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Ankle Osteoarthritis

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Other Names

  • Osteoarthritis of the ankle
  • Degenerative joint disease (DJD) of the ankle
  • Tibiotalar Osteoarthritis
  • Fibulotalar Osteoarthritis
  • Ankle Arthritis
  • Ankle OA
  • Traumatic Ankle Arthritis

Background

Normal mortise radiograph of the ankle showing the articular components of the distal fibula, tibia and talus[1]
  • This page refers to osteoarthritis (OA) of the Ankle Joint
    • Herein referred to as 'Ankle OA'

History
Epidemiology

  • Approximately 1% of the adult population have ankle OA[2]
  • Estimated incidence of 30 cases per 100,000 people[3]
  • Affects roughly 2-4% of all people with general OA
  • Far less common than hip, knee OA

Introduction

General

  • Progressive, degenerative condition, results in loss of loss of articular cartilage
  • Typically becomes more severe, frequent, and debilitating over time
  • Diagnosis is easily made with plain radiographs
  • Patients tend to be younger, suffer rapid loss of function and progress to advanced stages quickly

Etiology

  • Primary Ankle OA [2]
    • Uncommon, accounts for less than 10% of all ankle arthritis
    • Only 7% of cases are considered idiopathic
  • Secondary Ankle OA
  • Posttraumatic Ankle OA
  • Osteochondral Defect of the Ankle
    • Controversial relationship with Ankle OA
    • Weigelt et al: 14 year follow up study of OCD with no relevant ankle OA when treated correctly[5]
    • Stufkens et al: anterolateral talar, posteromedial tibial, and medial malleolar osteochondral lesions are more likely to develop ankle OA[6]]]

Associated Conditions

  • See secondary OA above

Pathoanatomy of the Ankle Joint


Risk Factors

  • Older Age
  • Obesity

Differential Diagnosis

Differential Diagnosis Ankle Pain


Clinical Features

History

  • Typically insidious onset
  • Patient may report remote injury or recurrent injuries
  • Often better in the AM, worse over the day
  • Associated with pain, swelling, antalgic gait
  • Pain with weightbearing
  • Loss of range of motion
  • Muscle atrophy can be seen

Physical Exam: Physical Exam Foot And Ankle

  • Swelling and effusion of joint
  • Asymmetry compared to unaffected joint
  • Osteophytes may be present and palpable
  • Tenderness around joint space
  • Painful range of motion, loss of range of motion
  • Angular deformities can be present depending on etiology

Specialty Test

  • Needs to be updated

Evaluation

Advanced degeneration in a patient with a history of trauma. Deformity and severe degenerative changes are seen at the ankle, accompanied by distal fibular bowing and malposition. The posterior part of the talus is fragmented.Case courtesy of Mohammadtaghi Niknejad, Radiopaedia.org, rID: 98712</ref>
Mortise view: (A) grade 0 normal, (B) grade 1 lateral tibial osteophyte, (C) grade 2 lateral tibial osteophyte, and (D) grade 3 lateral tibial osteophyte[7]

Radiographs

  • Standard Radiographs Ankle
    • All views must be weight-bearing AP, Lateral, Oblique
  • Consider: Saltzman view of the hindfoot
  • Common findings
    • Joint space narrowing
    • Subchondral Sclerosis, Cysts
    • Eburnation
    • Angular deformity

Ultrasound

  • Role of ultrasound in evaluating ankle OA is not well characterized

MRI

  • Used to evaluate cartilage and periarticular soft tissues and tendons around the ankle joint
  • Useful to make diagnosis in early stages of suspected ankle OA

CT

  • Single-photon emission computed tomography/computed tomography (SPECT-CT) [8]
    • Used to evaluate degenerative changes and their biological activities
    • Helps assess other osteoarthritic changes in other nearby bone
    • Adds details on the activity of the OA or chondral lesions
    • Weight bearing CT is gaining popularity

Classification

Grading System by Giannini[9]

  • Stage 0 - Normal joint or subchondral sclerosis
  • Stage 1 - Presence of osteophytes without joint-space narrowing
  • Stage 2 - Joint-space narrowing with or without osteophytes
  • Stage 3 - Subtotal or total disappearance or deformation of joint space

Grading System by Cheng(Based on Weight-Bearing Radiographs) [10]

  • Stage 0
    • No reduction of the joint space
    • Normal alignment
  • Stage 1
    • Slight reduction of the joint space
    • Slight formation of deposits at the joint margins
    • Normal alignment
  • Stage 2
    • More pronounced change than mentioned above
    • Subchondral osseous sclerotic configuration
    • Mild malalignment
  • Stage 3
    • Joint space reduced to about half the height of the uninjured side
    • Rather pronounced formation of deposits
    • Obvious varus or valgus alignment
  • Stage 4
    • Joint space has completely or practically disappeared

