5 Surgeries Used to Treat Ankle Arthritis

Surgery may be considered when conservative therapies fail

Ankle arthritis is a condition where the cartilage of the ankle joint deteriorates, causing pain and restricted movement. Progressive arthritis leads to bone cysts and bone spur formation. When conservative therapies—such as ankle braces, cushioned insoles, anti-inflammatory drugs, cortisone injections, and physical therapy—fail to provide relief, surgery may be considered if the pain and loss of mobility seriously impair your quality of life.

Depending on the severity of your symptoms, surgical options can range from less-invasive arthroscopic ("keyhole") surgeries to the total replacement of the ankle joint.

Ankle Debridement and Exostectomy

Ankle arthritis is characterized by the development of bone spurs (osteophytes), typically on the front of the joint. Over time, the spurs can become quite large and extend to the outside (periphery) of the joint, where they are likely to break and cause loose, bony fragments. The cartilage surrounding the joint will also begin to roughen and deteriorate, causing pain and a significant reduction of movement.

Ankle debridement and exostectomy are two procedures used to "clean up" the joint so that the range of motion can be restored and the pain reduced. Both are used to treat mild to moderate ankle arthritis and typically performed on an outpatient basis.

Ankle debridement is used to remove inflamed tissue in the joint space (synovium), smooth out rough cartilage, and extract loose bits of cartilage or bone. Exostectomy refers specifically to the removal of motion-blocking osteophytes.

Both can be performed arthroscopically using narrow instruments and a flexible tube-like scope to access the ankle through a series of small incisions. If the damage is extensive or difficult to access, open surgery may be performed using a larger incision.

To prevent fractures in weakened areas of bone—particularly fluid-filled subchondral cysts inside the ankle joint—a bone marrow injection (using cells harvested from the patient) may be recommended.

Although the procedures can provide significant relief, bone spurs can often reform over time. Secondary scar tissues can also develop and interfere with joint function. In such cases, additional surgery may be required.

Ankle Arthrodesis

Ankle arthrodesis, also known as tibiotalar arthrodesis or ankle fusion, is a surgical technique used when debridement is unable to provide stability or sustained pain relief. It is generally considered when there minimal degeneration of the ankle joint or misalignment of the ankle bones.

Fusing together the major bones of the lower leg (the tibia and fibula) with the talus bone of the ankle increases stability and eliminates bone-on-bone friction, thereby decreasing pain. Depending on the severity of your condition, the surgery may either be arthroscopic or open.

To perform arthrodesis, the surgeon will make an incision in your ankle, debriding and compressing the bones to correct any minor misalignments. The bones will then be permanently fixed with plates, nails, screws, or other hardware.

The downside to ankle fusion is that it significantly reduces ankle flexibility. This lack of flexibility can put significant strain on the knee and foot joints, making them more prone to arthritis in the future.

Cartilage Repair

If joint cartilage has been severely diminished in the joint space, a cartilage repair may be considered. It is typically performed when a sizable, well-defined defect in the ankle’s cartilage is present.

The simplest type of repair is called a microfracture in which tiny holes are made into the talus bone after the damaged cartilage has been removed. Blood and cells will then trickle into the holes, forming blood clots. The clots will gradually turn into a type of scar tissue called fibrocartilage. The microfracture procedure can be performed arthroscopically on an outpatient basis.

People with more extensive cartilage damage may benefit from a newer product called BioCartilage. The powder, comprised of collagen, proteins and growth factors, is mixed with stem cells harvested from the patient’s blood or bone marrow and transferred to tiny holes drilled in the talus bone.

The final surgical option is an osteochondral graft. For this procedure, cylinders of cartilage harvested from the patient's knee (or a cadaver) are directly grafted onto the ankle bone. This is a more invasive procedure and often requires breaking a portion of bone to access the damaged area.

Osteochondral grafts are reserved for extremely large defects or when other cartilage repair efforts fail. 

Ankle Arthrodiastasis

Ankle arthrodiastasis has emerged as a viable surgical option for people with severe ankle arthritis who want to avoid ankle replacement.

The procedure involves stretching out the ankle joint to increase the space between the talus and tibia bones. During the surgery, an external fixation device is secured to the talus and tibia with metal pins and wires. The device is worn for approximately three months, during which time you are able to walk on the affected ankle.

The goal of ankle arthrodiastasis is to provide the damaged cartilage enough time and space to repair itself. Stem cells extracted from our own body (usually the pelvis) can then be used to "regrow" cartilage (referred to as neo-cartilage).

While attractive to younger people who want to avoid more invasive procedures, ankle arthrodiastasis is effective in only around 50% of cases. Still, it doesn't destroy any underlying tissues and may help preserve future treatment options.

Ankle Arthroplasty

Ankle arthroplasty, also known as an ankle replacement surgery, involves the replacement of parts to the fibula, tibia, and talus bones with a movable, artificial prosthetics. For this surgery, the top surface of the talus bone and the bottom surfaces of the tibia and fibula bones are removed and replaced with artificial components separated by a soft polyethylene pad. Modern prosthetics are composed of porous metallic materials stabilized with or without cement.

Although prosthetic designs have improved in recent decades, ankle replacement remains challenging because of the joint’s multidirectional physiology. Success rates tend to be lower than with knee and hip replacements.

There are pros and cons to ankle replacement. On the one hand, it offers a better range of motion and higher satisfaction among recipients. On the other, ankle fusion is safer and more reliable, with half as many people needing additional surgery compared to arthroplasty.

Recovery times are invariably longer and require more extensive physical therapy and rehabilitation. People with ankle replacements are advised against high-impact activities such as running and jumping. Swimming, cycling, and hiking are generally acceptable.

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