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End‐stage haemophilic arthropathy of the ankle: ankle fusion or total ankle replacement

In the final stages of haemophilic arthropathy of the ankle, when the joint is severely destroyed and the intense joint pain and/or major functional disability do not respond to non-surgical treatment (haematological prophylaxis, analgesics, anti-inflammatories, orthotics) or conservative surgical treatment of the joint (arthroscopic debridement, arthrodiastasis, supramalleolar osteotomy for realignment), we can consider the need to conduct an arthrodesis or a total ankle replacement (TAR) [1–4]. Today there is much controversy about which technique is most advisable in haemophilia (arthrodesis or TAR). The purpose of this letter is to review the literature on arthrodesis and TAR in the non-haemophilic population and in patients with haemophilia, to try to clarify the above controversy. Systematic reviews and registries have shown that prosthetic survival of the TAR in the general population is far from that of total hip replacements (THR) and total knee replacements (TKR) [5–8] (Table 1). TAR survival at 14 years is 77%, while that of THR is 93% and 88% at 15 and 20 years respectively.TKR survival is somewhat less than that of THR, 84% and 71% at 10 and 20 respectively [9,10]. Obviously, there are no TAR survival studies with over 14 years of follow-up. My opinion is that TAR survival will not come close to that of THR and TKR in the near future in the population with advanced ankle degenerative arthrosis. We must not forget that TAR currently presents a high complication rate, failures and revision (Table 2). The literature with a high level of scientific evidence does not clarify the controversy over TAR or ankle arthrodesis, but it does state that TAR has not reached the levels of survival of THR and TKR. The literature on TAR vs. ankle arthrodesis in haemophilia is very limited and has a limited degree of evidence. Therefore, the literature does not tell us which of the two techniques is more suitable in advanced haemophilic ankle arthropathy. Before TAR or arthrodesis we should think about arthroscopic debridement, arthrodiastasis or supramalleolar osteotomy for realignment [1–4]. In a period of 36 years (1976–2012), the author performed 454 orthopaedic surgical procedures on 398 haemophilic patients. Of these, only six were ankle procedures: four arthroscopic debridement, two ankle arthrodesis (one tibiotalar, one tibiotalocalcaneal). To date, we have not performed any TARs given their short survival in the long term and high rate of complications. In our experience, ankle arthropathy can be sufficiently relieved in a large percentage of cases with non-surgical treatment, and the need for surgical intervention on this joint is very rare. For us, removing the ankle joint (via arthrodesis or TAR) is always the last option: we always try arthroscopic debridement before considering arthrodesis or TAR. On the other hand, given the controversy in the literature on ankle arthrodesis or TAR and the lack of literature on the subject in haemophilia, I currently tend to prefer arthrodesis to TAR in people with haemophilia. If the subtalar joint is affected, I prefer open tibiotalocalcaneal arthrodesis with locking nail. If not, I would opt for open tibiotalar arthrodesis with crossed cannulated screws or staples. The current literature concerning the controversy on ankle arthrodesis or TAR in non-haemophilic patients is not definitive (it does not clarify the controversy). As regards haemophilic patients, the uncertainty is even greater, as there is very little literature available. On the basis of all of this and on my 36 years of experience treating people with haemophilia, my advice is to exhaust all types of non-surgical treatment. When surgical treatment is considered absolutely necessary, my recommendation is to conserve the joint at all costs using arthroscopic debridement, arthrodiastasis or supramalleolar osteotomy for realignment, according to each surgeon’s preferences. If these techniques fail, when in doubt on whether to perform arthrodesis or TAR, in haemophilia I would always opt for arthrodesis, as the current results for TAR quite frankly have much room for improvement. It is likely that in the mid-long term, new TAR designs will allow these results to improve. It is really hard, however, to achieve definitive conclusions with such limited numbers in haemophilic patients. Correspondence: E. Carlos Rodriguez-Merchan, Department of Orthopaedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046-Madrid, Spain. Tel.: +34 60 671 2724; fax: +34 91 571 2871; e-mail: ecrmerchan@gmx.es