Ankle Arthritis Treatment – Melbourne

Ankle Arthritis –  A Patient’s Guide

Mr Troy Keith MBBS (Hons), FRACS (Orth), FAOrthA
Orthopaedic Foot and Ankle Surgeon

Treatment including Ankle Fusion and Total Ankle Joint Replacement

Your Ankle Joint

Your ankle joint is a hinge joint that consists of your tibia (shin bone) and the talus (ankle bone). It allows up and down movement. The fibula bone lies on the outside of the joint.

Your ankle has to bear 5 to 7 times your body weight during daily activities, such as standing and walking.

Below the ankle is the subtalar joint (the “under ankle” joint). The subtalar joint, between the talus and heel bone (calcaneus) allows side
to side movement when you walk on uneven ground.

Ankle Joint

Who is prone to ankle arthritis?

Anyone can get ankle arthritis. Osteoarthritis (degeneration or wear and tear) tends to become more common as we get older. Ankle trauma including fractures, repeated sprains, and inflammatory arthritis can cause arthritis at a younger age.

What is ankle arthritis?

Ankle arthritis can be caused by degeneration (osteoarthritis) or inflammation (e.g. rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis). In both cases the cartilage, which is the shiny white surface that lines the joint, becomes damaged. This causes bone to rub on bone, which is painful.

Osteoarthritis is usually secondary to damage to the joint, for example as a result of previous facture, repeated sprains of ankle, malalignment of the joint or infection.

Excess body weight can overload a joint or worsen the symptoms of arthritis. Every extra kilogram of body weight is multiplied by 5 to 7 times when carried by your ankle.

The alignment of the leg is such that the weight passes from the centre of the hip, through the centre of the knee, and into the centre of the ankle. Anything which changes this alignment will alter the way the ankle is loaded and cause it to wear unevenly and more quickly. ‘Bow legs’ or ‘knock knees’ are examples of malalignment, which can affect your ankle.

Similarly, ankles which point inwards are more prone to sprains, and consequently early arthritis. In some cases, realignment of the bones may be helpful in treatment.

What are the symptoms of ankle arthritis?

Pain – Ankle pain is the most common symptom and is usually made worse by walking. The pain may even keep you awake at night. Simple ways to see if your pain is getting worse is to record whether your walking distance is decreasing, or whether you are needing more pain relief medications to ease the pain.

Joint stiffness – With osteoarthritis, ankle joint stiffness or reduced movement is common. With rheumatoid arthritis, also called inflammatory arthritis, stiffness often is worse first thing in the morning.

Cracking/popping/locking – There may be little pieces of loose cartilage or bone caught within the joint causing this sensation.

Ankle weakness or giving way – This may be due to looseness of the ligaments, or secondary due to to pain. 

Swelling – Swelling may be as a result of extra bone, or fluid within the joint. The soft tissues around your ankle can also inflame and swell.

How do you find out if you have ankle arthritis?

An x-ray of your ankle taken whilst you are standing may reveal if you are suffering from ankle arthritis. Blood tests may also be used to investigate inflammation, or gout.

Occasionally, special tests are needed to determine the extent of the arthritis, or exactly which joint in your ankle is involved. An MRI scan can give a lot of information on the thickness of the cartilage lining the joint, and whether there are small areas of wear and loose cartilage. CT and bone scans may also be used to investigate ankle arthritis.

An arthroscopic operation may also be performed, (there is a separate information sheet regarding this subject) which allows your surgeon to see the amount of wear within the joint. An Arthroscopy can sometimes be used to clean out the joint, and help in the treatment of arthritis.

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Ankle Arthritis Treatment

Ankle Arthritis Treatment – Melbourne

With any form of arthritis there are two forms of treatment. The first is without an operation (non-operative), and the second is with surgery (operative). Most arthritis can be treated without surgery, and only in severe arthritis cases should surgery be considered.

Ankle Arthritis – non-operative treatments

Modifying the way, you lead your life should be tried first. This may include:

  • Resting more when the pain increases
  • Weight loss
  • Supportive walking boots and walking sticks
  • Splints or braces
  • Low impact activity – swimming, cycling etc.
  • Pain killers such as Paracetamol or Panadol Osteo
  • Anti-inflammatories (NSAID), such as nurofen and Diclofenac can also reduce inflammation.

Check with your general practitioner or pharmacist that NSAID’s are suitable for you, as they may have side effects, especially if you have asthma, or stomach ulcers.

