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Review

Ankle Osteoarthritis
Baris Yilmaz1, Baran Komur2, Serhat Mutlu2, Guzelali Ozdemir1, Nurettin Heybeli2
1
MD, Fatih Sultan Mehmet Training and Research Hospital, Orthopaedics and Traumatology Department, Istanbul, Turkey
2
MD, Kanuni Sultan Suleyman Research and Training Hospital, Orthopaedics and Traumatology Department, Istanbul, Turkey

Corresponding author: Baran Komur, Email: barankomur@gmail.com.

Citation: Yilmaz B, Komur B, Mutlu S, Ozdemir G, Heybeli N. Ankle Osteoarthritis. J Minim Invasive Orthop,

2014, 1(4): e4. doi:10.15383/jmio.4.

Competing interests: The authors have declared that no competing interests exist.

Conflict of interest: None

Copyright: 2014 By the Editorial Department of Journal of Minimally Invasive Orthopedics. This is an open-

access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract: Degenerative osteoarthritis (OA) is the most common form of arthritis and is a major cause of morbidity

and disability. OA presentation is less commonly in the ankle than in other lower limb joints. Although nonsurgical

methods had been shown to be effective in some studies, surgery have to be considered where non-surgical

treatment has failed to control the patient’s symptoms. The aetiology, incidence, presentation and treatment options

of ankle osteoarthritis was discussed in this review article.

Keywords: Ankle; Ankle osteoarthritis; Ankle osteoarthrosis

Introduction Osteoarthritis (OA)can be defined as progressive destruction of

The ankle joint is made up of three bones: the lower end of the articular cartilage, leading to joint space narrowing, subchondral

tibia, the fibulaand the talus.The talus sits on top of the sclerosis, subchondral cyst, synovial inflammation and osteophyte

calcaneusand articulates with tibia. Working like a formation. Stiffness, swelling, and pain are typical symptoms

hinge,talus,allows your foot to move only in the sagittal associated with OA. Pain is the main problem with OA of any

plane.Ligaments on both sides of the ankle joint help hold the joint. In the lower extremity it is sometimes described in the

bones together. Many tendons cross the ankle to move the ankle posterior or midfoot.Initially pain is only activity related. Usually,

and the toes. Inside the joint, the bones are covered with a slick, once the activity gets underway there is not much pain, but after

smooth material called articular cartilage. Articular cartilage resting for several minutes the pain and stiffness increase. Later,

allows the bones to move against one another in the joints of the when the condition worsens, pain may be present even at rest. The

body. The cartilage lining is about one-quarter of an inch thick in pain may interfere with sleep. The joint may swell, fill with fluid,

most joints that carry body weight, such as the ankle, hip, or knee. and feel tight, especially following increased activity. As the

It is soft enough to allow for shock absorption but tough enough to articular cartilage starts to wear off the joint surface, the joint may

last a lifetime, as long as it is not injured(1). squeak as crepitation when moved. This sound refer as crepitation.

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Some patients complain the ankle locks or gives way, which may injuries that may result in OA includefractures of the malleoli,

be due to a loose body but usually just represents attacks of severe tibial plafond, talus, isolatedosteochondral damage of the talar

pain with reflex inhibition of the supporting muscles. The joint dome, and ankle ligamentinjury (7,9,10).

becomes stiff and loses flexibility. Certain movements can become Age did not differ between men and women (11). Etiology of

painful, and it may become difficult to trust the joint to hold your ankle OAconsists of post-traumatic ankle OA in approximately

weight in certain positions. When OA has reached a very severe 78%, secondary arthritis in approximately 13%, and primary OA

stage, the bone itself under the articular cartilage may become in approximately 9% of the cases. Patients in the posttraumatic

worn away. This can lead to increasing deformities around the ankle OA group have malleolar ankle fractures, ankle ligament

joint. In the final stages, the alignment of the bones can begin to lesions (16%), pilon tibial fractures, tibial shaft fractures, talus

form odd angles where they meet at the joint (15). fractures (2%), and severe combined fractures (2%). Patients in the

Over the past several years, there has been increasing evidence secondary OA group have rheumatoid arthritis (5%),

that OA is genetic, meaning that it runs in families. OA that occurs hemochromatosis (3%), hemophilia (1%), clubfoot deformity (1%),

without any injury may prove to be related to differences in the avascular necrosis of the talus (1%), osteochondritis dissecans

chemical makeup of articular cartilage. Arthritis may come from (1%), and postinfectious arthritis (1%)(11,12). Malleolar fractures

differences in how each of us is put together based on our genes, a and tibial plafond fractures were the two most common causes of

condition best described as OA. OA may also develop years after fracture-related post-traumatic ankle OA.

