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