Symptomatic Ankle Osteoarthritis Research Articles

“It's like a nail being driven in the ankle”: A qualitative study of individuals' lived experiences to inform a core domain set for ankle osteoarthritis

ObjectivesExplore individuals' lived experience with ankle osteoarthritis and to identify health-related domains for ankle osteoarthritis based on the perspectives of people living with the condition, as an initial step to address the International Foot and Ankle Osteoarthritis Consortium's recommendation to develop a core domain set for ankle osteoarthritis. MethodsA qualitative study using semi-structured interviews was conducted. Interviews were undertaken with individuals with symptomatic ankle osteoarthritis who were aged ≥35 years. Interviews were recorded, transcribed verbatim and thematically analysed. ResultsTwenty-three individuals (16 females; mean (range) age 62 (42–80) years) were interviewed. Five themes were identified: pain, often severe, is a central feature of living with ankle osteoarthritis; stiffness and swelling are key symptoms; ankle osteoarthritis induced mobility impairments compromise enjoyment in life; ankle osteoarthritis instability and balance impairments lead to concerns about falling; there are financial implications of living with ankle osteoarthritis. We propose 17 domains based on individuals’ experiences. ConclusionStudy findings indicate that individuals with ankle osteoarthritis live with chronic ankle pain, stiffness and swelling which affect their ability to participate in physical, and social activities, maintain an active lifestyle, and work in physical occupations. From the data, we propose 17 domains that are important to people with ankle osteoarthritis. These domains require further evaluation to ascertain their inclusion in a core domain set for ankle osteoarthritis.

The efficacy of platelet-rich plasma in osseous foot and ankle pathology: a review.

The purpose of this review is to develop evidence-based practices for the use of platelet-rich plasma (PRP) to treat osseous pathologies of the lower extremity. There is moderatehigh-quality evidence to support the efficacy of PRP as a surgical augment to microfracture in osteochondral lesions of the talus (OLT). The literature supports a conceivable positive impact on bony union and osseous healing. There is insufficient evidence to support PRP injections in the conservative management of OLT or symptomatic ankle osteoarthritis. PRP may serve as a viable treatment method in the surgical augmentation of microfracture surgery in OLT and has promise for increasing bony union following surgical operations. Further high-quality, comparative studies with longer clinical follow-up are required.

An open-label, single-arm trial of cryoneurolysis for improvements in pain, activities of daily living and quality of life in patients with symptomatic ankle osteoarthritis

ObjectiveCryoneurolysis, cold-induced reversible conduction block of peripheral nerves, is an effective treatment for reducing knee osteoarthritis (OA) symptoms and opioid use following knee arthroplasty. There are however, limited data concerning its use for ankle OA. Our aim was to assess clinically significant long-term symptomatic relief of ankle OA with cryoneurolysis. MethodThis single-center, open-label trial included participants aged >18 years with radiographic tibiotalar OA, unilateral ankle pain ≥5/10 on Numerical Rating Scale (NRS), and with no ankle surgery within 6-months of screening. Following ultrasound-guided cryoneurolysis of nerves in the participant's pain distribution (sural, saphenous, superficial and/or deep fibular nerves), outcomes were assessed at clinic visits (6, 12 and 24-weeks) and by telephone interview (3, 9, 18-weeks). The primary endpoint was change in Foot and Ankle Outcome Score (FAOS) (pain subscale) at 12-weeks. Change in quality of life (FAOS-QoL), activities of daily living (FAOS-ADL), NRS-pain, and physical performance measures were also assessed. Longitudinal mixed models were constructed to evaluate changes from baseline at 6, 12- and 24-weeks post-treatment. ResultsForty participants enrolled (50% female, mean ​± ​SD age 63.0 ​± ​12.8 years). At 12-weeks post treatment, FAOS-pain (20.8, p ​< ​0.0001), ADL (18.1, p ​= ​0.0003), QoL (19.9, p ​= ​0.0003) and NRS-pain (−2.6, p ​< ​0.0001) were significantly improved from baseline. No difference in 40-m fast-paced walking test was detected at 12-weeks post-treatment (−1.2sec, p ​= ​0.59). For all outcomes, similar findings were observed at 6- and 24-week visits. ConclusionCryoneurolysis resulted in statistically significant improvements in ankle pain, physical function and QoL for up to 24-weeks in participants with unilateral, symptomatic ankle OA.

