Ankle Arthritis

Author: John Badylak

Topic updated on 03/01/13 8:19pm

Introduction
Defined as osteoarthritis of tibial-talar joint Incidence less common than OA of knee and hip Causes include post-traumatic arthritis most common etiology accounting for greater than 2/3 of all ankle arthritis primary osteoarthritis accounts for less than 10% of all ankle arthritis other etiologies include rheumatoid arthritis, osteonecrosis, neuropathic, septic, gout, and hemophiliac Pathoanatomy nonanatomic fracture healing alters the joint contact forces of the ankle and changes the load bearing mechanics of the ankle joint loss of cartilage on the talar body and tibial plafond results in joint space narrowing, subchondral sclerosis and eburnation
Relevant Anatomy
Osteology a ginglymus joint that includes the tibia, talus, and fibula talar dome is biconcave with a central sulcus Range of motion ankle dorsiflexion: 20 degrees ankle plantar flexion: 50 degrees
Presentation
Symptoms pain with weight bearing loss of motion Physical exam joint effusion pain with ROM testing, loss of ROM compared to the contralateral side angular deformity may be present depending on the history of trauma
Imaging
Radiographs recommended views weight bearing AP, lateral, and obliques radiographic findings include loss of joint space subchondral sclerosis and cysts eburnation possible angular deformity
Treatment
Nonoperative activity modification, bracing to immobilize the ankle, and NSAIDS indications indicated as first line of treatment in mild disease single rocker sole shoe modification can improve gait and pain symptoms Operative surgical management indications indicated upon failure of conservative treatment in a patient with radiographic evidence of ankle arthritis
Surgical Techniques
Ankle debridement with anterior tibial/dorsal talar exostectomy indications mild disease with pain during push off Distraction arthroplasty indications controversial but may be beneficial for mild disease Supramalleolar osteotomy indications mild to moderate disease with malalignment of ankle, with near-normal ROM Arthrodesis indications ideal for the elder, less active patient outcomes reliable relief of pain and return to activities of daily living complications long term studies demonstrate subtalar arthrosis 50% of patients demonstrated subtalar arthrosis 10 years following ankle arthrodesis in one study Risk factors for nonunion include smoking, adjacent joint fusion, history of failed previous arthrodesis, and avascular necrosis Arthroplasty indications patient selection is crucial indications posttraumatic or inflammatory arthritis, elderly patient contraindications uncorrectable deformity, severe osteoporosis, talus osteonecrosis, charcot joint, ankle instability, obesity, and young laborers increase the risk of failure and revision techniques new generation arthroplasty minimizes bony resection, retains soft tissue stabilizers, and relies on anatomic balancing outcomes recent 5-10 year outcome studies demonstrate up to 90% good to excellent clinical results, long-term studies are still pending on the newest generation of ankle arthroplasty complications syndesmosis nonunion include wound infection, deep infection, and osteolysis

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Qbank (5 Questions)

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(OBQ11.10) The single rocker sole shoe modification is best indicated for relief of pain in patients with what foot or ankle pathology? Topic

Review Topic

1. Midfoot prominences associated with Charcot arthropathy
2. Severe toe-tip ulcerations
3. End-stage tibiotalar arthritis with limited motion
4. Fixed ankle dorsiflexion deformity
5. Fixed planovalgus deformity

PREFERRED RESPONSE ▶

DISCUSSION: A single rocker sole shoe modification (Illustration A) is intended to increase propulsion at toe-off, decrease pressure on heel strike, and reduce the need for ankle motion. It is indicated for use in patients with severe tibiotalar or subtalar arthritis, or those status-post fusion of these joints.

Janisse et al review shoe modifications and foot orthoses as they relate to the nonsurgical management of foot and ankle pathology. With regards to rocker soles, they describe the six-types and how each is specifically used for an individual patient's foot problem. In general, the biomechanical effects of the rocker soles are restoring lost motion in the foot and ankle and off-loading plantar pressure on some part of the foot. Use of a rocker sole can result in overall improvement in gait.

incorrect answers:
1-Midfoot prominences are best relieved with double rocker soles (Illustration B), which offload this region of the foot with weight bearing.
2-Although all rocker sole shoes relieve forefoot pressure to some degree, severe toe-tip ulcerations in particular achieve the greatest relief with the use of a severe angle rocker sole (Illustration C).
4-Fixed ankle dorsiflexion deformities are best accomodated with a negative heel rocker sole (Illustration D).
5-Rocker sole shoe modifications are not typically used in the treatment of fixed planovalgus deformities.

Illustrations: A

REFERENCES:

1. Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008 Mar;16(3):152-8. PMID:18316713 (Link to Abstract)

2. Jeng CL, Logue J. Shoes and orthotics. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:15-24.

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, John Badylak MD,

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(OBQ08.89) A 57-year-old male has right ankle pain for 6 years and has failed conservative management. Radiographs of the ankle are shown in Figures A and B. Which of the following is a contraindication for a total ankle arthroplasty? Topic

Review Topic

FIGURES: A

1. Posttraumatic arthritis
2. Reconstructible ankle ligament damage
3. Neuropathic joint disease
4. Inflammatory arthritis
5. Age greater than 50 years old

PREFERRED RESPONSE ▶

DISCUSSION: Total ankle arthroplasty (TAA) is an alternative to arthrodesis, especially for elderly patients with end-stage arthritis and normal ankle and hindfoot alignment.

