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Please see foot & ankle anatomy for more information about the ankle joint.
Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain and joint deformity.
Ankle arthritis is when arthritis involves the ankle joint.
The ankle joint bone
A – Normal ankle x-ray, white arrows indicate the even joint space (filled with cartilage) B – Abnormal ankle x-ray in a patient with severe arthritis
Any condition that damages the cartilage (joint surface) will cause ankle arthritis to develop.
The common conditions that cause ankle arthritis are:
Clinical radiograph (x-ray) demonstrating post traumatic ankle arthritis in an ankle that was previously fractured (see screws used to fix the break), the other ankle is normal
Typical symptoms of ankle arthritis include:
Clinical picture of patient with bilateral ankle arthritis worse in the right ankle, with obvious deformity at the ankle joint (blue lines)
Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Weight bearing plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they maybe normal. Most people however present when there is some structural damage.
The following are features of arthritis on a plain radiograph:
A – Normal ankle x-ray, yellow line displays normal perpendicular relationship between ankle joint line and tibia, white arrows indicate normal joint space, dotted blue line indicates normal ankle joint line B – Abnormal ankle x-ray, yellow lines show obvious angular deformity, red arrow indicates fracture of fibula due to abnormal stresses, green arrow indicates fibular impingement against side of calcaneum, dotted blue line indicates the now obliterated joint space
MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
MRI is particularly useful in assessing:
A – MRI of ankle arthritis, Reactive bone changes (blue arrow), synovitis (yellow arrow), subchondral cyst (yellow arrow) B – MRI of ankle arthritis, anterior bone growth (shaded blue area) which results in anterior impingement and restricted movement, reactive bone changes (orange arrow), normal subtalar joint (white arrow)
CT images give excellent information on bone structure and is superior to plain radiography in that respect.
CT is particularly useful in the following cases:
Ultrasound is a quick, painless and non invasive method of assessing soft tissue structures.
Ultrasound is particularly good at ascertaining:
Bone scan is a non specific test. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present.
This test is done in special circumstances.
Picture of a bone scan showing increased uptake in the foot
The natural history of ankle arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.
The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe increasing pain and discomfort.
You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:
As the ankle arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.
Grading a disease in medicine is used for the following reasons:
There are a number of grading systems used for arthritis. We use the following grading system based on radiographic (x-ray) features at The London Foot & Ankle Clinic:
As the arthritis gets worse, the grade goes higher.
X-ray and MRI of the ankle in the same patient demonstrating localised arthritis in the joint – with time the disease spreads to involve more of the joint
Non-operative management for ankle arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.
Wearing above ankle boots that give more support to the joint. The use of a shoe with a rocker bottom sole can also help.
Ankle braces give more support and stability to the ankle joint and could ease pain particularly when doing sports and exercise. Custom orthotics in the form of an AFO (ankle foot orthosis) coupled with insoles can be successful in easing symptoms.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with ankle arthritis by reducing inflammation in the joint.
The use of paracetamol and other painkillers to help reduce pain levels.
Physiotherapy works by strengthening muscles around not only the joint but the whole kinetic chain. Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.
The use of a walking stick or cane to reduce the forces going across the damaged joint.
Can relieve the pressure on painful damaged joints.
These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.
Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.
Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.
There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.
Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.
There are a number of treatments that involve an injection or series of injections for the treatment of ankle arthritis.
This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.
The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.
Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.
We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of steroid and long acting local anaesthetic is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.
The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.
Injections are not repeated less than 6 monthly intervals.
Please read here for more information regarding injections and possible complications.
A – Placement of fine needle in ankle joint B – Radio-opaque dye confirms needle is in the ankle joint
Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.
It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.
Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. In general, mild deformities can be treated by ankle arthroscopy and debridement while severe deformities may require an ankle fusion.
This is suitable for patients with mild to moderate arthritis. It allows for not only direct visualisation of the joint surfaces (diagnostic) but also treatment as well, such as:
The operation is carried out via keyhole surgery. It is performed under a short general anaesthetic as a daycase.
In a very select group of patients this procedure maybe suitable.
In patients who are not suitable for an ankle arthroscopy and debridement, or have persistent symptoms despite this procedure, BUT are not at a stage where they are ready or suitable for an ankle fusion/replacement, this operation may be recommended. It involves the cutting (osteotomy) the bone (tibia) above the level of the ankle and realigning the ankle joint. The aim of the surgery is to move the weight bearing axis away from the damaged to the healthy cartilage. In some cases the heel bone (calcaneum) may be cut (osteotomy) and the bone shifted to achieve the same result.
