Ankle Arthritis - Treatment
How can ankle arthritis be treated without surgery?
There are a variety of non-operative measures which can be trialed
- In the first instance lifestyle modifications should be trialed. Altering sporting activities if possible and resting when pain comes on.
- Pain killers may be helpful. Your GP will let you know what you can and cannot take. For the majority of people paracetamol and simple non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen or diclofenac are trialed although not always with success. There are a variety of stronger pain killers available but they do have side effects and again your GP will be able to advise you on these.
- Ankle supports. These come in two main forms- ankle braces or high topped lace up boots. Ankle braces can be bought readymade or made bespoke by an Orthotist. They come in hundreds of shapes, styles and levels of support. Unfortunately many people find them hot, cumbersome and uncomfortable. High topped lace up sturdy boots with a cushioned sole (ideally a “rocker” sole) are often found to be easier to use and more helpful.
- Dietary supplementation with chondroitin and glucosamine is becoming increasingly popular. There is not a huge amount of scientific evidence on which to support their use but they are found to be helpful by some patients. They are available in most health food shops.
- Physiotherapy and hydrotherapy can help some people by strengthening the muscles around the joint and thereby decreasing pain, stiffness and swelling.
- Injections of cortisone with local anaesthetic into the ankle joint can help to reduce pain and swelling. They can be performed while in clinic and most people do not find them to be painful. Contrary to popular belief there is no set or maximum number that can be given.
What operations can help ankle arthritis?
For many, surgery is felt to be the preferred solution as it can provide long lasting pain relief and a return to being active. The correct treatment very much depends on the severity and type of arthritis and the age, general fitness and activity levels of the person affected.
Keyhole surgery or arthroscopic debridement of the ankle joint is also known as Cheilectomy. It can be very effective in certain cases of arthritis. It is particularly suitable in people where the majority of the symptoms are coming from the pinching of bone spurs or soft tissue at the front or back of the ankle during joint movement. It does not actually cure the arthritis or halt its progression but in appropriate cases it can be very effective in controlling symptoms. The advantage is that this is a small procedure which is joint preserving and has a quick recovery time. There is no need for crutches or a cast after this type of surgery.
Surgical Osteotomy / Realignment
In some types of arthritis there is uneven wear across the joint. These are generally the result of long term abnormalities in the overall alignment of the joint. In certain cases it is possible to surgically realign the joint and make the forces go through the unworn portion of the joint thereby getting rid of the arthritis pain and preserving movement. This is an exciting new area in the treatment of ankle arthritis. Mr. Al-Nammari has been involved in research in this area and has published on new osteotomy techniques.
Ankle Joint Replacement
- Ankle replacement is also known as ankle arthroplasty and has been around for many years. They are, however, not performed anywhere near as frequently as joint replacements in the hip and knee. The earlier designs of ankle replacement were generally unsuccessful with almost universal early failure. Newer designs are more successful with some encouraging reports. However, the indications for ankle replacement remain more limited than those for the hip and knee. Unfortunately it is not yet a suitable operation for young, athletic people hoping to get back to normality. It is a useful treatment option in appropriately selected cases but it is definitely not the right choice for everyone. Ideal patients for an ankle replacement are over 60 years of age, with a well aligned ankle (no deformity), not overweight and not very active. Patients with arthritis in both ankles also may be better served by considering an ankle replacement.
- The main goal of ankle replacement surgery is to relieve pain. With the pain relief one can expect walking to improve. Movement in the ankle joint itself is unlikely to be improved by having an ankle replacement but the movement that is there is comfortable.
- In an ankle replacement the worn out joint is surgically removed making very precise bone cuts. It is then replaced with metal surfaces on both the tibial and talar sides of the joint separated by a smooth layer of specially hardened and exta durable polyethylene plastic. The metal surfaces are designed in such a way as to allow bone to grow into and form a living bond with the metal creating a durable fixation. The ankle replacement permits both up and down and some side to side movements.
- The long term results of ankle replacement is still not as good as that for hip or knee replacements either in terms of symptom relief or time to failure. That being said in the UK 90% of ankle replacements are doing well at five years post-surgery and the procedure is successful in relieving pain in 80%-90%.