According to the paper by Deorio et al, the indications for TAA include primarily posttraumatic and inflammatory arthritis. Contraindications to TAA include unresectable osteonecrotic bone, peripheral vascular disease, neuropathy, neuropathic joint disease (Charcot arthropathy), ankle infection, severe joint laxity, nonreconstructible ankle ligaments, loss of lower leg muscular control, and severe osteopenia or osteoporosis

REFERENCES:

1. Deorio JK, Easley ME. Total ankle arthroplasty. Instr Course Lect. 2008;57:383-413. Review. PMID:18399599 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ08.115) At long-term follow-up, patients undergoing the procedure shown in Figure A have been shown to have significant rates of findings of which of the following? Topic

Review Topic

FIGURES: A

1. Need for revision surgery
2. Hardware failure
3. Need for crutches or walker
4. Ipsilateral knee and/or hip degenerative changes
5. Ipsilateral midfoot and/or hindfoot degenerative changes

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a radiograph of an ankle arthrodesis. Long term follow-up has shown the increased rate of ipsilateral midfoot and hindfoot arthritis, hypothesized to be secondary to the increased stresses seen at these joints with loss of ankle range of motion. The referenced study by Thomas et al concluded that ankle fusion provides good pain relief and improves overall function, but it is a salvage procedure and can cause persistent alterations in gait with a potential for deterioration secondary to development of ipsilateral hindfoot arthritis. Cuester et al provided long term followup (mean 22 yrs) of patients who underwent ankle fusion and noted that majority of patients had substantial and accelerated arthritic changes in the ipsilateral foot but not the knee.

REFERENCES:

1. Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PMID:16510818 (Link to Abstract)

2. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PMID:11216683 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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(OBQ08.197) A 65-year-old man complains of ankle pain refractory to bracing, physical therapy and NSAIDS. A radiograph is provided in Figure A. He is treated with ankle arthroplasty but continues to have pain and limited ambulation 10 months following surgery. Physical exam is notable for well healed incisions and no instability with anterior drawer and inversion testing. A current radiograph is provided in Figure B. Which of the following is the most likely cause of the continued pain? Topic

Review Topic

FIGURES: A

1. Improper surgical procedure
2. Component loosening due to polyethylene wear
3. Lateral ligament failure
4. Syndesmotic nonunion
5. It is normal to have continued pain at 10 months following this surgery

PREFERRED RESPONSE ▶

DISCUSSION: Figure A demonstrates an osteoarthritic ankle. Figure B demonstrates a total ankle arthroplasty with nonunion of the syndesmotic fixation above the components. Arthroplasty and arthrodesis are both options for surgical treatment of osteoarthritis. Contraindications to arthroplasty include heavy laborers, Charcot joint, neurologic muscle imbalance, severe malalignment, and/or uncorrectable ankle instability. This patient is struggling with pain due to nonunion of the syndesmotic fixation. Illustration A demonstrates a well-healed syndesmotic fixation above a total ankle replacement for comparison. Syndesmotic nonunion increases the risk of tibial component loosening. Pyevich et al reviewed mid-term (2-12 years) follow-up of 86 total ankle arthroplasties. Five ankles (6 percent) had been revised for component loosening. Delayed union and nonunion of the syndesmosis was associated with revision. In a review article, Alvine emphasizes proper patient selection and careful postoperative rehabilitation to achieve long-term success with ankle arthroplasty.

Illustrations: A

REFERENCES:

1. Pyevich MT, Saltzman CL, Callaghan JJ, Alvine FG. Total ankle arthroplasty: a unique design. Two to twelve-year follow-up. J Bone Joint Surg Am. 1998 Oct;80(10):1410-20 PMID:9801209 (Link to Abstract)

2. Alvine FG. The Agility ankle replacement: the good and the bad. Foot Clin. 2002 Dec;7(4):737-53 PMID:12516731 (Link to Abstract)

Question Authors:

John Badylak MD,

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(OBQ08.257) All of the following have been recognized as risk factors for nonunion or delayed union following subtalar arthrodesis EXCEPT: Topic

Review Topic

1. smoking
2. failure of previous subtalar arthrodesis
3. more than 2 millimeters of avascular bone at arthrodesis site
4. prior ipsilateral tibiotalar arthrodesis
5. use of autograft

PREFERRED RESPONSE ▶

DISCUSSION: Easley et al reported on a series of isolated subtalar arthrodeses in adults. Their results suggest that the outcome following isolated subtalar arthrodesis is not as favorable as has been reported in previous studies. The rate of union was significantly diminished by smoking, the presence of more than two millimeters of avascular bone at the arthrodesis site, and the failure of a previous subtalar arthrodesis (p < 0.05 for all). Other factors that probably affect the union rate include the use of structural allograft and performance of the arthrodesis adjacent to the site of a previous ankle arthrodesis.

REFERENCES:

1. Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am. 2000 May;82(5):613-24. PMID:10819272 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Ben Taylor MD,

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Groups

ABOS II: Ankle arthritis

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Pyevich MT, Saltzman CL, Callaghan JJ, Alvine FG. Total ankle arthroplasty: a unique design. Two to twelve-year follow-up. J Bone Joint Surg Am. 1998 Oct;80(10):1410-20 PMID:9801209 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Deorio JK, Easley ME. Total ankle arthroplasty. Instr Course Lect. 2008;57:383-413. Review. PMID:18399599 (Link to Abstract)
Alvine FG. The Agility ankle replacement: the good and the bad. Foot Clin. 2002 Dec;7(4):737-53 PMID:12516731 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008 Mar;16(3):152-8. PMID:18316713 (Link to Abstract)
Jeng CL, Logue J. Shoes and orthotics. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:15-24.
Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PMID:16510818 (Link to Abstract)
Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PMID:11216683 (Link to Abstract)
Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am. 2000 May;82(5):613-24. PMID:10819272 (Link to Abstract)

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Ankle Arthritis

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