Your ankle joint is an important joint. You use it with every step. It allows you to move your foot up and down and keeps you balanced while walking, running or even standing.
There are three bones that makeup your ankle joint: the Talus (ankle bone), the Fibula (outer leg bone) and the Tibia (inner leg bone). The two leg bones connect with the anklebone in a hinge-like fashion creating the ankle’s unique mortise anatomy.
A significant amount of force and pressure are placed upon this joint with each step you take. And while the ankle joint can usually withstand such pressure, sometimes injury, genetics or just plain wear and tear can create problems.
Arthritis is a disease of the joints. It is simply a deterioration and destruction of the cartilage within the joint. Cartilage is the smooth thin layer of soft tissue that covers the surface of bone on either side of a joint. The only reason that the two bones do not simply fuse together (like when a fracture mends) is because cartilage is in the way, preventing it from happening. Any part of the body that moves involves a joint with cartilage. For the two bones to move over one another, cartilage needs to be present over the bones.
Cartilage takes on a great deal of pressure and force and absorbs these forces very efficiently. However, cartilage is not strong enough when there is a sheering force applied or when it is fractured. Even a small amount of damage to cartilage creates an uneven amount of pressure within the joint. This causes the bones to move along the damaged surface, searching for bone contact, eroding more and more cartilage along the way.
It is this deterioration or damage to the cartilage that causes arthritis. Arthritis of the ankle joint can be greatly debilitating, leading to pain, decreased activity, decreased quality of life, and immobility.
Any trauma to the joint can potentially damage the cartilage of the ankle joint. The trauma can be acute as in a fractured ankle, or something degenerative that happens over time. Genetics can also be a factor, as is the case of Rheumatoid arthritis, which affects all parts of the body equally. Unfortunately, arthritis is a progressive disease that will compound itself. When there is a constant overuse and impact on the joint surface, the cartilage breaks down. This leads to a decreased range of motion, which, in turn, causes additional cartilage breakdown because the bones continue to wear on one another.
The symptoms of ankle arthritis are typically pain and decreased range of motion. The pain comes because of movement in the damaged joint. As the joint becomes increasingly damaged, the bones rub against each other , which causes irritation and inflammation. As the joint fluid becomes inflamed, the nerves that are part of this inflammatory reaction become over stimulated, leading to pain. This condition is called synovitis. The loss of motion occurs when as cartilage dissipates. The joint moves less, creating stiffness and increased irritation and pain. As the movement decreases, the joint can change shape and flatten, making it even more difficult for the bones to move. Bone fragments and spurring can also be created as motion decreases. This can lead to even a further decrease of motion and increase of pain.
The clinical examination is used to determine the level of joint movement and range of motion. An analysis of the patient's gait is also important to evaluate because compensation triggered by ankle problems. Plain radiographs, x-rays, are used to evaluate the bone and joint directly. Multiple views are taken at different angles to determine the degree of arthritis and to see if any other joints are involved. CT and MRI scans may be helpful in determining any angular deformities, as well as assessing the amount of bone stock and cystic formations within the bone. An MRI shows the degree of cartilage loss to the bone surface and in what location.
There are several treatments for ankle arthritis ranging from conservative to surgical treatments. Determining the correct treatment for each individual patient depends on several factors. There is no one-way to correct or treat the damaged cartilage. It is often a stepwise approach to treatment, with the determining factor being the degree of damage to the joint.
It is important to remember that there is no one-cure for arthritis and many, many options, but which is right for you? The right treatment choices are critical for a great outcome. University Foot and Ankle Institute's personalized approach to care and decades of combined experience gets each patient the best outcome possible and treatment options include:
Many patients can benefit by simple accommodations of the ankle arthritis. This can be achieved by using orthotics or bracing. Custom orthotics can control some of the motion at and below the ankle that may remove some of the stresses that are being put on the ankle joint. This is usually effective in low-grade cases of ankle arthritis. Custom bases that cross the ankle joint can be very effective. These limit the amount of motion at the joint; less motion can lead to less pain. These braces can be hinged to allow for some movement, or unhinged to allow for no movement. Learn more about our custom orthotics.
Hyaluronic acid is a naturally occurring material that makes up joint cartilage. By injecting this material into the joint is lubricated to allow some increased mobility and decreased pain. This is usually performed 2 to 6 times at 1 to 2 week intervals. There is no way to determine how well or how long pain relief will be felt. A patient can have as many injections as they can tolerate over time. This procedure is usually best suited for patients who have a small degree of deterioration of the joint. It is important to note that these injections do not create cartilage, nor do they cure or replace missing or damaged cartilage.
Injections of Platelet Rich Plasma (PRP) and bone marrow aspirate stem cells and restart the inflammatory healing process in chronic arthritis. By injecting the patient's own blood and/or bone marrow that has been spun in a centrifuge to obtain a high concentration of platelets (healing cells), there is higher healing potential within the joint.
While the PRP injections reduce pain, the stem cell combination injections with PRP have the additional benefit of cartilage and bone healing to help deal with the noted damage. PRP injections alone can be done in an office setting, while the bone marrow aspirate stem cell injections may be done in an office or surgical facility. Learn more about PRP and Stem Cell Injections.
Surgical arthroscopy of the ankle is performed in the operating room. Two small incisions are made in the front of the ankle joint. A small camera is placed into one of the holes to visualize the joint. Instrumentation is placed into the other hole to "clean out" the joint. The painful synovitis is removed, along with any floating bone or cartilage fragments. If there is any spurring of the talus or the tibia, this can also be shaved down by the instrumentation. Any small areas of damaged cartilage can be repaired by placing small holes into the bone to allow for bleeding onto the bone surface, encouraging some new development of cartilage.