- Following an ankle replacement you will be in a plaster cast for anywhere between two to six weeks. It is possible to walk on the leg after a fortnight.
- Ankle fusion- this is also known as ankle arthrodesis. Although many people are concerned about the idea of having an ankle fusion it is important to realise that an ankle fusion is still considered to be the “gold standard” surgical treatment for severe end stage ankle arthritis and it is the “tried & tested” surgical treatment. It has an excellent track record of providing reliable and long lasting pain relief.
- It is successful in approximately 95% of cases. Although the ankle joint is stiff it is fused in a position that allows people to keep an active lifestyle- brisk walking, golf and occasionally jogging are possible. There are reports of people being very active after ankle fusions and even running marathons- this is however the exception rather than the rule. The foot is not completely rigid after an ankle fusion and approximately 30% of the up and down movement and the majority of the side to side movements remain- as these arise from the joints in the foot which remain.
- An ankle fusion can be performed through an arthroscope with a keyhole technique or through an open incision. Keyhole surgery has advantages in that the incisions are much smaller, postoperative pain is less and it can speed bone healing. Open surgery is useful where there is significant deformity or bone loss which is often present in severe arthritis and which cannot be addressed with a keyhole technique.
- The aim of surgery with both keyhole and open techniques is to remove the remaining damaged cartilage and any underlying unhealthy damaged bone in the joint. The joint surfaces are then placed together in the correct position with compression applied to encourage bone healing. The bone ends are then held together with screws or a plate and screws under x-ray guidance. Given time the bone ends then join together or fuse- much like the bone ends in a fractured or broken bone.
- Unfortunately following an ankle fusion the recovery is prolonged. It is necessary to stay off the foot completely for four to six weeks and to use a plaster cast during this time. After this there is a further six weeks in a removable boot and the amount of weight going through the leg gradually builds up based on X-ray signs of bone healing over the next six weeks. This means there are restrictions on your mobility for up to three months from surgery. It will be approximately six months until the benefits of surgery are apparent and symptoms continue to improve for over a year from surgery.
Arthroscopic "keyhole" ankle debridement is a fairly small procedure and takes approximately 45 minutes to be performed. It can be undertaken as a day case under regional anaesthetic block making the leg numb for six to twelve hours. You will be seen by an Anaesthetist and can be awake, sedated or have a general anaesthetic during surgery. It is possible to walk straight away after the operation with just a special shoe or boot. There is no need for a cast or prolonged immobility with modern surgical techniques.
Ankle osteotomies, ankle replacement and ankle fusions are larger surgical procedures and they take approximately 1.5 - 2 hours to be performed. They generally require an overnight stay in hospital and can be undertaken under regional anaesthetic block making the leg numb for six to twelve hours. You will be seen by an Anaesthetist and can be awake, sedated or have a general anaesthetic during surgery. You will have a plaster cast placed on the leg during surgery and will not be able to put any weight through the leg for a minimum of 4 – 6 weeks.
Should I have an ankle fusion or an ankle replacement?
The decision to have an ankle fusion or an ankle replacement is often straightforward. On occasions however it is not clear cut and it is a matter for discussion between the patient and their surgeon. There is no single correct answer and it is generally a matter of individual preference.
Perhaps surprisingly, there is not much evidence to support ankle replacements being better than an ankle fusion in terms of controlling symptoms. In fact in one study looking at a group of patients that had one ankle fused and the other side replaced the patients did not have a “preferred” or “better” side. The patients were equally happy with both.
Mr. Al-Nammari undertakes the majority of his private operating at The Nuffield Hospital in Ipswich. Using the latest techniques in local anaesthetic blocks means that most people having surgery are comfortable enough to get home on the day of surgery should they so wish. For those who need to or just feel more comfortable spending the night in hospital after surgery this is of course possible. The choice of anaesthetic is based upon your own preferences and the opinion of the Consultant Anaesthetist who you will meet before any surgery. Many people prefer to be asleep during surgery and have the local anaesthetic block performed while asleep to control any post-operative pain.