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 login to view 3 more bullets primary osteoarthritis login to view 1 more bullet 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 (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 CT scan indications useful for surgical planning for both arthrodesis and arthroplasty 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 login to view 3 more bullets intraarticular injections corticosteroids remain the mainstay of treatment can consider PRP or hyaluronic acid login to view 1 more bullet Operative arthroscopic ankle debridement with anterior tibial/dorsal talar exostectomy indications login to view 2 more bullets outcomes login to view 2 more bullets supramalleolar osteotomy indications login to view 3 more bullets outcomes login to view 1 more bullet complications login to view 1 more bullet distraction arthroplasty indications login to view 4 more bullets outcomes login to view 2 more bullets ankle arthrodesis indications login to view 2 more bullets outcomes login to view 2 more bullets complications login to view 2 more bullets total ankle arthroplasty indications login to view 2 more bullets contraindications login to view 9 more bullets outcomes login to view 2 more bullets complications login to view 2 more bullets Techniques Arthroscopic ankle debridement with anterior tibial/dorsal talar exostectomy technique anterior ankle arthroscopy can be performed open login to view 1 more bullet Distraction arthroplasty technique static versus hinged external fixator or spatial frame can be combined with adjunctive techniques login to view 1 more bullet Supramalleolar osteotomy tibial osteotomy varus deformity login to view 1 more bullet valgus deformity login to view 2 more bullets dome osteotomy login to view 1 more bullet gradual correction login to view 2 more bullets fibular osteotomy outcomes do not differ between patients who require a fibular osteotomy and those who do not Arthrodesis approach open login to view 5 more bullets arthroscopic login to view 1 more bullet fixation options include login to view 4 more bullets Arthroplasty approaches anterior approach login to view 2 more bullets implant design fixed bearing devices mobile bearing devices adjunctive procedures tendoachilles lengthening or gastrocnemius recession foot osteotomies for deformity correction ligamentous reconstruction Complications Arthrodesis 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 Arthroplasty intraoperative medial malleolus fracture may consider prophylactic medial malleolus pinning intraoperatively prosthetic joint infection aseptic loosening periprosthetic cyst formation can be related to infection or aseptic loosening, although pathogenesis not always clear small asymptomatic cysts may be observed large, progressive, or painful cysts may require operative intervention login to view 2 more bullets Prognosis Arthrodesis vs. Arthroplasty pain arthrodesis has shown reliable relief of pain and return to activities of daily living function arthroplasty shows increased gait speed and stride length compared with arthrodesis survivorship recent 5-10 year outcome studies demonstrate up to 90% good to excellent clinical results for arthroplasty long-term studies are still pending on the newest generation of ankle arthroplasty