Takakura Classification[11]

  • Stage I: No narrowing of the joint space, but early sclerosis and formation of osteophytes
  • Stage II: Narrowing of medial joint space (no subchondral bone contact)
  • Stage IIIA: Obliteration of this space with subcondral bone contact (medial gutter only)
  • Stage IIIB: Extension of the obliterarion to the roof of the dome of the talus
  • Stage IV: Obliteration of the whole joint space with complete bone contact

Management

Global treatment algorithm for ankle osteoarthritis.[12]

Nonoperative

  • Indications
    • First line in mild disease
    • Should be attempted for at least 6 months to assess effectiveness
  • Patient Education
    • Important to discuss modifiable risk factors, namely obesity
  • Activity modification considerations
    • Avoid high impact sports
    • Avoid ascending or descending stairs
    • Use a cane or walking stick when necessary
  • Diet
    • Diet modification has not been studied for the ankle specifically
    • However, metabolic syndrome and type 2 diabetes mellitus have been associated with onset and progression of OA[13]
    • Increased consumption of long chain omega 3 fatty acids can improve pain, function in patients with OA
    • Reduce serum cholesterol, increase intake of foods rich in vitamin K foods
  • Vitamin D Supplementation
    • Influence and efficacy of Vitamin D supplementation for the treatment of OA remains controversial[13]
  • Physical Therapy
    • Strengthening the musculature that stabilizes the ankle joint
    • Stretching exercises
    • Locally applied cold therapy
  • Footwear Modifications
    • Consider single rocker sole shoe, which has been shown to unload pressure from the ankle joint during push-off[14]
  • Orthotics
    • Objective: reduce pain, maintain correct alignment, limit mobility
    • Not many studies looking at Ankle OA
    • Ankle foot orthoses are effective in treatment instability or misalignment[14]
    • Consider Arizona brace (gauntlet ankle brace)

Pharmacotherapy

  • General
    • No clinical guidelines specific to Ankle OA
    • Most recommendations are extrapolated from the hip and knee literature
  • Acetaminophen
    • Efficacy in treating OA is controversial, possibly not superior to placebo[15]
  • Topical NSAIDS
    • Safe and should be considered as an adjunct to other therapies
    • Systematic reviews suggest topical NSAIDS improve pain relief, physical function superior to placebo[15]
  • Topical Capsaicin
    • Shown to be effective in treating knee OA, should be considered in ankle OA[15]
  • Oral NSAIDS
    • Shown to provide relief in patients with OA
    • Given side effect profile; prescribe lowest dose for shortest period of time
  • Opioids
    • Literature is scarce
    • Should be avoided or considered 3rd line treatment
  • Other medications
    • Glucosamine
    • Chondroitin Sulfate
    • Diacerein

Procedures

  • Boffa et al[16]
    • Published meta-analysis evaluating the evidence, safety and effectiveness for intra-articular injections of the ankle
    • Looked at hyaluronic acid (HA), platelet-rich plasma (PRP), saline, methylprednisolone, botulinum toxin type A (BoNT-A), mesenchymal stem cells, and prolotherapy
    • Authors support the safety, best evidence was apparently for HA
  • Viscosupplementation
    • Produce quick clinical improvement in pain, stiffness, patient satisfaction
    • Studies suggest improvement for between 6 months[17] and 18 months[18]
  • Corticosteroid Injection (CSI)
    • Provides short term pain relief lasting between 4 and 8 weeks
    • Reserve for persistent, high grade OA with maximum of 3-4 injections per year[19]
  • Platelet Rich Plasma
    • May be superior to CSI for pain[20]
    • May delay the need for surgical intervention[21]
  • Mesenchymal Stem Cells
    • Not well studied

Operative

  • Indications
    • Failure of conservative treatment
  • Joint Preserving Procedures
    • Debride, talar/tibial exostectomy
    • Distraction Arthroplasty
    • Arthrodiastasis
    • Supramalleolar osteotomy
  • Joint Sacrificing Procedures
    • Arthrodesis
    • Arthroplasty
    • Tibiotalocalcaneal arthrodesis

