Updated: 1/28/2019

Ankle Arthritis

Topic
Review Topic
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0
Questions
13
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0
Evidence
15
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Cases
3
Techniques
2
https://upload.orthobullets.com/topic/7037/images/stage_i.jpg
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https://upload.orthobullets.com/topic/7037/images/stage_iv.jpg
Introduction
  • Defined as osteoarthritis of the tibiotalar joint
  • Epidemiology
    • less common than OA of knee and hip
  • 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
Classification
 
 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 bone 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 
  • 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
    • 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  
  • Arthrodesis
    • indications
      • ideal for the elderly, 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  
      • 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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Technique Guides (2)
Questions (13)
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(OBQ13.245) Medial opening wedge supramalleolar osteotomy is considered a treatment option for ankle osteoarthritis. In which of the following scenarios would this procedure be most appropriate? Review Topic

QID: 4880
1

Complete obliteration of the ankle joint space with bone-on-bone contact; valgus ankle alignment

1%

(30/3413)

2

No joint-space narrowing, but early ankle joint sclerosis and osteophyte formation; valgus ankle alignment

9%

(305/3413)

3

Symptomatic narrowing of the ankle joint space medially; varus ankle alignment

81%

(2752/3413)

4

Symptomatic narrowing of the ankle joint space laterally; neutral ankle alignment

4%

(129/3413)

5

Obliteration of the medial joint space that extends to the roof of the talar dome; varus ankle alignment

5%

(162/3413)

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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? Review Topic

QID: 3433
1

Midfoot prominences associated with Charcot arthropathy

18%

(394/2168)

2

Severe toe-tip ulcerations

8%

(184/2168)

3

End-stage tibiotalar arthritis with limited motion

61%

(1322/2168)

4

Fixed ankle dorsiflexion deformity

8%

(179/2168)

5

Fixed planovalgus deformity

4%

(78/2168)

ML 3

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PREFERRED RESPONSE 3
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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? Review Topic

QID: 583
FIGURES:
1

Improper surgical procedure

6%

(162/2801)

2

Component loosening due to polyethylene wear

8%

(219/2801)

3

Lateral ligament failure

1%

(38/2801)

4

Syndesmotic nonunion

83%

(2330/2801)

5

It is normal to have continued pain at 10 months following this surgery

2%

(43/2801)

ML 1

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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? Review Topic

QID: 501
FIGURES:
1

Need for revision surgery

2%

(44/2671)

2

Hardware failure

2%

(52/2671)

3

Need for crutches or walker

0%

(12/2671)

4

Ipsilateral knee and/or hip degenerative changes

6%

(173/2671)

5

Ipsilateral midfoot and/or hindfoot degenerative changes

89%

(2385/2671)

ML 1

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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: Review Topic

QID: 643
1

smoking

1%

(9/1702)

2

failure of previous subtalar arthrodesis

1%

(25/1702)

3

more than 2 millimeters of avascular bone at arthrodesis site

3%

(57/1702)

4

prior ipsilateral failed tibiotalar arthrodesis

6%

(94/1702)

5

use of autograft

89%

(1513/1702)

ML 1

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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? Review Topic

QID: 475
FIGURES:
1

Posttraumatic arthritis

1%

(18/1669)

2

Reconstructible ankle ligament damage

3%

(53/1669)

3

Neuropathic joint disease

87%

(1457/1669)

4

Inflammatory arthritis

8%

(132/1669)

5

Age greater than 50 years old

0%

(5/1669)

ML 1

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PREFERRED RESPONSE 3
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