an injury that leads to slow damage to the joint surfaces, a Post-traumatic arthritis patients are often younger and have only

condition probably best described as post-traumatic arthritis.In one joint involved. They may still hope to return to an active

post-traumatic OA, imbalance in the joint mechanics usually leads lifestyle including contact or extreme sports, which may have

to damage to the articular surface (Fig.1). precipitated their injury in the first place and may be intolerant of

Posttraumatic osteoarthritis %78 residual restrictions or discomfort(13). Studies indicate that


Malleolar fracture
Ankle ligament lesions
Tibial plafond fracture severity of the initial injury and adequacy of reduction may play a
Tibial shaft fracture
Talus fracture
Severe combined fractures role in the development of post-traumatic ankle OA. Other studies
Secondary osteoarthritis %13
Rheumatoid arthritis revealed that subsequent post-traumatic OA development
Hemochromatosis
Hemophilia
Clubfoot correlates with the initial cartilage damage. Even if an injury to a
Avascular talus necrosis
Osteochondrosis dissecans
Postinfectious arthritis joint does not injure the articular cartilage directly, can potentially
Primary osteoarthritis %9

Figure 1. Etiology of Ankle Osteoarthritis alter joint biomechanics. When an injury results in a change in the

Degenerative OA is the most common form of arthritis and is a way the joint moves, the injury may increase the forces on the

major cause of morbidity and disability.Approximately 15% of the articular cartilage. This is similar to any mechanical device or

world’s adult population is affected by joint pain and disability machinery. If the mechanism is out of balance, it wears out

resulting from osteoarthritis(OA), and among these approximately faster(14,15).

1% have OA of the ankle joint (2,3). OA presents less commonly Rheumatoid arthritis and other inflammatory diseases such as

in the ankle than in other lower limb joints.There are several psoriatic arthritis, where the inflammatory component has burnt

reported causes of ankle OA.5 These include primary, systemic out leaving a damaged joint. Contrary to post-traumatic OA these

(rheumatoid arthritis and other systemic diseases) and post- patients often have several joints involved. Primary osteoarthritis

traumatic OA. Although hipand knee OA are mostly of primary is probably commoner than formerly believed. Some of these

origin, clinicaltreatment studies of ankle OA have shown the most patients have monoarticular or oligoarticular disease, remain fairly

commontype is of posttraumatic origin (4,5,6,7,8).Traumatic ankle active and expect to continue doing so. Others have multiple joint

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involvement and in this sense are more like rheumatoid patients, If there is malalignment, a standing hindfoot alignment view will

but without the systemic effects. Patients with intra-articular show at which level - ankle, subtalar or both - the malalignment is

disease such as osteochondritis dissecans, osteonecrosis of the occurring. Where there is loss of bone stock or complex anatomy

talus or synovial chondromatosis clinically resemble the primary post trauma or infection a CT can be helpful. MR will show joint

osteoarthritics. Few patients have arthritis, related to chronic surface lesions such as osteochondritis dissecans, and soft tissue

instability, such as arthritis secondary to instability or foot abnormalities including infection and sinuses. If there is

deformity. Persistent ligamentous instability is likely to preclude osteonecrosis, usually of the talus, MR will show the extent of the

ankle replacement. Major foot deformities such as pes cavus or abnormality, which will help surgical planning, but an isotope

severe flatfoot, or proximal malalignments such as a malunited bone scan is required to show how much revascularisation has

tibial fracture, can lead to asymmetric loading of the ankle or occurred. If there is any question whether the arthritis may be

ligamentous instability and subsequent arthritis. The abnormal coming from something other than OA, blood tests may be ordered

biomechanics can preclude an ankle replacement, or require a to look for systemic diseases such as rheumatoid arthritis. A

preliminary realignment or stabilisation. The joint may be needle may be inserted into the joint to remove some of the joint

destroyed by sepsis which then limits the reconstructive options. fluid. This fluid may be sent to a lab to look for crystals due to

These patients often require complex reconstruction(14). gouty arthritis or signs of infection.

The diagnosis of OA begins with a history of the problem. Details Nonsurgical treatment of ankle OA usually begins when the ankle

about any injuries that may have occurred to the joint, even years first becomes painful.The pain may only occur at first with heavy

before, are important to understanding why the condition exists. use and may simply require the use of mild anti-inflammatory

Regular X-rays will be taken to see how severely the joint is medications such as aspirin or ibuprofen. Reducing the activity or

damaged. This is usually the most practical and useful screeninig changing from occupations that require long periods of standing

method to determine how severe the OA has become. X-Rays and walking may be necessary to help control the symptoms.

allow assessment of remaining joint space, spurs and loose bodies. Nowadays newer medications such as glucosamine and

Several radiologic grading systems have been used to evaluate OA chondroitin sulfate are being used andthese medications seem to

of the ankle. In general, these grading systems classifies the be effective in reducing the pain of OA in all joints.There are also

relationship between radiographic grade and severity of the new injectable medications that lubricate the arthritic joint such as

articular cartilage damage. Mostly, Kellgren-Lawrence, Takakura knee but these are not usually prescribed for ankle OA yet.

