Baris Yilmaz1, Baran Komur2, Serhat Mutlu2, Guzelali Ozdemir1, Nurettin Heybeli2
1 MD, Fatih Sultan Mehmet Training and Research Hospital, Orthopaedics and Traumatology Department, Istanbul, Turkey
2 MD, Kanuni Sultan Suleyman Research and Training Hospital, Orthopaedics and Traumatology Department, Istanbul, Turkey
Corresponding author: Baran Komur, Email: firstname.lastname@example.org.
Citation: Yilmaz B, Komur B, Mutlu S, Ozdemir G, Heybeli N. Ankle Osteoarthritis. J Minim Invasive Orthop, 2014, 1(4): e4. doi:10.15383/jmio.4.
Competing interests: The authors have declared that no competing interests exist.
Conflict of interest: None
Copyright: 2014 By the Editorial Department of Journal of Minimally Invasive Orthopedics. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract: Degenerative osteoarthritis (OA) is the most common form of arthritis and is a major cause of morbidity and disability. OA presentation is less commonly in the ankle than in other lower limb joints. Although nonsurgical methods had been shown to be effective in some studies, surgery have to be considered where non-surgical treatment has failed to control the patient’s symptoms. The aetiology, incidence, presentation and treatment options of ankle osteoarthritis was discussed in this review article.
Keywords: Ankle; Ankle osteoarthritis; Ankle osteoarthrosis
The ankle joint is made up of three bones: the lower end of the tibia, the fibulaand the talus.The talus sits on top of the calcaneusand articulates with tibia. Working like a hinge,talus,allows your foot to move only in the sagittal plane.Ligaments on both sides of the ankle joint help hold the bones together. Many tendons cross the ankle to move the ankle and the toes. Inside the joint, the bones are covered with a slick, smooth material called articular cartilage. Articular cartilage allows the bones to move against one another in the joints of the body. The cartilage lining is about one-quarter of an inch thick in most joints that carry body weight, such as the ankle, hip, or knee. It is soft enough to allow for shock absorption but tough enough to last a lifetime, as long as it is not injured(1).
Osteoarthritis (OA)can be defined as progressive destruction of articular cartilage, leading to joint space narrowing, subchondral sclerosis, subchondral cyst, synovial inflammation and osteophyte formation. Stiffness, swelling, and pain are typical symptoms associated with OA. Pain is the main problem with OA of any joint. In the lower extremity it is sometimes described in the posterior or midfoot.Initially pain is only activity related. Usually, once the activity gets underway there is not much pain, but after resting for several minutes the pain and stiffness increase. Later, when the condition worsens, pain may be present even at rest. The pain may interfere with sleep. The joint may swell, fill with fluid, and feel tight, especially following increased activity. As the articular cartilage starts to wear off the joint surface, the joint may squeak as crepitation when moved. This sound refer as crepitation. Some patients complain the ankle locks or gives way, which may be due to a loose body but usually just represents attacks of severe pain with reflex inhibition of the supporting muscles. The joint becomes stiff and loses flexibility. Certain movements can become painful, and it may become difficult to trust the joint to hold your weight in certain positions. When OA has reached a very severe stage, the bone itself under the articular cartilage may become worn away. This can lead to increasing deformities around the joint. In the final stages, the alignment of the bones can begin to form odd angles where they meet at the joint (15).
Over the past several years, there has been increasing evidence that OA is genetic, meaning that it runs in families. OA that occurs without any injury may prove to be related to differences in the chemical makeup of articular cartilage. Arthritis may come from differences in how each of us is put together based on our genes, a condition best described as OA. OA may also develop years after an injury that leads to slow damage to the joint surfaces, a condition probably best described as post-traumatic arthritis.In post-traumatic OA, imbalance in the joint mechanics usually leads to damage to the articular surface (Fig.1).
Figure 1. Etiology of Ankle Osteoarthritis
Degenerative OA is the most common form of arthritis and is a major cause of morbidity and disability.Approximately 15% of the world’s adult population is affected by joint pain and disability resulting from osteoarthritis(OA), and among these approximately 1% have OA of the ankle joint (2,3). OA presents less commonly in the ankle than in other lower limb joints.There are several reported causes of ankle OA.5 These include primary, systemic (rheumatoid arthritis and other systemic diseases) and post-traumatic OA. Although hipand knee OA are mostly of primary origin, clinicaltreatment studies of ankle OA have shown the most commontype is of posttraumatic origin (4,5,6,7,8).Traumatic ankle injuries that may result in OA includefractures of the malleoli, tibial plafond, talus, isolatedosteochondral damage of the talar dome, and ankle ligamentinjury (7,9,10).
