Ankle Arthritis

There has been a tremendous rise in the incidence of arthritis of the ankle in the past 10-15 years. This may be the result of a changing pattern of osteoarthritis and arthritis of the ankle after injury or fracture.

Note the absent cartilage in this ankle joint which occurred after a fracture.

The ankle joint is responsible for the up and down movement of the foot. 75% of all of the up and down movement of the foot occurs in the ankle joint. The main internal anklebone is called the talus and is surrounded by the bones on the end of the leg on the inside (called the medial malleolus) and on the outside (called the fibula). The talus sits in the ankle joint quite snugly and permits up and down but very little side to side and rotational movements.

Arthritis of the ankle can occur in a number of different settings. This is unlike the knee and the hip, where the majority of patients with arthritis develop this without any specific cause (this is called osteoarthritis). Fewer patients develop ankle osteoarthritis than arthritis in the knee and the hip. The majority of patients in our society with ankle arthritis develop repetitive injuries to the ankle or poor healing after an ankle fracture.

Other causes of arthritis of the ankle include rheumatoid arthritis, gout and recurring instability of the ankle from multiple ankle sprains.

Both the patient and the clinician can easily spot symptoms of ankle arthritis.

The patient understands that limited up and down movement of the ankle is present and the little movement that may be present is painful. Stiffness and aching is present in the morning when beginning to walk. After a while, this will loosen up and walking is possible but the aching then begins again or gets worse. There may be some grinding and clicking in the ankle with movement activities. When examining the foot and ankle it is easy to detect the arthritis, warmth, inflammation and swelling associated with limited movement. This is confirmed by taking an x-ray. A CAT scan or an MRI scan is not necessary.

The two pictures on the left are XR’s of the ankle of a patient with arthritis. The left XR is a view from the side and the middle XR is a view from the front of the ankle. On the side view, there are large bone spurs in the front of the ankle. In the middle XR there is abnormal tilting of the ankle with arthritis. Both show irregular cartilage lining. Compare these to the XR on the right that shows smooth, round shadows representing normal cartilage.

The severity of the condition, extent of pain and the ability of the patient to tolerate walking with a painful stiff ankle determine the treatment of ankle arthritis. Like most other forms of arthritis, there is rarely any urgency to commence with surgery. The success rate of the surgery is the same, whether the surgical procedure is performed promptly upon diagnosis or a year later. There is only one type of ankle arthritis that should be treated promptly with reconstructive surgery. This is arthritis that develops following an ankle fracture where the bone and joint do not heal in the correct alignment.

The treatment is therefore often initiated with rest, some form of immobilization of the ankle, arthritis medication and occasionally an injection of cortisone into the joint. Multiple cortisone injections are to be avoided. Physical therapy should be avoided because it will likely aggravate the arthritis pain. Immobilization requires a soft brace that fits inside the shoe or a hard molded brace or a boot used temporarily for walking.

There are four main surgical procedures for the management of ankle arthritis, which are:

1.    Total Ankle Replacement
2.    Ankle Fusion (Arthrodesis)
3.    Distraction Ankle Arthroplasty
4.    Allograft (Cadaver Bone) Joint Replacement

Each of these four procedures is discussed in some by clicking on the corresponding links. There are clearly advantages and disadvantages of one procedure over the other and the success rates of these various operations are different. These decisions are not always easy for the patient to make. The final decision should be made with an orthopedic surgeon who has considerable experience in the management of ankle arthritis. This experience is very important. Studies have shown that the successful results of surgery increase and complication rates decrease with greater surgical experience.