Ankle Arthritis

ANKLE ANATOMY

DISEASE EXPLAINED

SYMPTOMS

The symptoms of arthritis vary depending on which joint is affected. In many cases, an arthritic joint will be painful and inflamed. Generally, the pain develops gradually over time, although sudden onset is also possible. There can be other symptoms, as well, including:

Pain with motion

Pain that flares up with vigorous activity

Tenderness when pressure is applied to the joint

Joint swelling, warmth, and redness

Increased pain and swelling in the morning, or after sitting or resting

Difficulty in walking due to any of the above symptoms

CAUSES

Previous ankle injury is the most common cause of ankle arthritis. In people who have sustained an injury such as an ankle fracture, the cartilage may be damaged and this could lead to accelerated arthritis. When the ankle is injured, it is also susceptible to an injury called osteonecrosis. When osteonecrosis occurs as the result of an ankle injury, there is damage to the blood flow to a portion of the bone. Osteonecrosis can also lead to ankle arthritis.

Another cause of ankle arthritis is rheumatoid arthritis. Rheumatoid disease causes joint inflammation and damage to the cartilage. Over time, this can lead to significant problems, necessitating treatment.

Infections of a joint, which lead to damage of the cartilage cells, is another cause. Because cartilage cells cannot regrow, the damage from an infection can last permanently.

Although the effect of genetics on the development of arthritis is not well understood, some people have been observed to have a genetic tendency to wear out joints faster than others.

Body weight is another common factor for ankle arthritis. People who are overweight place a larger burden on their weight-bearing joints—hips, knees, ankles, as well as their feet. They have more of a tendency to develop arthritis, and often have more accelerated damage to the joint cartilage.

TREATMENT

TREATMENT OPTIONS

There is no cure for arthritis but there are a number of treatments that may help relieve the pain and disability it can cause.

NONSURGICAL TREATMENT
Initial treatment of arthritis of the foot and ankle is usually nonsurgical. Your doctor may recommend a range of treatment options.

LIFESTYLE MODIFICATIONS.
Some changes in your daily life can help relieve the pain of arthritis and slow the progression of the disease. These changes include:

Minimizing activities that aggravate the condition.

Switching from high-impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) to lessen the stress on your foot and ankle.

Losing weight to reduce stress on the joints, resulting in less pain and increased function.

PHYSICAL THERAPY.
Specific exercises can help increase range of motion and flexibility, as well as help strengthen the muscles in your foot and ankle. Your doctor or a physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.

Although physical therapy often helps relieve stress on the arthritic joints, in some cases it may intensify joint pain. This occurs when movement creates increasing friction between the arthritic joints. If your joint pain is aggravated by physical therapy, your doctor will stop this form of treatment.

ASSISTIVE DEVICES.
Wearing a brace—such as an ankle-foot orthosis (AFO)—may help improve mobility. In addition, wearing shoe inserts (orthotics) or custom-made shoes with stiff soles and rocker bottoms can help minimize pressure on the foot and decrease pain. In addition, if deformity is present, a shoe insert may tilt the foot of ankle back straight, creating less pain in the joint.

MEDICATIONS.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can help reduce swelling and relieve pain. In addition, cortisone is a very effective anti-inflammatory agent that can be injected into an arthritic joint. Although an injection of cortisone can provide pain relief and reduce inflammation, the effects are temporary.

SURGICAL TREATMENT
Your doctor may recommend surgery if your pain causes disability and is not relieved with nonsurgical treatment. The type of surgery will depend on the type and location of the arthritis and the impact of the disease on your joints. In some cases, your doctor may recommend more than one type of surgery.

ARTHROSCOPIC DEBRIDEMENT.
This surgery may be helpful in the early stages of arthritis. Debridement (cleansing) is a procedure to remove loose cartilage, inflamed synovial tissue, and bone spurs from around the joint.

During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your foot or ankle joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments. Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for a traditional, open surgery.

Arthroscopic surgery is most effective when pain is due to contact between bone spurs and the arthritis has not yet caused significant narrowing of the joint space between the bones. Arthroscopy can make an arthritic joint deteriorate more rapidly. Removing bone spurs may increase motion in the joint, causing the cartilage to wear away quicker.

ARTHRODESIS (FUSION).
Arthrodesis fuses the bones of the joint completely, making one continuous bone out of two or more bones. The goal of the procedure is to reduce pain by eliminating motion in the arthritic joint.

During arthrodesis, the doctor removes the damaged cartilage and then uses pins, plates and screws, or rods to fix the joint in a permanent position. Over time, the bones fuse or grow together, just like two ends of a broken bone grow together as it heals. By removing the joint, the pain disappears.

Arthrodesis is typically quite successful, although there can be complications. In some cases, the joint does not fuse together (nonunion), and the hardware may break. While the broken hardware does not cause pain, the nonunion of the fusion can lead to pain and swelling. If nonunion occurs, a second operation to place bone graft and/or place new hardware may be needed. However, repeated fusions are not as likely to be successful, so it is best to closely follow your doctor’s guidelines during the recovery period of your original operation.

A small percentage of patients have problems with wound healing, but these problems can usually be addressed by local wound care (dressing changes) or by an additional surgery. In some cases, loss of motion in the ankle after a fusion causes the joints adjacent to the one fused to bear more stress than they did before the surgery. This can lead to arthritis in the adjacent joints years after the surgery.

TOTAL ANKLE REPLACEMENT (ARTHROPLASTY).
In total ankle replacement, your doctor removes the damaged cartilage and bone, and then positions new metal or plastic joint surfaces to restore the function of the joint.

Although total ankle replacement is not as common as total hip or total knee replacement, advances in implant design have made it a viable option for many people.

Ankle replacement is most often recommended for patients who have:
Advanced arthritis of the ankle

Arthritis that has destroyed the ankle joint surfaces

Ankle pain that interferes with daily activities

Ankle replacement relieves the pain of arthritis and offers patients more mobility and movement than fusion. In addition, being able to move the formerly arthritic joint means that less stress is transferred to the adjacent joints. This lessens the chance of developing adjacent joint arthritis.

As in any type of joint replacement, an ankle implant may loosen or fail over the years. If the implant failure is severe, the replaced joint can be exchanged for a new implant — this procedure is called a revision surgery. Another option is to remove the implant and fuse the joint. This type of fusion is more difficult than when fusion is done as the initial procedure. When the implant is removed, there is space in the bone that must be filled with bone graft to maintain the length of the leg. Because the new bone may not be as strong, the risk of nonunion is greater.