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Efficacy of total ankle replacement with meniscal-bearing devices: a systematic review and meta-analysis

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Abstract

Introduction

The reputation of total ankle arthroplasty for treating end-stage ankle arthritis of different origin is dubious. Newer generation meniscal-bearing prostheses may have overcome the known problems with earlier implants. There is, however, no systematic approach to the available scientific evidence allowing for a critical appraisal of their benefits and risks.

Materials and methods

We conducted a systematic review meta-analysis of studies exploring the efficacy of three-component total ankle prostheses. We demanded a minimum sample size of 20 subjects, at least 1 year of follow-up, and a clinically relevant study endpoint (for example, results of ankle scoring, ranges of motion [ROM], complications, and survival rates). We identified citations by electronic medical databases and a manual search. We made no restrictions for language. We used an eight-point quality scale to appraise methodological standards, and modeled outcomes by random-effects meta-regression analysis.

Results

Eighteen of 1830 citations including 1086 patients fulfilled our eligibility criteria. Studies met a median of four quality items (interquartile range 2–5). Outcome estimates did not depend on methodological quality. There was no evidence of strong heterogeneity or publication bias. With standardized 100-point ankle and hindfoot scores, formal data pooling was possible for 10 trials ( n =497), showing a mean improvement of 45.2 points (95% confidence interval [CI] 39.3–51.1). Overall ROM improved slightly (6.3°, 95%CI 2.2–10.5°). Weighted complication rates ranged from 1.6% (deep infections) to 14.7% (impingement). Secondary surgery had to be performed in 12.5%, whereas secondary arthrodesis was necessary in 6.3%. The weighted 5-year prosthesis survival rate averaged 90.6%.

Conclusions

Ankle arthroplasty improves pain and joint mobility in end-stage ankle arthritis. Its performance in comparison to the current reference standard (that is, ankle fusion) remains to be defined in a properly designed randomized trial.

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References

  1. Anderson T, Montgomery F, Carlsson Å (2003) Uncemented STAR total ankle prostheses. Three to eight-year follow-up of fifty-one consecutive cases. J Bone Joint Surg Am 85:1321–1329

    Google Scholar 

  2. Anderson RB, Davis WH, Cohen BE, Pleimann JH (2004) A concurrent-controlled trial of the Link Orthopaedics Scandinavian Total Ankle Replacement (STAR) vs arthrodesis for treatment of degenerative ankle disease. Available online at http://www.millerclinic.com/miller_research/clinical_trials/

  3. Bhandari M, Tornetta P, Ellis T, Audige L, Sprague S, Kuo JC, Swiontkowski MF (2004) Hierarchy of evidence: differences in results between non-randomized studies and randomized trials in patients with femoral neck fractures. Arch Orthop Trauma Surg 124:10–16

    Article  Google Scholar 

  4. Coester LM, Saltzman CL, Leupold J, Pontarelli W (2003) Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 83:219–228

    Google Scholar 

  5. Cook RD, Weisberg S (1983) Diagnostics for heteroscedasticity in regression. Biometrika 70:1–10

    Google Scholar 

  6. Department of Health (2002) NHS performance indicators, February 2002. Available online at http://www.performance.doh.gov.uk/nhsperformanceindicators/2002/haesj_a.html

  7. Ernst C, Ernst G, Szczesny E (2003) Does learning matter for knee replacement surgery? Financial Accountability and Management 19:375–396

    Article  Google Scholar 

  8. Giannini S, Leardini A, O’Connor JJ (2000) Total ankle replacement: review of the designs and of the current status. Foot Ankle Surg 6:77–88

    Article  Google Scholar 

  9. Greenland S (1994) Quality scores are useless and potentially misleading. Am J Epidemiol 140:300–301

    Google Scholar 

  10. Guyton GP (2001) Theoretical limitations of the AOFAS scoring systems: an analysis using Monte Carlo modeling. Foot Ankle Int 22:779–787

    Google Scholar 

  11. Hamblen DL (1985) Can the ankle joint be replaced? J Bone Joint Surg Br 67:689–690

    Google Scholar 

  12. Hintermann B, Valderrabano V (2001) Endoprothetische Versorgung am oberen Sprunggelenk. Z Ärztl Fortbild Qualitätssich 95:187–194

    Google Scholar 

  13. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, Gavaghan DJ, McQuay H (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12

    Google Scholar 

  14. Kerkhoffs GMMJ, Handoll HHG, Bie R de, Rowe BH, Struijs PAA (2004) Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults (Cochrane review). In: The Cochrane Library, issue 1. John Wiley & Sons, Chichester

  15. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems fort the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349–353

    CAS  PubMed  Google Scholar 

  16. Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, Alliman KJ, Alvine FG, Saltzman CL (2004) The Agility total ankle arthroplasty: seven to sixteen-year follow-up. J Bone Joint Surg Am 86:1161–1171

    Google Scholar 

  17. Kofoed H, Sturup J (1994) Comparison of ankle arthroplasty and arthrodesis. A prospective series with long-term follow-up. Foot 4:1–9

