Hospital for Special Surgery, New York, NY, USA.
Foot Ankle Int. 2021 Mar;42(3):257-267. doi: 10.1177/1071100720965120. Epub 2020 Nov 13.
Patients presenting with end-stage ankle osteoarthritis (OA) in the setting of a concomitant extra-articular limb deformity pose a challenging problem that has not yet been described in the literature. We describe a case series of patients treated with external and internal fixation techniques followed by total ankle arthroplasty (TAA) in a staged approach to treat this complex presentation.
Eight patients with limb deformity and end-stage ankle OA who underwent staged deformity correction and TAA from 2016 to 2019 at our institution were retrospectively identified. Average age was 58.5 (range, 49-68) years, with an average follow-up of 2.6 (range, 0.8-4.2) years. All patients underwent limb reconstruction with either tibial osteotomy with a circular frame (n=6) or intramedullary nail (n=2). Limb deformities consisted of the following: posttraumatic tibial malunion (2), limb length discrepancy (1), acquired tibial deformity (1), genu varum (2), or genu valgum (2). Radiographic parameters were assessed pre- and postoperatively on 51-inch standing and ankle radiographs: limb length discrepancy (LLD), genu varum/valgum deformity, recurvatum deformity, mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, anterior distal tibial angle, and tibiotalar alignment. Pre- and postoperative patient-reported outcomes were assessed using 2 metrics, the Limb Deformity-Scoliosis Research Society (LD-SRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Intensity, Pain Interference, Global Physical Function, and Global Mental Function).
Following staged limb deformity correction and TAA, all patients achieved correction of LLD and angular deformities of the lower limb, along with restoration of normal alignment of the ankle joint. There was significant mean improvement in all patient-reported LD-SRS and PROMIS domains, except for LD-SRS mental health. LD-SRS function improved from 2.6 (±0.7) to 4.6 (±0.2), = .008; pain improved from 2.9 (±0.9) to 4.8 (±0.2), = .012; self-image improved from 2.9 (±0.4) to 4.7 (±0.3), < .001; and total LD-SRS improved from 3.3 (±0.4) to 4.8 (±0.2), = .002. Average satisfaction was 4.9 (±0.3). PROMIS physical function improved from 32.3 (±6.8) to 51.3 (±5.3), = .008; pain interference improved from 66.0 (±9.1) to 41.3 (±6.2), = .004; pain intensity improved from 60.0 (±13.3) to 33.1 (±5.3), = .007; global physical health improved from 39.3 (±6.8) to 60.7 (±5.1), = .002; global mental health improved from 54.8 (±5.9) to 65.6 (±2.8), = .007. There was one incidence of pin site infection and one reoperation.
Deformity correction with either external frame or intramedullary nail fixation followed by TAA in a staged approach was a viable surgical option in the treatment of end-stage ankle OA with concurrent extra-articular limb deformity. This unique approach was capable of achieving deformity correction with improved patient-reported outcomes, minimal complications, and good patient satisfaction.
Level IV, retrospective case series.
患有伴发关节外肢体畸形的终末期踝关节骨关节炎（OA）的患者提出了一个具有挑战性的问题，目前尚未在文献中描述。我们描述了一系列患者的病例系列，这些患者通过外部和内部固定技术进行治疗，然后进行分期全踝关节置换术（TAA）以治疗这种复杂的表现。
2016 年至 2019 年，我们机构回顾性地确定了 8 例伴有关节外肢体畸形和终末期踝关节 OA 的患者，这些患者接受了分期畸形矫正和 TAA。平均年龄为 58.5 岁（范围，49-68 岁），平均随访时间为 2.6 年（范围，0.8-4.2 年）。所有患者均采用胫骨截骨术伴环形框架（n=6）或髓内钉（n=2）进行肢体重建。肢体畸形包括以下几种：创伤后胫骨畸形愈合（2 例）、肢体长度差异（1 例）、获得性胫骨畸形（1 例）、膝内翻（2 例）、膝外翻（2 例）。术前和术后 51 英寸站立位和踝关节 X 线片评估了以下影像学参数：肢体长度差异（LLD）、膝内翻/外翻畸形、后倾畸形、机械轴偏差、胫骨近端内侧角、胫骨远端外侧角、胫骨远端前角和距下关节对线。使用 2 项指标（肢体畸形-脊柱侧凸研究协会（LD-SRS）和患者报告的结果测量信息系统（PROMIS）评分）评估术前和术后患者报告的结果，包括身体功能、疼痛强度、疼痛干扰、整体身体功能和整体心理健康。
经过分期肢体畸形矫正和 TAA 后，所有患者均实现了 LLD 和下肢角度畸形的矫正，以及踝关节的正常对线。所有患者报告的 LD-SRS 和 PROMIS 领域均有显著的平均改善，除了 LD-SRS 心理健康。LD-SRS 功能从 2.6（±0.7）提高到 4.6（±0.2）， =.008；疼痛从 2.9（±0.9）提高到 4.8（±0.2）， =.012；自我形象从 2.9（±0.4）提高到 4.7（±0.3）， <.001；总 LD-SRS 从 3.3（±0.4）提高到 4.8（±0.2）， =.002。平均满意度为 4.9（±0.3）。PROMIS 身体功能从 32.3（±6.8）提高到 51.3（±5.3）， =.008；疼痛干扰从 66.0（±9.1）提高到 41.3（±6.2）， =.004；疼痛强度从 60.0（±13.3）提高到 33.1（±5.3）， =.007；整体身体健康从 39.3（±6.8）提高到 60.7（±5.1）， =.002；整体心理健康从 54.8（±5.9）提高到 65.6（±2.8）， =.007。有 1 例发生针道感染，1 例再次手术。
伴发关节外肢体畸形的终末期踝关节 OA 患者采用外部框架或髓内钉固定术分期矫正后再行 TAA 是一种可行的手术选择。这种独特的方法能够实现畸形矫正，改善患者报告的结果，减少并发症，提高患者满意度。
IV 级，回顾性病例系列。
