Degenerative bilateral ankle osteoarthritis manageable with simultaneous TAR

Alexej Barg

SAN DIEGO — Swiss orthopedists studying the effects of simultaneous bilateral total ankle replacement on pain, function and quality of life compared with unilateral total ankle replacement found the simultaneous procedures were a viable option for individuals with severe degenerative bilateral ankle osteoarthritis.

“Simultaneous bilateral total ankle replacement (TAR) can be offered to the patients with bilateral ankle osteoarthritis [OA], however these patients should be informed about possibly prolonged recovery and pain,” Alexej Barg, MD, of Liestal, Switzerland, said.

Barg presented the comparative study at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons, noting the severe pain for which simultaneous sequential bilateral TAR is indicated may occur in individuals with a previous trauma, endstage OA, rheumatoid arthritis, or other conditions. Only a few investigations have studied the procedure’s pain and functional improvements and none to his knowledge have done so in a comparative fashion, he said.

“We continue to offer this treatment modality to the patients presenting with severe bilateral end-stage ankle OA. To date, 28 patients underwent simultaneous bilateral total ankle procedures with results comparable to those which have been presented. All patients experienced significant pain relief and functional improvement resulting in high patient satisfactions,” Barg told Orthopedics Today.

Matched study groups

Between June 2001 and March 2008, Barg and colleagues prospectively enrolled 23 consecutive patients (46 ankles) in their observational study, all of whom underwent simultaneous sequential bilateral TAR. They compared this group to 46 patients (46 ankles) who underwent unilateral TAR. The two groups were similar in terms of demographics, as well as body mass index, American Society of Anesthesiologists classification and etiology of their ankle OA, according to Barg.

AP radiographs showed painful bilateral ankle osteoarthritis in a 64-year-old man.

This AP radiograph shows the prosthetic components were properly positioned in both ankles at 2.2 years after surgery. Images: Barg A

Postoperatively, researchers followed up with both groups at 4 months, 1 year and 2 years. “No patients were lost to follow-up due to prosthesis loosening or revision,” Barg noted.

Neither group experienced any significant surgical complications, however the bilateral cases had longer hospital stays.

TAR effectively reduced pain

Investigators compared both groups’ outcomes using the Visual Analog Scale (VAS) for pain, SF-36 instruments, and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score.

“Preoperatively, all patients had a relatively high level of pain. Postoperatively, all patients experienced a significant pain relief, however the patients with the unilateral TAR were in less pain at 4 months follow-up, but not at 1 or 2 years,” Barg said.

VAS scores at 4 months were 2.2 and 1.6 for the bilateral and unilateral groups, respectively, based on study findings.

Also at 4 months follow-up the unilateral TAR patients had higher AOFAS hindfoot scores, where higher scores represent more function and less pain, but the differences between the scores were only statistically significant at this time point. In addition, some range of motion differences existed between the groups and SF-36 scores were slightly lower in the bilateral group, but only at the 4-month follow-up, according to Barg

Despite reduced pain and improved function observed the unilateral group was comparable to the bilateral group 4 months after surgery, “We can say that simultaneous bilateral ankle replacement is a technique that brings pain relief and function to the patient. These results are comparable to those which can be achieved in a patient with unilateral disease,” Barg concluded. – by Susan M. Rapp

Reference:

• Barg A, Knupp M, Hintermann B. Simultaneous bilateral vs. unilateral total ankle replacement: Pain relief, QOL, functional outcome. Paper #59. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 15-19. San Diego.

• Alexej Barg, MD, can be reached at Kantonsspital Liestal, Rheinstrasse 26, Liestal, BL, 4410 Switzerland; 4-4-161-925-2220; e-mail: alexejbarg@mail.ru.
• Disclosure: Barg received support for the study from research funding from the Swiss Society of Orthopaedics and from the Basel Foundation Orthopaedic Surgery and Biomechanics of Foot and Ankle. One of the coauthors, Hintermann, received and will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, all benefits have been or will be directed to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors are associated.

For decades, patients having total hip and knee replacement have been immediately immersed in a postoperative rehabilitation program, including full weight-bearing and aggressive range of motion. However, due to differences in the soft tissue environment around the ankle, total ankle arthroplasty has traditionally been followed with weeks of immobilization, elevation, and nonweight-bearing. This clinical case series shows that bilateral ankle replacement is possible, and in fact can be considered safe. Although the rehabilitation program still is not as aggressive as following surgery of the hip or knee, and probably never will be, this could be considered relatively rapid rehabilitation. But bilateral ankle replacement can not be considered the gold standard or routine. The procedure requires a very experienced surgeon and an appropriate patient, as well as an expectation of a slower recovery.

— Justin K. Greisberg, MD
NewYork-Presbyterian/Columbia Hospital, New York
AAOS Session moderator
Disclosure: He has no relevant financial disclosures.