Arthritis of the Foot and Ankle

Ankle arthritis
Arthritis of the ankle may occur for multiple reasons. The most common causes are post-traumatic (after a traumatic injury of the foot and ankle, such as an ankle fracture or talus fracture), inflammatory arthritis (i.e. rheumatoid arthritis), instability of the ankle (poor ligaments around the ankle), osteochondral lesions of the ankle (cartilage defects in the ankle joint), or degenerative arthritis of the ankle. Conservative treatments are limited but some patients do improve with bracing or occasional steroid injection treatment. When conservative treatments fail, surgical intervention may be indicated. For focal arthritic lesions, minimally invasive or other joint preserving procedures may be indicated. For more diffuse arthritis of the ankle (end-stage arthritis), surgical options include ankle replacement, ankle fusion, and distraction of the ankle joint. Evaluation by an orthopaedic foot and ankle specialist who is familiar with all of these possible surgical options and experienced with these treatments should be considered and appropriately individualized for each patient in order to maximize outcomes. Dr. Vora has lectured, published, and teaches these types of surgical treatments to other orthopaedic surgeons, foot and ankle surgeons, and other health care providers and provides all available options to each patient.
 

Total ankle replacement
Ankle replacement is an excellent option for many patients with ankle arthritis. Traditionally, ankle replacements were fraught with failure but newer designs have shown and continue to show improvements and promise. Dr. Vora is trained to perform two of the very few FDA approved ankle replacement options and offers both to patients as appropriately individualized for each patient. Ankle replacements have the benefit of maintaining ankle motion as best possible, thus allowing for possible improvement in walking ability and a limitation on the stresses across the other nearby joints of the foot and ankle over time. By maintaining this motion, it is theorized that other nearby joints will be less likely to develop arthritis and subsequent pain over time.

Patients who have a well lined up ankle and good motion are typically better candidates for ankle replacement then ankle fusion. One of the ankle replacement types Dr. Vora performs is particularly advantageous because it minimizes the amount of bone removed and can be inserted in a relatively easy fashion, allowing for multiple options in the future should additional surgery be required. The other type of ankle replacement available generally requires more bone resection and but has unique advantages as well which make it suitable for certain patients and can be an excellent option for use in revision situations.

Ankle replacement surgery can now often be performed on an outpatient basis (going home the same day of your surgery). The recovery generally involves 6 weeks of non-weight bearing followed by 6 weeks of protected weight-bearing in a removable boot. A cast is utilized until the incisions are healed (usually around 2 to 3 weeks) and at that point a boot which can be removed is used so that therapy on the ankle can be started. During the recovery, physical therapy to initiate ankle motion, swimming, and non-impact exercise may be started. At 3 months, most patients are able to walk without a boot or any braces and resume most daily activities with continued improvement in strength and ankle function for up to 1 year occurring.

Ankle replacement surgery requires extensive training and specialization and treatment with an orthopaedic foot and ankle specialist specialized in such procedures should be considered.
 

Arthroscopic minimally invasive ankle fusion (arthrodesis)
Ankle fusion (arthrodesis) is still an excellent alternative for patients with severe ankle arthritis. A fusion procedure is preformed by gluing together the bones of the ankle (the tibia and talus) usually with screws. This procedure causes stiffness of the ankle but still allows for some up and down motion of the foot through the maintained motion of small joints of the middle of the foot. In addition, the joints under the ankle (subtalar and hindfoot joints) are able to demonstrate some additional compensatory motion to allow for some continued up and down motion of the ankle and foot. The great majority of the side to side motion of the ankle and foot is maintained after this procedure.

For many patients with ankle arthritis, particularly those with multiple previous surgeries and / or previous fractures or trauma to the ankle or foot, the ankle joint may already have a severe restriction in the range of motion present. In this scenario, ankle replacement may not restore normal range of motion and for such patients, a fusion may be a better option. After ankle fusion, most patients report a dramatic improvement in pain relief and function. In addition, with appropriate shoes or shoe wear modifications, many patients walk may walk without any limp. The disadvantages of the fusion are the stiffness of the ankle and the potential to develop painful arthritis to the adjacent joints of the foot over time.

Most ankle fusions can now be performed arthroscopically (thorough two small incisions in the skin using a camera and a shaver) in a minimally-invasive technique. The bones are prepared to glue together through the camera and then 2 to 3 screws are placed across the ankle joint site to allow for healing. When this is possible, patients are casted and off their foot for four weeks and then allowed to bear weight in a boot for an additional 8 weeks. At this point, patients are allowed to return to shoe wear and increase activity as tolerated. With this minimally-invasive technique, a failure of healing (nonunion) is rare.

In some scenarios, because of severe misalignment of the ankle or because of previous failed surgery of the ankle, an arthroscopic minimally invasive fusion is not possible. In these cases, an open incision is utilized to prepare the bone surfaces and the joints are glued together with a similar technique as that described above. The healing is slightly longer with this technique.

Dr. Vora has lectured and published on this type of minimally-invasive procedure and teaches this procedure to other foot and ankle surgeons and orthopaedists from both the United States and internationally.
 

