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Updated: Sep 12 2024

Ankle Arthritis

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  • Summary
    • Ankle Arthritis is a common degenerative joint disease of the tibiotalar joint that presents with pain, stiffness, and deformity of the ankle.
    • Most commonly caused by post-traumatic etiology but can also present as primary osteoarthritis or inflammatory arthritis.
    • Diagnosis is typically 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 
      • estimated incidence of 30 per 100,000 people annually
      • prevalence of approximately 1% of the world population
      • less common than OA of knee and hip
    • Risk Factors
      • prior ankle fracture
      • chronic ligamentous laxity
      • inflammatory arthropathy
  • Etiology
    • Pathophysiology
      • causes include
        • post-traumatic arthritis
          • most common etiology, accounting for 75% to 80% of ankle arthritis
          • ankle fractures account for the majority of post-traumatic arthritis
          • chronic ligamentous laxity (typically lateral) account for the rest
        • 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 (based on mortise radiograph)
      • Stage I
      • Osteophytes and early sclerosis, no joint space narrowing
      • Stage II
      • Narrowing of medial joint space, no subchondral 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
      • stiffness
      • locking or catching
    • Physical exam
      • variable joint effusion
      • pain with range of motion (ROM), loss of ROM compared to the contralateral side
      • angular deformity may be present depending on the history of trauma
      • crepitus
  • Imaging
    • Radiographs
      • recommended views
        • weight bearing AP, lateral, and mortise
      • radiographic findings include
        • loss of joint space
        • subchondral sclerosis and cysts
        • eburnation
        • possible angular deformity
    • MRI
      • indications
        • identify specific foci of cartilage disease
        • higher sensitivity in early disease
      • findings
        • cartilage injury
        • subchondral bone marrow edema
        • ligament tears
  • 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)
      • intraarticular injections
        • corticosteroids remain the mainstay of treatment
        • can consider PRP or hyaluronic acid
          • no consensus on the efficacy
    • Operative
      • Arthroscopic ankle debridement with anterior tibial/dorsal talar exostectomy
        • indications
          • isolated anterior impingement
          • joint preserving option
        • outcomes
          • successful in treating anterior impingement from anterior-based tibial osteophytes
          • insufficient evidence supporting the routine use for treating advanced ankle arthritis
      • Supramalleolar osteotomy
        • indications
          • mild to moderate arthritis
          • tibiotalar malalignment or eccentric articular wear
          • medially focused ankle arthritis
        • 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%
      • Distraction arthroplasty
        • indications
          • indicated for young patients with moderate to severe post-traumatic arthritis
          • theoretically allows for biologic repair of damaged articular surfaces with offloading
          • joint preserving option for young patients not a candidate for arthroplasty or arthrodesis
          • requires good preoperative range of motion
        • outcomes
          • controversial
          • paucity of literature suggesting long-term benefit
      • Ankle arthrodesis
        • indications
          • moderate to severe post-traumatic arthritis or inflammatory arthritis refractory to conservative treatments
          • young, high-demand laborers
        • outcomes
          • remains the gold standard treatment of end-stage ankle arthritis
          • reliable relief of pain and return to activities of daily living
        • complications
          • subtalar arthrosis
            • 50% of patients demonstrated subtalar arthrosis 10 years following ankle arthrodesis
          • nonunion
            • 10% nonunion rate
            • risk factors include smoking, adjacent joint fusion, history of failed previous arthrodesis, and avascular necrosis
            • revision arthrodesis union rates are 85% or greater
      • Total ankle arthroplasty
        • indications
          • post-traumatic or inflammatory arthritis in an elderly patient
          • controversial but may be better option for patients with concomitant talonavicular or subtalar fusion
        • contraindications
          • relative
            • obesity
            • young laborers
            • severe deformity
          • absolute
            • active infection
            • inadequate bone stock
            • talus osteonecrosis
            • Charcot neuropathy
        • 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 compared with arthrodesis
        • complications
          • syndesmosis nonunion
          • wound infection, deep infection, and osteolysis
  • Techniques
    • Arthroscopic ankle debridement with anterior tibial/dorsal talar exostectomy
      • technique
        • anterior ankle arthroscopy
        • can be performed open
          • consider future approaches for arthrodesis or arthroplasty
    • Distraction arthroplasty
      • technique
        • static versus hinged external fixator or spatial frame
        • can be combined with adjunctive techniques
          • microfracture, chondroplasty, orthobiologics
    • Supramalleolar osteotomy
      • tibial osteotomy
        • varus deformity
          • typically treated with medial opening wedge tibial osteotomy
        • valgus deformity
          • typically treated with a medial closing wedge osteotomy
          • may require oblique fibular lengthening osteotomy
        • dome osteotomy
          • technically challenging but reduces translation or changes in limb length
        • gradual correction
          • computer assisted deformity correction can be performed with a spatial frame
          • useful in multiplanar or large deformity correction
      • fibular osteotomy
        • outcomes do not differ between patients who require a fibular osteotomy and those who do not
    • Arthrodesis
      • technique
        • open approaches
          • classic anterior approach
          • transfibular approach
            • 8-10 cm distal fibula resected
          • mini-open approaches
            • joint preparation performed with a burr
        • can be performed arthroscopically
        • fixation
          • transarticular compression screws
          • bridge plating
          • external fixation
          • hindfoot retrograde fusion nail (for tibiotalocalcaneal arthrodesis)
    • Arthroplasty
      • approaches
        • anterior approach
          • interval between tibialis anterior and extensor hallucis longus
          • protect SPN, DPN, anterior tibial artery
      • implant design
        • fixed bearing devices
        • mobile bearing devices
      • adjunctive procedures
        • tendoachilles lengthening or gastrocnemius recession
        • foot osteotomies for deformity correction
        • ligamentous reconstruction
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