr GP. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am. 1980;62(5):777-784.

8. Akra GA, Middleton A, Adedapo AO, Port A, Finn P. Outcome of ankle arthrodesis using a transfibular approach. J Foot Ankle Surg. 2010;49(6):508-512.

9. Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop Rel Res. 1991;(268):84-95.

10. Heifner JJ, Monir JG, Reb CW. Impact of bone graft on fusion rates in primary open ankle arthrodesis fixated with cannulated screws: a systematic review. J Foot Ankle Surg. 2021;60(4):802-806.

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12. Vier D, Irwin TA. Open ankle arthrodesis for deformity correction. Foot Ankle Clin. 2022;27(1):199-216.

Counterpoint References

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2. Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA, Amendola A. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44-6.

3. Cameron SE, Ullrich P. Arthroscopic arthrodesis of the ankle joint. Arthroscopy. 2000;16(1):21–6.

4. Townshend D, Di Silvestro M, Krause F, et al. Arthroscopic versus open ankle arthrodesis: a multicenter comparative case series. J Bone Joint Surg Am. 2013;95:98-102.

5. Martinelli N, Bianchi A, Raggi G, Parrini MM, Cerbone V, Sansone V. Open versus arthroscopic ankle arthrodesis in high-risk patients: a comparative study. Int Orthop. 2022;46(3):515-521.

6. O’Brien TS, Hart TS, Shereff MJ, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis: a comparative study. Foot Ankle Int. 1999; 20:368-374.

7. Schneider D. Arthroscopic ankle fusion. Arthroscopic Video J. 1983;3.

8. Ferkel RD, Hewitt M. Long-term results of arthroscopic ankle arthrodesis. Foot Ankle Int. 2005;26(4):275–280.

9. Dannawi Z, Nawabi DH, Patel A, Leong JJ, Moore DJ. Arthroscopic ankle arthrodesis: Are results reproducible irrespective of pre-operative deformity? Foot Ankle Surg. 2011;17:294-299.

10. Winson IG, Robinson DE, Allen PE. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br. 2005;87(3):343–347.

11. Elmlund AO, Winson IG. Arthroscopic ankle arthrodesis. Foot Ankle Clin. 2015;20:71–80.

12. Hutchinson B. Arthroscopic Ankle Arthrodesis. Clin Podiatr Med Surg. 2016;33(4):581-9.

13. Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul P, Femino JE, Amendola A. Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Joint Surg Am. 2012;94:439-446.

14. Duan X, Yang L, Yin L. Arthroscopic arthrodesis for ankle arthritis without bone graft. J Orthop Surg Res. 2016;11(1):154.

15. Zwipp H, Rammelt S, Endres T, Heineck J. High union rates and function scores at midterm follow-up with ankle arthrodesis using a four screw technique. Clin Orthop Relat Res. 2010;468:958–68.

16. Piraino JA, Lee MS. Arthroscopic ankle arthrodesis: an update. Clin Podiatr Med Surg. 2017;34:503-514.

17. Adukia V, Mangwani J, Issac R, Hussain S, Parker L. Current concepts in the management of ankle arthritis. J Clin Orthop Trauma. 2020;11(3):388-398.

18. Cannon LB, Brown J, Cooke PH. Early weight bearing is safe following arthro- scopic ankle arthrodesis. Foot Ankle Surg. 2004;10(3):135-139.

19. Zvijac JE, Lemak L, Schurhoff MR, Hechtman KS, Uribe JW. Analysis of arthroscopically assisted ankle arthrodesis. Arthroscopy. 2002;18(1):70–75.

20. Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop Relat Res. 1991;268:84–95.

21. Quayle J, Shafafy R, Khan MA, Ghosh K, Sakellariou A, Gougoulias N. Arthroscopic versus open ankle arthrodesis. Foot Ankle Surg. 2018;24:137-142.

22. Dent CM, Patil M, Fairclough JA. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br. 1993;75(5):830–2.

23. Collman DR, Kaas MH, Schuberth JM. Arthroscopic ankle arthrodesis: factors influencing union in 39 consecutive patients. Foot Ankle Int. 2006;27(12):1079–1085.

24. Petersen KS, Lee MS, Buddecke DE. Arthroscopic versus open ankle arthrodesis: a retrospective cost analysis. J Foot Ankle Surg. 2010;49:242–7.

25. Bai Z, Yang Y, Chen S, Dong Y, Cao X, Qin W, Sun W. Clinical effectiveness of arthroscopic vs open ankle arthrodesis for advanced ankle arthritis: A systematic review and meta-analysis. Medicine (Baltimore). 2021;100(10):e24998.

26. Nielsen KK, Linde F, Jensen NC. The outcome of arthroscopic and open surgery ankle arthrodesis: a comparative retrospective study of 107 patients. Foot Ankle Surg. 2008;14(3):153–7.

27. Yasui Y, Vig KS, Murawski CD, Desai P, Savage-Elliott I, Kennedy JG. Open Versus Arthroscopic Ankle Arthrodesis: A Comparison of Subsequent Procedures in a Large Database. J Foot Ankle Surg. 2016; 55:777-781.

28. Woo BJ, Lai MC, Ng S, Rikhraj IS, Koo K. Clinical outcomes comparing arthroscopic vs open ankle arthrodesis. Foot Ankle Surg. 2020;26(5):530-534.

29. Mok TN, He Q, Panneerselavam S, Wang H, Hou H, Zheng X, Pan J, Li J. Open versus arthroscopic ankle arthrodesis: a systematic review and meta-analysis. J Orthop Surg Res. 2020 May;15(1):187.

30. Veljkovic AN, Daniels TR, Glazebrook MA, Dryden PJ, Penner MJ, Wing KJ, Younger ASE. Outcomes of total ankle replacement, arthroscopic ankle arthrodesis, and open ankle arthrodesis for isolated non-deformed end-stage ankle arthritis. J Bone Joint Surg Am. 2019;101(17):1523–9.

31. Kats J, van Kampen A, de Waal-Malefijt MC. Improvement in technique for arthroscopic ankle fusion: results in 15 patients. Knee Surg Sports Traumatol Arthrosc. 2003;11(1):46–9.

32. Odutola AA, Sheridan BD, Kelly AJ. Headless compression screw fixation prevents symptomatic metalwork in arthroscopic ankle arthrodesis. Foot Ankle Surg. 2012 Jun;18(2):111-113.

33. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83:219–28.

34. Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle: a study of adjacent joints. J Bone Joint Surg Br. 2003;85(7):994-8.