The twentieth-century economist John Maynard Keynes once described the “gold standard” as “a barbarous relic” and noted that “the difficulty lies not so much in developing new ideas as in escaping from old ones.”1 Often our clinical judgment is borne from the principles that we learned from our mentors during our training, and the practicing orthopaedist may struggle with the “gold standard” dictum when exposed to new techniques. In the past few years, access to cutting-edge procedures has become readily available through web-based media and web symposia, permitting instant dissemination of new treatments that may not have been adequately or objectively peer-reviewed.
The late 1990s marked the advent of minimally invasive hip and knee replacement, image guidance, percutaneous fracture plating, and reliable arthroscopic shoulder techniques. In the past decade, our profession has made great strides in performing musculoskeletal procedures that focus on the preservation of surrounding soft tissues and the reduction of postoperative pain. Between 1997 and 2004, the number of Medicare-approved ambulatory surgery centers nearly doubled, and a drastic change in the ratio of inpatient to outpatient procedures occurred from the early 1980s to the 2000s2.
These advances have allowed for shorter hospital stays and a shift toward more outpatient procedures, which can lower the rate of complications and decrease the overall cost of care. While the aforementioned trends are exciting for patients and surgeons alike, our profession must be certain that novel technologies undergo thorough scientific analysis so that we can offer unbiased options to our patients.
The article by Townshend et al. is a well-written and systematically researched article that addresses the choice between traditional open ankle arthrodesis (the “gold standard”) and arthroscopic ankle arthrodesis.
Ankle arthritis is twenty-five times less common than hip and knee arthritis, and >80% of ankle arthritis is posttraumatic. Recent studies have shown that the impact on patients is just as important as arthritis involving other large joints. One study of health-related quality of life among patients with end-stage degenerative joint disease compared 130 patients who had undergone ankle arthritis with 130 patients who had hip arthritis and were awaiting definitive surgery3. The authors found that there was no difference between the two groups in terms of pain and disability and that the Short Form-36 (SF-36) scores for both groups were two standard deviations below the norm. Ankle fusion can lead to a change in gait, with an effect on cadence and stride length, leading to abnormal motion of the subtalar joint; however, reduction in pain and return to activities still make the procedure a good choice for properly selected patients4.
Modern ankle arthroscopic techniques can address such problems as ankle instability, osteochondral defects of the talus, and subtalar arthritis. In 1991, Myerson and Quill compared open and arthroscopic techniques for ankle arthrodesis and found a decreased time to fusion in association with arthroscopic arthrodesis5. In 2005, Ferkel and Hewitt performed a study of arthroscopic ankle fusion in thirty-five patients and demonstrated a 97% rate of fusion, with an average fusion time of 11.8 weeks, no infections, and no nerve injuries6. Those studies had promising results, but during the late 2000s, arthroscopic ankle arthrodesis was still relatively contraindicated for patients with substantial varus or valgus deformities of >10°. Moreover, the use of the technique was limited to surgeons with a particular skill set in small joint arthroscopy, making the “gold standard” of open fusion more appealing for most orthopaedists.
This article by Townshend et al. compares two cohorts of thirty patients who had either an open or arthroscopic ankle arthrodesis and two years of follow-up. The primary outcome was the Ankle Osteoarthritis Scale score, and secondary outcomes included the SF-36 physical and mental component scores, the length of hospital stay, and radiographic alignment.
The patients in the study were not randomized but were separated by institution. Open arthrodeses were performed at one site by a single surgeon through an anatomic transfibular approach, and arthroscopic arthrodeses were performed at a second site by one of three surgeons, leading to a potential selection bias. Regardless of the surgery type, all patients had identical postoperative management with immobilization of the ankle in a cast or cast boot, non-weight-bearing for the first six weeks, and progression to full weight-bearing during the second six weeks.
The study used validated outcome scoring systems with data that were evaluated with appropriate statistical methods. The authors found that both groups showed significant improvement in the Ankle Osteoarthritis Scale score and the SF-36 physical component score at one and two years. Complications and surgical time were similar between the two groups, with a shorter hospital stay in the arthroscopic arthrodesis group.
One of the most important findings in this study was that there was improvement in ankle alignment in both groups. In the open arthrodesis group, the mean postoperative coronal plane alignment was 4° (range, 1° to 12°) and the mean postoperative sagittal plane alignment was 20° (range, 5° to 32°). In the arthroscopic arthrodesis group, the mean postoperative coronal plane alignment was 2° (range, 0° to 8°) and the mean postoperative sagittal plane alignment was 20° (range, 10° to 35°). These findings demonstrate that correction of deformity is possible with both ankle fusion techniques.
This article is an important contribution to the literature on the treatment of ankle arthritis. The results of this study demonstrate that a minimally invasive approach is not only is safe for our patients but leads to improved patient outcomes. Certainly, there is a learning curve associated with the arthroscopic technique, but as the next generation of surgeons incorporate arthroscopy as part of their basic skill set, it is possible that arthroscopic ankle fusion will be the new “gold standard.”
One of my mentors once told me, “Just because you have a hammer, the world doesn’t have to be your nail.” As I end my first decade of practice, I still agree with this statement and always consider my patients’ well-being above all else; however, once we are sure that new techniques are safe and effective, can we trade in that hammer for an arthroscope?