Health Leader, Distracted by Ankle Pain?

STORY BY

Thea Trötscher, BSN, RN

ANKLE ARTHRITIS
Time heals all wounds…for awhile, anyway.

Athletes who were sidelined years before from a nasty ankle injury sometimes find themselves limping from new pain.

Though ankle arthritis is far less common than that of other joints, it certainly can be equally debilitating and often requires treatment by an orthopedist.

Osteoarthritis generally only settles in the ankle years after significant injury to the joint. Otherwise, rheumatoid arthritis may be a cause. In either case, the effect on the joint is quite similar.

There is often a narrowing of the ankle joint space between the tibia (lower leg bone) and the talus (ankle bone), with varying degrees of damaged cartilage. Bony outgrowths known as osteophytes may also be present in and around the joint space.

In addition to chronic or intermittent pain, patients may notice that the ankle is swollen and warm to the touch. They may feel grinding or popping in the ankle, and the ankle may be particularly stiff in the morning or at the beginning of activity.

Treatment Options

Fortunately, there are a variety of treatment options that range from the very minimally invasive to complete replacement of the joint.

The use of orthotics (shoe inserts customized to a person’s foot and foot strike) and/or various ankle wraps or ankle braces may be adequate for some.
Doctors often recommend medications like non-steroidal anti-inflammatories (NSAIDs) such as aspirin and ibuprofen. COX-2 inhibitors, available by prescription only, are the newer generation of anti-inflammatories.
Injections delivered directly to the joint may provide temporary relief. A corticosteroid (steroid) injection offers relief of inflammation, but the degree and extent of that relief varies from patient to patient.
The same is true for intra-articular injections of hyaluronate products. Hyaluronic acid is a natural component of joint fluid which provides cushion and lubrication for joints. Consequently, these derivative injections do not affect inflammation, but temporarily increase joint space and provide additional cushion for the joint.

Thomas Clanton, M.D., professor in the Department of Othorpedic Surgery at The University of Texas Medical School at Houston and co-medical director of the Roger Clemens Institute for Sports Medicine & Human Performance says, “Physicians have searched for optimal treatment strategies that can be used as a continuum of care for patients with severe ankle arthritis. However, when non-operative solutions fail, surgery may be necessary.”

Surgical Options

The many surgical options for patients with ankle arthritis include:

arthroscopic debridement
joint distraction
total joint replacement
joint fusion (arthrodesis)

Arthroscopic debridement only requires the surgeon to make three small incisions around the joint to insert a camera and necessary surgical instruments. Any arthritic spurs or loose bodies can be removed and irregularities in remaining cartilage may be shaved.

Joint distraction is a rather new, but promising technique which is based on evidence that if the joint is “distracted” or unloaded for a period of time, remaining cartilage may naturally regenerate and the joint space will expand.

Though the patient must wear an external fixed frame for up to three months, no bone in the ankle is removed or permanently surgically altered. About 50 patients in the Netherlands were followed for up to seven years after the procedure and three-fourths report

Total replacement of the ankle joint is also a relatively new science when compared to hip and knee replacement. The first generation of ankle replacements consisted of two component designs: one metal component was cemented into the tibia, the other in the talus.

Now, three components are used: one metal component is fixed to the tibia, the other is fixed to the talus, and the third, a polyethelene bearing, that floats between the other two. This type of ankle replacement was also originally cemented in place, but now almost all ankle devices have beaded surfaces which are coated with a natural compound that encourages bony ingrowth.

Perhaps the most resisted solution for patients, but considered the “gold standard” treatment for severe ankle arthritis, is ankle fusion. This surgical technique involves removing bone from the tibia and talus and binding them together with a plate or large screws.

Eventually, the surgically treated ends of the bones grow or fuse together. Though this stabilizes the ankle, it allows no motion at the ankle joint. But problems can set in later. William McGarvey, MD, assistant professor of orthopaedics at UT-Houston Medical School explains, “Though the ankle joint motion is eliminated, adjacent joints compensate and may allow 50 percent of this motion to return. As a result, long term degenerative arthritis may over take these adjacent joints.”

Particularly in younger patients, preservation of motion, while relieving pain, is the primary goal. Every effort is made to avoid fusion, but even in the most skilled hands and the best of circumstances, this is not always possible. In such circumstances, fusion may prove the only viable option, allowing the younger ankle arthritis patient to return to work and participate in some mild athletic activities.

Last Updated: 5-15-2003

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About Dr. Clanton:

Dr. Thomas Clanton is a professor in the Department of Othorpedic Surgery at the UT Medical School and co-medical director of the Roger Clemens Institute for Sports Medicine & Human Performance.

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Health Tip:

Packing Bag Lunches Safely

If you pack lunches for your child to take to school, be careful that you do not accidentally expose them to foodborne illness.

Bagged lunches, especially those containing perishable foods, need to be packed and handled properly in order to keep the food safe. In general, perishable foods should not be left at room temperature for more than two hours. If left out too long, the temperature of the food can enter the danger zone where bacteria grow most rapidly, which is between 40 and 140 degrees Fahrenheit.

Below are some tips to help families pack bagged lunches safely:

Pack foods that are nonperishable and won't require refrigeration.
If you do pack perishable foods such as luncheon meats or prepackaged cheese and crackers, include a frozen gel pack or a frozen juice carton with the food in an insulated lunch bag or box.
Pack only the amount of perishable food that your child can eat at lunch.
Preparing lunches the night before and storing them in the refrigerator until you pack your child's lunchbox in the morning can help keep food cold longer the next day.
Don't reuse packaging materials such as paper or plastic bags, aluminum foil, etc. as they can contaminate other foods and cause foodborne illness. Have your child discard all used food packaging and paper bags after lunch.

Before eating lunch or snacks at school, make sure your child washes his or her hands with soap and warm water for at least 20 seconds. If your child's school does not have a handwashing program in place, encourage them to adopt a such a program, as handwashing is one of the best ways kids and parents can protect health and stop the spread of germs.