Fuss und Sprunggelenk最新文献

Ankle arthrodesis has long been considered the gold standard surgical treatment for end stage ankle osteoarthritis, although recent data suggests a trend towards increased numbers of total ankle replacements. Both total ankle replacements and ankle arthrodesis appear to improve the function and quality of life of patients with end stage ankle osteoarthritis as measured by clinical scores, but both procedures also carry pros and cons. In this paper we review the literature to assess the impact of different factors on the outcome of total ankle replacement and ankle arthrodesis, to try and determine whether ankle arthrodesis is indeed the gold standard.

The valgus total ankle replacement (TAR) presents a considerable challenge and tests the skill and ingenuity of even the most accomplished foot and ankle surgeon. Coronal plane deformity used to be considered a relative contra-indication for TAR, however with implant innovation and greater surgical understanding, the indications for TAR in deformity continue to expand. Success requires a bespoke approach to each patient to ensure that intra- and extraarticular deformities and imbalance are adequately addressed to avoid TAR failure. The overall goal in TAR surgery is achieving a well aligned and stable ankle with a well aligned and stable foot below. This article presents some of our strategies to achieve this when considering TAR in the valgus ankle.

Introduction

Ankle osteoarthritis poses significant challenges, affecting patients’ quality of life and often necessitating surgical intervention. Total ankle replacement (TAR) has emerged as an effective treatment, in patients with post-traumatic arthritis. Precise preoperative planning is crucial for achieving optimal outcomes in TAR procedures. This article explores the use of advanced imaging techniques, virtual modeling, and surgical strategies in preoperative planning for TAR.

Methods

The preoperative planning process involves thorough patient assessment, including clinical examination and imaging studies such as Weight Bearing CT scans (WBCT) and MRI. Classification systems like the Canadian Orthopedic Foot & Ankle Society (COFAS) classification help guide treatment decisions and staging of procedures. Virtual foot/ankle models derived from WBCT scans enable accurate assessment of deformities and facilitate precise implant positioning.

Discussion

Optimal TAR outcomes rely on restoring normal ankle anatomy and function while addressing associated deformities and pathology. Precise alignment, joint congruency, and rotational positioning of implant components are Important considerations. Virtual planning allows for simulation of implant placement and axis correction, aiding surgical decision-making and predicting outcomes. However, it has limitations in predicting soft tissue effects and final implant size.

Conclusion

Preoperative planning plays a important role in TAR procedures, understanding optimal implant placement. Advanced imaging modalities, classification systems, and virtual modeling techniques enhance surgical precision. Continued refinement of preoperative planning strategies is essential for further advancing TAR outcomes and patient satisfaction.

Alignment and balance are mandatory for implant survival of joint replacement. Satisfactory results can be achieved in patients with significant preoperative deformity if alignment and balance were obtained. In case of associated rigid foot deformity, a two-stage procedure involving primary deformity correction and secondary total ankle arthroplasty is a comprehensive solution. We describe the principal aspects of this concept and illustrate our current approach to these challenging cases.

Recent developments in the design of modern total ankle replacements have significantly increased the implant survival rate. Detection of reasons for persistent symptoms is complex. The most common reasons for persistent symptoms and revision are aseptic loosening, periprosthetic joint infection, impingement, inlay wear, periprosthetic fracture, malalignment and instability as well as osteoarthritis of adjacent joints. This article provides an overview of the surgical options in the light of the current literature. Whereas in previous times mostly arthrodesis was recommended for revisions, the full spectrum of revision surgery is now available for total ankle replacement. Measured by functional, clinical scores, a good result can often be demonstrated after revision surgery.

In end-stage ankle osteoarthritis (OA) more than half of all patients show a varus malalignment (tibiotalar surface angle <90°). Total ankle arthroplasty (TAA) preserves tibiotalar joint motion with a low incidence of secondary subtalar joint fusion, offering a better health-related quality of life than ankle arthrodesis. The most important factors in the preoperative assessment are highlighted. Intraoperative key points are illustrated and the current literature is discussed regarding the outcome of TAA in varus ankle OA. Of paramount importance for a satisfactory outcome is to reestablish neutral alignment, ligamentous stability and a plantigrade foot. This frequently necessitates soft-tissue and bony concomitant procedures.