The recovery period for arthroscopy is about 2-3 weeks and patients are allowed to bear weight in a shoe as soon as they feel comfortable. The idea is to keep the incisions small and perform the procedure in a way that allows early range of motion and movement of the ankle. If there is damaged cartilage in the ankle joint, a period of no weight on the ankle may be necessary to allow the cartilage to heal.
Joint distraction of the ankle is performed with the use of an Ilizarov ring fixator. Once the joints are distracted (pulled apart), lubrication injections are used to decrease the abnormal stress in the joint. Distraction of the ankle allows cartilage and bone to to rest and heal, with no stress on the surface of the joint. The procedure is fairly simple but the fixator can be somewhat cumbersome. The use of a bone marrow aspirate or cartilage cells may be added to the procedure to help with the cartilage and bone healing during this period. The average time with the fixator ring is 6-12 weeks.
The Denovo cartilage procedure is commonly used in limited amounts of cartilage damage in localized regions of the ankle. Small amounts of cartilage cells are attached to the damaged area of bone and cartilage. These cells will then heal and fill in the damaged cartilage region over a period of 6-8 weeks.
An Osteochondral autograftis the procedure which human donor transplants bone and cartilage to replace cartilage defects. In patients with defects that involve injury to the cartilage and the bone underneath it, (osteochondral lesion), the defect could be replaced by donor bone. This is performed surgically. The joint is opened and the area of damage on the anklebone is removed. An exact piece of bone with cartilage attached is taken from donor anklebone and placed into the patient's bone.
Over time, the patient’s bone will incorporate this new bone as their own. In those cases where the defect is very large, the same procedure can be performed by placing multiple plugs of the new bone into the defect. There is little chance of rejection of the bone and recovery time is 6-8 weeks due to the fact that the bone and cartilage needs to grow into the surrounding region of bone and cartilage. During this period, weight is not allowed on the ankle.
Recent research has increased area of stem cell regeneration of cartilage. In patients with minor defects in the cartilage surface and minimal bone damage, stem cell replacement may be an option. Stem cells are cells in our body that live primarily in our bone marrow. These cells have yet to have become the cells they are destined to become. When these cells are placed near a cell that has already differentiated, the stem cell will become like this cell. By placing a patient's own stem cells into a cartilage defect, they become cartilage cells and produce cartilage.
This procedure is sometimes performed in the office setting but more commonly in an operating room. Bone marrow is taken from the patient's leg or heel bone through a small incision. This marrow is collected and spun in a centrifuge to collect the highest concentration of stem cells called mesenchymal cells. The product is then formed into a gel and "glued" onto the bone in the area of the defect on the anklebone. Over time, these cells will become cartilage and rejuvenate the joint. Learn more about Stem Cell Therapies.
For many years, fusion of the ankle has been the gold standard treatment in cases of severe ankle arthritis. A fusion is done by taking the ankle bone (talus) and the leg bone (tibia) and fusing them together into one bone using screws and plates. Once the bones are fused together, they become one bone and therefore, there is no more ankle joint, no more movement and no more pain. This procedure is reserved for the most severe cases of ankle joint arthritis, patients with high impact needs and in severe deformity of the ankle. It is the option used for those patients with increased demand on the ankle.
Who is the right patient for Ankle Replacement?
Ankle replacement procedures are outstanding as long as the proper implant is placed in the proper patient. Furthermore, proper patient selection for replacement versus fusion procedures is essential for the best outcome. In general, UFAI reserves ankle fusions for younger very active patients who require a great deal of strength and stability from their ankle. Ankle fusions are still preferred for patients with severe angular deformities of the ankle joint, which is often not correctable with a TAA.
TAA is reserved for patients who are less active and athletic, do not perform heavy manual labor, are over 45 (preferably over the age of 55), and have little to no angular deformity. Active patients put undo stress on the implant that can lead to failure. Younger patients presumably have many more years ahead of them, which increases the chance of implant failure.
Although some level of angular deformity can be corrected with soft tissue and or bone realignment procedures, in a separate and prior surgery, the best result is an arthritic ankle that is well-aligned on all three planes. It is interesting to note that those patients who have arthritis in other joints of the foot, (the midfoot and hindfoot), seemingly have more success with a TAA than an ankle fusion. This is because the loss of motion at the ankle with an ankle fusion places greater stresses on the surrounding joints; this may lead to furthering the already-arthritic changes of the other joints. A TAA allows motion of the ankle resulting in less strain about the already arthritic surrounding joints.
Some patients arrive at our offices with a pre-conceived notion of what procedure is best for them. This is important to address early in the relationship between the patient and doctor. It is essential that the the patient and doctor have a thorough discussion where all of the risks, benefits and differences between a TAA and an ankle fusion are fully understood.
Using steroid injections into the ankle joint have little effectiveness. They do not do anything to solve the problem or heal the arthritic changes. They can reduce the inflammation and pain for some time in some cases. However, the initial problem of the arthritis will remain, so the inflammation and pain will eventually return. In some cases, too many injections into the same joint can lead to increased destruction of the cartilage.
The doctors of University Foot and Ankle Institute are well versed in all three types of ankle replacement noted above. This allows us to better offer the proper ankle replacement for each patient.
University Foot and Ankle Institute understands the function of the ankle as well as anyone as well as the need to try conservative and non-invasive treatments, whenever possible because there are often more options for care than just surgery and an ankle replacement. From realignment procedures and cartilage transplantation, to bracing, arthroscopic debridement and joint lubrication our team treats the most common to complex ankle deformities and conditions.