    Article  Google Scholar 

  18. Kofoed H, Sørensen TS (1998) Ankle arthroplasty for rheumatoid arthritis and osteoarthritis. J Bone Joint Surg Br 80:328–332

    Article  Google Scholar 

  19. Landis JR, Koch GG (1997) The measurement of observer agreement for categorial data. Biometrics 33:159–174

    Google Scholar 

  20. MacLehose RR, Reeves BC, Harvey IM, Sheldon TA, Russell IT, Black AM (2000) A systematic review of comparisons of effect sizes derived from randomised and non-randomised studies. Health Technol Assess 4:1–154

    CAS  Google Scholar 

  21. Mazur JM, Schwartz E, Simon SR (1979) Ankle arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg Am 61:964–975

    Google Scholar 

  22. McGuire MR, Kyle RF, Gustilo RB, Premer RF (1988) Comparative analysis of ankle arthroplasty versus ankle arthrodesis. Clin Orthop 226:174–181

    Google Scholar 

  23. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet 354:1896–1900

    Article  CAS  PubMed  Google Scholar 

  24. National Audit Office (2000) Report by the Comptroller and Auditor General, NHS Executive. Hip replacements: getting it right first time. National Audit Office, London

    Google Scholar 

  25. Parker MJ, Handoll HHG (2004) Replacement arthroplasty versus internal fixation for extracapsular hip fractures (Cochrane review). In: The Cochrane Library, issue 1. John Wiley & Sons, Chichester

  26. Parker RA, Berman NG (2003) Sample size: more than calculations. Am Stat 57:166–170

    Google Scholar 

  27. Ramsay CR, Grant AM, Wallace SA, Garthwaite PH, Monk AF, Russell IT (2001) Statistical assessment of the learning curves of health technologies. Health Technol Assess 5:1–79

    Google Scholar 

  28. SooHoo NF, Shuler M, Fleming LL (2003) Evaluation of the validity of the AOFAS clinical rating systems by correlation to the SF-36. Foot Ankle Int 24:50–55

    Google Scholar 

  29. Spirt AA, Assal M, Hansen ST (2004) Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am 86:1172–1178

    Google Scholar 

  30. Stauffer RN, Chao EYS, Brewster RC (1977) Force and motion analyis of the normal, diseased, and prosthetic ankle joint. Clin Orthop 127:189–196

    PubMed  Google Scholar 

  31. Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F (2000) Methods for meta-analysis in medical research. Wiley, Chichester, pp 109–132

  32. Thomas RH, Daniels TR (2003) Ankle arthritis. J Bone Joint Surg Am 85:923–936

    Google Scholar 

  33. Thompson SG, Sharp SJ (1999) Explaining heterogeneity in meta-analysis: a comparison of methods. Stat Med 18:2693–2708

    Article  CAS  PubMed  Google Scholar 

  34. Thompson SG, Higgins JPT (2002) How should meta-regression analyses be undertaken and interpreted? Stat Med 21:1559–1573

    Article  Google Scholar 

Download references

Acknowledgment

The authors thank Mr. Peter Wood, Wrightington, UK, for critical reading of the manuscript and valuable suggestions.

Author information

Authors and Affiliations

  1. Department of Orthopaedic and Trauma Surgery, Ernst Moritz Arndt University, Friedrich Loeffler Str. 23b, 17489, Greifswald, Germany

    Dirk Stengel, Kai Bauwens & Axel Ekkernkamp

  2. Clinical Epidemiology Division, Department of Orthopaedic and Trauma Surgery, Unfallkrankenhaus Berlin Trauma Centre, Warener Str. 7, 12683 , Berlin, Germany

    Dirk Stengel, Kai Bauwens, Axel Ekkernkamp & Jörg Cramer

Authors
  1. Dirk Stengel
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  2. Kai Bauwens
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  3. Axel Ekkernkamp
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  4. Jörg Cramer
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Corresponding author

Correspondence to Dirk Stengel.

Appendix: References to studies included in this review

Appendix: References to studies included in this review

An asterisk (*) indicates studies suitable for quantitative data synthesis.

  • Amiens, France

    • Jarde O, Gabrion A, Meire P, Trinquier-Lautard JL, Vives P (1997) Complications et échecs des prothèses totales de la cheville. A propos de 21 observations. Rev Chir Orthop Reparatrice Appar Mot 83:645–651

  • Amsterdam, The Netherlands

    • *Doets HC (1998) The low contact stress/Buechel-Pappas total ankle prosthesis. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 29–33

  • Bad Kreuznach, Germany

    • *Schill S, Biehl C, Thabe H (1998) Prothetische Versorgung des Sprunggelenkes. Mittelfristige Ergebnisse nach Thompson-Richards- und STAR-Prothesen. Orthopäde 27:183–187

    • Biehl C, Schill S, Thabe H (1999) Mittelfristige Ergebnisse nach prothetischer Versorgung des Sprunggelenkes [Abstract]. Z Orthop 137:A22

    • Schill S, Thabe H (1998) Ankle arthroplasty: a clinical follow-up. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 90–93

  • Basel, Switzerland

    • *Hintermann B, Valderrabano V (2001) Endoprothetische Versorgung am oberen Sprunggelenk. Z Ärztl Fortbild Qualitätssich 95:187–194