Age did not differ between men and women (11). Etiology of ankle OAconsists of post-traumatic ankle OA in approximately 78%, secondary arthritis in approximately 13%, and primary OA in approximately 9% of the cases. Patients in the posttraumatic ankle OA group have malleolar ankle fractures, ankle ligament lesions (16%), pilon tibial fractures, tibial shaft fractures, talus fractures (2%), and severe combined fractures (2%). Patients in the secondary OA group have rheumatoid arthritis (5%), hemochromatosis (3%), hemophilia (1%), clubfoot deformity (1%), avascular necrosis of the talus (1%), osteochondritis dissecans (1%), and postinfectious arthritis (1%)(11,12). Malleolar fractures and tibial plafond fractures were the two most common causes of fracture-related post-traumatic ankle OA.
Post-traumatic arthritis patients are often younger and have only one joint involved. They may still hope to return to an active lifestyle including contact or extreme sports, which may have precipitated their injury in the first place and may be intolerant of residual restrictions or discomfort(13). Studies indicate that severity of the initial injury and adequacy of reduction may play a role in the development of post-traumatic ankle OA. Other studies revealed that subsequent post-traumatic OA development correlates with the initial cartilage damage. Even if an injury to a joint does not injure the articular cartilage directly, can potentially alter joint biomechanics. When an injury results in a change in the way the joint moves, the injury may increase the forces on the articular cartilage. This is similar to any mechanical device or machinery. If the mechanism is out of balance, it wears out faster(14,15).
Rheumatoid arthritis and other inflammatory diseases such as psoriatic arthritis, where the inflammatory component has burnt out leaving a damaged joint. Contrary to post-traumatic OA these patients often have several joints involved. Primary osteoarthritis is probably commoner than formerly believed. Some of these patients have monoarticular or oligoarticular disease, remain fairly active and expect to continue doing so. Others have multiple joint involvement and in this sense are more like rheumatoid patients, but without the systemic effects. Patients with intra-articular disease such as osteochondritis dissecans, osteonecrosis of the talus or synovial chondromatosis clinically resemble the primary osteoarthritics. Few patients have arthritis, related to chronic instability, such as arthritis secondary to instability or foot deformity. Persistent ligamentous instability is likely to preclude ankle replacement. Major foot deformities such as pes cavus or severe flatfoot, or proximal malalignments such as a malunited tibial fracture, can lead to asymmetric loading of the ankle or ligamentous instability and subsequent arthritis. The abnormal biomechanics can preclude an ankle replacement, or require a preliminary realignment or stabilisation. The joint may be destroyed by sepsis which then limits the reconstructive options. These patients often require complex reconstruction(14).
The diagnosis of OA begins with a history of the problem. Details about any injuries that may have occurred to the joint, even years before, are important to understanding why the condition exists. Regular X-rays will be taken to see how severely the joint is damaged. This is usually the most practical and useful screeninig method to determine how severe the OA has become. X-Rays allow assessment of remaining joint space, spurs and loose bodies. Several radiologic grading systems have been used to evaluate OA of the ankle. In general, these grading systems classifies the relationship between radiographic grade and severity of the articular cartilage damage. Mostly, Kellgren-Lawrence, Takakura (modified) and Van Dijk classification systems have been used to evaluate of OA of the ankle. The Kellgren-Lawrence system based on spur formation while the other classification systems emphasizes mainly on joint space narrowing. The classification of Takakura and Van Dijk differ in that the former was especially for medial ankle OA, also subclassifies medial joint narrowing. Some studies show that correlation of the radiologic findings and arthroscopic findings. Arthroscopic Outerbridge classification which has been using for knee surgery also have been used to classify chondral damages of the ankle.The purpose of grading of OA of the ankle is to predict the future of the cartilage, prognosis of the patient and select the best method for treatment.
If there is malalignment, a standing hindfoot alignment view will show at which level - ankle, subtalar or both - the malalignment is occurring. Where there is loss of bone stock or complex anatomy post trauma or infection a CT can be helpful. MR will show joint surface lesions such as osteochondritis dissecans, and soft tissue abnormalities including infection and sinuses. If there is osteonecrosis, usually of the talus, MR will show the extent of the abnormality, which will help surgical planning, but an isotope bone scan is required to show how much revascularisation has occurred. If there is any question whether the arthritis may be coming from something other than OA, blood tests may be ordered to look for systemic diseases such as rheumatoid arthritis. A needle may be inserted into the joint to remove some of the joint fluid. This fluid may be sent to a lab to look for crystals due to gouty arthritis or signs of infection.
Nonsurgical treatment of ankle OA usually begins when the ankle first becomes painful.The pain may only occur at first with heavy use and may simply require the use of mild anti-inflammatory medications such as aspirin or ibuprofen. Reducing the activity or changing from occupations that require long periods of standing and walking may be necessary to help control the symptoms. Nowadays newer medications such as glucosamine and chondroitin sulfate are being used andthese medications seem to be effective in reducing the pain of OA in all joints.There are also new injectable medications that lubricate the arthritic joint such as knee but these are not usually prescribed for ankle OA yet.