(modified) and Van Dijk classification systems have been used to An injection of steroid into the joint can give temporary relief

evaluate of OA of the ankle. The Kellgren-Lawrence system based from symptoms of OA since steroid is a powerful anti-

on spur formation while the other classification systems inflammatory medication. When injected into the joint itself,

emphasizes mainly on joint space narrowing. The classification of steroidcan help relieve the pain. Unfortunately, pain relief is

Takakura and Van Dijk differ in that the former was especially for temporary and usually only lasts several weeks to months. Steroid

medial ankle OA, also subclassifies medial joint narrowing. Some injections are often helpful on an empirical basis, although there is

studies show that correlation of the radiologic findings and no good evidence base for their use and in other joints they may

arthroscopic findings. Arthroscopic Outerbridge classification not be much better than placebo(16). There is a small risk of

which has been using for knee surgery also have been used to infection with any injection into a joint, and steroid injections are

classify chondral damages of the ankle.The purpose of grading of no exception. Heidari (17) found the anterolateral portal slightly

OA of the ankle is to predict the future of the cartilage, prognosis more accurate for ankle injection, with a 86.1% success rate

of the patient and select the best method for treatment. compared with 77.5% for the anteromedial portal, although the

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difference was not statistically significant. Hyaluronan The arthroscope can help to remove these loose bodies and bone

supplementation injections have been described in other joints. spurs and smooth the cartilage surfaces of the ankle

Three small RCTs have been reported in the ankle. Salk (18) and joint.Arthroscopic debridement for impingement had a 75%

Cohen (19) compared hyaluronate to saline injections in 17 and 28 success rate at 5 years in the presence of spurs, but only 50% with

patients respectively. The main outcome measure was the Ankle loss of joint space (21).

Osteoarthritis Scale. In each case there was a significant When the ankle joint becomes so painful that it is difficult to walk,

improvement in AOS in hyaluronate-treated patients, but this also surgery may be suggested to fuse the ankle joint. An ankle fusion

occurred after saline injection and a significant difference between is also called an ankle arthrodesis and in this operation, the three

treatment groups occurred only at one time-point in one trial. bones that make up the ankle joint are allowed to grow together, or

Karatosun (20) compared hyaluronate injections to exercise fuse, into one bone. In this condition the ankle no longer is able to

therapy in 30 patients. Again, both groups improved on the move, but with a successful fusion the pain is gone. The ankle

AOFAS ankle score, and there were no significant differences fusion is a good operation, especially for a young, active person. It

between the groups. Larger trials are required to assess the real is usually the preferred option for post-traumatic arthritis of the

significance of the differences found. At the moment hyaluronate ankle. Once the ankle is successfully fused it can last a lifetime,

should probably be used only in the context of such trials. but there are still complications associated with this procedure, and

Physical therapy plays a critical role in the treatment plan for ankle not all ankle fusions are successful.Preparing the joint surfaces is

joint arthritis. The main goal of therapy is to help how to control crucial to maintane a proper aligment of the ankle joint. The ankle

symptoms and maximize the health of ankle. Therapists work to should be positioned in neutral plantar/dorsiflexion, 5 deg. valgus

improve flexibility, balance, and strength. Training is done to help and 5-10 deg. external rotation (22). Fixation in most series is with

walk smoothly and without a limp, which may require that use a 2-4 cancellous bone screws. Additionally, stability of the fusion

walking aid such as a walker, crutches or cane.Modifying shoe can be increased with an anterior or lateral plate, blade plate or

with a rocker sole may give some relief of symptoms andthis can ring fixator.

help take stress off the ankle. Braces that reduce the motion in the The arthroscopic technique is now the standard method of fusing

ankle can also be beneficial in reducing pain. Special braces that the ankle unless there is severe deformity, bone loss or revision

transfer some of the body weight to the knee can help protect the surgery. However, it requires advanced arthroscopic skills. It is

ankle. These braces are called patellar tendon bearing braces. They feasible in patients whose soft tissues would not be suitable for

are quite large and bulky and may not be well tolerated by some open surgery. However, there has never been a RCT comparing

patients. open and arthroscopic fusion.

