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Updated: Jan 7 2024

Ankle Arthritis

  • summary
    • Ankle Arthritis is degenerative joint disease of the tibiotalar joint that can be broken into three main types: osteoarthritis, post-traumatic arthritis, and inflammatory arthritis.
    • Diagnosis is primarily made with plain radiographs of the ankle. 
    • Treatment can be nonoperative or operative depending on patient age, patient activity demands, severity of arthritis, and presence of tibiotalar deformity.
  • Epidemiology
    • Incidence 
      • less common than OA of knee and hip
  • Etiology
    • Pathophysiology
      • 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
  • 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
      • Takakura Classification
      • Stage I
      • Early sclerosis and osteophyte formation, no joint space narrowing
      • Stage II
      • Narrowing of medial joint space (no subchondral bone contact)
      • Stage IIIA
      • Obliteration of joint space at the medial malleolus, with subchondral bone contact
      • Stage IIIB
      • Obliteration of joint space over roof of talar dome, with subchondral bone contact
      • Stage IV
      • Obliteration of joint space with complete tibiotalar contact
  • 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
          • Arizona brace (gauntlet ankle brace)
    • Operative
      • surgical management
        • indications
          • indicated upon failure of conservative treatment in a patient with radiographic evidence of ankle arthritis
  • Techniques
    • Ankle debridement with anterior tibial/dorsal talar exostectomy
      • indications
        • mild disease with pain during push off
    • Distraction arthroplasty
      • controversial
      • ideal candidate younger than 45 yrs with post-traumatic arthritis
      • indications
        • well-preserved ankle ROM
        • moderate to severe arthritis
        • congruent tibiotalar surface
        • also for partial AVN talus
    • Supramalleolar osteotomy
      • indications
        • near-normal ROM
        • minimal talar-tilt or varus heel alignment
        • medially focused ankle arthritis
          • stage 2 or 3a according to the Takakura-Tanaka classification for varus-type osteoarthritis
      • outcomes
        • patients with 4-10° of preoperative talar tilt have five-year survival rates of 85% while those with > 10° of talar tilt have five-year survival rates of 65%
        • outcomes do not differ between patients who require a fibular osteotomy and those who do not
    • Arthrodesis
      • indications
        • posttraumatic or inflammatory arthritis, malalignment (with osteotomy)
        • young, high demand laborers
      • 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
        • revision arthrodesis union rates are 85% or greater
    • 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
        • increased gait speed and stride length
      • complications
        • syndesmosis nonunion
        • include wound infection, deep infection, and osteolysis
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