Ankle Arthritis

What is Ankle Arthritis?

Ankle Arthritis is a degenerative condition of the ankle - the joint between the shin and the ankle bone. Most often ankle arthritis developed secondary to previous distal tibia, ankle or talus fracture, chronic ankle instability (untreated ankle ligament ruptures), osteochondral defects, talus AVN (collapse of talus secondary to loss of blood supply). Less commonly ankle arthritis may be caused by septic arthritis (infection), Charcot neuroarthropathy (joint destruction common in complicated diabetic patients), autoimmune conditions (rheumatoid arthritis, psoriatic arthritis etc.). Talus and tibia joint surface wears off, bone on bone contact, bone spurs, deformity and synovitis (inflammation of inner capsule layer) developed causing pain and stiffness. Walking pattern becomes abnormal, patient starts to walk with a limp. Activities of daily living become progressively more limited.

What are the nonoperative treatment options?

Nonoperative treatment may range from pain killers to steroid injection, bracing, physiotherapy and weight loss.

Steroid injection often can alleviate symptoms for an average of 3 months and can be repeated about 3 times a year. Every subsequent injection tends to provide less improvement. There is limited evidence to support the use of hyaluronic acid, platelet rich plasma (PRP), stem cell injection in ankle arthritis treatment.

Ankle foot orthoses (AFO), such as lace up brace, solid AFO or athletic ankle brace will limit range of ankle joint motion and prevent symptom aggravation. Comfortable shoes, particularly with rocker bottom sole and avoidance of walking on uneven surfaces (hiking), may prevent aggravation of symptoms.

Maintain physically active lifestyle. Take regular walks, cycling, swimming sessions. Avoid high impact activities like running, team or racket sports. Weight loss will reduce stresses going through arthritic joint and will improve general health.

What are the operative treatment options?

Early stage ankle arthritis can be treated with ankle arthroscopy, where bone spurs limiting motion are removed, cartilage defects smoothened and micro fractures (perforations made to bone underlying cartilage to form scar tissue substituting cartilage) performed. This may improve symptoms to a degree and buy time before ankle fusion or ankle replacement is necessary.

Ankle arthrodesis (fusion) is a procedure where remnants of cartilage and some underlying bone is removed. Shin bone and ankle bone are held together by metalwork construct for them to heal as one bone, eliminating the joint. Two surgical techniques of ankle fusion are practised: arthroscopic and open. Arthroscopic ankle arthrodesis (AAA) is performed with the aid of arthroscope (small camera introduced in the joint via 6-8mm incision, allowing 8 times magnified live viewing and constant joint irrigation) and a burr (instrument mincing cartilage and bone and sucking out the debris simultaneously). Two or three screws are introduced via small incisions to hold shin and ankle bone together. Open fusion is performed via open skin incisions, preparing joint surfaces with chisels, osteotomes, bone saw and using a plate and screws to hold bones together. Once the ankle joint has fused, neighbouring joints start to move more than they used to and compensate the function losses by the fusion of the ankle joint. Patient are often surprised to see how much foot movement is retained after ankle fusion.

What are the advantages of arthroscopic (AAA) over open ankle arthrodesis?

• Small incisions. Can be performed even over preexisting metalwork used to fix the fracture without a need to remove it via 6-8mm incisions

• Higher fusion rates. Reported fusion rates are more reliable and average 92-100% vs 85-95% in open surgery. However latest meta analysis shows no significant difference of fusion rates attributable to more advanced anatomical ankle fusion plate availability (1)

• Lower wound complication rates. Wound complication or infection is significantly less common in Arthroscopic Ankle Arthrodesis (AAA) 1.4%, whereas open fusion bares 10.2% wound complication risk. (2)

• Shorter hospital admission. Arthroscopic ankle fusion most of the times is performed as day case procedure. Patients are subjected to 2.29 (mean difference) longer length of stay after open ankle fusion. (1)

• Less postoperative pain (1-3)

• Better function. better Ankle Osteoarthritis Scale patient reported outcome scores in arthroscopic ankle fusions shown in up to 2 year follow up studies (3).

Total Ankle Replacement (TAR). A procedure where ankle joint is approach via a large operative incision usually in the front of the ankle. Degenerated joint is removed and replaced with a metal components introduced to the shin bone and ankle bone with a plastic liner in between. This preserves the movement that was present before the surgery, but does not restore normal ankle movement. It does help to reduce the stresses through the neighbouring joints reducing rate of their wear, however TAR components may cause bone cysts, wear and loosen requiring further surgery.

Who are best candidates for a TAR?

• Older age and lower physical demand patients. TAR tends to wear out and become loose when subjected to high repetitive load. Standard long term implant survival is Modern ankle replacement implants have limited survival studies, showing up to 97% 8 year survival rates. (5) However standard TAR 10 year survival rates are known to be 73-89% with older implant generations. Once implant wears out and becomes loose - patient needs revision TAR or takedown to fusion, which are more complex and has higher risks. Therefore ideally TAR should be offered to patients over 60

• Healthier patients with normal Body Mass Index (BMI). Patients with Systemic inflammatory conditions (Rheumatoid arthritis, Psoriatic Arthritis, etc.), patients with high BMI have worse outcomes after TAR surgery. Patients with peripheral vascular disease (Calcified arteries), Diabetes, neuropathy should not be offered a TAR, as the risk of Wound complication, infection, loosening are significantly increased.

