Repeated arthroscopy of the ankle joint after distraction arthroplasty, a case series

Abstract

BACKGROUND: Distraction arthroplasty of the ankle joint is the treatment method used for the cases of terminal osteoarthritis of the ankle joint that allows for delaying the arthrodesis or the total endoprosthesis replacement. The therapeutic effect is being achieved due to the separation of the articular surfaces (arthrodiastasis) with using the Ilizarov frame (or other devices for external fixation) for a period of 8–12 weeks. Only one research was described with the patients undergoing repeated arthroscopy of the ankle joint after the distraction arthroplasty in a combination with microfracturing of the cartilage defects, or repeated arthroscopy at the moment of removing the external fixation device (after 3 months).

АIM: To study the changes in the articular surfaces according to the Outerbridge before and after the distraction arthroplasty of the ankle joint using the repeated arthroscopy of the ankle joint.

METHODS: A total of 17 distraction arthroplasty surgical interventions of the ankle joint were performed (7 [41.2%] females and 10 [58.8%] males; the mean age of the patients was 48.5±13.57 years). Repeated arthroscopy of the ankle joint due to the recurrence of anterior impingement-syndrome after the distraction arthroplasty of the ankle joint within up to 12 months from the moment of removing the Ilizarov frame was carried out in 4 patients. For the evaluation of the treatment results, the Foot and Ankle Ability Measure (FAAM) scales were used, with an evaluation of pain, functions, deformity and the alignment of the foot and of the ankle joint (АОFAS Ankle-hindfoot scale), with subjective evaluation of pain (VAS); the status of the cartilage tissue in the ankle joint was evaluated using the modified Outerbridge scale.

RESULTS: In all the patients, a statistically significant improvement of the functional result was found in 12 months from the moment of surgery when using the FAAM (р=0.0006) and АОFAS Ankle-hindfoot scales, as well as after removing the Ilizarov frame in 1, 3 and 6 months. The pain intensity according to the VAS scale has decreased from 6.17±1.32 cm before surgery to 2 cm (1.4; 2.1) (p=0.00002) in 12 months. The arthroscopic findings upon the repeated interventions demonstrate the development of the massive arthrofibrosis with its further degradation to the end of 6 months, also showing the restoration of the cartilage defects from Outerbridge grade IV to grade II–III.

CONCLUSION: Upon the repeated arthroscopy, including the one performed at the end of 12 months after the distraction arthroplasty of the ankle joint, signs of regeneration were observed in the cartilage tissue defects with further defect coverage with a cartilage-like tissue, which, probably, determines the analgesic effect of the distraction arthroplasty of the ankle joint.

Keywords

distraction arthroplasty / ankle / Ilizarov frame / osteoarthritis

References

[1] 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

[2] Fragomen AT, McCoy TH, Meyers KN, Rozbruchhomas SR. Minimum distraction gap: How much ankle joint space is enough in ankle distraction arthroplasty? HSS J. 2014;10(1):6–12. doi: 10.1007/s11420-013-9359-3

[3] Greenfield S, Matta KM, McCoy TH, et al. Ankle distraction arthroplasty for ankle osteoarthritis: A survival analysis. Strategies Trauma Limb Reconstr. 2019;14(2):65–71. doi: 10.5005/jp-journals-10080-1429

[4] Murray C, Marshall M, Rathod T, et al. Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: A systematic review and cross-sectional study. PLoS One. 2018;13(4):e0193662. EDN: YHYCPJ doi: 10.1371/journal.pone.0193662

[5] Intema F, Thomas TP, Anderson DD, et al. Subchondral bone remodeling is related to clinical improvement after joint distraction in the treatment of ankle osteoarthritis. Osteoarthritis Cartilage. 2011;19(6):668–675. EDN: OEMGCV doi: 10.1016/j.joca.2011.02.005

[6] Li K, Wang P, Nie C, et al. The effect of joint distraction osteogenesis combined with platelet-rich plasma injections on traumatic ankle arthritis. Am J Transl Res. 2021;13(7):8344–8350.

[7] Ikuta Y, Nakasa T, Tsuyuguchi Y, et al. Clinical outcomes of distraction arthroplasty with arthroscopic microfracture for advanced stage ankle osteoarthritis. Foot Ankle Orthopaedics. 2019;4(4):2473011419S0022. doi: 10.1177/2473011419S00228

[8] Lamm BM, Gourdine-Shaw M. MRI evaluation of ankle distraction: A preliminary report. Clin Podiatric Med Surg. 2009;26(2): 185–191. EDN: XXWDYY doi: 10.1016/j.cpm.2008.12.007

[9] Chen Y, Sun Y, Pan X, et al. Joint distraction attenuates osteoarthritis by reducing secondary inflammation, cartilage degeneration and subchondral bone aberrant change. Osteoarthritis Cartilage. 2015;23(10):1728–1735. doi: 10.1016/j.joca.2015.05.018

[10] Flouzat-Lachaniette C, Roubineau F, Heyberger C. Distraction to treat knee osteoarthritis. Joint Bone Spine. 2017;84(2):141–144. doi: 10.1016/j.jbspin.2016.03.004

[11] Harada Y, Nakasa T, Mahmoud EE, et al. Combination therapy with intra‐articular injection of mesenchymal stem cells and articulated joint distraction for repair of a chronic osteochondral defect in the rabbit. J Orthop Res. 2015;33(10):1466–1473. doi: 10.1002/jor.22922

[12] Hung SC, Nakamura K, Shiro R, et al. Effects of continuous distraction on cartilage in a moving joint: An investigation on adult rabbits. J Orthop Res. 1997;15(3):381–390. doi: 10.1002/jor.1100150310

[13] Wiegant K, Intema F, van Roermund PM, et al. Evidence of cartilage repair by joint distraction in a canine model of osteoarthritis. Arthritis Rheumatol. 2015;67(2):465–474. doi: 10.1002/art.38906

[14] Inori F, Ohashi H, Minoda Y, et al. Possibility of “distraction arthrogenesis”: First report in rabbit model. J Orthop Sci. 2001;6(6):585–590. doi: 10.1007/s007760100016

[15] Teunissen M, Bedate MA, Coeleveld K, et al. Enhanced extracellular matrix breakdown characterizes the early distraction phase of canine knee joint distraction. Cartilage. 2021; 13(2, Suppl):1654S–1664S. doi: 10.1177/19476035211014595

[16] Stupina TA, Shchudlo MM, Shchudlo NA, Stepanov MA. Histomorphometric analysis of knee synovial membrane in dogs undergoing leg lengthening by classic Ilizarov method and rapid automatic distraction. Int Orthop. 2013;37(10):2045–2050. EDN: UEOLEL doi: 10.1007/s00264-013-1919-0

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