For many people pain from arthritis can be eased through using an ankle brace and or a high topped, lace up walking boot with a cushioned sole. Elasticized boots commonly don’t provide a great amount of support.

Dietary supplementation with Chondroitin and Glucosamine, which can be bought in health food shops, may be effective in some patents with early symptoms of ankle arthritis. Hydrotherapy can be very helpful with pain and stiffness.

Patents with inflammatory arthritis are usually looked after by a Rheumatologist. Disease modifying ant-rheumatoid drugs (DMARD’s) are used to treat these conditions, in conjunction with painkillers and NSAID’s.

Operative Treatments – Arthroscopic debridement

Cleaning out of the ankle is normally done through keyhole surgery. Under anaesthetic, a telescope is inserted into the joint through 2 small incisions on the front of the ankle. The ankle is washed out with fluid and the loose bits of ‘gristle’ and bone are removed. If there are any bony spurs which block movement, these can be removed at the same time.

This does not reverse the damage done to the cartilage. Pain and stiffness may decrease for an unspecified period of time. If the symptom relief is worthwhile the arthroscopy can be repeated. Please visit ankle Arthroscopy Information page if you are interested.

The complications of arthroscopy may include:

Failure of the pain to resolve – Approximately two thirds of people obtain significant benefit from the surgery, but in one third the symptoms are largely unaltered, or deteriorate as a result of progression of the arthritis.

Infection – This is rare, with significant infection occurring in less than 1 in 1,000.

Wound healing problems – In rare cases the arthroscopy ports can be slow to heal.

Nerve damage – Nerves in the skin can become entrapped in the scars where the arthroscope is inserted, leading to a numb area overlying the skin.

Most problems can be treated by medications, therapy and on occasion by further surgery, but even allowing for these, sometimes a poor result ensues.

Operative Treatments – Fusion of the ankle joint

Fusion of the ankle to treat arthritis is a “tried and tested” treatment for severe ankle arthritis.

The joint surface is removed and the joint is made permanently stiff, fixed with screws, allowing bone to heal across the joint. The medical term for fusing a joint is “arthrodesis.”

Fusion of the ankle is successful in 96% of cases. The pain is much reduced as there is no joint remaining. There is no ‘up and down’ movement at the ankle after a successful fusion. However, approximately 30% ‘up and down’ movement of the foot actually comes from movement at other joints in the foot, and this remains.

How is ankle fusion surgery performed?

Ankle fusion surgery can be done through key hole surgery using an ‘arthroscope’ to see into the joint. Cartilage is removed from both sides of the ankle using a burr. This creates two raw bone surfaces which are then fused together using screws under x-ray guidance.

In some cases it is only possible to correct severe ankle deformity using an open technique, and extra bone may be required at the fusion site. As with any open procedure, there is the potential for would healing problems.

Key hole surgery has the advantage of much smaller incisions, and the pain is usually not as severe.

Ankle Arthritis Treatment Melbourne

Advantages of this approach

The advantage of this operation is that the incisions are much smaller, and the pain is not usually as severe. Patents will spend 12 weeks in a cast, and are allowed to walk on the foot after 2 weeks in their cast with a post-operative shoe.

Alternatively, fusion can also be done with an open incision. Normally it is also only possible to correct severe deformity using an open technique. Occasionally extra bone is needed at the fusion site. This can be taken usually through the same incision. As with any large open procedure, there is the potential for would healing problems.

Post-operative care

After either operation you will go into a plaster splint and remain non weight bearing until your 2 week review with Mr Keith. You will then have a below knee cast fitted and allowed to commence weight bearing in the cast. A repeat x-ray is taken at your 6 and 12 week reviews to confirm the joint is fusing. The plaster cast is finally removed at 12 weeks and you are able to weight bear as tolerated.

Following removal of the cast, a compression or flight sock maybe helpful to reduce swelling. It will be at least 6 months until the benefits of surgery become apparent.

In the longer term, walking and golf are possible, but only the occasional person will be able to jog. You may walk with a limp, but this is usually less marked than it was before surgery, as a result of the reduced pain.

Following surgery, there will be limitation of the height of the heel that you can wear (usually less than 3cm). Some will find wearing a shoe with a curved “rocker bottom” sole will help walking.

