Arthritis of the Foot and Ankle

The pain and stiffness you feel in your feet and ankles as you age could be arthritis. If left untreated, this nagging pain can get worse over time, eventually making it difficult to walk even short distances. Severe arthritis can restrict your mobility, but with proper treatment, you can minimize the pain and maximize your quality of life.

Arthritis is a broad term for a number of conditions that destroy the workings of a normal joint. Arthritis may occur in your back, neck, hips, knees, shoulders or hands, as well as your feet and ankles. Almost half of people in their 60s and 70s have arthritis of the foot and/or ankle, but not all of them have symptoms.

There are many different types of arthritis. The most common type, osteoarthritis, results from wear and tear to joint cartilage, the cushioning between joints that allows them to glide smoothly. The damage can cause inflammation, redness, swelling, and pain in the joint.

Also, a sudden and traumatic injury such as a broken bone, torn ligament, or moderate ankle sprain can cause the injured joint to become arthritic in the future. Sometimes a traumatic injury will result in arthritis in the injured joint even though the joint received proper medical care at the time of injury. This type of arthritis, called post-traumatic arthritis, is the most common type that affects the ankle.

Another less common type, rheumatoid arthritis, is an inflammatory condition caused by an irritation of the joint lining. Other types of inflammatory arthritis include gout, lupus, ankylosing spondylitis, and psoriatic arthritis.

Diagnosis

The foot has 26 bones and more than 30 joints. Tough bands of tissue called ligaments hold these together. The muscles, tendons, and ligaments work together with the many joints of the foot to control motion and weight bearing position. This smooth motion makes it possible for a person to walk well. When you get arthritis in the foot, you develop pain and limited motion so that you cannot walk as well.

Arthritis can develop in any of these joints but some are more commonly affected than others. A foot and ankle orthopedic surgeon can help you locate the source of your pain and determine the best course of treatment.

If your foot and ankle orthopedic surgeon suspects you have arthritis, he or she will ask you to have a complete medical history and physical examination. X-rays and laboratory tests often can confirm the type and extent of the arthritis. Other tests such as a bone scan, CT scan, or MRI may be used to evaluate your condition.

The ankle is made up of three bones:

• the tibia (shin bone), which forms the inside, front, and back of the ankle
• the fibula, which forms the outside of the ankle
• the talus, a small bone that sits between the tibia and fibula and the heel bone

The ends of these bones are called malleoli. The tibia has a medial (inside) malleoli and a posterior malleoli. The fibula forms the lateral (outside) malleoli.

A broken ankle (ankle fracture) occurs when the malleoli are broken. These fractures are very common. Ankle fractures happen with twisting of the ankle, falls, car accidents, or other injury. One, two, or all three malleoli can be broken. Ankle fractures can be displaced (out of place) or non-displaced. Symptoms of an ankle fracture include pain especially with weight bearing, swelling, bruising, and problems with ankle motion. X-rays help determine if treatment from a foot and ankle orthopedic surgeon is needed.

Ankle Fracture Surgery

The main goal of ankle fracture surgery is to put the ankle joint back in place and to stabilize the bones to heal. Getting the ankle joint back in place helps to decrease the risk of developing arthritis of the ankle. Stabilizing the ankle with plates and screws may allow earlier motion.

Diagnosis

When the ankle fracture is unstable or in bad position, surgery is needed to repair the ankle. In some cases, the bones of the ankle may poke through the skin. These are called open ankle fractures and require surgery.

Ankle fracture surgery is not needed if the ankle is in position and stable despite the fracture. Surgery may be too risky when patients have a severe medical condition.

Treatment

Antibiotics are given shortly before the start of the surgery. Once the patient receives antibiotics and anesthesia, the surgery can safely begin. Incisions are made through the skin of the ankle where the bones are broken. The breaks in the bone are then repositioned and held in place with implants (screws and plates). After the ankle fracture is repaired, the patient’s leg is placed in either a protective splint, cast or boot. Some patients go home after surgery the same day while others may stay overnight in the hospital.