Surgery is an option where non-surgical treatment has failed to Arthroscopic fusion has developed to the point where it is now the

control the patient’s symptoms and they are seriously affecting the standard technique for most foot and ankle surgeons. In

patient’s activities of daily living, work and sleep. There are arthroscopic fusion, synovitis and spurs are cleared to expose the

several different types of surgery that can be performed. The joint line. Curettes and burrs are then used to remove the

choices for surgery are arthroscopic surgery to clean up the joint, remaining articular cartilage and freshen the subchondral bone so

fusion of the joint, or replacing the joint with an artificial ankle that multiple bleeding points are seen. It is important to clear all

joint.Sometimes when OA of the ankle occurs, loose pieces of the way to the back, includingthe FHL tendon, usually seen

cartilage and bone float around inside the ankle joint. These loose through the posterior ankle capsule, as a landmark. It is also

bodies can cause irritation in the joint, leading to inflammation. important to clear the gutters, the malleoli and the medial and

They can also get caught between the joint surfaces of the ankle. lateral surfaces of the talus and to ensure that no osteophytes on

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the talus prevent compression of the talus into the mortise. Once Many surgeons are now beginning to use the artificial ankle for

preparation is complete, fixation is usually with two or three post-traumatic arthritis instead of doing a fusion. Patients are able

cancellous lag screws inserted over guidewires.Over 15 series of to keep the motion in the ankle and avoid some of the problems

arthroscopic ankle fusions have been reported. Overall about 550 associated with the ankle fusion. But the ankle is a difficult joint to

arthroscopic fusions have been reported with a total fusion rate of replace for many reasons. Tibia and fibula move against one

93.3%. Several series have commented on the quicker rate of another slightly when we walk. This makes it difficult to get the

union in arthroscopic procedures although this can be influenced artificial ankle socket to stay connected to the bone.The biggest

by the intervals at which radiographs are taken, and all series problem with the older artificial ankle designs is that they loosened

diagnosed union on plain radiography rather than CT (23). after a relatively short time and began to cause pain. However the

Open fusion can be done using anterior, posterior and lateral newer artificial ankle designs, surgeons have tried to solve this

approaches. A short medial arthrotomy is sometimes a useful problem by actually fusing the tibia and fibula together during the

adjunct to a lateral approach, although an extensile medial operation and placing screws across the two bones. This has

approach can be used to access talonavicular, subtalar and ankle dramatically increased the success rate for the artificial ankle

joints. The lateral approach exposes the lateral malleolus, which replacements done today.

can be excised and morcellised for graft, or removed, decorticated Replacement of the ankle has been around for over 30 years.

and attached as a large graft at the end. An alternative technique However, early prostheses did not reproduce the biomechanics of

for graft harvest is to use an acetabular reamer to remove the the ankle well and had a very high failure rate. Second-generation

lateral malleolus. The superficial peroneal and sural nerves, and prostheses from the late 1980s onward introduced improved

their communicating branches, are at risk. Many series of open engineering, often with three components.10-20 year results are

ankle fusion have used flat cuts with a power saw or osteotome to now being published, indicating success in over 90% of patients

excise the joint. Others use techniques to increase stability and (28,29). The Wrightington series is a realistic and critical account

congruency, such as anatomical resection of the joint surfaces in with 5-8 year follow-up and 92% 5-year success (30). This has

the manner of arthroscopic fusion, or a chevron cut (24). now been updated with 80.3% survival at 10 years (31).Ankle

Preservation of the malleoli increases stability. Generally fusions prostheses also seem to be best uncemented; the long term results

have been reported with a total fusion rate of 92%-%96 of patients of the STAR ankle have been significantly better in the

at an average of 2-10 years follow-up in the open uncemented design. Like all joint replacements, failure occurs and

tecnique(25,26,27). Although many studies are quite old and use may require revision replacement or fusion. The failure rate for

techniques that are uncommon now, the risk of non-union is revision arthroplasty is high and most patients will be better

almost certainly higher in open than arthroscopic fusion. revised to a tibiotalocalcaneal fusion (Fig. 2).

CONSERVATIVE THERAPY
JOINT PRESERVING
JOINT REPLACEMENT
SURGERY
Insoles ANKLE ARTHODESİS
Analgesics Three component
Corrective
Shoe modifications prosthesis +/- additional Arthroscopic or open
osteotomiesLigament
Chondroprotective agents surgery for adjustment of surgery
repair
alignment and stability
Tendon surgery

Figure 2. Staged treatment approach for progressing ankle osteoarthritis.

Osteochondral surgery
Distraction
Gougoulias published a systematic review of 13 series arthroplasty
amounting years’ follow-up. Survivorship rates were variable, satisfaction

to 1105 ankle replacements, of which the Agility, STAR and rates varied from 79-97% but 23-60% of patients still had some

Hintegra were commonest (32). Only 4 studies had more than 10 pain. Wood reported the only RCT in ankle replacement,

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comparing 100 STAR ankles with 100 Buechel-Pappas ankles (33). 3.Peyron JG. The epidemiology of osteoarthritis. In: Moskowitz

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