What is ankle arthritis?
Ankle Arthritis, or osteoarthritis, is a chronic disease of the articulations (artropathy).
It can affect all articulations of the rachis and of the inferior limbs.
It is a degenerative disease caused by the progressive loss of cartilage tissue that normally covers the articular heads, leading to an exposure of the underlying bone (sub chondral bone) and a progressive alteration of the articulation’s morphology.
It is not only a disease of the cartilage but of the entire articulation: skeletal structures, ligaments, capsules and of all the (or some) muscles involved in the articulation’s movement.
In the specific case of the ankle, Dr. Steven Raikin (Orthopaedic surgeon at the Rothmans Institute in Philadelphia and member of the AOFAS) has recently demonstrated how arthritis has an extremely negative impact on a subject’s quality of life, with consequences of the same degree as those affected by orthosis of the hip and even more serious than those affected by that of the knee.
The presence of arthritis is usually correlated to age. However in the case of ankle arthritis age is not a contributing factor. The ankle, contrary to the knee or hip, is an articulation defined by us doctors as extremely congruent (in so far) as one side of the surface of the articulation corresponds exactly to its other. On one hand, this represents a protective factor in regards to degenerative arthritis, but on the other it explains how, in case of a traumatic event capable of alternating the anatomy of the ankle, it is sufficient to determine severe arthritic alterations.
This is the reason why 70% of ankle arthritis cases have a post-traumatic origin. Patients who have suffered from malleolar, tibia, fibula, astragalus (ankle bone) or heel fractures, even when cured (in full or in part) are more prone to developing arthritis of the ankle.
We must also consider patients affected by ankle instability caused by lesions or deformities of the ligaments. On this matter I would like to invite you to read my contribution on the Instabilità peritalare lateral – lateral PERITALARE instability.
In the remainder of cases, osteoarthritis of the ankle is caused by chronic inflammatory systemic diseases such as rheumatoid arthritis, or other diseases that can induce articular changes, such as haemophilia.
The most common symptom of ankle arthritis is pain caused by rigidity.
At the beginning of the manifestation, pain is more acute after long hours of immobility, for example, when waking up in the morning. During the course of the day, after having resumed movement, these symptoms subside but can also appear in periods of exacerbation.
During the late stages of the disease, pain may occur also during periods of rest. It is a deep and localized pain, favoured by a precedent overload of the articulation o due to meteorological changes.
The articulation may appear swollen, rigid and painful to the touch, to passive movements and to even walking. During movement, the patient may experience crackling or a flowing sensation due to the incongruence of the articulation heads and\or due to the presence of osteophytes.
Furthermore, due to its predominantly post-traumatic nature – 70% of instances as above mentioned – the ankle can present itself as deformed and out of axis. This is due to the fact that after reductive and synthesising surgeries, executed after a fracture of the ankle, are not always able to restore the correct anatomy of the articulation.
Once the illness is diagnosed, after an adequate analysis of the symptoms, it is necessary to proceed with specialized exams.
An x-ray (RX) is sufficient to bring out the characteristic signs of arthritis: thinning of the joint line, sub-chondral bone remodelling, formation of osteophytes (small bone spurs) and geodes (bone cysts).
In the event of necessary ankle arthritis surgery, all of the recommended clinical exams recommended will be more in depth.
Since the ankle exercises its function in a standing up position, it is in this specific position that it must return to function. It is therefore necessary to undergo x-rays of the foot and ankle in load, and when standing, in order to study the alignment and the time necessary to obtain a stable implant. Therefore, I would like to point out that, although public opinion is contrary, that magnetic resonance imaging (MRI) does not provide more evolved or accurate information than x-rays because it is executed when lying down and not in a position of stress. This is an important factor when evaluating the ankle’s functionality.
In my personal planning, in addition to the recommendations specified above, I consider it very important to perform a radiographic projection, designed by colleague Donald I. Saltzman performed with the foot tilted at a 20 degrees angle. It is a simple radiography performed in such a position as to allow the study of the correlation between the position of the calcaneus, the talus and the tibia.
Furthermore, in order to study the quality of the bone on which I have to intervene, a CT scan of the ankle and the hind- foot is just as important.
How is ankle arthritis cured?
Ankle arthritis is a degenerative and irrevocable pathology. This means that it can be kept under control, but still today it is not possible to recover a fully damaged articulation.
FANS (Non-steroid anti-inflammatory chemicals) are useful for reducing pain. Their continuous use is unadvised due to possible side effects (gastritis and ulcers). Opiates, such as morphine, are also unadvised as they can cause addiction. Cortisone is not suggested either since it is associated to the risk of osteoporosis and infection.
In brief, pharmacological approach can be useful during certain periods of the patients’ life but it does not represent a long term solution.
Physical therapies, such as Interx and Tecar Therapy, even more effective if combined, can improve the biology and functionality of tendons and muscles involved in the articulation’s movement.