Balance is impaired in symptomatic ankle osteoarthritis: A cross-sectional study

Ankle osteoarthritis (OA) is associated with several physical impairments but investigations into balance impairments in this population are limited. Understanding balance impairments in ankle OA may help inform the management of this condition. Does balance overall performance differ between individuals with symptomatic radiographic ankle OA, asymptomatic radiographic ankle OA and healthy controls? Are there any differences in mediolateral or anteroposterior balance, or confidence to perform balance tasks between these groups? Ninety-six volunteers (31 symptomatic radiographic ankle OA, 41 asymptomatic radiographic ankle OA and 24 healthy controls) completed six static balance tasks: bilateral stance on a firm surface, bilateral stance on foam, and tandem stance, all performed with eyes open and closed. Centre of pressure (COP) data were collected using force plates. Confidence to perform each balance task was collected using an 11-point numerical rating scale. Compared to controls, participants with symptomatic radiographic ankle OA had greater COP area when standing on a firm surface, foam and in tandem with eyes closed (all p < 0.05) and greater total COP sway in both firm surface and tandem stance conditions (p < 0.04). Participants with symptomatic ankle OA had greater COP area (p < 0.04) and total COP sway (p = 0.01) than those with asymptomatic ankle OA during tandem stance. Total COP sway and area were similar between asymptomatic ankle OA and control participants. Some differences in mediolateral and anteroposterior balance were identified between groups. Individuals with symptomatic ankle OA had lower confidence to perform the tandem stance eyes closed task compared to controls. Balance impairments and decreased balance confidence were identified in those with symptomatic radiographic ankle OA compared to asymptomatic individuals with and without radiographic ankle OA. This suggests that balance deficits in ankle OA may be related to symptoms, rather than radiographic evidence of disease.

Efficacy and Safety of a Single Intra-articular Injection of Platelet-rich Plasma on Pain and Physical Function in Patients With Ankle Osteoarthritis—A Prospective Study

Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. The aim was to evaluate the efficacy and safety of a single intraarticular injection of platelet-rich plasma (PRP) for patients with ankle OA. In a prospective study done in a university-affiliated tertiary care medical center, 44 patients with symptomatic ankle OA for at least 6 months were recruited. Patients received a single injection of PRP (3 mL) into symptomatic ankles. The primary outcome was the change from baseline in the visual analog scale (VAS) pain (0-10 cm) at 6 months. Secondary outcomes included the Ankle Osteoarthritis Scale (AOS) score, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle score, single-leg stance test (SLS), rescue analgesics consumption and patient satisfaction. Thirty-nine participants (88.64%) completed the study. Significantly improvement in the VAS and AOS was noted at 1-, 3-, and 6-month follow-ups (p < .001). The mean VAS pain decreased significantly from 4.1 ± 1.7 at baseline to 2.2 ± 1.9, 1.7 ± 1.5, and 1.8 ± 1.6 at 1, 3, and 6 months (p < .001). The mean total AOS score reduced by 1.5, 2.2, and 2.1 from baseline respectively postinjection (p < .001). The mean AOFAS hindfoot-ankle score improved from 80.3 points at baseline to 87.2, 91.6, and 89.7 points at 1, 3, and 6 months (p < .001). SLS tests improved significantly (p < .001) at each follow-up. Acetaminophen consumption dropped significantly (p < .001) and no serious adverse events occurred. The study showed promise for a single intraarticular injection of PRP in the treatment of ankle OA.

The effect of ankle osteoarthritis and total ankle arthroplasty on center of pressure position.