Specific Technique

Most ankle fracture surgery involves open reduction and internal fixation (ORIF). An incision is made over the ankle to see the fractured bones. Like a jigsaw puzzle, the pieces of the broken bones are placed back together (open reduction). The broken bones are then held together (internal fixation) in this correct position with metal plates and/or screws. This internal fixation provides stability so movement can begin shortly after surgery as the ankle fracture heals.

Left, a bimalleolar ankle fracture before surgery. Right, the ankle fracture after it has been fixed.

Recovery

Surgical treatment of ankle fractures allows patients to regain ankle function while the bones and joint heal. Immediately after surgery, your ankle will be immobilized for a few weeks. Once the wounds are healed, you will be fitted for either a cast or a boot. Many surgeons use a removable boot. The boot protects the ankle as it heals but can be removed to allow washing, wound checks, and icing.

Once the broken bones start to heal, you will be told when you can put weight on the ankle in your cast or boot. You are then allowed to wean out of the cast or boot. You can progress to normal activities once the bones are fully healed. Some patients may need physical therapy for their ankle to regain full movement and strength. While everyone is different, it may take up to a year after surgery for some patients to regain ankle function.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Potential long-term problems after ankle fracture surgery include ankle joint stiffness, weakness, and arthritis. Possible complications include infection and problems with healing. Factors that increase risks after ankle fracture surgery include diabetes, steroid use, and cigarette smoking.

FAQs

Will my ankle hardware (plate and/or screws) have to be removed at some point?

Plates and screws used to fix an ankle fracture are not removed if they are not causing problems. Most people do not have problems with the plate and screws. In rare cases, the plate and screws can cause some pain or irritation. When this happens, the hardware may be removed after the fracture is healed, about a year from the original surgery.

Ankle Arthroscopy

Ankle arthroscopy is a minimally invasive surgical procedure that orthopedic surgeons use to treat problems in the ankle joint. Ankle arthroscopy uses a thin fiber-optic camera (arthroscope) that can magnify and transmit images of the ankle to a video screen. Ankle arthroscopies can reduce ankle pain and improve overall function.

Arthroscopy can be used to diagnose and treat different disorders of the ankle joint. The list of problems that can sometimes be treated with this technology is constantly evolving and includes:

Ankle arthritis: Ankle fusion is a treatment option for many patients with end-stage ankle arthritis. Ankle arthroscopy offers a minimally invasive way to perform ankle fusion. Results can be equal to or better than open techniques.

Ankle fractures: Ankle arthroscopy may be used along with open techniques of fracture repair. This can help to ensure normal alignment of bone and cartilage. It also may be used during ankle fracture repair to look for cartilage injuries inside the ankle.

Ankle instability: Ligaments of the ankle can become stretched out, which can lead to a feeling that the ankle gives way. These ligaments can be tightened with surgery. Arthroscopic techniques may be an option for treating moderate instability.

Ankle Arthrodesis or Ankle Fusion

The goal of ankle arthrodesis (also known as ankle fusion) is to relieve pain and maintain or improve function for patients with ankle arthritis. Ankle arthritis is degeneration of the cartilage that covers the ends of the bones that form the ankle joint. These bones are the tibia, the fibula, and the talus. Pain typically is made worse with movement of the arthritic ankle. In ankle arthrodesis the ankle bones are fused into one bone. This eliminates the joint motion and reduces pain coming from the arthritic joint.

Diagnosis

Patients may be candidates for ankle arthrodesis if they have severe ankle arthritis and non-surgical treatments have failed. Many patients may find relief from the pain associated with ankle arthritis using:

• Anti-inflammatory medication (such as ibuprofen)
• Injections of steroids into the ankle joint
• Modification or limitations of activity
• Walking aids (such as canes)
• Specialty braces that stabilize the ankle and restrict its movement
• Cushioned and specially contoured shoes

These treatments do not reverse ankle arthritis. In many patients they may temporarily or permanently provide relief from pain. If these measures fail to provide adequate pain relief or maintain function, a patient may be a candidate for ankle fusion. You should discuss your options with your foot and ankle orthopedic surgeon.

