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Arthritis of the Ankle
Primary arthritis of the ankle is rare—6-9%
- Trauma is the most common cause of ankle arthritis—approximately 80% (malleolar ankle fracture, 39%; distal tibia pilon fracture, 16%; ligamentous injuries, 14%). Avascular necrosis of talus, hemophilia, gout, infection, and malalignment from paralytic deformity are some other causes.
- •Many patients with ankle arthritis can be effectively managed without surgery.
- •Historically, ankle arthrodesis has been the current gold standard for surgical treatment of ankle arthritis in which conservative measures have failed
- Ankle replacement is an alternative surgical treatment option for end-stage arthritis in carefully selected patients, although long-term results are less predictable
History
- •Ankle stiffness, swelling, and pain
- •Most often unilateral
- •Difficulty with inclines and stairs secondary to impingement
- •Often report history of trauma or instability (recurrent ankle sprains)
- •Less commonly, history of inflammatory arthropathy, infection, or bleeding
- •History of swelling, erythema, or warmth without significant pain in a patient with neuropathy may suggest Charcot (neuropathic) arthropathy, which is most frequently related to diabetes.
Physical Examination
- •Observation
- •Effusion/swelling
- •Surgical scars
- •Deformity, limb/hindfoot malalignment
- •Gait
- •Palpation
- •Tenderness at anterior ankle joint line
- •Lateral hindfoot pain indicates subtalar involvement.
- •Range of motion
- •Ankle (dorsiflexion/plantarflexion); compare with contralateral side
- •Hindfoot motion (inversion/eversion); assess for concomitant hindfoot (subtalar) arthritis
- •Special tests
- •Diagnostic injection: Injection of local anesthetic into the ankle or subtalar joint can help differentiate ankle from subtalar joint pain.
- •Use of contrast and fluoroscopy can ensure appropriate placement of the injection.
- •Addition of steroid can provide short-term relief.
Imaging
- •Radiographs
- •Anteroposterior and mortise (15-degree oblique) views of the ankle
- •Assess for loss of joint space, syndesmosis, widening, angular deformity, subchondral sclerosis, evidence of previous trauma.
- •Anteroposterior and mortise (15-degree oblique) views of the ankle
Lateral view of the ankle
- •Anterior or posterior osteophytes result in impingement.
- •Assess for subtalar joint.
- Anteroposterior, oblique, and lateral weight-bearing views of the foot
- •Assess for concomitant degenerative changes, malalignment.
- Anteroposterior, oblique, and lateral weight-bearing views of the foot
- •Computed tomography
- •Not required to make the diagnosis
- •Study of choice to assess adjacent joint arthritis
- •Magnetic resonance imaging
- •Useful to assess for localized osteochondral lesions of the talus or associated tendon disorders, but generally not required in cases of advanced ankle arthritis
Differential Diagnosis
- •Charcot (neuropathic) arthropathy: swelling, minimal pain in relation to the destructive bony architectural changes on radiographs
- •Acute gouty arthritis: acute onset, history of gout, joint effusion
- •Subtalar arthritis: pain walking on uneven surfaces, limited and painful hindfoot inversion/eversion, pain localized laterally over sinus tarsi (inferior to the tip of the fibula); diagnostic subtalar injection if source of pain is unclear
- •Osteochondral lesion of the talus: paroxysmal pain with locking, catching, or instability; focal defect noted on plain radiographs; magnetic resonance imaging to further evaluate
Treatment
- •At diagnosis
- •Initial management is nonoperative.
- •Lifestyle modifications include weight loss in obese patients (joint reactive forces in the ankle are estimated at five times the body weight during normal gait), termination of vigorous activities, and changing to a more sedentary job, if possible.
- •Antiinflammatory medications and intra-articular steroids may be useful for symptomatic management, particularly for acute exacerbations.
- •Injectable viscosupplementation is also an option if steroids are contraindicated or there is a need for to delay surgery. It has not been U.S. Food and Drug Administration (FDA) approved for use in the ankle joint, and reports on efficacy are unclear.
- •Later
- •Chronic arthritis pain may be managed with mechanical unloading via modified footwear or a brace.
- •Shoe modifications with a rocker-bottom sole and solid ankle cushioned heel may improve gait dynamics and symptoms.
- •A custom polypropylene ankle-foot orthosis or Arizona ankle-foot orthosis brace may provide symptomatic relief, particularly in the setting of deformity or instability.
- •Finally, a trial of immobilization in a short-leg walking cast may provide symptomatic relief and simulate an ankle fusion for patients contemplating surgery.
