Clinical Research on Foot & Ankle
Open Access

We conducted a retrospective analysis on 12 patients who underwent lateral approach Total Ankle Arthroplasty (TAA) along with supplementary procedures such as Subtalar joint fusion, Tibionavicular fusion, Syndesmotic repair, First metatarsophalangeal joint fusion, Perineal tendon repair, and Lateral Ankle Ligament stabilization. Results revealed a notable improvement in postoperative AOFAS scores, averaging 89.25 across all patients, surpassing outcomes typically reported for isolated lateral approach TAR. Furthermore, at an average follow-up of 23.7 months, there were no instances of nonunion, and the infection rate remained at 0%. Our study underscores the efficacy of the lateral approach in facilitating additional procedures while ensuring biomechanical stability of the hind foot joint complex. This approach allows for streamlined access to address clinical and radiographic arthritis sequela, potentially obviating the need for staged or omitted hind foot arthrodesis. Moreover, employing a lateral incisional approach enables efficient execution of lateral ankle ligament stabilization procedures and subtler joint preparation for fusion, thereby reducing operative time and anesthesia duration. An IRB exempt retrospective cohort chart review was performed which included a total of 22 patients who underwent total ankle arthroplasty utilizing a lateral approach performed by a single surgeon from April of 2019 to September of 2021. Patients were excluded if follow up was less than one year, 1year post-op AOFAS scores were not available, and no concomitant procedures were performed in addition to TAR. Average age of patients and follow up was 60 years and 23.7 months respectively.

Patients were positioned supine on the operative table with a bump under the ipsilateral hip. An 8 cm incision beginning with the fibula along the sinus tarsi and somewhat poster lateral to the base of the fifth metatarsal. Deep dissection commenced down to periosteal where a fibular osteotomy was performed in an oblique fashion from 2.5 cm proximal to the ankle joint. The anterior talofibular ligament was then sectioned and the posterior capsule and respective ligaments released. The fibula was reflected posteriorly and distally into the calcaneus. Using the Zimmer Biomet (ZB) system, a stabilization and alignment guide was applied to the lower extremity and connected with half pins to realign the ankle in all planes. The fibular osteotomy was repaired with a 3.5 interfragmentary screw in a lag fashion and was supplemented with a locking plate. A lateral incisional approach was used for all subtler joint arthrodesis surgeries, and curettage, subchondral drilling, and fish scaling with a ¼ inch osteotomy was utilized for joint preparation. Fixation was subsequently achieved with one single 6.5 mm partially threated, cannulated screw. For the talonavicular arthrodesis, a 5 cm incision was made along the dorsomedial column and joint preparation was performed in a similar fashion to the subtalar joint utilizing curettage, subchondral drilling, and fish scaling. Fixation was achieved with a 4.0 mm partially threaded cannulated, cancellous lag screw oriented distal medial to proximal lateral across the joint in addition to a locking plate or one 4.0 mm screw with two compression staples. Postoperatively, patients were made non weight bearing for 6 weeks to 8 weeks and progressed to full weight bearing after osseous consolidation had been demonstrated radiographically. Passive range of motion exercises were initiated at the time of incision healing. Physical therapy was initiated at the time of progression to full weight bearing around the 6 weeks to 8 weeks mark.

A total of 12 subjects were included in post-operative analyses after a mean follow up of 23.7 months. There were 9 males and 3 females within this group with an average age of 60.25 years (Range 50-66). Post traumatic arthritis was the most common etiology followed by primary osteoarthritis. The most frequent complication was hypertension in 10 patients followed by elevated cholesterol levels in 4 cases.

At the final follow-up, diagnostic and postoperative radiographs were reviewed, and no wound healing issues were found. Each patient's post-operative AOFAS was computed. Average sagittal ROM was 7.66 and total pain for the cohort at 32.5. Average activity, distance, and surfaces scores were 7.91, 4.83, and 4.33 respectively. Average total AOFAS amongst the entire cohort was reported to be 89.25. Average tourniquet time across the cohort was 126 minutes.

There was one reported complication of medial gutter pain which ultimately required a gutter debridement and hardware removal. There were no reported cases of implant subsidence or per prosthetic latency and all patients stated they would undergo the procedure again.

A key concern with a lateral approach stems around the sectioning of the lateral ankle ligamentous complex. In our center, we have not experienced lateral ankle instability with isolated TAA or in concomitant procedures. No patients in our study had experienced complications related to the fibular osteotomy or lateral ankle ligamentous repair. Gutter impingement has been reported to occur throughout anterior approach anywhere from 17-21% for anterior approach. Although a limited cohort, we did encounter 1 patient with post-operative medial gutter pain requiring further debridement [1-10].

Ankle-hind foot mean post-operative AOFAS score of 80 was previously reported in a recent cohort of 50 isolated lateral approach TAA patients. Following a final follow-up, our center reported a final mean AOFAS score of 89.25, exceeding previous reports of scores of 84.3 and 86.0 from an anterior approach without concurrent procedures. Our post-operative outcomes and low complication rate have been slightly increased compared to what has been previously reported in the literature at short term follow up. However, this did not meet statistical significance given the absence of preoperative AOFAS scores which is certainly a limitation of this study. Given there has not been any report on TAA with ancillary procedures, we suggest that this approach is safe and allows for more anatomic visualization of the native ankle mortise and allows for additional procedures to be performed through a lateral incision thus decreasing tourniquet time and time under anesthesia. Lateral approach TAA may be considered in patients requiring additional procedures, while certainly subsequent studies with longer follow up will be warranted as the data becomes available [11-27].

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