Performed by – David Hinsley, Ngwe Phyo, Nick Ward

Osteoarthritis, or wear and tear, of the ankle is a common problem. It is more likely to have occurred if you have fractured your ankle in the past or if a family member has osteoarthritis of other joints. Most patients will complain of an aching pain along the front of the ankle joint which may be present at rest and at night if the wear within the joint is advanced.

In the early stages there are many conservative measures that can be helpful. Painkillers such as Paracetamol or Ibuprofen can be useful in taking the edge of the pain. In addition, Glucosamine and Chondroitin (available in health shops as well as on prescription) is sometimes beneficial.

The ankle is a weight bearing joint so weight loss will be helpful in reducing pain. Behaviour modification such as the reduction of high impact activities (running) and substituting this with cycling or swimming will reduce pain.

Wearing boots rather than shoes can offer more support to the ankle which may reduce pain.

Once the pain in the ankle becomes worse, and is not helped by the above measures, a corticosteroid injection into the ankle joint often helps to settle the pain down for anything up to a year. The response to injections is however variable and it may only help for weeks. It is also useful in confirming that the ankle is the sole source of your pain. This is particularly useful if any further surgery is considered. Key hole surgery can be employed to smooth off ragged cartilage (the smooth covering of the ends of your bones within the ankle joint which is damaged with osteoarthritis) and is also useful in reducing pain in the medium term.

In patients with severe pain then more major surgery can be beneficial. Ankle Fusion and Total Ankle Replacement (TAR) are both used for people with ankle arthritis. Ankle replacement has the benefit of giving the patient slightly more movement than a fusion (deliberate joining of the shin bone and talus foot bone that sits within the Ankle mortise) hence abolishing all movement and hence pain. Ankle replacement also protects the joints of the middle part of the foot which are more likely to become arthritic if a fusion is performed.

Fusion is a tried and tested technique whilst ankle replacement surgery continues to evolve, though modern implants have superior results when compared with their predecessors. Ankle replacements may fail, i.e. become loose and the components may migrate into abnormal positions. They would then need to be revised (often to a fusion) which would involve further surgery.

As a result, TAR is usually reserved for patients with inflammatory arthritis (such as rheumatoid arthritis) or more elderly patients with ankle arthritis.

Ankle Arthrodesis (Fusion)
This operation is performed for patients with Ankle arthritis that no longer responds to more conservative treatments or procedures. It can be done arthroscopically (keyhole surgery), if the ankle/foot position is not too deformed, or via an open operation if deformity needs to be dealt with as well. The bones are held in position by two or more large screws that fix the ankle in position and compress the two bone surfaces together to encourage fusion.

After surgery, you will be placed into a half cast (to allow swelling) and asked to keep your foot elevated at the level of your heart (putting it up on two cushions on a coffee table is usually adequate) for the first two weeks. You will then be reviewed in clinic at 2 weeks to check that all your wounds have healed and you will be placed into a new, complete, lightweight cast. You may be allowed to bear some weight at this stage but you will still be using crutches to ensure that only a small amount of your weight is transmitted through the operated on leg. A further review is arranged at 6 weeks and 12 weeks to ensure that the fusion is progressing, assessed clinically and by x-rays. At the 12 week point you should be able to bear all your weight through the affected leg whilst wearing a splint.

The minimum time for fusion is 3 months and it can take longer before your ankle is completely comfortable. The best result is often obtained about a year post-surgery.