    • Hintermann B (1999) Die STAR-Sprunggelenkprothese. Kurz- und mittelfristige Erfahrungen. Orthopäde 28:792–803

  • Bern, Switzerland

    • *Köstli A, Huber M, Huber H (1999) Revue à court terme d’une série de 21 prothèses totales de cheville non cimentées. Swiss Surg 5:265–270

  • Boulogne, France

    • Mendolia G (1998) Ankle arthroplasty- the RAMSES prosthesis. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 99–105

  • European Multicenter Study

    • *Schernberg F (1998) Current results of ankle arthroplasty. European multi-center study of cementless ankle arthroplasty. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 41–46

    • Haukeland (The Norwegian Arthroplasty Register), Norway

    • *Havelin LI, Furnes O, Espehaug B (2003) Nasjonalt Register for Leddproteser. Rapport 2002. Haukeland Sykehus, Bergen. Available online at: http://www.haukeland.no/nrl/ (last date of access: September 26, 2003)

  • Copenhagen, Denmark

    • *Kofoed H (1998) Medium-term results of cementless Scandinavian Total Ankle Replacement prosthesis (Link STAR) for osteoarthritis. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 116–120

    • *Levi N (1997) Deep refection following total ankle arthroplasty. Int J Risk Saf Med 10:47–49

    • Kofoed H (1998) Comparison of cemented and cementless ankle arthroplasty. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 47–49

    • Kofoed H (1998) Ankle arthroplasty: indications, alignment, stability and gain in mobility. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 16–21

    • Kofoed H, Danborg L (1995) Biological fixation of ankle arthroplasty: A sequential consecutive prospective clinico-radiographic series of 20 ankles with arthrosis followed for 1–4 years. Foot 5:27–31

    • Kofoed H, Lundberg-Jensen A (1999) Ankle arthroplasty in patients younger and older than 50 years: a prospective series with long-term follow-up. Foot Ankle Int 20:501–506

  • Malmö, Sweden

    • *Anderson T, Montgomery F, Carlsson Å (2003) Uncemented STAR total ankle prostheses. Three to eight-year follow-up of fifty-one consecutive cases. J Bone Joint Surg Am 85:1321–1329

    • Carlsson ÅS (1998) Revision of different ankle prostheses. In: Kofoed H (ed) Current status of ankle arthroplasty. Springer, Berlin Heidelberg New York, pp 50–58

  • Nancy, France

    • Delagoutte JP (2002) Retrospective analysis of 110 ankle prostheses. Eur J Orthop Surg Traumatol 12:198–205

  • Newark, NJ, USA

    • *Buechel FF, Pappas MJ, Iorio LJ (1988) New Jersey low contact stress total ankle replacement: biomechanical rationale and review of 23 cementless cases. Foot Ankle 8:279–290

    • *Buechel FF, Buechel FF, Pappas MJ (2003) Ten-year evaluation of cementless Buechel-Pappas meniscal bearing total ankle replacement. Foot Ankle Int 24:462–472

    • Buechel FF, Pappas MJ (1992) Survivorship and clinical evaluation of cementless, meniscal-bearing total ankle replacements. Semin Arthroplasty 3:43–50

  • Oakland, CA, USA

    • *Mann RA, Mann JA, Jaakola J, Kennedy MP (2001) Short term results with 50 Scandinavian Total Ankle Replacements [abstract]. American Orthopaedic Foot and Ankle Society Summer Meeting, San Diego, 2001. Available online at: http://www.aofas.org/01summer/200107201001.asp (last date of access: September 26, 2003)

    • Jaakola JI (2002) Short-term results with 50 Scandinavian Total Ankle Replacements [Abstract]. American Academy of Orthopaedic Surgeons, Dallas, 2002. Available online at: http://www.aaos.org/wordhtml/anmt2002/sciprog/105.htm (last date of access: September 26, 2003)

  • Offenburg, Germany

    • Rudigier J, Grundei H, Menzinger F (2001) Prosthetic replacement of the ankle in posttraumatic arthrosis: 10-year experience with the cementless ESKA ankle prosthesis. Eur J Trauma 27:66–74

  • Pellenberg, Belgium

    • *Natens P, Dereymaeker G, Abbara M, Matricali G (2003) Early results after four years experience with the S.T.A.R. uncemented total ankle prosthesis. Acta Orthop Belg 69:49–58

  • Wrightington, UK

    • *Wood PL, Deakin S (2003) Total ankle replacement. The results in 200 ankles. J Bone Joint Surg Br 85:334–341

    • Wood PL (2002) Experience with the STAR ankle arthroplasty at Wrightington Hospital, UK. Foot Ankle Clin 7:755–764

    • Wood PLR, Clough TM, Jari S (2000) Clinical comparison of two total ankle replacements. Foot Ankle Int 21:546–555

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Stengel, D., Bauwens, K., Ekkernkamp, A. et al. Efficacy of total ankle replacement with meniscal-bearing devices: a systematic review and meta-analysis. Arch Orthop Trauma Surg 125, 109–119 (2005). https://doi.org/10.1007/s00402-004-0765-3

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