BRIAN E. STRAUS, M.D.

FOOT AND ANKLE SPECIALIST, TEXAS SPORTS MEDICINE
BOARD ELIGIBLE, American Board of Orthopaedic Surgery
Candidate Member, American Academy of Orthopaedic Surgeons
CANDIDATE MEMBER, American Orthopaedic Foot and Ankle Society
APPROVED DOCTOR (ADL), Texas Division of Workers' Compensation
ASSISTANT TEAM PHYSICIAN, Dallas Mavericks

ANKLE ARTHRITIS

Arthritis, meaning inflammation of a joint, can occur at any joint in the human body.  The majority of ankle arthritis occurs due to previous injury to the joint and may be termed “post-traumatic arthritis.”  Otherwise, ankle arthritis can occur due to inflammatory arthritis such as rheumatoid arthritis.  Less commonly, the cause may not be known.  In any case, the effect on the joint is quite similar.  There is often a narrowing of the ankle joint space between the tibia (lower leg bone) and the talus (ankle bone), with varying degrees of damaged cartilage.  Bony outgrowths known as osteophytes may also be present in and around the joint space.   These can occasionally bump into each other causing pain and decreased range of motion.

When the joint sustains an injury, the cartilage holding the joint together becomes damaged.  The patient may not know that this initial damage has taken place.  There may be no symptoms, mechanical symptoms such as clicking and locking, or mild to moderate pain and swelling.  In the severely damaged ankle joint, the cartilage tends to loosen from the bone. The fragments of cartilage will then float around in the joint causing pain and additional damage. Because cartilage does not heal or grow back, this causes a defect in the joint. Patients may feel grinding or popping in the ankle, and the ankle may be particularly stiff in the morning or at the beginning of activity.  The joint ultimately reaches a point when it is no longer able to properly function without significant pain because of the continual damage, resulting in increased inflammation and severe pain.

An orthopaedic surgeon is able to obtain a specific history, considering all factors important in determining the type of arthritis you may have. He will also conduct a thorough physical examination of the ankle joint to evaluate and determine the type and extent of damage to the joint. In this physical examination, the physician will measure the range of motion of the ankle, and determine the exact location of the pain.  Weight-bearing x-rays will be taken to assess the amount of damage to the joint and determine the proper diagnosis.

Arthritis in its mildest form may not need any treatment whatsoever except simple activity modification – avoiding impact activities such as jumping – and recommending activities that are more controlled with less impact such as swimming, cycling, and walking on cushioned surfaces.  Anti-inflammatory medications may be utilized as well.
For patients with stiff and painful joints, bracing is another form of treatment. The bracing may be simple, such as a brace that one would typically use for an ankle sprain. These can frequently alleviate the symptoms of ankle arthritis at minimal cost. If this type of brace is not effective in relieving pain, then a custom brace may be utilized such as an Arizona brace or ankle-foot orthosis (“AFO”).  These are individualized braces that are fashioned by taking a mold of the patient's foot and ankle for exact fitting. This orthosis is usually designed and fitted to the patient at an orthotics and prosthetics shop.  There are other orthoses, or shoe inserts that may be utilized as well to take stress off of damaged areas. 
Occasionally, steroid injections into the ankle joint may help to decrease inflammation and reduce pain.    

OPERATIVE TREATMENT

When all these above measures fail and the patient still has significant arthritis limiting lifestyle, then there are multiple types of surgical options that can be undertaken to help the patient improve their quality of life.

Ankle Arthroscopy
If arthritis is fairly mild, and pain is due mainly to bony outgrowths (“osteophytes”), or focal defects in the cartilage, then a minimally invasive procedure such as arthroscopy may be considered.  This involves tiny incisions so that a camera (“arthroscope”) and specialized instruments may be inserted into the ankle joint itself.  Cartilage tears may be smoothed and bone spurs removed with this technique. 



Ankle Osteotomy
If the joint destruction is on one side of the joint (asymmetric), then the physician can consider an osteotomy (or cutting the bone to change the weight-bearing surface of the joint and help distribute the weight more evenly) followed by fixation with plate and screws.

Ankle Fusion / Arthrodesis / Arthroscopically-Assisted Ankle Fusion
This has been the “gold standard” for treatment of severe ankle arthritis for many years.   The procedure involves removing any remaining cartilage from the joint followed by placing screws across the joint itself.  In certain individuals, this may be performed via small incisions with arthroscopic assistance.  Eventually, the surgically treated ends of the bones grow or fuse together. This permanently stiffens the ankle joint.  Although motion in the ankle is eliminated with this procedure, patients considering this procedure typically have very little motion prior to surgery and may notice little difference.  It is surprising for many to see that patients may continue to walk without a limp after this procedure.   Though the ankle joint motion is eliminated, adjacent joints compensate and may allow 50% of this motion to return. As a result, long term degenerative arthritis may affect these joints.


Ankle Replacement / Arthroplasty
Ankle replacement is a relatively new technology when compared to hip and knee replacements.  This option can be very successful if the patient is chosen carefully.  The joint is replaced with a combination of metal and high grade plastic.  There are currently multiple designs that are FDA approved for use in the United States.  When successful, this allows pain relief from arthritis while maintaining some degree of ankle motion.