Patients should avoid ankle arthrodesis if they have:

• Insufficient quantity or quality of bone for fusion
• Poor blood supply to the ankle
• Severely impaired nerve function
• Medical conditions that increase the risk of anesthetic
• Severe deformity of the limb

Treatment

Patients are asleep or sedated in the operating room during the procedure. Incisions are made in and around the ankle to access the joint. Any remaining cartilage within the ankle joint is removed so there is contact between the bony surfaces. The ankle is held in the most functional position with metal hardware. This allows the bones to heal together.

Flexor Digitorum Longus

The flexor digitorum longus (FDL) is one of the tendons responsible for bending the toes down to the floor. The goals of a FDL tendon transfer surgery are to relieve pain and to help restore the arch in patients with painful fallen arches. A fallen arch occurs when the foot loses its support and flattens out, generally due to weakening of tendons and ligaments in the foot.

Diagnosis

Tendon transfer surgery is indicated for people with a flexible flatfoot that can be moved into a more normal position. The posterior tibial tendon (PTT) is a main support for the arch of the foot. If it becomes diseased, it no longer functions properly and the arch begins to fall. The patient begins to walk on the inside of the foot as it flattens. The toes may begin to turn outward resulting in a flatfoot deformity. When non-surgical treatment such as arch supports fail to provide relief, surgery may be necessary.

If the deformity becomes stiff or arthritis develops, more advanced surgery is needed. This typically includes re-making the arch by fusing bones of the foot together. Patients with other medical problems may be too sick to safely undergo surgery.

Treatment

The PTT connects to the navicular bone near the middle of the foot at the instep. In this surgery, the FDL tendon is moved from its usual position and transferred to the navicular bone. This helps support or replace the diseased PTT to improve function. The diseased PTT is cleaned up or removed to eliminate it as a source of pain.

Specific Technique

The surgery is done through an incision on the inside of the ankle and foot. The initial step is to remove the scarred or inflamed tissue of the PTT. The tendon may be completely removed if it is severely damaged. Just below the PTT is the tendon of the FDL. The FDL is cut so that it is as long as possible. A hole is drilled in the navicular bone. The end of the FDL is placed through the bone. While the foot is held in the corrected position, the tendon is attached to the bone. It may be held in place with stitches and/or an anchor or screw. The incision is then closed. Other procedures may be performed with the tendon transfer to improve the arch. These can include moving or shifting of bones and stretching of the calf muscles or Achilles tendon.

Recovery

Patients usually are placed in a well-padded dressing with a splint or split cast. No weight is allowed on the ankle and foot. Patients are given crutches, a walker, or a knee walker/scooter. This procedure may be done as an outpatient or may require an overnight stay.

At two weeks the sutures are removed and a new cast or removable brace is applied. At six weeks most patients transition into a walking cast or boot with a well-molded arch. At three months, patients return to a shoe with an arch support. Elastic hose may be used for swelling and physical therapy may be prescribed to help with walking and to restore muscle strength and joint flexibility. It may take up to one year for patients to fully recover.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Standard wound complications can occur and may include delayed healing and infection. Irritation of an adjacent nerve can occur and may cause numbness or burning. These symptoms typically resolve with time. Rarely the repositioned tendon may pull out of the navicular bone and require re-placement. A more common problem is failure to restore the arch and a residual flat foot.

FAQs

Can I expect pain relief with this surgery?

Typically, improvement in pain control is achieved with the procedure. The use of arch supports often is recommended even after successful surgery. Ankle bracing may also be helpful.

What alternatives do I have if my arch is not restored or falls again?

If the arch is not restored or falls further, and arch supports and/or bracing are not helpful, additional surgery may be considered.