Ankle Arthritis

The pain and reduced mobility caused by ankle arthritis can prevent you from doing the things you enjoy.

Primary ankle arthritis is rare,the commonest cause is post traumatic. Other causes include inflammatory arthropathies such as rheumatoid arthritis and psoriasis and also haemophilia. Patients usually present with pain and stiffness and sometimes instability.

Xray showing the results of severe ankle arthritis

Xray showing the results of severe ankle arthritis

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Treatment for ankle arthritis initially consists of anti-inflammatories, modification of activity and orthotics. Should these fail there are a number of surgical options including initially a debridement of the ankle. The definitive treatments are either an arthrodesis(fusion) or an arthroplasty(joint replacement).

Figure shows arthroscopic debridement of osteochondral injury

Figure shows arthroscopic debridement of osteochondral injury.

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Ankle fusion has been the traditional way of managing ankle arthritis. By fusing the joint the pain that patients experience is significantly reduced or abolished. Although the ankle joint is fused stiff with screws patients retain a surprising amount of movement in the foot. Ankle fusion remains the gold standard in managing patients with end stage arthritis with associated severe deformity and or neurological disorders.

Anthroscopic Ankle Fusion is a less invasive way of performing a fusion and some surgeons believe this leads to a quicker recovery. The operation is performed through small incisions using arthroscopic instruments rather than the more conventional open fusion requiring larger incisions.

Ankle arthroscopy is a technique where a camera is placed inside the ankle joint. This allows direct visualisation of the joint to assess any pathology. It is also possible to treat some conditions arthroscopically such as osteochondral injuries (where the cartilage in the joint is damaged) and impingement by resecting bony spurs.

Other options include lateral ligament reconstruction in cases of lateral instability and early medial compartment arthritis. Joint distraction with an Llizarov construct and corrective osteotomies have also been described.

Total Ankle Replacement

Image of Rebalance Total Ankle Replacement(Biomet) implant

Rebalance Total Ankle Replacement(Biomet) implant

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When conservative treatments fail Total Ankle Replacement surgery can reduce pain significantly and help you return to an active life.

We currently use the Rebalance Total Ankle Replacement. The Rebalance Total Ankle Replacement is one of the newest replacements to be launched. It was first released in May 2011 in a limited fashion. The implant has a surface coating of Bonemaster which has been very successfully used in total hip replacements. The polyethylene insert is made of ʻEʼ poly (Vit E infused polyethylene) which has been shown to have 85% lower wear rates in vitro compared to existing replacements. Over 200 ankles have now been implanted. The early results are encouraging with a very low incidence of radiolucent lines and no early balloon osteolysis.

Xray of severe ankle arthritis treated by a total ankle replacement

Severe ankle arthritis treated by a total ankle replacement

You may watch this video of Nick Harris performing a Total Ankle Replacement surgery. For greater detail please use the 'Full screen' option or view on YouTube

Osteolysis - a complication of Total Ankle Replacement

Osteolysis is a recognised complication of Total Ankle Replacement. Cysts develop in the bone adjacent to the replacement. If these become large the implant can become loose or subside. Some implants have a much higher incidence of osteolysis than others such as the old AES.

The exact cause remains unclear although it is likely to be multifactorial. Small asymptomatic cysts do not require treatment just observation. Larger cysts however may become symptomatic.

The safest treatment is to remove the implant and convert the replacement to a fusion. Sometimes the cysts can be bone grafted but this is usually only successful in a 1/3 of cases.

Following a total ankle replacement you should have regular x -rays to check for osteolysis. The x-rays below show an ankle replacement with marked osteolysis around the tibia. The replacement was removed and a successful fusion performed with an intra medullary nail.

Xray image of weight bearing Osteolysis

Xray of weight bearing Osteolysis

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Xray image of weight bearing Osteolysis

Xray of weight bearing Osteolysis

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Ankle Sprain and Instability

Lateral ankle sprains are one of the most common sporting injuries especially with sports such as basketball. They can result in injuries to the lateral ligaments, damage to the cartilage in the ankle joint itself (osteochondral injuries), and sometimes damage to the surrounding tendons such as the peroneal tendons. In most cases ankle sprains can be treated conservatively with a short period of immobilization in a walker boot followed by physiotherapy.

In cases where there is gross instability, osteochondral damage and tendon damage sometimes early surgery is advocated. Late complications such as impingement and instability may also warrant surgery.

The increasing use of MRI scans allows us to accurately diagnose ankle sprains and tailor treatment accordingly. Here at the A2F clinic we can access urgent MRI scans usually within 24-48 hours of a request allowing quick and definitive treatment. We offer all types of surgical treatment from ankle arthroscopy to open reconstructions and cater for all levels of athlete from Premiership footballers and rugby players to keen amateur athletes.

