Ankle Joint Arthritis
Let’s meet the Ankle Joint:
The ankle joint plays a very important role in gait and propelling the body forward when it flexes downward and pushes off the ground. A significant amount of force and pressure are imparted upon this joint with each step. The ankle joint has a complex construct that takes on these forces while having most of its motion in a flexion direction while having rigidity in and side-to-side and rotation motion. It has a mortise type anatomy that makes it more complex than the hip or knee joints. The bones that make up the ankle joint are: the Talus (ankle bone), the Lateral Malleolus of the Fibula (outer leg bone), the Tibial Plafond (leg bone), and the Medial Malleolus of the Tibia (inner leg bone). The normal ankle joint should be able to have a total range of motion of about 70 degrees (20 upward flexion and 50 downward flexion) for normal function. When there is limited motion of the ankle joint it cannot propel the body forward efficiently leading to other joints of the body to compensate, adding undo strain through the rest of the foot and lower extremity. Pain and fatigue from this inefficient gait pattern will develop.
What is Arthritis?
Arthritis is a disease of the joints. Arthritis is simply damage to the cartilage of a joint. Each part of the body that moves has a joint between the bones that move. Cartilage is the material that lays over the surface of each bone of the joint. If there were no cartilage between a joint, the two bones would want to join together. Cartilage takes on a great deal of pressure and force and can absorb these forces very efficiently. However, cartilage is not strong when there is a sheering force applied to it or when it is fractured. Arthritis is a progressive disease that will compound on itself. Even a small amount of damaged cartilage, leads to an uneven amount of pressure within the joint and the bones will move upon the damaged surface and erode more and more of the cartilage until there is more bone contact. Any amount of damage to the cartilage of a joint is referred to as arthritis.
There are many types of arthritis. Some diseases like, Rheumatoid Arthritis, are an autoimmune problem where the body attacks its own cartilage. This kind of arthritis will affect the whole body equally. Osteoarthritis or Degenerative Joint Disease (DJD) is a problem that affects one joint at a time. There must be an external force, such as a fracture of the bone and joint, or a biomechanical deformity that leads to the deterioration of the joint.
What is Ankle Joint Arthritis?
Ankle joint arthritis is defined as any damage to the cartilage of the ankle joint. Ankle joint arthritis usually presents as a form of osteoarthritis. It will usually affect one ankle, but it can be symmetrical as well. As the cartilage begins to wear, and the ankle bends with each step that is taken the bones rub against the worn defect. This constant pressure continually enlarges the amount of damaged cartilage. The space between the bones becomes less and less, limiting the amount the ankle can bend when walking. The limited bending causes the bones to jam into each other causing even more cartilage damage. The constant jamming of the joint stimulates extra bone growth, which is seen as a spur or growth of bone bump at the front of the joint. This spur additionally limits the motion of the joint, accelerating the joint damage. This becomes a vicious cycle of progressive damage. When there is arthritis, movement of the joint is painful. Arthritis is always progressive and will always get worse. As the population ages, there is a greater need for joint replacement surgery and the ankle is no exception.
What are the Symptoms of Ankle Joint Arthritis?
Patients will complain of pain within the joint. The pain will be mild to severe depending on the amount of cartilage damage. In the early stages of ankle arthritis and in patients with small voids of cartilage (talar dome lesion / osteochondritis dessicans) will complain of a deep achy pain that is difficult to pinpoint. The joint will move less and have a smaller range of motion than it used to. Movement of the joint becomes painful and debilitating. Patients will complain of a feeling of stiffness in the joint. Extra bone formation (bone spur) will appear on the sides of the joint and sometimes. This spur will also limit the motion of the joint. There can be increased swelling around the joint that will come and go depending on the amount of activity and irritation. The more severe arthritis will lead to a more permanent swelling and thickening around the joint. High heel shoes become harder to wear because the ankle will not bend enough. Activities that are demanding of the ankle will become painful and difficult. In later stages, even walking will become painful. There is usually no pain at rest. Some patients will hear cracking and popping from the joint when it is moving.
What Causes Ankle Joint Arthritis?