Potential complications

The complications of fusion may include:

  • Infection and wound healing problems
  • Failure of the bones to heal (non-union) – In non-smokers a non-union is far less common. With smokers, nicotine increases the chances of a non-union by a factor of five. If you are a smoker it is advisable to stop smoking a minimum of 3 months before surgery.
  • The bones not healing in the correct position (malunion)  This can usually be rectified by a second operation.
  • Screw removal – Prominent metalware may require the screws to be removed as a day case procedure.
  • Failure of the pain to resolve This is usually because of one of the reasons outlined above – occasionally no cause can be found.
  • Blood clots  In the leg and rarely on the lung (deep vein thrombosis and pulmonary embolus).
  • Nerve and blood vessel damage – This may lead to numbness, pain or weakness in the foot.
  • Long term complications – Arthritis (after 10 years) can develop in adjacent joints in the foot, as a result of stress placed on it by the absence of the ankle joint. If this becomes painful, it can be treated with further surgery.

Most problems may be treated by medications or in special circumstances further surgery but even allowing for these, sometimes a poor result ensues.

Operative treatments – Total Ankle Replacement

Ankle replacement surgery has been around for many years. The initial attempts were unsuccessful and failed almost universally. Newer designs are more successful, and have encouraging results.

An ankle replacement is not an operation for the young, athletic patient to return to “normality”, it is a powerful technique to be used on selected patents. Mr Keith will advise you about your suitability. Patents who are more suitable for an ankle replacement tend to be older with lower functional demands.

The main object of this surgery is to relieve pain. It will restore the same movement back to the ankle, and walking may improve; but only as a consequence of pain relief.

The principle of the operation is to remove the worn out joint and replace it with a metal surface on both the tibial (top) and talar (bottom) sides with a plastic liner sandwiched between them (middle).

Ankle Replacement

The metal surfaces encourage bone to grow onto their surface creating solid fixation with the surrounding bone. The plastic liner in between is flat on one side and curved on the other. This allows the up and down movement of the ankle.

Other suitable patients may include those with arthritis involving both ankles and patents with rheumatoid arthritis. Rheumatoid patients often have other joints damaged by arthritis in their feet which may not stand up to the stresses that can follow a fusion operation.

Total ankle replacement may not improve your range of ankle movement after surgery. Long term results for ankle replacements are not as good as those for hip or knee replacements.

The success of ankle replacements for relieving pain is about 80-90%. With approximately 80-90% of total ankle replacements surviving to 10 years.

Ankle Arthritis Treatment – Melbourne

What happens after my ankle replacement surgery?

You will be in plaster for between two and six weeks. However, you will not be able to walk on the leg until the wound settles usually at the two week review. One of the major problems following surgery is swelling and slow healing of the wound, it is therefore very important to keep the foot elevated in the first few weeks after surgery.

The complications of total ankle replacement may include:

  • Infection  Worldwide the overall infection rate is approximately 2%, and every effort is made to avoid this.
  • Wound healing problems  This is associated with infection and occasionally requires plastic surgery. It is best avoided by keeping the leg elevated after surgery. Smoking also predisposes you to this problem.
  • Nerve and blood vessel damage  This may lead to numbness, pain or weakness in the foot.
  • Fracture of the ankle  In rare instances the bones around the ankle fracture at the time of the surgery. This is treated by the insertion of extra screws during the surgical procedure.

Wearing out of the bearing  This occurs over several years, and is the usual cause of failure after 10 years or more. It can be treated by either replacement of the plastic bearing, or total revision of the replacement.

Dislocation  This is rare with ankle replacement.

Failure of pain to resolve  This is usually due to one of the complications, but occasionally no cause is found.

The decision as to whether to undergo fusion or replacement is often straightforward, but on occasion is a matter for discussion between you and your surgeon. There is no “correct” answer; it is a matter of individual preference.

A Message from Mr Keith

These guidelines are intended to help you understand your treatment and prepare for your operation.

I understand the level of detail may cause concern or worry for some patients.

If you do have further questions, please don’t hesitate to ask me at your consultation or contact a member of my team.

We will happily address your concerns.

It is important for me that you feel comfortable and satisfied you have all the information you need before your surgery day.

 Mr Troy Keith – Orthopaedic Foot & Ankle Surgeon.

Any questions please email

Ankle Arthritis Treatment Melbourne

If you have any questions or would like to book an appointment, please contact us.

Mr Troy Keith – Foot & Ankle Surgeon.

VISIT CONTACT INFORMATION

Ankle Arthritis Treatment Melbourne

Mr Keith sees patients from all over Melbourne to diagnose and treat ankle arthritis. Mr Keith consults with patients from the following practice locations in Melbourne including Malvern, Armadale, Richmond, Heildelberg and Shepparton in country Victoria.