An injection of steroid into the joint can give temporary relief from symptoms of OA since steroid is a powerful anti-inflammatory medication. When injected into the joint itself, steroidcan help relieve the pain. Unfortunately, pain relief is temporary and usually only lasts several weeks to months. Steroid injections are often helpful on an empirical basis, although there is no good evidence base for their use and in other joints they may not be much better than placebo(16). There is a small risk of infection with any injection into a joint, and steroid injections are no exception. Heidari (17) found the anterolateral portal slightly more accurate for ankle injection, with a 86.1% success rate compared with 77.5% for the anteromedial portal, although the difference was not statistically significant. Hyaluronan supplementation injections have been described in other joints. Three small RCTs have been reported in the ankle. Salk (18) and Cohen (19) compared hyaluronate to saline injections in 17 and 28 patients respectively. The main outcome measure was the Ankle Osteoarthritis Scale. In each case there was a significant improvement in AOS in hyaluronate-treated patients, but this also occurred after saline injection and a significant difference between treatment groups occurred only at one time-point in one trial. Karatosun (20) compared hyaluronate injections to exercise therapy in 30 patients. Again, both groups improved on the AOFAS ankle score, and there were no significant differences between the groups. Larger trials are required to assess the real significance of the differences found. At the moment hyaluronate should probably be used only in the context of such trials.
Physical therapy plays a critical role in the treatment plan for ankle joint arthritis. The main goal of therapy is to help how to control symptoms and maximize the health of ankle. Therapists work to improve flexibility, balance, and strength. Training is done to help walk smoothly and without a limp, which may require that use a walking aid such as a walker, crutches or cane.Modifying shoe with a rocker sole may give some relief of symptoms andthis can help take stress off the ankle. Braces that reduce the motion in the ankle can also be beneficial in reducing pain. Special braces that transfer some of the body weight to the knee can help protect the ankle. These braces are called patellar tendon bearing braces. They are quite large and bulky and may not be well tolerated by some patients.
Surgery is an option where non-surgical treatment has failed to control the patient’s symptoms and they are seriously affecting the patient’s activities of daily living, work and sleep. There are several different types of surgery that can be performed. The choices for surgery are arthroscopic surgery to clean up the joint, fusion of the joint, or replacing the joint with an artificial ankle joint.Sometimes when OA of the ankle occurs, loose pieces of cartilage and bone float around inside the ankle joint. These loose bodies can cause irritation in the joint, leading to inflammation. They can also get caught between the joint surfaces of the ankle. The arthroscope can help to remove these loose bodies and bone spurs and smooth the cartilage surfaces of the ankle joint.Arthroscopic debridement for impingement had a 75% success rate at 5 years in the presence of spurs, but only 50% with loss of joint space (21).
When the ankle joint becomes so painful that it is difficult to walk, surgery may be suggested to fuse the ankle joint. An ankle fusion is also called an ankle arthrodesis and in this operation, the three bones that make up the ankle joint are allowed to grow together, or fuse, into one bone. In this condition the ankle no longer is able to move, but with a successful fusion the pain is gone. The ankle fusion is a good operation, especially for a young, active person. It is usually the preferred option for post-traumatic arthritis of the ankle. Once the ankle is successfully fused it can last a lifetime, but there are still complications associated with this procedure, and not all ankle fusions are successful.Preparing the joint surfaces is crucial to maintane a proper aligment of the ankle joint. The ankle should be positioned in neutral plantar/dorsiflexion, 5 deg. valgus and 5-10 deg. external rotation (22). Fixation in most series is with 2-4 cancellous bone screws. Additionally, stability of the fusion can be increased with an anterior or lateral plate, blade plate or ring fixator.
The arthroscopic technique is now the standard method of fusing the ankle unless there is severe deformity, bone loss or revision surgery. However, it requires advanced arthroscopic skills. It is feasible in patients whose soft tissues would not be suitable for open surgery. However, there has never been a RCT comparing open and arthroscopic fusion.
Arthroscopic fusion has developed to the point where it is now the standard technique for most foot and ankle surgeons. In arthroscopic fusion, synovitis and spurs are cleared to expose the joint line. Curettes and burrs are then used to remove the remaining articular cartilage and freshen the subchondral bone so that multiple bleeding points are seen. It is important to clear all the way to the back, includingthe FHL tendon, usually seen through the posterior ankle capsule, as a landmark. It is also important to clear the gutters, the malleoli and the medial and lateral surfaces of the talus and to ensure that no osteophytes on the talus prevent compression of the talus into the mortise. Once preparation is complete, fixation is usually with two or three cancellous lag screws inserted over guidewires.Over 15 series of arthroscopic ankle fusions have been reported. Overall about 550 arthroscopic fusions have been reported with a total fusion rate of 93.3%. Several series have commented on the quicker rate of union in arthroscopic procedures although this can be influenced by the intervals at which radiographs are taken, and all series diagnosed union on plain radiography rather than CT (23).
