CONSENSUS RECOMMENDATION No eligible comparative studies evaluating arthroscopic debridement, periarticular osteotomy, or distraction arthroplasty vs appropriate controls in patients with ankle osteoarthritis (OA). Most available studies were case series, technique reports, or retrospective cohort studies with no relevant comparator, small sample size, or outcomes below inclusion thresholds. Therefore, this recommendation is based on expert consensus.
Benefits and Harms
Potential benefits:
- Pain relief and improved functional scores
- Delay or avoidance of joint-sacrificing procedures
- Preservation of motion and potential restoration of alignment or joint mechanics
Potential harms:
- Procedure-specific complications (infection, neurovascular injury, hardware problems, nonunion/malunion for osteotomy, pin-site infection for distraction)
- Longer rehabilitation time and higher resource utilization (distraction)
- Possible progression to end-stage arthritis despite intervention
Outcome Importance
For younger or more active patients, delaying arthrodesis or arthroplasty while maintaining ankle motion aligns with patient preferences, emphasizing activity, motion, and avoidance of fusion or implant surgery. Preservation of joint motion and pain relief are important considerations in patients with ankle arthritis, especially those who want to lead an active lifestyle.
Cost Effectiveness/Resource Utilization
Surgery is generally costly, however, distraction is more costly than supramalleolar osteotomy (SMO), which is more costly than arthroscopy. Arthroscopy, being minimally invasive and commonly available, represents the least resource-intensive option but may yield more limited benefit in advanced OA.
Distraction and osteotomy require specialized equipment, prolonged rehabilitation, and extended follow-up, which increase cost compared to arthroscopy.
Acceptability
This will depend on both surgeon and patient factors. The joint-preserving options discussed in the recommendation are widely accepted among surgeons experienced in reconstructive foot and ankle surgery. However, acceptability varies by institutional expertise, access to postoperative resources, and patients' willingness to commit to a prolonged recovery (distraction). Additionally, older and lower demand patients may opt for total ankle (TAR) or ankle arthrodesis (AA).
Feasibility
Arthroscopy is feasible in most centers with arthroscopic capabilities. Osteotomy and distraction require more advanced surgical expertise, preoperative planning, and infrastructure support (distraction).
Future Research
- Identify clear indications/contraindications for each joint-preserving technique
- Evaluate comparative outcomes (ie. pain, function, time to conversion to fusion/TAA, impact on subsequent outcomes after fusion/TAA)
- Standardize PROMs and long-term follow-up
- Investigate cost-effectiveness and value-based frameworks for joint-preserving surgery in ankle OA
Summary
No eligible comparative evidence currently supports or refutes the use of arthroscopic debridement, periarticular osteotomy, or distraction arthroplasty for the treatment of ankle OA.
However, based on clinical experience and non-comparative literature, these procedures may offer meaningful symptomatic relief and delay more definitive joint-sacrificing options for appropriately selected patients seeking motion preservation.
Additional Citations Not Meeting Inclusion Criteria
Arthroscopy
- Hassouna et al., 2007 — 5yr survival analysis. Reports durable symptom improvement and survivorship without immediate conversion to arthrodesis/TAA in select cases (when impingement/focal pathology coexists with early OA).i
- Herrera-Pérez et al., 2019; 2020 — Post-debridement motion-facilitation associated with improved symptoms and function in degenerative ankles.ii, ii
? Short- to mid-term pain and functional improvement in carefully selected patients with early/moderate ankle OA w/impingement or focal lesions
Osteotomy
- Ahn et al., 2015 — Distal tibial osteotomy (without fibular osteotomy) for medial ankle arthritis with mortise widening. Demonstrated improved alignment and associated with pain relief and functional improvement in varus OA with preserved joint space.iv
- Krähenbühl et al., 2017; 2019 — SMO techniques/outcomes in ankle OA. Repeatedly showed pain/functional improvement and joint-space realignment in asymmetric OA. Realignment improved load distribution and PROMs; many patients delayed conversion to arthrodesis/TAA.v, vi
- Lai et al., 2022 — Reported clinically meaningful gains (pain/function) in intermediate-stage OA after SMO.vii
? Can offload diseased compartments, improve patient-reported outcomes, and delay conversion to fusion/TAA in appropriately selected asymmetric varus/valgus OA with residual cartilage.
Distraction
- Nguyen & Saltzman, 2016 — PROM improvement with delay of joint-sacrificing surgery, especially in younger/active patients.viii
- Greenfield et al., 2019 — Pain/function gains and extended time-to-conversion to fusion/TAA in selected near-end-stage OA.ix
- Barg et al., 2013 — Summarized multi-center experiences: symptom relief with motion preservation, highlighting patient-selection principles.x
? Symptom relief and postponement of joint-sacrificing surgery, particularly in younger, motivated patients seeking motion preservation. However, without comparative data, the magnitude and durability of benefit relative to continued non-operative care or joint-sacrificing procedures remain unclear.
Reference Citations
i. Hassouna H, Kumar S, Bendall S. Arthroscopic ankle debridement: 5-year survival analysis. Acta Orthop Belg. 2007;73(6):737-740.
ii. Herrera-Perez M, Alrashidi Y, Galhoum AE, Kahn TL, Valderrabano V, Barg A. Debridement and hinged motion distraction is superior to debridement alone in patients with ankle osteoarthritis: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2019;27(9):2802-2812. doi:10.1007/s00167-018-5156-3
iii. Herrera-Pérez M, García-Paños JP, González-Martín D, Ramírez-De Paz R, Herrera-Navarro L. Hinged Motion Distraction Surgery for Ankle Osteoarthritis. Tech Foot Ankle Surg. 2020;19(1):14-18. doi:10.1097/BTF.0000000000000262
iv.Ahn TK, Yi Y, Cho JH, Lee WC. A cohort study of patients undergoing distal tibial osteotomy without fibular osteotomy for medial ankle arthritis with mortise widening. J Bone Joint Surg Am. 2015;97(5):381-388. doi:10.2106/JBJS.M.01360
v. Krahenbuhl N, Zwicky L, Bolliger L, Schadelin S, Hintermann B, Knupp M. Mid- to Long-term Results of Supramalleolar Osteotomy. Foot Ankle Int. 2017;38(2):124-132. doi:10.1177/1071100716673416
vi. Krähenbühl N, Susdorf R, Barg A, Hintermann B. Supramalleolar osteotomy in post-traumatic valgus ankle osteoarthritis. Int Orthop. 2020;44(3):535-543. doi:10.1007/s00264-019-04476-x
vii. Lai L, Wang Y, Wu Y, et al. Outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomy. J Orthop Surg. 2022;30(3):10225536221132769. doi:10.1177/10225536221132769
viii. Nguyen M, Saltzman C, Amendola A. Outcomes of Ankle Distraction for the Treatment of Ankle Arthritis. Instr Course Lect. 2016;65:311-319.
ix. Greenfield S, Matta KM, McCoy TH, Rozbruch SR, Fragomen A. Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis. Strateg Trauma Limb Reconstr. 2019;14(2):65-71. doi:10.5005/jp-journals-10080-1429