Ankle arthritis is a condition in which the cartilage of the ankle joint deteriorates, causing pain and restricting movement. Progressive arthritis can lead to bone cysts and the formation of bone spurs (osteophytes). When conservative therapies—such as ankle braces, cushioned insoles, anti-inflammatory drugs, cortisone injections, and physical therapy—fail to provide relief, surgery may be considered if the pain and loss of mobility seriously impair your quality of life.
Depending on the severity of symptoms, surgical options can range from arthroscopic (“keyhole”) procedures to more invasive ones such as total replacement of the ankle joint.
Ankle Debridement and Exostectomy
Ankle arthritis is characterized by the development of bone spurs, typically on the front of the joint. Over time, the spurs can become quite large and extend to the outside (periphery) of the joint, where they are likely to break and leave behind loose, bony fragments. The cartilage surrounding the joint will begin to roughen and deteriorate as well, causing pain and significantly impeding movement.
Ankle debridement and exostectomy are procedures used to “clean up” the joint to restore range of motion and reduce pain. Both are used to treat mild to moderate ankle arthritis and typically performed on an outpatient basis.
The purpose of ankle debridement is to remove inflamed tissue in the joint space (synovium), smooth out rough cartilage, and extract loose bits of cartilage or bone. Exostectomy refers specifically to the removal of motion-blocking osteophytes.
Both can be performed arthroscopically using narrow instruments and a flexible tube-like scope to access the ankle through a series of small incisions. If the damage is extensive or difficult to access, open surgery may be performed using a larger incision.
Although these procedures can provide significant relief, bone spurs can reform over time. Secondary scar tissue can also develop and interfere with joint function. In such cases, additional surgery may be required.
To prevent fractures in weakened areas of bone—particularly fluid-filled subchondral cysts inside the ankle joint—a bone marrow injection (using cells harvested from the patient) may be recommended.
Ankle Arthrodesis
Ankle arthrodesis, also known as tibiotalar arthrodesis or ankle fusion, is a surgical technique used when debridement is unable to provide stability or sustained pain relief. It is usually considered when there is minimal degeneration of the ankle joint or misalignment of the ankle bones.
Fusing together the major bones of the lower leg (the tibia and fibula) with the talus bone of the ankle increases stability and eliminates bone-on-bone friction, thereby decreasing pain. Depending on the severity of the condition, surgery may either be arthroscopic or open.
To perform arthrodesis, the surgeon will make an incision in your ankle, debriding and compressing the bones to correct minor misalignments. The bones will then be permanently fixed with plates, nails, screws, or other hardware.
Cartilage Repair
If joint cartilage has been severely diminished in the joint space, a cartilage repair may be considered. It typically is performed when there is a sizable, well-defined defect in the cartilage of the ankle.
The downside of ankle fusion is that it significantly reduces ankle flexibility. This lack of flexibility can put significant strain on the knee and foot joints, making them more prone to arthritis in the future.
In the simplest type of repair, microfracture, the damaged cartilage is removed and tiny holes are made in the talus bone, allowing blood and cells will then trickle into the holes, forming blood clots. The clots will gradually turn into a type of scar tissue called fibrocartilage. The microfracture procedure can be performed arthroscopically on an outpatient basis.
People with more extensive cartilage damage may benefit from a newer product called BioCartilage. The powder, comprised of collagen, proteins, and growth factors, is mixed with stem cells harvested from the patient’s blood or bone marrow and transferred to tiny holes drilled in the talus bone.
The final surgical option is an osteochondral graft. For this procedure, cylinders of cartilage harvested from the patient’s knee (or a cadaver) are directly grafted onto the ankle bone. This is a invasive procedure and often requires breaking a portion of bone to access the damaged area.
Ankle Arthrodiastasis
Ankle arthrodiastasis has emerged as a viable surgical option for people with severe ankle arthritis who want to avoid ankle replacement.
Osteochondral grafts are reserved for extremely large defects or when other cartilage repair efforts fail.
The procedure involves stretching out the ankle joint to increase the space between the talus and tibia bones. During the surgery, an external fixation device is secured to the talus and tibia with metal pins and wires. The device is worn for approximately three months, during which time it’s possible to walk on the affected ankle.
The goal of ankle arthrodiastasis is to provide the damaged cartilage time and space to repair itself. Stem cells extracted from the body (usually the pelvis) can then be used to “regrow” cartilage (referred to as neo-cartilage).
While attractive to younger people who want to avoid more invasive procedures, ankle arthrodiastasis is effective for only about half of people. Still, it doesn’t destroy underlying tissues and may help preserve future treatment options.
Ankle Arthroplasty
Ankle arthroplasty, also known as an ankle replacement surgery, involves the replacement of parts to the fibula, tibia, and talus bones with a movable, artificial prosthetics. For this surgery, the top surface of the talus bone and the bottom surfaces of the tibia and fibula bones are removed and replaced with artificial components separated by a soft polyethylene pad. Modern prosthetics are composed of porous metallic materials stabilized with or without cement.
Although prosthetic designs have improved in recent decades, ankle replacement remains challenging because of the joint’s multidirectional physiology. Success rates tend to be lower than with knee and hip replacements.
Recovery times are invariably longer and require more extensive physical therapy and rehabilitation. People with ankle replacements are advised against high-impact activities such as running and jumping. Swimming, cycling, and hiking are generally acceptable.
There are pros and cons to ankle replacement. On the one hand, it offers a better range of motion and higher satisfaction among recipients. On the other, ankle fusion is safer and more reliable, with half as many people needing additional surgery compared to arthroplasty.
