Ankle arthritis

Causes

• Primary 10%
• Secondary
  • Trauma
  • Infection
  • Inflammation
  • Neuropathy
  • Crystal
  • OCD

History

• Pain
• Stiffness
• Deformity
• Instability
• Functional limitation

H/E

• History
• Look: Standing, walking and sitting
• Feel First ask where is pain
• Move
• Special: Valgus, varus, Anterior drawer, muscle power
• NV

Inv

• FBC, ESR , CRP, RA FACTOR
• Xray
  • Hypertrophic changes: Osteophyte, sclerosis
  • Atrophic changes: reduced joint space, cysts
  • Angular deformities

Options of management of ankle arthritis include NON SURGICAL measures, limited surgical procedures especially in hypertrophic arthritis and more definite procedure like arthrodesis and TAR

Management

• Wt reduction, activity mod
• Foot wear: cushioned heel and stiff rocker bottom sole
• Splint and orthosis: moulded ankle foot orthosis
• Inj
• NSAIDS

Operative

• Limited surgical
  • Arthroscopy
  • Open ankle debridement
  • Join distraction with ilizarov
  • Realignment osteotomy
• Definitive surgical
  • Arthrodesis: gold standard
    • Fusion rate up to 90%
    • Good pain relief
    • Walking on uneven ground is difficult

Arthrodesis: Goal is to obtain a stable painless plantigrade foot

Arthrodesis

• Indications
  • Young active
  • Bone loss
  • Failed TAR
• C/I
  • Infection
  • NV
  • Malalignment

Types

• Open ankle fusion, with cross screws/plate
• Arthroscopic
• Ilizarov
• IM nail

Incision

• make15 cm incision over anterior ankle

  • begin 10 cm proximal to joint
  • cross joint midway between malleoli
  • stay superficial to avoid injury to superficial peroneal nerve branches

• Superficial dissection

  • incise deep fascia of leg in line with skin incision
  • incise extensor retinaculum
  • find plane between EDL and EHL a few cm above joint
  • identify neurovascular bundle
    • mobilizing tibialis anterior artery and deep peroneal nerve
  • retract EHL and neurovascular bundle medially
  • retract EDL laterally
  • remaining joint capsule tissue cleared to expose anterior ankle joint

• Deep dissection

  • incise capsule of ankle joint in line with incision
  • expose full width of ankle joint by subperiosteal and subcapsular dissection of the tibia and talus

• Anterior Approach

Dangers

• Superficial peroneal nerve cutaneous branches
  • at greatest danger during skin incision
• Neurovascular bundle (deep peroneal nerve and anterior tibial artery)
  • above joint runs between TA and EHL
  • crosses behind EHL at level of the joint

Position

• FABER (0,5,5) with posterior translation
• compli
  • Infection
  • non/mal union
  • NV injury

TAR

• Painless stable plantigrade foot with near normal kinematics

• 1st gen:

  • PE tibia
  • Metal talar
  • Cemented

• 2nd gen

  • 2 component design: Agility (Fixed bearing)
  • 3 component design: STAR (Mobile bearing) uncemented

• Indications

  • Low demand

  • 65

  • <10 malalignment
  • competent ligaments

• C/I

  • NV
  • poor soft tissue
  • High demand

  • 20 degree may alignment

STAR

• 3 component design

Compli

• Low grade
  • I/O fracture
• Medium grade
  • post op #,
  • subsidence
• High grade
  • Deep infection
  • Aseptic loosening
  • Implant failure

TARVA trial

• Underway
• NJR 8 year failure 8%