Arthritis of the ankle occurs when the cartilage that lines the ankle joint, which is the joint between the tibia (shin bone) and talus (main ankle bone) is worn (see figure 1). It may occur through simple wear and tear or can arise as a result either of trauma to the ankle such as a previous fracture, or as a result of an inflammatory condition such as rheumatoid arthritis.
Figure 1 – ankle arthritis, seen as a reduction in the joint space between the tibia and talus
The two main symptoms that occur in ankle arthritis are pain across the front of the ankle joint and stiffness causing a loss of movement. There may also be swelling. The symptoms tend to occur whilst walking and often cause a limp. As the arthritis progresses, there may be destruction of the bony anatomy of the ankle causing the ankle joint and alignment of the heel to become deformed.
Treatment Options for Ankle Arthritis
1. Non operative treatment.
The non operative treatment options include anti-inflammatory tablets, the use of a walking stick and occasional use of splinting. These tend to work only in very mild cases and once the disease has progressed beyond a certain level will often not give satisfactory pain control.
We will occasionally consider injection of the ankle joint, again in mild cases or if the diagnosis is not certain. The injection involves the insertion of a long-acting local anaesthetic combined with a steroid into the ankle joint. The effects of the injection tend only to be temporary and will often wear off within a few weeks or months.
Figure 2 – Arthroscopic ankle fusion
3. Ankle arthroscopy.
This involves keyhole surgery through 2 small incisions at the front of the ankle. In mild cases of arthritis, this allows us to tidy up any loose cartilage and remove spurs of bone around the front of the ankle joint. We can also treat osteochondral lesions of the ankle joint through keyhole surgery. These are isolated areas of cartilage and underlying bone damage that often occur as a result of severe sprains of the ankle and can be the precursor for arthritis at a later date. As with injection and splinting, keyhole surgery and tidying up the joint tends to only be successful in mild to moderate cases of arthritis.
4. Ankle fusion.
A fusion of the ankle joint involves removing all residual cartilage of the joint and preparing the bony surfaces to allow the joint to fuse completely. This removes all movement from the ankle joint and is usually stabilised with 2 metal screws (see fig 2). This has been the conventional and proven method of treating ankle arthritis and has an excellent success rate in removing pain. Mr Taylor now performs the majority of ankle fusions using keyhole surgery. This significantly reduces the risk of wound problems and the risk of infection post-operatively. There is also a higher rate of successful union of the ankle fusion as the blood supply around the ankle joint is not significantly affected, as would be the case for a conventional open ankle fusion. The disadvantage of ankle fusion is that it creates increased stresses on the surrounding joints and may cause arthritis in these at a later date.
5. Total ankle replacement.
Ankle replacement is the latest and most exciting means of treating ankle arthritis. It involves relining the bones of the ankle joint (the tibia and the talus) and the insertion of a plastic meniscus between the two metal relining implants. The advantage of ankle replacement over ankle fusion is that it preserves the majority of the up and down movement in the ankle joint. This makes for a more normal walking pattern whilst still having the advantage of removing the pain from the ankle arthritis. In the past, there has been a high failure rate for ankle replacements.
Figure 3. Front view ankle replacement
Figure 4. Side view ankle replacement
Mr Taylor currently uses the Infinity Ankle Replacement (Wright Medical) (see figure 3 & 4). This has excellent short to mid-term follow-up and to date we have been very pleased with the outcomes of patients having their Infinity Total Ankle Replacement. He is lead investigator in a prospective study into the Infinity Ankle Replacement, a highly prestigious international study into ankle replacement.
Mr Taylor will discuss the options of treatment with you in more detail when he sees you in the Outpatient Clinic.