An external force or an internal biomechanical deformity can cause ankle arthritis. Athletes, soldiers, ballet dancers, construction workers, and others that place great demand on the big toe joint can eventually develop arthritis. Constant micro damage to the joint from these activities will eventually lead to a significant loss of cartilage. A biomechanical disadvantage to the structure of the ankle bones can cause damage to the joint. Structural abnormalities lead to poor movement of the ankle joint leading to chronic micro trauma and arthritis. A severe ankle sprain, multiple mild ankle sprains and those with ankle instability can chronically injure the ankle joint cartilage leading to arthritis. Ankle Fractures that involve the joint will lead to arthritis. Bone heals well after a fracture, while cartilage has difficulty healing. This means that there will be damage to the joint surface after a fracture leading to chronic micro trauma and progressive arthritis of the joint. Misalignment of the joint such after poor fracture healing or ankle sprains can lead to arthritis. Chronic Gout can lead to arthritis of the ankle.
How is Ankle Joint Arthritis Diagnosed?
Diagnosis is simply achieved by the clinical examination and x-rays of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and ankle and an evaluation of gait. Digital radiographs (x-rays) of the ankle will be obtained and reviewed with the patient. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated deformities. In some cases MRI or CT scans are used to determine the quality of the bone and the cartilage.
How is Ankle Joint Arthritis Treated?
Dr. Soomekh educates that early diagnosis and treatment of ankle arthritis are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment for Ankle Joint Arthritis:
Joints do not have a significant blood supply. For this reason it is difficult for joints to repair damage on their own.
Conservative treatments rely on their ability to accommodate the ankle arthritis. This can be achieved by wearing appropriate shoes or high top shoes with a stiff sole. A stiff soled shoe reduces the amount of movement in the joint leading to less pain with each step. Rocker-bottom shoes will roll the foot forward leading to less movement of the ankle joint. Reducing the activities that cause pain and damage to the joint can help to reduce the painful inflammation and the progressive wear on the joint. Ice and anti-inflammatories can reduce the irritation when there is a flare. Custom molded orthotics can be made as an important tool to slow the progression of the damage to the joint in cases of a biomechanical deformity.
Bracing and Custom Molded Functional Orthotics:
Many patients may benefit by simple accommodation of the ankle arthritis. This can be achieved by using custom molded orthotics or bracing. Custom orthotics can control some of the motion at the ankle and below the ankle that may remove some of the stresses that are put on the ankle joint. This is usually effective in low-grade cases of ankle arthritis. Custom braces, called Ankle Foot Orthosis (AFO) that cross the ankle joint can be very effective. They are used to limit the amount of motion at the joint; less motion can lead to less pain. These braces can be hinged to allow for some movement, or unhinged to allow for no movement. Both these devices are custom made. A mold is taken of the foot and ankle with plaster casting material, in the proper position to achieve the desired results. The molds are then sent to the manufacturing lab along with a prescription from the doctor. Once the device is ready, Dr. Soomekh will fit the device to the patient in the office.
Physical therapy can be an integral part of conservative management for ankle Joint arthritis. In those patients with low-grade arthritis, range of motion exercises, when done properly, and with the proper bracing, can be beneficial in slowing the progression of the disease. Patients will be asked to see the therapist up to two times a week for several weeks.
Injected steroids are catabolic. This means that they break down tissue. They are used in an effort to reduce inflammation and scar tissue that are a secondary cause of pain within the arthritic joint. They cannot reverse or heal any damaged cartilage. They are used to bring temporary relief. There is a limit to the number of these injections that are recommended. Dr. Soomekh offers this injection with little discomfort in the office setting under ultrasound guidance for precision. There is no restriction of activity after this type of injection. Most patient’s pain will return over time.
Joint Fluid Replacement (Sodium Hyaluronate Injections, Supartz):
Dr. Soomekh offers an injectable material that can lubricate the joint. Hyaluronic acid is a naturally occurring material that makes up joint cartilage. Injection of this material into the joint has been shown to help the joint move with less irritation and damage to the cartilage. This can translate to less pain within the joint. Some studies even show mild regeneration of cartilage after these injections. Most patients will need multiple injections, usually performed 2 to 6 times at 1 to 2 week interval, to achieve relief. There is no limit to the number of injections. This procedure is usually best suited for those patients that have a small degree of deterioration of the joint. Dr. Soomekh offers this injection with little discomfort in the office setting under ultrasound guidance for precision.
