Ankle arthritis: diagnosis and conservative management

Introduction The ankle joint is the most commonly injured joint in the body and absorbs more force per square centimetre than any other joint. However, the incidence of ankle arthritis is nine times less common than symptomatic arthritis in the knee and hip. This paper reviews ankle arthritis. Discussion Post-traumatic arthritis is the most common form of ankle osteoarthritis. The most current literature on the diagnosis and non-surgical management of ankle arthritis, including physical examination, radiographic parameters, advanced imaging and treatment modalities are reviewed. Conclusion This paper gives an overview of the most recent literature to assist physicians in the diagnosis and non-surgical management of ankle osteoarthritis Introduction The ankle joint is the most commonly injured joint in the body and absorbs more force per square centimetre than any other joint. However, the incidence of ankle arthritis is nine times less common than symptomatic arthritis in the knee and hip1. Unlike arthritis in the knee and hip joint, ankle arthritis is most commonly post-traumatic and primary arthritis remains very uncommon. Saltzman reported 7.2% of primary ankle arthritis compared to 70% of Ankle arthritis: diagnosis and conservative management R Grunfeld*, U Aydogan*, P Juliano*, J Bustillo* post-traumatic arthritis, in a sample of 639 patients across a 13-year period2. Rheumatoid arthritis was seen in 11.9% of patients2. The aim of this review was to discuss the diagnosis and conservative management of ankle arthritis. Aetiology/Pathophysiology Previous trauma to the ankle joint is the most significant predisposing factor contributing to the development of ankle osteoarthritis2. This includes ankle fractures, pilon fractures (distal tibia, intra-articular fractures), recurrent ankle sprains and ankle instability, and osteochondral injuries to the talus (OCD). A rate of 14% of posttraumatic ankle arthritis can be seen with ankle fractures3. Obtaining an anatomic reduction, either closed or open means appears to be the most important factor in decreasing the risk of post-traumatic arthritis3. Pilon fractures are high energy intra-articular ankle fractures with a high degree of comminution (Figure 1). These are also associated with the development of ankle arthritis and damage to the articular cartilage. Open fractures can lead to an additional increased risk of infection and post-traumatic arthritis4 (Figure 2). In one study, onset of osteoarthritis occurred at an average of 20.9 years after the original injury5. Patients’ age (i.e. older patients) as well as complications during the treatment of the fracture was related to a shorter latency in the onset of arthritis5. Osteochondral injuries to the talus (OCD lesions), whether acquired at the time of an ankle fracture-dislocation or of idiopathic origin, predispose patients to the development of ankle arthritis. These lesions are best diagnosed with MRI scans (Figure 3). Clinical presentation Pain and functional limitations are the most common presenting symptoms in patients with ankle arthritis6. A simple * Corresponding author Email: [email protected]; uaydogan@ hmc.psu.edu; [email protected]; [email protected] Penn State College of Medicine, Department of Orthopaedic Surgery, Milton S. Hershey Medical Center, Pennsylvania, USA Figure 1: A) X-ray(AP) of comminuted, high-energy pilon fracture, with continued deformity and tibiotalar joint arthritis . B) Lateral radiograph of pilon fracture, previous external fixator pin site seen.