Summary Ankle Arthritis is a common degenerative joint disease of the tibiotalar joint that presents with pain, stiffness, and deformity of the ankle. Most commonly caused by post-traumatic etiology but can also present as primary osteoarthritis or inflammatory arthritis. Diagnosis is typically made with plain radiographs of the ankle. Treatment can be nonoperative or operative depending on patient age, patient activity demands, severity of arthritis, and presence of tibiotalar deformity. Epidemiology Incidence estimated incidence of 30 per 100,000 people annually prevalence of approximately 1% of the world population less common than OA of knee and hip Risk Factors prior ankle fracture chronic ligamentous laxity inflammatory arthropathy Etiology Pathophysiology causes include post-traumatic arthritis most common etiology, accounting for 75% to 80% of ankle arthritis ankle fractures account for the majority of post-traumatic arthritis chronic ligamentous laxity (typically lateral) account for the rest primary osteoarthritis accounts for less than 10% of all ankle arthritis other etiologies include rheumatoid arthritis, osteonecrosis, neuropathic, septic, gout, and hemophiliac pathoanatomy nonanatomic fracture healing alters the joint contact forces of the ankle and changes the load bearing mechanics of the ankle joint loss of cartilage on the talar body and tibial plafond results in joint space narrowing, subchondral sclerosis and eburnation Anatomy Osteology a ginglymus joint that includes the tibia, talus, and fibula talar dome is biconcave with a central sulcus Range of motion ankle dorsiflexion: 20 degrees ankle plantar flexion: 50 degrees Classification Takakura Classification (based on mortise radiograph) Stage I Osteophytes and early sclerosis, no joint space narrowing Stage II Narrowing of medial joint space, no subchondral contact Stage IIIA Obliteration of joint space at the medial malleolus, with subchondral bone contact Stage IIIB Obliteration of joint space over roof of talar dome, with subchondral bone contact Stage IV Obliteration of joint space with complete tibiotalar contact Presentation Symptoms pain with weight-bearing stiffness locking or catching Physical exam variable joint effusion pain with range of motion (ROM), loss of ROM compared to the contralateral side angular deformity may be present depending on the history of trauma crepitus Imaging Radiographs recommended views weight bearing AP, lateral, and mortise radiographic findings include loss of joint space subchondral sclerosis and cysts eburnation possible angular deformity CT scan indications useful for surgical planning for both arthrodesis and arthroplasty MRI indications identify specific foci of cartilage disease higher sensitivity in early disease findings cartilage injury subchondral bone marrow edema ligament tears Treatment Nonoperative activity modification, bracing to immobilize the ankle, and NSAIDS indications indicated as first line of treatment in mild disease single rocker sole shoe modification can improve gait and pain symptoms Arizona brace (gauntlet ankle brace) intraarticular injections corticosteroids remain the mainstay of treatment can consider PRP or hyaluronic acid no consensus on the efficacy Operative arthroscopic ankle debridement with anterior tibial/dorsal talar exostectomy indications isolated anterior impingement joint preserving option outcomes successful in treating anterior impingement from anterior-based tibial osteophytes insufficient evidence supporting the routine use for treating advanced ankle arthritis supramalleolar osteotomy indications mild to moderate arthritis tibiotalar malalignment or eccentric articular wear medially focused ankle arthritis outcomes patients with 4-10° of preoperative talar tilt have five-year survival rates of 85% while those with > 10° of talar tilt have five-year survival rates of 65% distraction arthroplasty indications indicated for young patients with moderate to severe post-traumatic arthritis theoretically allows for biologic repair of damaged articular surfaces with offloading joint preserving option for young patients not a candidate for arthroplasty or arthrodesis requires good preoperative range of motion outcomes controversial paucity of literature suggesting long-term benefit ankle arthrodesis indications moderate to severe post-traumatic arthritis or inflammatory arthritis refractory to conservative treatments young, high-demand laborers outcomes arthrodesis remains the gold standard treatment of end-stage ankle arthritis reliable relief of pain and return to activities of daily living complications subtalar arthritis (see complications below) nonunion (see complications below) total ankle arthroplasty indications post-traumatic or inflammatory arthritis in an elderly patient controversial but may be better option for patients with concomitant talonavicular or subtalar fusion contraindications relative obesity young laborers severe deformity absolute active infection inadequate bone stock talus osteonecrosis Charcot neuropathy outcomes recent 5-10 year outcome studies demonstrate up to 90% good to excellent clinical results, long-term studies are still pending on the newest generation of ankle arthroplasty increased gait speed and stride length compared with arthrodesis complications wound infection, deep infection, and osteolysis periprosthetic fracture Techniques Arthroscopic ankle debridement with anterior tibial/dorsal talar exostectomy technique anterior ankle arthroscopy can be performed open consider future approaches for arthrodesis or arthroplasty Distraction arthroplasty technique static versus hinged external fixator or spatial frame can be combined with adjunctive techniques microfracture, chondroplasty, orthobiologics Supramalleolar osteotomy tibial osteotomy varus deformity typically treated with medial opening wedge tibial osteotomy valgus deformity typically treated with a medial closing wedge osteotomy may require oblique fibular lengthening osteotomy dome osteotomy technically challenging but reduces translation or changes in limb length gradual correction computer assisted deformity correction can be performed with a spatial frame useful in multiplanar or large deformity correction fibular osteotomy outcomes do not differ between patients who require a fibular osteotomy and those who do not Arthrodesis approach open classic anterior approach transfibular approach 8-10 cm distal fibula resected mini-open approaches joint preparation performed with a burr arthroscopic can be performed arthroscopically fixation options include transarticular compression screws bridge plating external fixation hindfoot retrograde fusion nail (for tibiotalocalcaneal arthrodesis) Arthroplasty approaches anterior approach interval between tibialis anterior and extensor hallucis longus protect SPN, DPN, anterior tibial artery implant design fixed bearing devices mobile bearing devices adjunctive procedures tendoachilles lengthening or gastrocnemius recession foot osteotomies for deformity correction ligamentous reconstruction Complications Arthrodesis subtalar arthrosis 50% of patients demonstrated subtalar arthrosis 10 years following ankle arthrodesis nonunion 10% nonunion rate risk factors include smoking, adjacent joint fusion, history of failed previous arthrodesis, and avascular necrosis revision arthrodesis union rates are 85% or greater Arthroplasty intraoperative medial malleolus fracture may consider prophylactic medial malleolus pinning intraoperatively prosthetic joint infection aseptic loosening periprosthetic cyst formation can be related to infection or aseptic loosening, although pathogenesis not always clear small asymptomatic cysts may be observed large, progressive, or painful cysts may require operative intervention debridement and bone grafting revision total ankle arthroplasty Prognosis Arthrodesis vs. Arthroplasty pain arthrodesis has shown reliable relief of pain and return to activities of daily living function arthroplasty shows increased gait speed and stride length compared with arthrodesis survivorship recent 5-10 year outcome studies demonstrate up to 90% good to excellent clinical results for arthroplasty long-term studies are still pending on the newest generation of ankle arthroplasty