Platelet Rich Plasma Therapy (PRP) with Stem Cell Therapy using Bone Marrow Aspirate (BMA):
Platelets are the cells that produce the healing factors in the body. When there is an injury, platelets rush to the area to begin the healing process. In a chronic injury there are very little platelets in the area to aid in repair. The introduction of platelets by injection can lead to a higher concentration that may be able to better aid in the healing process. In the office setting, a small amount of blood is taken from the patient’s arm. The blood is spun in a centrifuge to filter the platelets from the other blood products and obtain the PRP.
Within the bone marrow live the stem cells. These cells have not differentiated into the cells they will eventually become. When a stem cell is in an environment with of adult cells, the stem cells will differentiate and become that adult cell. When the bone marrow aspirate is placed within a joint, the new cells can then become new cartilage cells. Acquiring the bone marrow from the heel bone can be done in the office setting with little discomfort. The patient is given an injection to numb the skin around the heel bone. A special needle is introduced into the heel bone. The marrow is then drawn out into a syringe. The product is then spun in a centrifuge to filter the stem cells from the other marrow products to obtain the BMA. The skin is closed with one small stitch.
BMA can be combined with PRP and injected back into the ankle joint. This will bring the necessary healing potential from the PRP and the new stem cells from the BMA that can become cartilage cells and repair small defects of missing cartilage in the joint. This procedure is performed in an office setting.
The patient is given an anesthetic injection at the level of the ankle joint. The PRP/BMA mixture is then injected into the ankle joint. The patient is placed into a walking boot for a period of two to three weeks during the healing process. Some patients will need an additional injection several weeks after the first. Dr. Soomekh performs this procedure in the office setting with little discomfort under ultrasound guidance for precision.
Surgical Treatment for Ankle Joint Arthritis:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when ankle arthritis becomes painful, daily activities become a struggle, and conservative treatments have failed, surgical repair may be indicated.
Considering surgery can be intimidating. Ankle surgery including surgery to correct ankle arthritis is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. In cases of mild arthritis, the goal of surgery is to clean out the joint, prevent further damage, promote new cartilage growth when possible, alleviate pain, allow a return to normal shoes, and allow a return to activities. In cases of severe arthritis, the goal is to eliminate pain and return to some activity. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
There are many different procedures and techniques to treat ankle arthritis. It is the responsibility of the surgeon to investigate each specific aspect of the deformity for each individual patient in order to formulate the proper procedure for repair. Dr. Soomekh will use the information gained from the patient’s symptoms, age, activity level, lifestyle goals, the severity of the deformity, the clinical examination, the patient’s gait, and the x-rays, to make a recommendation on the proper procedure.
Mild Moderate Ankle Joint Arthritis
Ankle Arthroscopy (Ankle Joint Clean Out):
Ankle arthroscopy is a minimally invasive procedure with two small incisions into the ankle joint, using a camera to visualize the joint. The other incision is used for instrumentation placed into the joint to perform the repair. The purpose of this procedure is to “clean out” the joint and buy the joint some more time before it becomes even more arthritic and promoting new cartilage growth when possible. The earlier in the disease process that this procedure is performed, the more rewarding it will be for the patient.
Two small incisions are made on wither side of the front of the ankle joint. The camera is placed into the joint and a precise and systematic examination of the joint is performed. Any inflammation (synovitis), scar tissue, extra bone (spur), floating pieces of cartilage, and extra fibrous bands of tissue within the joint are removed. Areas of missing cartilage are stimulated to promote new growth of cartilage by varying methods. Dr. Soomekh will then close the skin using plastic surgery techniques. Ankle arthroscopy is a simple, well-tolerated outpatient procedure that allows for little down time.
Moderate Ankle Joint Arthritis
Cartilage Grafting with Stem Cell Therapy:
Dr. Soomekh is one of the few surgeons that perform an advanced procedure using cartilage grafting. The purpose of this procedure is an attempt to replace areas of missing cartilage with new cartilage growth. It is usually performed in addition to an Ankle Arthroscopy. Stem cells are special cells that have not decided (differentiated) what type of tissue they will become. When these stem cells are placed near cartilage, they become cartilage. Stem cells can be found within the bone marrow.