• Ankle arthritis with minimal deformity, ligament compromise and bone loss.

• Absence of previous infection to the ankle joint. Patients with septic arthritis should not be offered TAR as it would be subjected to risk of Prosthetic Joint Infection (PJI)

What is the post operative regime following Arthroscopic Ankle Arthrodesis (AAA):

• 2 weeks no weight bearing and immobilisation in a Back slab.

• 2 weeks elevation at the heart level 23hr a day.

• At 2 weeks follow up appointment the wound check is performed.

• At 2 weeks follow up appointment waking boot is applied and weight bearing is permitted as pain allows. Usually walking with two crutches for 4 weeks is required.

• At 6 weeks follow up appointment X-Rays are obtained.

• At 6 weeks weight bearing as pain allows with no walking aid can be commenced with a walking boot

• From 6 weeks after surgery gradual return to physical activities are advised. Starting with walking, cycling,

• At 10-12 weeks follow up appointment X- Rays are obtained

• Walking without a walking boot can be commenced

• It is not recommended to drive a car for 10 weeks after surgery. (You can drive automatic gear box car 2 weeks after surgery if your left foot was operated).

Possible risks and complications:

Intraoperative

• Nerve or vessel damage (numbness, pins and needles or bleeding, necrosis)

• Anaesthetic risks

Early postoperative

• Swelling, bruising, pain

• Surgical site infection (superficial wound infection or deep bone infection - osteomyelitis)

• Thrombosis (DVT and/or PE)

Late postoperative

• Nonunion (fusion site doesn’t heal)

• Maluinion (bone heals in undesired position)

• Complex regional pain syndrome (Sensitive, swollen, atrophic foot) 0,4%

• Metalwork failure (screws break, migrate, or irritate tissues)

• Adjacent joint arthritis - subtalar, talonavicular joints may wear in 10-20 years from surgery

• Need for further surgery.

List is extensive but likelihood of these risks is small.

How to prepare for the surgery

Preoperative period

• Have WEIGHT BEARING x-ray radiograms. Lateral of the foot and ankle and AP of the ankle and dorsoplantar view of the foot.

• MRI scan is not mandatory, but helps to asses neighbouring joint state if in doubt.

• Blood tests including Full Blood Count, Coagulation screen, Urea & Electrolytes, VitD not older than 1 month;

• Tell the doctor if you have diabetes and if so have HbA1c not older than 1 month.

• Tell the doctor if you are using blood thinning medication

• You can use Aspirin throughout the procedure for cardiological reasons.

• Don’t use nicotine 6 weeks before and 6 weeks after surgery. This includes cigarettes, cigars, vape with nicotine etc. This will reduce the risk of

  • Thrombosis (DVT and PE),

  • The risk of infection by 2.04 times

  • The risk of nonunion by 2.5 times

• Use Vit D (1000IU) and Calcium (500mg) supplement 6 weeks prior and 6 weeks after the surgery.

• Use high dose Vit C (500-1000mg) 6weeks before and 6 weeks after the surgery This will reduce the risk of CRPS.

• Dont use Non steroidal anti-inflammatory drugs NSAIDs Before and 6 weeks after surgery.

On the day of surgery

• Dont eat 8 hr before surgery

• You can drink plain water up to 2hr prior to surgery

• Take your medication that you use regularly on the morning of surgery.

1. Lorente A, Pelaz L, Palacios P, Bautista IJ, Mariscal G, Barrios C, Lorente R. Arthroscopic vs. Open-Ankle Arthrodesis on Fusion Rate in Ankle Osteoarthritis Patients: A Systematic Review and Meta-Analysis. J Clin Med. 2023 May 20;12(10):3574. doi: 10.3390/jcm12103574. PMID: 37240680; PMCID: PMC10218984.

2. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007 Sep;89(9):1899-905. doi: 10.2106/JBJS.F.01149. PMID: 17768184.

3. Townshend, David MBBS, FRCS(Orth)1; Di Silvestro, Matthew MSc, MD, FRCSC2; Krause, Fabian MD3; Penner, Murray MD, FRCSC4; Younger, Alastair MBChB, FRCSC4; Glazebrook, Mark MSc, PhD, MD, FRCSC, Dip Sports Med5; Wing, Kevin MD, FRCSC4. Arthroscopic Versus Open Ankle Arthrodesis: A Multicenter Comparative Case Series. The Journal of Bone & Joint Surgery 95(2):p 98-102, January 16, 2013. | DOI: 10.2106/JBJS.K.01240

4. Willegger M, Veljkovic A, Younger A, Wing K, Penner M. Long-Term Outcomes of Infinity Total Ankle Arthroplasty Compared to Ankle Arthrodesis. Foot Ankle Orthop. 2023 Dec 26;8(4):2473011423S00343. doi: 10.1177/2473011423S00343. PMCID: PMC10752088.

Treatment with Arthroscopic Ankle Arthrodesis