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Needs to be updated

Complications

  • Chronic Pain

See Also

Internal

External


References

  1. https://www.startradiology.com/internships/general-surgery/ankle/x-ankle/
  2. 2.0 2.1 Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009;467(7):1800-1806. doi:10.1007/s11999-008-0543-6
  3. Goldberg AJ, MacGregor A, Dawson J, Singh D, Cullen N, Sharp RJ, Cooke PH. The demand incidence of symptomatic ankle osteoarthritis presenting to foot and ankle surgeons in the United Kingdom. Foot 201222163–166. ( 10.1016/j.foot.2012.02.005)
  4. Herrera-Pérez M, González-Martín D, Vallejo-Márquez M, Godoy-Santos AL, Valderrabano V, Tejero S. Ankle osteoarthritis aetiology. Journal of Clinical Medicine 202110 4489. ( 10.3390/jcm10194489)
  5. Weigelt L, Laux CJ, Urbanschitz L, Espinosa N, Klammer G, Götschi T, Wirth SH. Long-term prognosis after successful nonoperative treatment of osteochondral lesions of the talus: an observational 14-year follow-up study. Orthopaedic Journal of Sports Medicine 202082325967120924183. ( 10.1177/2325967120924183)
  6. Stufkens SA, Knupp M, Horisberger M, Lampert C, Hintermann B. Cartilage lesions and the development of osteoarthritis after internal fixation of ankle fractures: a prospective study. Journal of Bone and Joint Surgery: American Volume 201092279–286. ( 10.2106/JBJS.H.01635)
  7. Kraus, Virginia Byers, et al. "Atlas of radiographic features of osteoarthritis of the ankle and hindfoot." Osteoarthritis and cartilage 23.12 (2015): 2059-2085.
  8. Barg A, Pagenstert GI, Hügle T, et al. Ankle osteoarthritis: etiology, diagnostics, and classification. Foot Ankle Clin. 2013;18(3):411-426. doi:10.1016/j.fcl.2013.06.001
  9. Giannini S, Buda R, Faldini C, et al. The treatment of severe posttraumatic arthritis of the ankle joint. J Bone Joint Surg Am 2007;89 Suppl 3:15.
  10. Cheng YM, Huang PJ, Hong SH, et al. Low tibial osteotomy for moderate ankle arthritis. Arch Orthop Trauma Surg 2001;121(6):355
  11. Tanaka Y, Takakura Y, Hayashi K, Taniguchi A, Kumai T, Sugimoto K. Low tibial osteotomy for varus-type osteoarthritis of the ankle. Journal of Bone and Joint Surgery: British Volume 200688909–913. ( 10.1302/0301-620X.88B7.17325)
  12. Bloch B, Srinivasan S, Manwani J. Current concepts in the management of ankle osteoarthritis: a systematic review. Journal of Foot and Ankle Surgery 201554932–939. ( 10.1053/j.jfas.2014.12.042)
  13. 13.0 13.1 Thomas S, Browne H, Mobasheri A, Rayman MP. What is the evidence for a role for diet and nutrition in osteoarthritis? Rheumatology 201857 (Supplement4) iv61–iv74. ( 10.1093/rheumatology/key011)
  14. 14.0 14.1 John S, Bongiovanni F. Brace management for ankle arthritis. Clinics in Podiatric Medicine and Surgery 200926193–197. ( 10.1016/j.cpm.2008.12.004)
  15. 15.0 15.1 15.2 Paterson KL, Gates L. Clinical assessment and management of foot and ankle osteoarthritis: a review of current evidence and focus on pharmacological treatment. Drugs and Aging 201936203–211. ( 10.1007/s40266-019-00639-y)
  16. Boffa A, Previtali D, Di Laura Frattura G, Vannini F, Candrian C, Filardo G. Evidence on ankle injections for osteochondral lesions and osteoarthritis: a systematic review and meta-analysis. International Orthopaedics 202145509–523. ( 10.1007/s00264-020-04689-5)
  17. Tejero S, Prada-Chamorro E, González-Martín D, García-Guirao A, Galhoum A, Valderrabano V, Herrera-Pérez M. Conservative treatment of ankle osteoarthritis. Journal of Clinical Medicine 202110 4561. ( 10.3390/jcm10194561)
  18. Bossert M, Boublil D, Parisaux JM, Bozgan AM, Richelme E, Conrozier T. Imaging guidance improves the results of viscosuplementation with HANOX-M-XL in patients with ankle osteoarthritis: results of a clinical survey in 50 patients treated in daily practice. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 20169195–199. ( 10.4137/CMAMD.S40401)
  19. Ward ST, Williams PL, Purkayashta S. Intra-articular corticosteroid injections in the foot and ankle: a prospective 1-year follow-up investigation. Journal of Foot and Ankle Surgery 200847138–144. ( 10.1053/j.jfas.2007.12.007)
  20. Mei-Dan O, Carmont MR, Laver L, Mann G, Maffuli N, Nyska M. Platelet-rich plasma or hyaluronate in the management of osteochondral lesions of the talus. American Journal of Sports Medicine 201240534–541. ( 10.1177/0363546511431238)
  21. Repetto I, Biti B, Cerruti P, Trentini R, Felli L. Conservative treatment of ankle osteoarthritis: can platelet-rich plasma effectively postpone surgery? Journal of Foot and Ankle Surgery 201756362–365. ( 10.1053/j.jfas.2016.11.015)
Created by:
John Kiel on 7 July 2019 08:08:56
Last edited:
2 October 2023 19:22:52
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