Electronic Letters to:

Foot and Ankle: P. L. R. Wood, H. Prem, and C. Sutton Total ankle replacement: MEDIUM-TERM RESULTS IN 200 SCANDINAVIAN TOTAL ANKLE REPLACEMENTS J Bone Joint Surg Br 2008; 90-B: 605-609 [Abstract] [Full text] [PDF]

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Electronic letters published:

Total ankle replacement comparison between osteoarthritis and inflammatory arthritis

Inder P S Gill   (17 September 2008)

Correction to 'Total ankle replacement' paper

Peter LR Wood   (11 June 2008)

STAR total ankle replacement

A. Vannineuse   (10 June 2008)

Clarification of medium-term results in 200 Scandinavian total ankle replacements

Andrew D Carrothers, Paul Cool   (6 June 2008)

Total ankle replacement comparison between osteoarthritis and inflammatory arthritis 17 September 2008
Inder P S Gill, Specialist Registrar Northern Deanery Send letter to journal: Re: Total ankle replacement comparison between osteoarthritis and inflammatory arthritis ipgill{at}yahoo.com Inder P S Gill	Sir, I read with interest the article by Wood et al1 in the May 2008 issue entitled, 'Total ankle replacement: medium-term results in 200 Scandinavian total ankle replacements.' The results do show greater revision rates as compared with other lower limb arthroplasties. It would be very helpful if the results were stratified by osteoarthritis and inflammatory arthritis. These are two separate group of patients with different functional demands. Total ankle replacement is generally well accepted for inflammatory arthritis, although there is still controversy in its use in osteoarthritis as compared with ankle fusion. Thus, a comparison between the two groups would really be informative as the number of patients in each group is quite significant (119 and 81 respectively). As suggested in another letter in response to this article, stratification by age would also be helpful. The article is very informative and does add to the volume of literature in support of total ankle replacement, although there is still a little way to go before it reaches the levels achieved by hip and knee replacements. I.P.S. Gill, Specialist Registrar, Northern Deanery, Newcastle upon Tyne, UK. 1. Wood PLR, Prem H, Sutton C. Total ankle replacement: medium-term results in 200 Scandinavian total ankle replacements. J Bone Joint Surg [Br] 2008;90-B:605-609.
Correction to 'Total ankle replacement' paper 11 June 2008
Peter LR Wood, Consultant Orthopaedic Surgeon Wrightington Hospital, Wrightington, Wigan and Leigh NHS Trust Send letter to journal: Re: Correction to 'Total ankle replacement' paper d.gray{at}jbjs.org.uk Peter LR Wood	Sir, In the first paragraph of our May 2007 paper entitled, "Total ankle replacement: medium-term results in 200 Scandinavian total ankle replacements" we stated that the Scandinavian total ankle replacement was approved for general use by the Federal Food and Drug Administration in April 2007. We now realise that this was a recommendation for approval made to the FDA by The Orthopaedic and Rehabilitation Devices Panel of the FDA's Medical Devices Advisory Committee, following a review of STAR safety and effectiveness. The FDA is to consider the recommendation before making a final decision and that final decision is still pending. We apologise for the misrepresentation and any inconvenience it may have caused. In response to the letters please refer to the table that appeared in the earlier article published in the Journal of Bone and Joint Surgery in April 2003.1 There were 115 women and 85 men. The mean age for the whole group was 60 years (18 to 83). For those with rheumatoid disease the mean age was 58 years (18 to 83) and 23 of the 119 were aged under 50 years. For those with osteoarthritis (OA) the mean age was 63 years (31 to 82) and six of the 81 were aged under 50 years. There was no loss to follow-up except by patient's death. The mean follow-up for the 176 unrevised ankles was 80 months (4 to 156). In total 27 patients died (33 ankles), giving an overall mortality of 13.5%. This was 17.6% for rheumatoid and 7.4% for OA. P.L.R. Wood, FRCS, Consultant Orthopaedic Surgeon, Wrightington Wigan and Leigh NHS Trust, Wigan, UK. 1. Wood PLR, Deakin S. Total ankle replacement: the results in 200 ankles. J Bone Joint Surg [Br] 2003;85-B:334-41.
STAR total ankle replacement 10 June 2008
A. Vannineuse, Orthopaedic Trauma Surgeon Centre Hospitalier - Chauny - France Send letter to journal: Re: STAR total ankle replacement alchir{at}aliceadsl.fr A. Vannineuse	Sir, I have appreciated the paper by Wood et al concerning the STAR prosthesis. However, two things are missing. Firstly, the age range of the patients and secondly, the results according to age. The younger the arthrodesis is undertaken, the greater is the handicap. Post-traumatic osteoarthritis of the ankle in young patients remains a challenge. The survival curve of the ankle prosthesis probably gives it no place in the management of these patients. What is the opinion of the authors? A. Vannineuse, MD, Orthopaedic Trauma Surgeon, Centre Hospitalier - Chauny, Chauny, France.
Clarification of medium-term results in 200 Scandinavian total ankle replacements 6 June 2008
Andrew D Carrothers, Specialist Registrar West Midlands Oswestry Rotation, Paul Cool Send letter to journal: Re: Clarification of medium-term results in 200 Scandinavian total ankle replacements carrothersandrew{at}hotmail.com Andrew D Carrothers, et al.	Sir, With interest we read the Wood, Prem and Sutton paper in the May 2008 issue entitled ‘Total ankle replacement’ and congratulate them on their published medium-term results. We would, however, raise a number of issues. Results state that out of 200 ankles in 184 patients, 143 ankles (137 patients) had a mean follow-up of 88 months and 43 months for 33 ankles (27 patients) who had died. We would seek clarification as to whether the 20 remaining patients are those who have been revised (24 ankles) or whether these patients have been lost to follow-up. It is unusual to split the mean result between remaining live patients and those who have died. The ‘missing’ 20 patients, if revised, should be included in the mean follow-up data, and if they have been lost to follow-up this should be made clear. In the Methods section, the authors state that the Kaplan-Meier analysis has been used to assess survival. However, the table clearly shows life-table analysis in conjunction with a Kaplan-Meier graph.1 This is confusing although it is accepted that the result is probably little different. Twenty percent seems a high mortality rate although the average age has not been stated. It is accepted, however, that patients with inflammatory joint disease have co-morbidities and reduced life expectancy. It is reasonable to count patients who died with a good functioning total ankle replacement as a success in survival analysis. This is not necessarily true for patients who have been lost to follow-up. The number of patients lost to follow-up is not clearly stated, but results suggest this could be as high as 20 (24 ankles). If this is true, the ‘worst-case’ survival curve would be altered significantly. If these 20 patients are those who had revision the average follow-up would be decreased. It would be interesting to compare the medium-term results for the 119 inflammatory arthritic ankles with the 81 osteoarthritic ankles. Once again we would like to congratulate Wood et al for presenting their results and we look forward to their further clarification. A. Carrothers, MRCS, Specialist Registrar, P. Cool, FRCS, Consultant Orthopaedic Surgeon, Royal Shrewsbury Hospital NHS Trust, Shrewsbury, UK. 1. Cool P. Medical Statistics. Second ed. Institute of Orthopaedics (Oswestry) Publishing Group, 2007:109-133.