Total ankle arthroplasty (TAA) is a common surgical approach for patients with end-stage ankle osteoarthritis (OA). However, very little is known about the path of the center of pressure (COP) of the foot, and thus important aspects of load transfer, muscle mechanical advantage, and balance, in patients before or after surgery. The objective of this study was to trace the pathway of the COP under the foot in patients with symptomatic ankle OA, comparing asymmetry between affected and unaffected limbs. From force plate data, proximodistal and mediolateral positions of the COP beneath the foot were calculated and compared for the affected and unaffected foot in patients with unilateral ankle OA (N = 93) before and after TAA. Gender and age at surgery had little or no effect in this study. Patients with ankle OA had minimal COP position asymmetry before surgery, and this asymmetry was reduced following surgery. Before surgery, patients had a slower walking speed and a shorter path of the COP which began relatively distal to the heel and ended relatively proximal to the hallux. TAA increased the proximodistal distance the COP traveled under both the unaffected and affected foot, a pattern that was maintained for over 2-yearpostsurgery. TAA allows patients with ankle OA to maintain a longer COP path than they had before surgery on both sides that is closer to that reported for unaffected individuals, extending effectively from the heel to the hallux, potentially improving pedal mechanics.

Efficacy of intraarticular botulinum toxin A and intraarticular hyaluronate plus rehabilitation exercise in patients with unilateral ankle osteoarthritis: a randomized controlled trial

BackgroundThere was an increasing requirement for novel treatments of osteoarthritis (OA). The aim was to compare the efficacy of intraarticular Botulinum toxin type A (BoNT-A) and intraarticular hyaluronate plus rehabilitation exercise in patients with ankle OA.MethodsThis was a prospective, randomized, assessor-blinded study with a 6-month follow-up period, conducted in the outpatient rehabilitation department at a university-affiliated tertiary care medical center. Seventy-five patients with symptomatic ankle OA (Kellgren-Lawrence grade 2) were randomized to receive either a single 100-unit BoNT-A injection into the target ankle (n = 38) or a single hyaluronate injection plus 12 sessions of rehabilitation exercise (30 minutes/day, 3 times/week for 4 weeks) (n = 37). The primary outcome measure was the Ankle Osteoarthritis Scale (AOS). Secondary outcome measures included American Orthopedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot Score, visual analog scale (VAS) for ankle pain, single leg stance test (SLS), Timed “Up-and-Go” test (TUG), consumption of rescue analgesics and global patient satisfaction.ResultsThere were no significant between-group differences in total AOS scores, pain subscale and disability subscale scores (adjusted mean difference AMD = -0.2, 95% CI = (-0.5, 0.2), p = 0.39; AMD = -0.1, 95% CI = (-0.5, 0.3), p = 0.57; AMD = -0.2, 95% CI = (-0.6, 0.2), p = 0.36). The 2 groups showed no significant differences in AOFAS, VAS, SLS, TUG scores and consumption of rescue analgesics at each follow-up visit, except that the hyaluronate group improved more in SLS than the BoNT-A group at 1-month follow-up. Patients’ satisfaction rate was high, with no serious adverse events. There was no difference in adverse events between the two groups (p = 1.00).ConclusionsTreatment with intraarticular BoNT-A or hyaluronate injection plus rehabilitation exercise was associated with improvements in pain, physical function and balance in patients with ankle OA. These effects were rapid at 2 weeks and might last for at least 6 months. There was no difference in effectiveness between the two interventions.Trial registrationThe trial was registered at clinical trials.gov (Registry number NCT01760577).