For a realignment osteotomy patients ideally should have:
Patients are not suitable for a corrective osteotomy for the following reasons (contraindications):
This operation has excellent outcomes in terms of pain relief and return to activities of daily living including sports. Please read this blog about return to sports after an ankle fusion.
It involves removing all remnants of the diseased joint (cartilage) and fusing the two main bones (tibia and talus) that form the ankle joint together. With no more joint there will be no more movement and therefore no more pain.
The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. Please read this blog for more details.
However, fortunately in the foot and ankle there are several joints that have the same joint movement as the ankle joint, that point the foot up and down (dorsiflexion and plantarflexion). The other joints have enough movement in them to compensate for the loss of movement in the ankle joint for most day-to-day activites.
Gait studies have actually shown an improvement in the gait pattern following an ankle fusion. So contrary to what most people think, after a fusion you will be less likely to limp and have an almost normal if not normal walking pattern.
The operation is usually carried out as a minimally invasive procedure. In case of a severe deformity an open technique maybe used. The operation is undertaken under a general anaesthetic and patients require an overnight stay in hospital.
The main longterm complication following an ankle fusion is the development of adjacent arthritic joint disease, particularly the joint under the ankle called the subtalar joint. Studies report incidence of subtalar joint arthritis from 10 to 50%. In the majority of cases this is not clinically relevant. The main short term complication is non union (the bones not fusing together). This is reported in numerous studies to be around 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.
Currently ankle fusion remains the treatment of choice for end stage ankle arthritis.
A – Clinical picture demonstrating deformity of right ankle as a result of ankle arthritis B – x-ray demonstrating severe arthritis and abnormal biomechanical axis C – clinical picture of ankle 10 weeks post operation D – x-ray post fusion with correction of biomechanical axis
Plain radiographs demonstrating A- severe post ankle fracture arthritis B – successful fusion and deformity correction of the ankle joint (note screws used for fusion have been removed in this case at patients request)
Mr Charnley popularised the total hip replacement in the 1960s for the treatment of hip arthritis. It allowed for pain free joint movement and significant improvement in quality of life. Over the last 50 years there has been incredible advances in technology and biomaterial science. Many changes have been and continue to be made to the total hip replacement. Total hip replacements now have a success rate of around 99% at 10 years and around 90% at 15 years. It is undeniably an orthopaedic success.
Orthopaedic surgeons wish to replicate the success of the total hip replacement by creating similar joint replacements for other arthritic and damaged joints around the body.
In the 1970’s the total knee replacement was introduced and while not as effective as the total hip replacement has a success rate of around 95% at 10 years.
Since the 1990’s orthopaedic foot and ankle surgeons have been testing and developing total ankle replacements. Several different types of ankle replacement have been developed in the last 20 years. In the last 5 years there has been a significant advance and the next generation total ankle replacement promises to offer excellent results in terms of pain free movement and return to function with minimal complications and failure rates.
Total ankle replacement is intended to improve function in patients with limited mobility by restoring alignment, reducing pain and preserving the flexion/extension movement within the ankle joint.
Mr Malik at the London Foot and Ankle Clinic uses the Zimmer Trabecular Metal Total Ankle, the first surgeon in the UK to do so. This latest total ankle replacement removes very little bone and utilises innovative technology. More information about this ankle replacement can be found here.
So why consider a total ankle replacement?
Who would be suitable for an ankle replacement?
Patients are not suitable for a total ankle replacement for the following reasons (contraindications):
A + B Radiographs demonstrating post traumatic ankle arthritis C + D treated successfully with a total ankle replacement
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
All surgical procedures for ankle arthritis will be carried out under a general anaesthetic.
Following ankle arthroscopy and debridement
You will have a small waterproof dressing applied to the front of the ankle to cover the arthroscopy portal sites and a bandage applied. It is advised not to remove this bandage for 48 hours and certainly not to remove the underlying dressings covering the wounds until reviewed by Mr Malik at the 2 week post operative check up. For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.
Weight bearing status will really depend on how much has been done in side the ankle. Most patients are touch weight bearing for 48 hours and then weight bear as tolerate after that with or without the use of crutches. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence ankle range of motion exercises as soon as possible after the operation to prevent stiffness. Activities can be gradually increased as pain allows.
