Ankle Arthritis - Everything You Need To Know - Dr.
Nabil Ebraheim
https://www.youtube.com/watch?v=ysx-FT6fllA
The patient will have
longstanding global pain that is inside the ankle. The patient will have antalgic gait with
swelling of the ankle and decreased ankle motion. You want to check the sensation. Lack of sensation with Simmons–Weinstein 5.07
monofilament testing is important because insensate patients are poor
candidates for ankle joint replacement.
The patient will usually have a trial of nonsurgical treatment first.
Treatment
- Anti-inflammatory
medication
- Activity
modification
- Ankle
orthosis/bracing
- Injections
Treatment Orthosis
· Single rocker sole shoe modification and custom Arizona brace. You may give the patient a cane.
With failed conservative treatment, the patient may need arthrodesis of the ankle, which is fusion of the ankle, or an ankle replacement. If you are going to do arthrodesis of the ankle, it will be arthrodesis of the tibiotalar joint. In ankle arthrodesis, the fixation can be done by multiple techniques. The whole idea is to obtain rigid fixation. You can use plates, screws, or combination of both.
How to you position
arthrodesis?
·
Neutral flexion
·
The gastroc
recession or TAL may be needed if we cannot achieve neutral dorsiflexion. From 0–5 hindfoot valgus when 5–10 external
rotation of the foot.
Arthrodesis
·
80% will have
difficulty on even ground.
· 75% will have difficulty with stairs.
If you find a person with an
ankle fusion that when they walk, they have knee hyperextension when the heel
comes off the ground during the stance phase, then that person's ankle is fused
and some plantar flexion. The plantar
flexion position will create forced recurvatum of the knee. The ankle should be fused in neutral
flexion. If the person has arthritis of
the ankle joint and the subtalar joint, then you will do tibiocalcaneal
arthrodesis. Some people elect to go for
total ankle replacement.
What are the contraindications
for total ankle replacement?
- Severe deformity
- Charcot joint
- Avascular necrosis of the talus
- Soft tissue compromise
- Active ankle infection
What is the relative
contraindication for ankle joint replacement?
- Ligament instability
- Diabetes
- Smoking
- Osteoporosis
- Morbid obesity
When do you do distraction
arthroplasty?
You do this in younger patients with some motion and less
severe joint destruction.
Arthritis of the ankle can be
osteoarthritis, posttraumatic arthritis, or inflammatory arthritis as
rheumatoid arthritis or gout.
Posttraumatic arthritis accounts for 80% of all ankle arthritis. The primary osteoarthritis is about 10%
only. Pain with weightbearing, swelling,
decreased range of motion compared to the other side, and you will be able to
see the arthritis on the x-ray. Ankle
arthrodesis will be done in younger patients with a high demand, or if the
patient has comorbidities such as diabetes and obesity. 10 years after ankle arthrodesis, 50% of the
patients will have subtalar arthritis.
Some of the patients may get nonunion. Revision of the nonunion can lead
to fusion in about 85%. A young, active
worker is a contraindication to total ankle arthroplasty. You will do the arthrodesis and end-stage
ankle arthritis and the union rate is about 90%. The arthrodesis gives us a reliable pain
control but will also give us adjacent joint arthritis. The entire foot and the patient's
comorbidities must be evaluated to choose the proper surgical technique. Total ankle arthroplasty has superior gait
mechanics compared to ankle arthrodesis.
Ankle arthrodesis is done 6 times more than a total ankle
replacement. If you have an elderly
patient with no comorbidities and you want to do a motion preserving procedure,
then this would be total ankle arthroplasty.
Revision of total ankle occurs due to loosening of the implant or
subsidence, especially in patients less than 55 years old. In a patient with rheumatoid arthritis with
end-stage arthritis, total ankle may be a reasonable option. In older patients with low demand, you will
give total ankle arthroplasty. In
younger, active patients he will do a fusion.
The total ankle arthroplasty is gaining a lot of popularity. For patients with nonunion, you need to
evaluate for infection and metabolic bone disease. You may also need a CT scan. Preservation of the fibula can help the
potential conversion to a total ankle at a later date. When you compare patient with an ankle
prosthesis to a patient with thin ankle fusion, there is more complication rate
and revision rate for a patient with total ankle and more increased wound
complications for people with rheumatoid arthritis. If you are in doubt, use ankle arthrodesis.
