Total ankle replacement in patients under the age of 50. Should the indications be revised?
Introduction
End-stage ankle osteoarthritis is a debilitating condition that, despite being relatively uncommon when compared with the more prevalent hip and knee osteoarthritis, is associated with significantly more severe mental and physical disability [1]. With population ageing, the absolute number of patients affected by ankle osteoarthritis is likely to increase. Unlike the hip and knee, in which the primary causes of degeneration are primary osteoarthritis and inflammatory diseases, 80% of ankle osteoarthritis is post-traumatic [2], [3]. For this reason, patients are usually younger and have higher physical demands, placing the damaged joint under increased stresses [4].
During the last decade, total ankle arthroplasty has resurged as an alternative to ankle arthrodesis in the treatment of painful ankle osteoarthritis [5]. A recent prospective controlled trial has shown that, when compared with ankle arthrodesis, ankle arthroplasty provides similar pain relief and better functional results [6].
As younger patients generally have higher physical demands, this procedure has mostly been used to treat those above the age of 50, with arthrodesis being preferentially offered to younger patients [7], [8]. This is due to reports of low clinical scores and early failure rates obtained in this subgroup of patients when using the previous generations of implants [9]. This rational, however, has not been applied to patients with osteoarthritis affecting other lower limb joints. In fact, young patients with total hip and knee arthroplasties perform better in terms of pain, disability and quality of life, and have survirvorship and revision rates at least comparable to older patients [10], [11], [12], [13], [14].
The fact that an implant can last several years, providing optimal quality of life has possibly been responsible for a recent change in this paradigm. Nowadays, a joint replacement is not necessarily a surgery for the old and inactive patient. In fact, some of the more recently published results on ankle replacements include patients under the age of 50 [15], [16], [17], [18], [19]. However, there is still controversy as to whether it should be used in this subgroup of patients and, to date, no study has directly compared the results of this procedure in young and old patients using the most recent ankle implants.
Since January 2005, a multicentric study has been conducted in Portugal and Spain to analyse the results of total ankle arthroplasty in the treatment of painful end-stage ankle osteoarthritis. This procedure has been performed independently of patient's age. The aim of this separate study was to analyse the clinical results, and survivorship between young and older patients submitted to total ankle replacements.
Section snippets
Study and prosthesis description
In January 2005 a prospective multicentric study was initiated in Portugal and Spain with the objective of analysing total ankle replacement results and its early to medium-term results, together with a detailed analysis of complications of the initial 119 cases were subjected to a separate publication in this issue [20].
The Salto® prosthesis (Tornier, Saint Ismier, France) was used in all cases. This prosthesis has been used in Europe since 1997; it is a third generation, non-cemented
Clinical and functional results
Patients in both age groups had equivalent mean pre-operative AOFAS scores (26.7 points (range, 15–51) in the <50 group versus 27.0 points (range, 10–55) in the ≥50 group, p = 0.848). A significant increase in the AOFAS score was seen in both groups from their pre-operative value to their values at follow-up (p < 0.001). This increase, however, was significantly higher in the <50 group (mean 66.8 points (range, 46–85) versus 62.8 (range, 20–80) points in the ≥50 group, p = 0.048), as was the mean
Discussion
Ankle replacement has traditionally been reserved for patients above the age of 50. The reason for this is that older patients have lower physical demands and will, therefore, place the prosthesis under considerable less stress, preventing premature failure [7], [8]. In the 21st century, however, information is widespread and it is not infrequent for patients to be aware of treatment alternatives and to approach surgeons enquiring about a specific intervention. Ankle arthroplasty is obviously
Conflict of interest statement
The authors declare they have no conflict of interest
Authorship
All authors were fully involved in the study and preparation of the manuscript. This material has not been and will not be submitted for publication elsewhere.
Acknowledgment
The authors would like to thank all the attending surgeons at local Hospitals for assisting in patient evaluation and follow-up.
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Total Ankle Replacement Options
2019, Clinics in Podiatric Medicine and SurgeryCitation Excerpt :It was previously thought that patients younger than 50 may not be suitable for TAR. However, studies are showing good clinical and functional outcomes in patients younger than 50 as well as in patients older than 70.11–13 However, the literature is dense with data showing increased rates of revision in younger patients;14 with advances in surgery and in implants, age is a factor that continues to vary.