In addition following an ankle supramalleolar osteotomy, ankle fusion and total ankle replacement –
You will have a backslab applied post operatively for two weeks. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.
A picture of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for approximately 6 to 8 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A photograph demonstrating high foot elevation after surgery
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection. Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months. If completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
A referral to physiotherapy will be made at this stage. This is the earliest you may return to work.
In addition following an ankle supramalleolar osteotomy and ankle fusion –
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your ankle will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.
In addition following a total ankle replacement –
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your ankle will be placed in a fixed walker boot and you will be allowed to touch weight bear. Early range of motion exercises will commence at this stage.
Significant improvement in swelling and pain. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.
Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.
If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
Full weight bearing through a fixed walker boot will be expected at this stage and weaning off the boot gradually over the next 4 weeks. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
Final clinical examination. Discharge if satisfactory.
Following an ankle supramalleolar osteotomy and ankle fusion
Check radiographs should show signs of bone healing.
Following a total ankle replacement
Check radiographs should show excellent secure positioning of the prosthesis. Patients after an ankle replacement are followed up at yearly interviews due to the lack of robust longterm data.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
The time given below is only a guide to the actual surgical time.
For an ankle arthroscopy and debridement
Up to 60 minutes.
For an ankle supramalleolar osteotomy and ankle fusion
60 to 90 minutes.
For an ankle replacement
Around 120 minutes.
For an ankle arthroscopy and debridement –
Most patients are able to drive after two weeks. Please see guidance below.
For an ankle supramalleolar osteotomy, ankle fusion and total ankle replacement –
Not for at least 3 months post surgery.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
Following ankle arthroscopy and debridement –
Most patients are able to return to work within 10 to 14 days.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Following an ankle arthroscopy and debridement –
Excellent pain relief and return to sports by 3 to 6 months. Failure of this outcome warrants further investigation and possible treatment.
For an ankle supramalleolar osteotomy –
Excellent pain relief and return to full activities of daily living. In some cases return to sport. Delay the progression of further arthritis. Possible need for further surgery. Aim is for this operation to delay the need for an ankle fusion by at least 5 years.
For an ankle fusion –
Excellent pain relief and return to full activities of daily living.
For a total ankle replacement –
Excellent pain relief and return to full activities of daily living. A yearly review will be necessary to monitor the ankle prosthesis.
After suffering with my ankle arthritis for quite sometime it became such a constant pain that it was becoming unbearable, and really was only getting worse and not better. After speaking to Mr Malik and going through some possible options I thought a Total Ankle Replacement would benefit me more as I wanted to keep the range of movement and have as normal an ankle as possible.
Would it even work? I understand every operation can come with risks but as the total ankle replacement is one of the less common joint replacements the success rate didn’t seem very high. I was also concerned with the length of time I would not be able to use the operated foot as it would be completely non weight bearing for 6 weeks.
The surgery went very well with no problems at all, everything had gone smoothly. I had a regional block so when I woke I was in no pain and that lasted for me until the next day. Once the block wore off the pain was then controlled by pain relief, pain is better treated before it arrives so a regular regime of pain killers were taken throughout my 3 night stay with some continued at home if needed. My operated foot was in a cast and elevated from the moment I woke and that was mandatory to keep it like that for the first two weeks to reduce as much swelling as possible.
I went to see Mr Malik for my 2 week check up, the operated ankle was healing great so stitches were removed and plaster cast was off and my ankle was placed into an Aircast walker boot which was a nice change. I was still advised to keep the foot elevated to help with the swelling which wasn’t a problem as I would still be non weight bearing for 4 more weeks. I went back for my 6 week review and had a few x-rays done which also showed everything is how it should and was healing well. I am now currently on week 8, fully weight bearing in no boot and best of all no pain.
I would say just being laid up for sometime, it could become very frustrating as you really won’t be able to do an awful lot yourself and will need to depend on those around you, but you do get set into a new routine and the days start passing by quickly.
Definitely opt for it. To be a few weeks down the line and have no pain is just amazing I cannot believe the difference. Just be patient and follow any advice/instructions given as it really does get better day by day. Make sure your prepared for the recovery time, plan home activities, find a new hobby, anything that will help with the weeks you wont be able to participate in normal activities. The key is to just rest and above all keep weight off the operated ankle and let it heal.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
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info@lfaclinic.co.uk