Treatment of ankle instability in most instances is functional and the majority of patients make an excellent recovery.

Persistent instability leading to recurrent sprains and chondral injuries are the two most common causes for persistent symptoms. Persistent instability can be treated surgically in most instances by an anatomic repair of the ligaments.

The management of chondral injuries is more difficult. Debridement, drilling and osteochondral autografts have all been described.

Illustration showing stress x-rays of an unstable ankle

Illustration showing stress x-rays of an unstable ankle

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Image of ankle stabilization combining anatomic and non-anatomic procedures

Ankle Stabilization combining anatomic and non-anatomic procedures

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Ankle stabilization procedures can be broadly divided into anatomic and non-anatomic. Anatomic stabilization procedures try to repair the existing ligaments. When these are severely damaged it may be necessary to perform a non-anatomic repair using a tendon transfer. Sometimes it is possible to combine both as in the illustration. The suture repairs the existing ligaments whilst the tendon transfer re-inforces them.

Posterior Impingement

Illustration of a posterior ankle arthroscopy showing a prominent os trigonum which has been resected.

An illustration of a posterior ankle arthroscopy showing a prominent os trigonum which has been resected.

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Posterior ankle impingement is a condition which occurs with maximal ankle plantarflexion. It usually presents with posterolateral ankle pain. It is seen in dancers in the demi-pointe and full pointe positions, and footballers when leaving the ground in a jump and striking the ball in full plantarflexion. It is more common in patients with a prominent os trigonum. It can be associated with FHL tendinitis and snapping. It can be bony or soft tissue. The diagnosis is often made with an MRI. Treatment includes rest and activity modification and anti-inflammatories. Image guided steroid injections can be helpful in both diagnosis and improving pain. A failure to improve with conservative treatment is an indication for surgery. The usual surgical treatment is a posterior arthroscopic debridement. We regularly see dancers and footballers here at the A2F clinic with posterior impingement and are able to resolve most without the need for surgery.

Ankle Anthroscopy

Image showing the usual set up for an ankle anthroscopy

Image showing the usual set up for an ankle anthroscopy.

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Many ankle problems can now be managed arthroscopically. This means putting a camera and small instruments such as shavers into the joint through two small incisions either anteriorly or posteriorly. One of the advantages of an arthroscopy compared to a traditional open procedure is the smaller incisions often mean less soft tissue damage and a quicker recovery.

One of the commonest indications for an ankle arthroscopy is either bony or soft tissue impingement.

Image taken from inside the joint showing a prominent anterior tibial spur.

Image taken from inside the joint showing a prominent anterior tibial spur which has been resected using small shavers.

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Fractured or Broken Ankle

Ankle fractures are one of the most common fractures accounting for approximately 9% of all fractures. They range from relatively minor simple avulsion fractures to more complex fractures involving both the tibia and fibula. Not all fractures require surgical treatment but in most cases patients need to remain non-weight bearing or partial weight-bearing for the first 6 weeks from the date of the injury. Not everyone needs to be immobilized in plaster nowadays. The use of removable walker boots are often more comfortable, allowing patients to clean and wash their foot and ankle, and also allowing early range of motion exercises speeding up recovery. With dedicated physiotherapy and rehabilitation many patients are able to return to sports after 12-16 weeks.

Here at the A2F clinic we are able to deal with the whole range of ankle fractures with quick access to all types of imaging including x-rays,MRI and CT scans. We have access to emergency and routine theatre slots and use the most up to date low profile titanium locking plates and screws often allowing early mobilization and reducing the need for future surgery to remove the metalwork.

Osteochondral Lesion

Osteochondral lesions are areas of damage to cartilage and underlying bone in joints. They are commonly found in the ankle on the talus following trauma. Small unstable flaps of cartilage can often be managed arthroscopically with a debridement of the loose cartilage flap and bone marrow stimulation such as microfracture. Larger areas of cartilage damage are often associated with cyst formation in the underlying bone. This is sometimes treated with an osteochondral autograft from the knee for example. It often requires an osteotomy of the tibia to gain access. The images below show a large area of cartilage damage over the talus following an osteotomy of the medial malleolus. The area of cartilage damage has been debrided and an osteochondral graft from the knee inserted into the defect. This is a major undertaking and is rarely a first line treatment.

Image showing Osteochondral Surgery (1 of 4)

Image showing Osteochondral Surgery (1 of 4)

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Image showing Osteochondral Surgery (2 of 4)

Image showing Osteochondral Surgery (2 of 4)

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Image showing Osteochondral Surgery (3 of 4)

Image showing Osteochondral Surgery (3 of 4)

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Image showing Osteochondral Surgery (4 of 4)

Image showing Osteochondral Surgery (4 of 4)

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