Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

 

Ankle Arthritis: Clinical Presentation and Management

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Clinical Presentation

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Common Symptoms

Patients with ankle arthritis typically present with:

• Long-standing, diffuse ankle pain
• Pain localized within the ankle joint
• Antalgic or altered gait
• Swelling
• Reduced range of motion

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Sensory Assessment

• Performed using Semmes–Weinstein 5.07 monofilament testing

Clinical Importance

• Significant sensory loss– poor candidate for Total Ankle Replacement (TAR)

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Initial (Conservative) Management

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General Principle

Non-operative treatment is the first-line approach.

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Treatment Options

Medications

• Anti-inflammatory drugs

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Activity Modification

• Reduce high-impact activities

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Orthoses and Bracing

• Single rocker sole shoe modification
• Custom Arizona brace

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Injections

• Corticosteroid injections
• Viscosupplementation

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Assistive Devices

• Cane or walking aid if required

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Surgical Options

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1. Ankle Arthrodesis (Fusion)

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Indications

• Failed conservative treatment
• Younger, high-demand patients
• Patients unsuitable for TAR:
  • Diabetes
  • Obesity
  • Poor soft tissue condition

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Technique

• Fusion of the tibiotalar joint
• Fixation using:
  • Screws
  • Plates
  • Combination constructs

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Optimal Positioning

• Neutral ankle flexion
• 0–5° hindfoot valgus

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Important Considerations

• Avoid plantarflexed fusion
  • May lead to knee hyperextension during gait
• Consider:
  • Gastrocnemius or Achilles recession
  • If neutral dorsiflexion cannot be achieved

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Outcomes

• High union rate: 85–90%
• Reliable pain relief

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Long-Term Complication

• Adjacent joint arthritis
  • Particularly subtalar joint
  • ~50% incidence at 10 years

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2. Total Ankle Replacement (TAR)

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Indications

• Elderly, low-demand patients
• Desire to preserve ankle motion

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Common Causes

• Post-traumatic arthritis (~80%)
• Inflammatory arthritis:
  • Rheumatoid arthritis
  • Gout (selected cases)

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Contraindications

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Absolute

• Severe deformity
• Avascular necrosis of talus
• Poor soft tissue envelope
• Active infection

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Relative

• Ligament instability
• Diabetes
• Smoking
• Osteoporosis
• Morbid obesity
• Young, high-demand patients

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Advantages

• Preserves ankle motion
• Improved gait mechanics compared to fusion

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Risks and Limitations

• Higher complication rates than fusion
• Higher revision rates
• Wound complications (especially in rheumatoid arthritis)
• Implant loosening or subsidence
  • More common in patients <55 years

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Preoperative Evaluation

• Rule out infection
• Assess for metabolic bone disease
• CT scan for:
  • Bone stock
  • Alignment

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Surgical Planning Tip

• Preserve fibula when possible
  • Allows future conversion to TAR if needed

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Decision-Making

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General Principles

• Older, low-demand patients – TAR preferred
• Younger, active patients – Arthrodesis preferred

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Clinical Rule

If uncertainty exists:
Arthrodesis is the safer option

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Key Takeaways

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• Total ankle replacement is:
  • Increasingly popular
  • Technically demanding

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• Patient selection is critical for successful outcomes

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• Arthrodesis remains:
  • Reliable
  • Predictable
  • Gold standard in many cases

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Comparison

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Total Ankle Replacement

• Preserves motion
• Better gait
• Higher complication and revision rates

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Arthrodesis

• Excellent pain relief
• Durable results
• Risk of adjacent joint arthritis

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Final Clinical Insight

Treatment choice should be individualized based on:

• Patient age
• Activity level
• Comorbidities
• Degree of deformity