Ankle distraction arthroplasty
For some patients with severe ankle arthritis, both an ankle replacement and an ankle fusion may not be appropriate procedures for their specific individualized cases. In such patients whom have failed conservative treatment options, one additional option is ankle distraction arthroplasty. This procedure is generally a reasonable one to try for younger patients who are not suitable for a fusion or replacement. The procedure involves arthroscopically cleaning out the ankle joint through two small incisions at the level of the ankle. An external fixator (cage type device) is then applied to the outside of the ankle and leg. This cage is left in place for approximately 12 weeks with gradual distraction (pulling apart) the two main opposing bones of the ankle. The normal ankle cartilage is bathed in its body fluid (synovial fluid) and the ankle is allowed to “rest” in this stretched position, this alleviating the pain from the opposing surfaces of bone rubbing against each other. After removal of the external fixator device, the hope is for maintained spacing of the ankle joint surfaces and less “bone on bone” rubbing. This in turn may lead to pain relief for a period of years. The procedure has varied results both in Dr. Vora’s hands as well as in studies accessing this procedure and should be carefully individualized and discussed with each patient before proceeding. One major advantage of this procedure is that it still may allow for ankle replacement or fusion if necessary in the future without any major increased difficulty. This procedure should be discussed with an orthopaedic foot and ankle surgeon experienced with this treatment option for younger patients who are not suitable candidates for other procedures for end-stage ankle arthritis.
 

Hindfoot arthodesis - Triple arthrodesis
When arthritis affects the bone of the hindfoot (the talus, navicular, calcaneus, and cuboid bones), these four bones may require a procedure in which all of these bones are glued together to create one solid bone mass for stability of the foot, correction of deformity, and pain relief. There are many reasons that a triple arthrodesis (fusion of the hindfoot bones) may be necessary. These include severe dysfunction of the tendons of the foot, such as the posterior tibial tendon, which in late stages results in severe deformity and arthritis, inflammatory arthritis (such as rheumatoid arthritis), arthritis after previous fractures of bones of the hindfoot, and other conditions. In these scenarios the ankle joint may or may not be involved and requires its own separate treatment.

The procedure involves incisions on the inside and outside of the ankle and foot, preparation of the joint surfaces for fusion and healing, and the placement of a combination of screws, plates, staples, or other orthopaedic devices to hold the bones while they are healing. After surgery, patients are casted for approximately 6 weeks, followed by weight bearing in a boot walker for 6 weeks. After this, patients usually can return to a regular shoe and aggressive physical therapy is necessary to strengthen the foot and ankle.

The bones of the hindfoot work in together to provide the side to side motion of the foot. After this procedure, limitation of side to side motion results but up and down motion of the ankle and foot is preserved. Walking on flat, even surfaces is usually able to be performed without difficulty, however, walking on uneven surfaces such as rocky trails or a beach may be difficult.

Dr. Vora is skilled in this procedure and has lectured and published on this treatment for conditions of the foot and ankle.

For more on this condition, also see:
Talus fractures
Calcaneus fractures
Subtalar arthrodesis
 

Hindfoot arthodesis - Subtalar arthrodesis
Arthritis can occur in the subtalar joint (joint below the ankle joint) secondary to multiple problems, including after fractures of the talus, calcaneus, bone collapse (avascular necrosis), arthritis of the hindfoot, posterior tibial tendon dysfunction, and other foot and ankle conditions. A subtalar arthrodesis (fusion or gluing together of this specific joint of the foot) results in significant improvement in pain relief and function. The joint is glued together using screws to hold the joints together until the body has healed across this fusion site. After fusion of this joint side to side motion is limited but all other motion of the foot, including up and down motion, is maintained. Typically, limitations after surgery mainly are related to walking on uneven surfaces, such as a beach or slanted rooftop.

A fusion of this joint is performed as an outpatient. The recovery involves 4 to 6 weeks of non-weight bearing in a cast or boot followed by protected weight-bearing in a boot for an additional 6 weeks. At 10 to 12 weeks return to a regular shoe can be expected. During the recovery, physical therapy, swimming, biking, and low-impact activity may be performed.

In some situations, a simple fusion may not be performed and a more complex fusion utilizing bone graft attained from the pelvis or cadaver graft may be necessary. In this scenario, the healing time may be longer and the time of being off the foot may be as long as 3 months after surgery. Dr. Vora is skilled in this procedure and has lectured and published on this treatment for conditions of the foot and ankle.

For more on this condition, also see:
Talus fractures
Calcaneus fractures
Triple arthrodesis
 

Arthritis of the foot - Midfoot arthrodesis
For patients with arthritis of the middle joints of the foot, secondary to degenerative arthritis (osteoarthritis) or after trauma (post-traumatic arthritis) of the midfoot, a fusion, or welding together of the midfoot joints may be necessary to relieve pain and restore the normal positioning of the foot. Once these joints become arthritic, some shoe wear options and conservative treatment can be considered but for severe pain and / or collapse of the arch of the foot, surgery may be necessary. This operation requires non-weight bearing for 8 weeks followed by protected increased weight bearing. The long term pain relief after such a procedure can be substantial and the limitations after this procedure involve stiffness across the middle of the foot. All of the up and down motion in the ankle persists and only the up and down motion contributed to the foot from these joints (less then 30% of the foot) is lost. These joints of the foot are particularly difficult to fuse together and thus treatment with an experienced foot and ankle surgeon skilled in this surgical technique is essential.

For more on this condition, also see:
Midfoot fractures
Reconstruction after midfoot fractures (Lisfranc injury)