The surgical treatment of severe ankle arthritis continues to be challenging and somewhat controversial. Although ankle arthrodesis is thought to be the “gold standard,” this procedure definitely carries with it the risk of hindfoot arthroses on radiographs with the passage of time1. Interest in ankle replacement has increased in recent years, but studies have shown a relatively high rate of revision arthroplasty at the time of early follow-up2.
The surgical treatment of degenerative joint disease of the ankle becomes even more taxing for younger patients. The risk of adjacent-joint arthritis will definitely increase with the passage of time after a tibiotalar arthrodesis. Similarly, the risk of requiring a repeat surgical procedure will increase when an ankle replacement is implanted into a younger patient. Thus, clinicians continue to search for other “joint-sparing” surgical modalities to help to effectively treat ankle arthritis, such as realignment osteotomies, allograft ankle reconstructions, and distraction arthroplasty.
The article by Dr. Saltzman et al. is a welcome and important contribution to the literature. It meets the rigid criteria for a prospective, randomized trial, and the authors should be congratulated for their diligence. Their inclusion criterion of selecting patients under the age of sixty years is also important as most clinicians would perform either an ankle arthrodesis or a total ankle replacement in patients with severe ankle arthritis over the age of sixty years. This report also serves to validate many of the European studies on the efficacy of distraction arthroplasty and shows the importance of motion when this technique is used3.
One of the concerns about this study, duly acknowledged by the authors, is the relatively “short” follow-up of two years for this patient population. This procedure is not for patients (or clinicians) who are looking for a simple and fast solution. This type of surgical treatment requires a substantial commitment on the part of both the patient and the clinician. In fact, patients in this study had the external fixator in place for approximately three months and did not progress toward full weight-bearing without support until six months. Therefore, it would be very interesting to see if these results continue to improve with time, say, at five or ten years, or begin to wane. With that important information, it would be easier for patients to make the decision to proceed with the lengthy treatment protocol associated with distraction arthroplasty. Also, although outcome information is the priority in this article, the mechanism by which distraction arthroplasty actually works is still largely conjectural4.
Nevertheless, this article does provide important information and support for distraction ankle arthroplasty. It also serves to cultivate interest in joint-sparing procedures for ankle arthritis. Hopefully, further studies with longer follow-up will show us how distraction arthroplasty with motion can truly “buy us time” in the treatment of our younger patients who have severe ankle arthritis.