What is it?
Arthritis is progressive wear and tear of the ankle joint. In early cases there may just be pain at the front of the ankle or when climbing stairs but as it gets worse the ankle becomes stiff and painful at all times. I am very careful to assess all of the joints around the ankle as sometimes the pain may be coming from the joint below the ankle or from the ligaments and tendons. Sometimes further scans or diagnostic steroid injections are needed to be sure about the origin of the pain.
Why does it happen?
Ankle arthritis is most commonly caused by previous injury. In fact in a paper that I published a few years back, I showed that after a certain type of ankle fracture around 10% of patients develop ankle arthritis. It can also be due to overuse such as “footballer’s ankle” where repetitive kicking leads to bony overgrowths over the front of the ankle
How can I treat it?
Initially we have to come to a clear diagnosis. Once we are happy that it is wear and tear in the ankle that is causing the pain, my first port of call is a low profile stabilising brace. Many braces are bulky and cumbersome and as such I take care in working with therapists who can provide you with a comfortable brace that you can wear with normal shoes. This is successful in controlling symptoms in a majority of patients but if the pain continues or becomes particularly acute an injection may give you fast and longlasting relief. I prefer to use a synovial fluid mixure, called hyaluronic acid, which mimics the natural cushioning fluid of the ankle as I feel it is more natural than a steroid injection but we can discuss this if it appropriate.
Other options which are newer but have less evidence are biological PRP injections which are also an option but I prefer these from tendon and ligament problems.
What does surgery involve?
If you have extra bone forming at the front of the ankle and pain on activity I find a keyhole removal of inflamed tissue and bone using a camera is very helpful and can really improve symptoms. If the arthritis is present with deformity or is very severe the options are an ankle fusion or an ankle replacement.
Fusion or replacement?
There is currently a lot of debate amongst specialists as to whether we should offer an ankle fusion or a replacement. An ankle fusion can be done keyhole, gives reliable results and gives surprisingly good function.
An ankle replacement maintains movement but requires a large incision and has a higher failure rate than hip and knee replacements. Our technology for redo ankle replacements is also not as advanced as the technology for redo hips and knees. Having worked alongside some of the worlds best ankle replacement surgeons, I have a good understanding of when it is a good idea and what patients benefit from it.
If we feel that an ankle replacement is the option you want, I am happy to recommend an appropriate specialist who does a large number and can offer good results. However, I find that after careful assessment and discussion of the pros and cons of both most patients are more happy to have a keyhole ankle fusion.
Recovery is relatively quick after a keyhole removal of bone and soft tissue from the front of the ankle. You will be in a boot for 2 weeks and then start therapy returning to normal activities at 2-3 months. After a keyhole ankle fusion you will be in a special cast and have to keep your weight of your foot for 6 weeks. We start therapy in earnest at this point. You will normally be back at normal activities by around 6 months.
Risks and complications
There are risks to all surgery and conservative measures should be tried when possible. If surgery is an option, we will discuss all of the pros and cons and the risks that are specific to you in detail. Specific risks of this procedure are-
Sometimes an ankle fusion does not take and has to be redone. With modern keyhole techniques this is in less that 10% of cases. If this is the case and you are still having pain after 6 months we will do a CT scan to assess fusion. If the fusion is not taking the redo involves opening the joint, using a biological stimulant and a strong plate for additional stability.