Open fusion can be done using anterior, posterior and lateral approaches. A short medial arthrotomy is sometimes a useful adjunct to a lateral approach, although an extensile medial approach can be used to access talonavicular, subtalar and ankle joints. The lateral approach exposes the lateral malleolus, which can be excised and morcellised for graft, or removed, decorticated and attached as a large graft at the end. An alternative technique for graft harvest is to use an acetabular reamer to remove the lateral malleolus. The superficial peroneal and sural nerves, and their communicating branches, are at risk. Many series of open ankle fusion have used flat cuts with a power saw or osteotome to excise the joint. Others use techniques to increase stability and congruency, such as anatomical resection of the joint surfaces in the manner of arthroscopic fusion, or a chevron cut (24). Preservation of the malleoli increases stability. Generally fusions have been reported with a total fusion rate of 92%-%96 of patients at an average of 2-10 years follow-up in the open tecnique(25,26,27). Although many studies are quite old and use techniques that are uncommon now, the risk of non-union is
almost certainly higher in open than arthroscopic fusion.
Many surgeons are now beginning to use the artificial ankle for post-traumatic arthritis instead of doing a fusion. Patients are able to keep the motion in the ankle and avoid some of the problems associated with the ankle fusion. But the ankle is a difficult joint to replace for many reasons. Tibia and fibula move against one another slightly when we walk. This makes it difficult to get the artificial ankle socket to stay connected to the bone.The biggest problem with the older artificial ankle designs is that they loosened after a relatively short time and began to cause pain. However the newer artificial ankle designs, surgeons have tried to solve this problem by actually fusing the tibia and fibula together during the operation and placing screws across the two bones. This has dramatically increased the success rate for the artificial ankle replacements done today.
Replacement of the ankle has been around for over 30 years. However, early prostheses did not reproduce the biomechanics of the ankle well and had a very high failure rate. Second-generation prostheses from the late 1980s onward introduced improved engineering, often with three components.10-20 year results are now being published, indicating success in over 90% of patients (28,29). The Wrightington series is a realistic and critical account with 5-8 year follow-up and 92% 5-year success (30). This has now been updated with 80.3% survival at 10 years (31).Ankle prostheses also seem to be best uncemented; the long term results of the STAR ankle have been significantly better in the uncemented design. Like all joint replacements, failure occurs and may require revision replacement or fusion. The failure rate for revision arthroplasty is high and most patients will be better revised to a tibiotalocalcaneal fusion (Fig. 2).
Figure 2. Staged treatment approach for progressing ankle osteoarthritis.
Gougoulias published a systematic review of 13 series amounting to 1105 ankle replacements, of which the Agility, STAR and Hintegra were commonest (32). Only 4 studies had more than 10 years’ follow-up. Survivorship rates were variable, satisfaction rates varied from 79-97% but 23-60% of patients still had some pain. Wood reported the only RCT in ankle replacement, comparing 100 STAR ankles with 100 Buechel-Pappas ankles (33). The survival rates at 6 years were %95.5 for the STAR and 79% for the BP. In both groups survivorship was lower with increasing coronal plane deformity.These studies tend to highlight need for revision as the main outcome measure. At 12 years, the survivorship of the current cementless Buechel-Pappas implant was 92% (29), but clinical results were presented only as excellent 88%, good 5%, poor 7%.The Wrightington series (31), reported 200 ankles followed for a minimum of 5years and a mean of 7.3 years. The 5-year survival was 93.3% and the 10-year survival 80.3%. As might be expected, ankle fusion affects the range of motion and kinematics more than does replacement, and certain designs are closer to normal than others (34).
There is not enough data to indicate whether fusion or replacement is to be preferred for patients in whom either procedure would be an option. At about 10 years clinical success rates appear similar. Ankle replacement probably has a small functional advantage but failure rates vary widely and there is a much higher rate of secondary surgery. Finally, non-surgical treatments should be considered prior to surgery. If there are concomitant factors such as malalignment and joint instability these should be corrected in order to decelerate further joint degeneration and thus postpone joint replacement or fusion. The improving outcome of new designs of TAR makes this procedure an increasingly popular treatment option for end-stage ankle OA to overcome the problems of arthrodesis. In cases of contraindications or failed TAR, ankle arthrodesis remains the standard treatment and reproducibly leads to a decrease in pain(35,36,37,38,39,40).
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