The area of missing cartilage is prepared and stimulated. The stem cells (Bone Marrow Aspirate (BMA)) are obtained from the patient’s own heel bone or leg bone. The stem cells are obtained from the preparation of the BMA. In addition to the BMA, donated human cartilage graft (DeNovo ®) is then mixed with the BMA. The cartilage graft and BMA complex is then placed upon the defect within the joint and glued into position. Over time, the patient will incorporate the new cartilage graft and use it as a scaffold to build new cartilage. The patient is placed in a cast below the knee on crutches for up to 6 weeks. This procedure requires an open incision over the ankle joint that Dr. Soomekh will then close using plastic surgery techniques. It is performed in an outpatient setting.
Ankle Joint Cartilage Transplant (OATS):
Osteochondral autograft transplantation surgery (OATS) is a procedure by which human donor bone with its attached cartilage are transplanted to replace larger cartilage defects. Defects that involve injury to the cartilage and the bone underneath are called an osteochondral lesion. This defect can be replaced by donor bone. This procedure is performed surgically. The joint in opened and the area of damage on the ankle bone (talus) is removed in a circular and cylindrical fashion into the bone. An exact piece of bone with cartilage attached is taken from a human donor talus and placed into the patient’s bone within the defect. Over time, the patient’s bone will incorporate this new bone and cartilage. In cases with a large defect, the procedure is modified by placing multiple plugs of the donated bone and cartilage into the defect. There is very little chance of rejection of the bone. The patient is placed in a cast below the knee on crutches for up to 6 weeks. This procedure requires an open incision over the ankle joint that Dr. Soomekh will then close using plastic surgery techniques. It is performed in an outpatient setting.
Severe Ankle Joint Arthritis
Ankle Joint Fusion:
Patients with severe arthritis and loss of cartilage will require a more aggressive treatment. When there is severe cartilage damage, or complete loss of cartilage, then the joint cannot be salvaged or saved. In these cases a fusion of the ankle joint may be recommended.
The purpose of a fusion of the ankle joint is to remove the joint and take away all movement of the joint. No movement = No pain. This procedure joins the ankle bone (talus) and the 2 leg bones (tibia and fibula) into one bone. The fusion of this joint still allows for normal walking and some activity. An incision is made on outside the ankle joint. Part of the fibula is removed, and will be placed back over the bones to be used like a plate to augment the fusion. Any extra bone spurs around the joint are removed. The surfaces of each bone are prepared by removing all the remaining cartilage. The 2 bones are joined together, while the foot is placed at 90 degree angle to the leg, and screws are placed across the joint. The screws hold the bone in its new corrected position while the bone heals into one. Once the bone heals, the screws are not needed and are generally not removed. The part of the fibula that was removed is then placed back and screwed onto the ankle and leg bones, across the joined bones as a bridge. In some cases a plate may also be used to hold the bones together. Dr. Soomekh will then close the skin using plastic surgery techniques.
In some cases, Dr. Soomekh may offer the patient the addition of Bone Marrow Aspirate (BMA) with Platelet Rich Plasma (PRP) to facilitate the fusion. Stem cells are special cells that have not decided (differentiated) what type of tissue they will become. When these stem cells are placed near bone, they become bone. Stem cells can be found within the bone marrow. Bone Marrow Aspirate (BMA) is obtained from the patient’s own heel bone. The stem cells are obtained from the BMA and mixed with PRP (the healing factors). The material is then placed into the space between the bones.
Total Ankle Joint Replacement
Dr. Soomekh is one of the few ankle surgeons that is extensively trained and experienced with the 3 main ankle replacements. Dr. Soomekh will take a great deal of care and examination to determine if a patient with severe arthritis is a candidate for an ankle replacement, and which devise appropriate. The purpose of this procedure is to replace the missing cartilage and bone with a new synthetic joint (metal on plastic on metal). An ankle replacement allows for some limited pain free motion at the joint. Since there is no bone moving on bone, this will allow for pain free motion of the joint. An incision is made on the side of the big toe joint. Any extra bone around the joint is removed. The surface of one side of the joint (the more damaged side) is prepared by removing all the remaining cartilage and some bone. A special, sized hemi-implant is placed and anchored into the bone. Dr. Soomekh will then close the skin using plastic surgery techniques. The patient will be place in a cast for 6 to 8 weeks on crutches. Physical therapy will be integral for the recovery period.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top Ankle arthritis specialists and Ankle surgeons in the Los Angeles area.