When to Refer
- •Patients with radiographic or clinical evidence of anterior impingement, loose bodies, or osteochondral lesions that may be amenable to open or arthroscopic debridement should be referred.
- •Patients with radiographic or clinical malalignment (e.g., previous malunited tibia fracture) may be candidates for surgical realignment procedures.
- •Finally, all patients who have end-stage arthritis and debilitating symptoms despite adequate nonoperative management should be referred for consideration for arthrodesis (fusion), joint replacement, or operative joint distraction procedures.
Prognosis
- •The use of rigid custom brace (ankle-foot orthosis or Arizona ankle-foot orthosis) can be a very successful treatment choice for patients who are compliant with brace use.
- •Common complaints include difficulty donning the brace, restricted range of motion, shoe-wear difficulty, cosmetic appearance, and pain when out of the brace.
- •Ankle arthrodesis is the most reliable surgical intervention with a high rate of fusion and pain relief using current surgical techniques. Ankle arthroplasty has become more popular in recent years as implants and techniques have improved, although long-term outcome studies are lacking.
- •Despite successful fusion, patients can have difficulty with uneven ground, stairs, driving, prone sleeping, and increased risk of arthritis in adjacent joints.
- •Recent gait analysis has shown a more symmetrical gait with reduced limp in patient with ankle replacement compared with fusion.
- •The benefits of an improved gait must be weighed against the less predictable longevity of ankle replacement and the higher complication rate.
Troubleshooting
- •Patients should be counseled on risks and benefits of surgery.
- •Fusion results in predictable relief of pain and good preservation of function in many patients. Permanent stiffness results from fusion.
- •Smokers (high risk of fusion failure) and patients with involvement of the adjacent joints are less likely to have a successful outcome with fusion.
- •Despite recent advances, ankle replacement remains in the early stages compared with total knee and hip replacement, with far less predictable results and limited long-term outcome studies, and patients should adjust their expectations accordingly.
Patient Instructions
- •There are multiple lifestyle modifications that can be made to help alleviate the pain from ankle arthritis.
- •Activities such as swimming, elliptical bike, and seated weight lifting are excellent for physical fitness yet minimize the impact on the ankle.
- •Avoidance of running, uneven ground (sand, grass, and gravel), inclines, and stairs will minimize the discomfort.
- •Walking is encouraged and will not cause the arthritis to worsen.
- •Using shoes with a rocket bottom is very helpful for relieving pain.
- •These can be custom made or purchased over-the-counter at many shoe stores.
- •Use of a boot limits ankle range of motion and will also provide relief during walking.
- •Given the restriction in the range of motion from arthritis, wearing a shoe with a small heel can decrease the pain from the spurs that commonly occur in the front of the ankle.
- •Ice and antiinflammatory medications can help reduce discomfort.
Considerations in Special Populations
- •Patients who are obese, diabetic, dysvascular, or smokers are poor candidates for ankle replacement surgery, given the risk of wound complications and risk of amputation. In addition, young patients and those with high-demand occupations may not be appropriate. Ankle fusion is the procedure of choice in this patient population, although each case is evaluated individually. In patients with poor soft-tissue envelope and minimal ankle deformity, arthroscopic ankle fusion is also an option.
Suggested Readings
- Coester LM, Saltzman CL, Leupold J, et al.: Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001; 83: pp. 219-228.
- In Coughlin MJ, Saltzman C, Anderson RB (eds): Mann’s Surgery of the Foot and Ankle., 9th ed 2014. Elsevier, Philadelphia
- Knecht SI, Estin M, Callaghan JJ, et al.: The agility total ankle arthroplasty. Seven- to sixteen year follow-up. J Bone Joint Surg Am 2004; 86: pp. 116-171.
- Lawton CD, Butler BA, Dekker RG, et al.: Total ankle arthroplasty versus ankle arthrodesis—a comparision of outcomes over the last decade. J Orthop Surg Res 2017; 12 (1): pp. 76.
- In Myerson MS (eds): Foot and Ankle Disorders. 2000. WB Saunders, Philadelphia
- Raikin SM, Rasouli MR, Espandar R, et al.: Trends in treatment of advanced ankle arthroplasty by total ankle replacement or ankle fusion. Foot Ankle Int 2013; 35: pp. 216-224.
- Soohoo NF, Zingmond DS, Ko CY: Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am 2007; 89A: pp. 2143-2149.
- Thomas R, Daniels TR, Parker K: Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am 2006; 88A: pp. 526-535.
- Thomas RH, Daniels TR: Ankle arthritis. J Bone Joint Surg Am 2003; 85A: pp. 923-936.