Treatment of Arthritis in the Ankle Joint
by Cam Goslin, OTC

When a patient who has been dealing with arthritis for years is finding no relief with physical therapy, injections, bracing or other methods of treatment, before an Orthotech makes a big decision about other care options they should to do extensive research on a variety of different procedures including: ankle arthroscopies, ankle replacements and ankle fusions. While each of these procedures has their pros and cons, some may not be the right choice for certain patients. This article will dive into the pros and cons of these procedures and the controversy surrounding the total ankle replacement.

When one is dealing with the pain and discomfort of arthritis in the ankle joint they may jump to a quick decision. There are many different types of arthritis including: osteoarthritis, also known as wear and tear arthritis, rheumatoid arthritis which is an autoimmune disease, and post traumatic arthritis which occurs after the foot or ankle is injured. Arthritic changes in the ankle joint can cause severe pain and stiffness and can be debilitating to ones lifestyle.

The word fusion sounds very limiting to most patients, whereas replacement seems like a much better idea. Many patients will think, “if I get a fusion I will be limited in what I can do, and the fusion may impact my daily activities. However, if I get a replacement I will be able to ambulate much better and move on with my life with my new ankle.” They hear about how well their friends have done with their new knees or hips and they decide to inquire about a total ankle replacement with their orthopedic surgeon.

The first surgical option for some patients may be an ankle arthroscopy, which is the least invasive surgery. An ankle arthroscopy allows the surgeon to clean out the joint through small incisions using cameras and monitors. An arthroscope is used in this procedure to transmit images to a monitor and allow the surgeon to visualize the joint. Although most arthroscopies are performed to remove loose bodies or fix damaged soft tissue such as torn or stretched ligaments that can cause ankle instability, this procedure can be helpful in performing ankle fusions. Patients recover much quicker from arthroscopies if their ankle does not require a fusion and can return to daily activities such as driving and sports sooner.

If an ankle scope is not sufficient due to the severity of arthritis in a patient’s joint the next surgical option could be an ankle fusion or “arthrodesis”. The ankle fusion can be done arthroscopically or open. In most cases the fusion is successful due to the fact the ankle is unable to move up and down after the procedure. As with most surgeries, complications after an ankle fusion can include infection, pain, or wound healing problems. A patient will be advised to quit using tobacco products at least three to four months before surgery as this can cause complications such as wound healing issues and malunion. In most cases, the patient will be placed into fiberglass or plaster cast for 3 months and will be non-weight bearing for approximately 6 weeks. The patient will be taken out of the cast at the 3 month anniversary and will be able to return to customary footwear. They may walk with a limp but will have much less pain than they did before surgery. In some cases patients can develop arthritis in other areas of the foot due to the extra pressure put on these areas after a fusion and they may need another operation to fuse these areas, limiting motion in the foot.

The total ankle replacement has been a controversial topic in the field of orthopedics for years. Many orthopedic surgeons will shy away from the idea of proceeding with an ankle replacement. The first attempt at an ankle replacement was performed in the 1970’s by two orthopedic surgeons, Lord and Marrote who used a long stemmed tibial component and a polyethylene talar component replacing the body of the talus. They attempted this procedure on 25 patients, with 12 of the attempts failing and only having success with 7 of the patients. The total ankle replacement should be avoided if the patient is diabetic, a smoker, has avascular necrosis of the talus, neuropathy, or a history of infection. As mentioned earlier, if possible the best way to deal with ankle pain is conservative treatment such as physical therapy, bracing options (off the shelf or custom) like the AFO brace, which come in a variety of different styles, and/or steroid injections. As technology evolves the ankle replacement may be an option for more patients in the future, and more surgeons may take on the challenge. Any one of these procedures may fail and go on to be a non-union or malunion causing the patient continued pain but for many patients this is their last option.

About the Author:
Cam Goslin is an orthopedic technologist from New Hampshire. He attended the New Hampshire Technical Institute graduating with a certificate in orthopedic technology in 2013. Cam became a certified orthopedic technologist after graduating the program. He is an active member of the New England Society of Orthopaedic Technologists and the National Association of Orthopaedic Technologists. He enjoys spending his free time with his girlfriend and son.