Ankle Arthrodesis

Ankle arthritis can be an extremely debilitating condition.  Most commonly it is seen as a complication of ankle fracture or other ankle trauma, but it can also be seen secondary to inflammatory arthritis such as rheumatoid arthritis, infection of the ankle joint, Charcot neuroarthropathy, or tumors of the foot, ankle or leg. 

Ankle arthritis will present with significant pain with motion and with walking, and will typically limit the activities of those that suffer with the condition.  It is primarily a clinical diagnosis, with a history of a causative agent typically being related.  Physical examination will reveal an ankle joint with limited, painful range of motion, and pain on palpation to the joint.  X-rays are used to evaluate the extent of the arthritis in the ankle, and to monitor it’s progression.  Occasionally an MRI or CT scan may be ordered to rule out infection or intra-articular fracture, if there is a high index of suspicion clinically.  However, these advanced tests are not always ordered.

The ankle joint is actually a combination of three different articular surfaces.  There is an articulation between the talus and lateral malleolus, between the talus and the medial malleolus, and between the weight bearing surfaces of the talus and the tibia.  In significant arthritis, all three of these surfaces will be involved.  Arthritis will develop when there is damage to the cartilage, with a loss of joint space and growth of spikes of bone called osteophytes.

An important distinction must be made by the doctor in separating ankle arthritis from subtalar joint arthritis.  Subtalar joint pain can often feel to the patient as if the pain is coming from their ankle, when in fact it is coming from the joint below their ankle. This distinction can be made by injecting local anesthetic into the ankle joint in the clinic.  If 100% of the pain is relieved following the injection, then it is likely to be ankle arthritis.  If after injection there is still some pain left, then the subtalar joint can also be injected.  If this now relieves all of the pain, a combination of ankle and subtalar joint arthritis may exist.  There is often pain from the soft tissues surrounding the joints and from the tendons of the muscles that cross the ankle joint.  This is also a distinction that must be made clinically. 

Treatment of ankle joint arthritis begins with conservative therapy.  This may include treatments such as cortisone injections into the joint to relieve the pain, use of NSAIDs, orthotics, braces, physical therapy, and shoe modifications.  Sometimes a rocker bottom can be placed on the bottom of the shoe, which minimizes the motion at the ankle joint.  This can relieve pain in some individuals. 

When conservative therapy fails, surgery can become an option.  Most commonly, the ankle joint may be fused.  This is called ankle joint arthrodesis.  Ankle arthrodesis involves stripping the joint of its remaining cartilage, aligning the joint in an optimal position, and placing screws through the joint to hold it in place.  Holding the joint in place after the cartilage is removed allows the bones to heal to each other, thus eliminating the joint completely.  This means that there is no longer motion at the joint, as it is now one solid piece of bone.  Fusing the two bones together eliminates the motion, as well as the pain associated with motion at the joint.

A number of techniques for ankle arthrodesis have been employed, but generally there are two incisions made at either side of the ankle.  Through these incision the joint is reached, and the fusion can be performed.  After surgery, the patient will likely be placed in a splint or hard cast, and will remain in the cast for several weeks.  No weight can be placed on the operated foot for a minimum of 6 to 8 weeks while the bones are healing.  After this period of time, the patient will likely be transitioned to a surgical boot, which they may be allowed to walk in for 4 to 6 weeks.  Once the bones are completely healed and there is no longer an ankle joint left, the patient may be allowed to walk on their foot normally. 

There is often a deformity of the foot as well as the ankle, which can be addressed at the same time during surgery.  When the subtalar joint is involved in the pathology, it may be fused as well.  The elimination of motion at the arthritic joint is what decreases pain.  Many times with ankle arthritis there is inflammation and scar tissue build-up in the soft tissues around the joint, which can be removed at the time of surgery.  If there is damage to any of the tendons around the ankle joint, these can be repaired as well.

Of course, ankle arthrodesis is only performed when it is absolutely necessary.  It is a lengthy process of surgery and the post-operative course, and it is imperative that both the surgeon and patient prepare for this course. 

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W. Winter Haven, FL 33881
Phone: 863-299-4551
FLFootandAnkle.com