These can represent, during the initial phase of the ankle arthritis, a valid and replicable solution capable of postponing any surgical intervention for a long time.
Please note that we are talking about therapies that require the presence of an expert and qualified operator that will build up a therapy plan alongside an orthopaedic surgeon specialised in the foot and ankle arthritis field.
My personal experience brings me today to advice against infiltrative procedures to the ankle. This is especially true in regards to cortisone based medicines. There have recently been new forms of viscosupplementation (hyaluronic acid and other derivatives) as well as intra-articular infiltrations of PRP, without any specific scientific rationale. The results observed are alternate and are often unstable.
There are two basic surgical techniques for intervening against ankle arthritis: arthrodesis or prosthesis?
What is Ankle Arthrodesis?
It is the fusion of an articulation. Below we will focus on that of the ankle.
It can be performed with an incision or by using arthroscopy. In both cases the objective is to obtain a complete fusion of the articulation at a 90 degrees angle. This implies not only the loss of movement of the ankle, but also a greater stress to the other adjacent articulations, which are thus exposed to an increased workload and consequently are at a higher risk of ankle arthritis.
A young patient suffering from arthrodesis of the ankle runs the risk of developing ankle arthritis in all the other joints of the foot and thus having to undergo new arthrodesis procedures during his life and ultimately finding himself with a more and more rigid foot.
What, instead, is ankle prosthesis?
Ankle Prosthesis is a substitution of the joint articulation with an implant that reproduces its movement and comes as close as possible to its original physiology.
Compared to patients affected by arthritis of the hip or knee, patients affected by arthritis of the ankle can be younger and thus have more mobility needs in their everyday life. Thanks to new generation implants, this factor is no longer in contradiction to prosthesis.
PRE-EXISTING FOOT DEFORMITIES
In the case of pre-existing foot deformities, prosthesis is advised. It is essential that the surgeon has a consolidated experience in ankle prosthetics and reconstruction techniques.
The only contraindication for prosthesis, in which case I advise ankle arthrodesis, is represented by bone stock loss (verifiable by CT scan), or excess bone on which to place the implant.
ANKLE PROTHESIS RESEARCH
By researching information pertaining to prosthesis technique on the internet, one may find many contrary opinions on this type of intervention. This erroneous school of thought has eradicated itself due to the old types of prosthesis used more than 15 years ago.
Today, looking towards the future, a technique called “ankle resurfacing” has been gaining ground, which consists of the reduction of the volume of prosthetic implants and of the development of prosthetic designs that are closer to the original anatomy of the ankle. This is possible thanks to materials capable of reproducing the physical characteristics of the bone, its porosity, stiffness and elasticity. For example, the introduction of a material such as Trabecular Metal (Tantalum subjected to a special processing) allows a resurfacing procedure with smaller and more anatomical implants that significantly speed up the recovery time. This implant is inserted from a lateral incision rather than from the front as usual procedure.
In Italy today, I am the leading foot and ankle surgeon that has performed the majority of resurfacing technique surgeries and follow ups. It is a revolutionary and reliable choice that offers great advantages but that is, at the moment, still reserved for a few select cases.
Before the ankle surgery, we proceed to pre-hospitalisation in which the patient will undergo blood tests and further orthopaedic controls as well as anaesthetic assessment. The anaesthesia used is generally combined, capable of putting the leg to sleep for a long time, if possible till the following morning, in order to reduce the amount of pain medication.
Hospital admission takes place on the day of or the day before the surgery. It can last from 2 to 4 days. Once verified that the surgical scar and the pain do not require daily medical check-ups, the patient will be discharged.
BACK IN THE GAME
Ankle prosthetic surgery is an increasingly frequent procedure that requires a rigorous follow up and a dedicated postoperative course that aims at guaranteeing the immediate osseointegration of the joint rather than a speedy a return to mobilisation.
My patients are immobilised by a plaster cast or a tutor for 6 weeks, even though load placement can be conceded after 3 weeks.
It is fundamental that the patient is present for weekly check-ups until the skin is completely healed (3 to 5 weeks after the operation).
After 3 to 6 weeks the first x-rays (to control stress loads) are performed.
After removing the immobilisation, re-education for pace and walking is fundamental. For this I recommend to my patients Hydrokinetic Therapy (rehabilitation in water), stretching of the triceps and, in a later stage, proprioceptive rehabilitation.
The patient is self-sufficient again after 2 months from the surgery, they can resume driving a car after 3 to 4 months and can reach complete postoperative satisfaction around 6 to 8 months.
These timings can reduce themselves drastically thanks to the resurfacing technique, although it must be carefully evaluated in each specific case.
My commitment to preventing and improving surgical techniques for the cure of ankle arthritis is combined with daily researching and studying within this medical field. To read more about foot and ankle diagnosis, treatment and recovery and my commitment in the development and innovation on an international level, please visit the foot and ankle “blog” section of this website.