Distraction Arthroplasty

Basic Theory of Distraction

Mechanical stress upon joint surfaces may inhibit the ability of
articular cartilage to undergo a reparative process
Distraction arthroplasty is based on the hypothesis that
articular cartilage repair can occur when the joint is unloaded
Mechanical unloading is achieved for several months with a
ring external fixator device.
Cartilage can undergo a healing phase undisturbed by axial loading
and shear forces

Subchondral bone remodeling occurs with distraction and may

affect cartilage repair
Subchondral bone remodeling has been linked to clinical improvement.
Manns Surgery of The Foot and Ankle:

Basic Theory of Distraction

Distraction arthroplasty is also based on the hypothesis that articular
cartilage can repair when joint is subjected to intermittent fluid
pressure change
During distraction, loading and unloading of the joint during weight
bearing results in intraarticular hydrostatic pressure changes.
These pressure changes are facilitated by allowing the patient to weight bear
with the frame in place causing fluctuations in intra-articular hydrostatic
pressure between swing phase and heel strike.
This movement of joint fluid is thought to improve the local environment for
cartilage healing

It is thought that intermittent flow is further enhanced by incorporating

articulated distraction with a hinge which allows for ankle joint range of
motion while in the frame
Manns Surgery of The Foot and Ankle:
Volume OneTellisi : Foot and Ankle

Patient Selection is Key

The optimal candidate is..
Compliant and motivated
Younger than 50 years
One who has posttraumatic arthritis or chronic ankle instability with
arthritis
No previous history of ankle joint sepsis or ankylosis
Has appropriate psychosocial support system to facilitate recovery

Demanding occupations may prevent optimal clinical results

Patients preferred recreational activities should be
nonimpact ones, such as swimming and bicycling.
Manns Surgery of The Foot and Ankle:

Rationale for your 22 year old

patient
You can delay the need for joint-sacrificing surgery
Distraction minimizes adjacent joint arthritis following
ankle arthrodesis and increases implant longevity
following total ankle arthroplasty.

Nguyen : Journal of Bone and Joint Surgery 201

Intermediate-Term Follow-up After Ankle

Distraction for Treatment of End-Stage
Osteoarthritis: JBJS 2015
29 patients underwent distraction arthroplasty
45% of the patients underwent a conversion procedure
by a mean of 8.3 2.2 years
Sixteen (55%) of the twenty-nine patients still had the
native ankle joint

Nguyen : Journal of Bone and Joint Surgery 201

Do you need to use a hinge?

Motion Versus Fixed Distraction of the Joint in the Treatment
of Ankle Osteoarthritis: JBJS 2012
Prospective randomized controlled trial comparing the outcomes with
fixed ankle distraction or ankle distraction permitting joint motion.
2 years after frame removal both groups showed significant
improvement
The motion-distraction group had significantly better AOS scores than
the fixed-distraction group
Conclusion: Level one evidence that distraction improved the
patient-reported outcomes of treatment of ankle osteoarthritis and
that adding ankle motion to distraction showed an early and
sustained beneficial effect on outcome.
Saltzman: Journal of Bone and Joint Surgery 2012

More Clinical Evidence It Can Work

Joint Preservation of the Osteoarthritic Ankle Using Distraction
Arthroplasty: FAI 2009
25 patients who under-went distraction arthroplasty.
All patients had painful posttraumatic ankle OA with preserved ankle range
of motion (at least 20 )
A 2-ring hinged fixator was used, with hinges placed along the axis of the
ankle motion. The ankle was distracted approximately 5 mm.
The frames were removed after 12 weeks after index surgery.
The mean follow-up in this study was 30 months
91% of patient experienced substantial pain relief.
The average AOFAS score significantly improved from 55 to 74.
The motion of the tibiotalar joint was maintained in all patients.
Two patients had undergone ankle arthrodesis because of progressive
ankle osteoarthritis
Tellisi : Foot and Ankle International 2009

Radiographic Evidence it Can Work

MRI Evaluation of Ankle Distraction: A
Preliminary Report: Clinics 2009
Pre-op and post-op MRI taken 3 patients treated with
hinged ankle distraction
MRI scans showed subchondral bone thickness
decreased by 0.5 mm and the average postoperative
cartilage thickness increased by an average of 0.5 mm.
The preoperatively observed subchondral bone cysts of
the talus and tibia decreased in number and size

Lamm : Clinics Podiatric Medicine and Surgery 2

MRI Evaluation of Ankle Distraction: A Preliminary Report:

Clinics 2009

Joint space or cartilage thickness appearing wider after

surgery

Lamm : Clinics Podiatric Medicine and Surgery 2

Radiographic Evidence it Can Work

Subchondral bone remodeling is related to clinical
improvement after joint distraction in the treatment
of ankle osteoarthritis: Osteoarthritis Cartilage 2011
26 patients with posttraumatic ankle OA treated with joint
distraction for 3 months using an Ilizarov frame
CT evaluated at 1 and 2 year follow up look at subchondral
bone density, analyzing width of joint space and bone
density.
Decreases in subchondral bone density were observed
postoperatively.

Intema : Osteoarthritis Cartilage 2011

Subchondral bone remodeling is

related to clinical improvement
after joint distraction in the
treatment of ankle
osteoarthritis: Osteoarthritis
Cartilage 2011

A: pre op
D: immediately after
distraction
C: 1 year post op
D: 2 year post op
From A to D you can
appreciate a decrease of
density in the sclerotic
area was observed,
whereas the cartilage layer
seemed to increase

Intema : Osteoarthritis Cartilage 2011

Bad News
Evidence-Based Indications for Distraction Ankle
Arthroplasty: FAI 2012
171 articles reviewed and they attempted to provide
evidence based recommendations for use of distraction
arthroplasty
Conclusion: Inadequate evidence based literature
exists to support or refute all currently accepted
indications for distraction ankle arthroplasty

Smith : Foot and Ankle International 20

Get me in on this case!

Joint salvage option definitely best option at 22 years of age
My review supports distraction as a good and viable treatment option
He is very young with posttraumatic ankle osteoarthritis
He has well-preserved hindfoot motion
He is relatively ideal candidate due to physical demands and adequate support
system
He should get clinical improvement without burning any bridges for future
operations when needed
Nguyen found that older age was a positive predictor of intermediate-term outcome,
and commented that this may be due to the younger patients having higher
expectations and physical demands.
He should probably know that pain relief is generally incomplete
About half the patients go for a definitive conversion in about 8 years according to literature

Nguyen : Journal of Bone and Joint Surgery 201