The HINTEGRA® Ankle Arthroplasty: Intermediate Term Results of 16 consecutive Ankles and a Review on the Current Literature

Purpose: Total ankle arthroplasty provides an alternative to arthrodesis for management of ankle osteoarthritis. The results of the third generation total ankle replacements have been promising. The purpose of the present study was to investigate the clinical and radiographical outcome and implant survival of 16 consecutive patients suffering from symptomatic ankle osteoarthritis treated with the HINTEGRA® (Newdeal SA, Lyon, France) prosthesis. Methods: The first 16 implanted HINTEGRA® total ankle replacements (between 2001 and 2006) by a fellowship-trained foot and ankle surgeon were assessed clinically and radiographically after a mean of 61,8 months (range, 7–116). Eight female and eight male patients were operated at a mean age of 55 years (range, 34–77). Diagnosis was post-traumatic osteoarthritis in 10 (62,5%), primary osteoarthritis in 3 (18,7%) and arthritis secondary to infection in 3 (18,7%) patients. Results: The mean AOFAS score at final follow-up was 77 (range, 49–91). Mean ankle ROM as determined clinically and fluoroscopically was 23,72 degrees (range, 12,0–47,5). Six patients required revisional surgery (37,5%). The mean follow up period until revisional surgery occured was 50,6 months (range, 24–116). In total, implant survival in all followed ankles was 66,7%. Discussion: Our study demonstrated that the functional results of the HINTEGRA® ankle were comparable to most high volume centres but the implant survival was lower. With regards to the steep learning curve of total ankle arthroplasty these results seem compatible.

Effect of anterior translation of the talus on outcomes of three-component total ankle arthroplasty

BackgroundAnkle osteoarthritis commonly involves sagittal malalignment with anterior translation of the talus relative to the tibia. Total ankle arthroplasty has become an increasingly popular treatment for patients with symptomatic ankle osteoarthritis. However, no comprehensive study has been conducted on the outcomes of total ankle arthroplasty for osteoarthritis with preoperative sagittal malalignment. The purpose of this study was to evaluate the effect of anterior translation of the talus on outcomes of three-component total ankle arthroplasty.MethodsOne hundred and four osteoarthritic ankles in 104 patients who underwent three-component total ankle arthroplasty were included in this study. The 104 ankles were divided into 2 groups: ankles with anteriorly translated talus (50 ankles), and ankles with non-translated talus (54 ankles). Clinical and radiographic outcomes were assessed in both groups. The mean follow-up duration was 42.8 ± 17.9 months (range, 24 to 95 months).ResultsForty-six (92%) of 50 ankles with anterior translation of the talus showed relocation of the talus within the mortise at 6 months, and 48 (96%) ankles were relocated at 12 months after total ankle arthroplasty. But, 2 (4%) ankles were not relocated until the final follow-up. The AOFAS scores, ankle range of motion, and radiographic outcomes showed no significant difference between the two groups at the final follow-up (p > 0.05 for each).ConclusionsIn majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty. The clinical and radiographic outcomes in the osteoarthritic ankles with anteriorly translated talus group were comparable with those in non-translated talus group.

The optimal injection technique for the osteoarthritic ankle: A randomized, cross-over trial

To optimize the injection technique for the osteoarthritic ankle in order to enhance the effect of intra-articular injections and minimize adverse events. Randomized cross-over trial. Comparing two injection techniques in patients with symptomatic ankle osteoarthritis. Patients received an injection with hyaluronic acid using either one of the techniques. Four weeks later the second injection was given using the other technique. Primary outcome was the failure rate of the injection. Seventy patients fulfilled the study. The failure rate for both injection techniques was 24%. Forty-one patients in the traction group and thirty-nine in the group without traction experienced treatment related local adverse events. Other secondary outcomes did not show any difference between injection techniques. There is no significant difference comparing the two injection methods regarding any of our formulated outcome measures. The use of contrast aided fluoroscopy for injecting the severe osteoarthritic ankle can be advised at all times.

The demand incidence of symptomatic ankle osteoarthritis presenting to foot & ankle surgeons in the United Kingdom

BackgroundAnkle arthritis is a cause of major disability; however reports in the literature on the incidence of ankle osteoarthritis are rare. ObjectivesTo explore the methodological challenges in obtaining an incidence of ankle osteoarthritis and to estimate the incidence of symptomatic osteoarthritis presenting to Foot & Ankle specialists in the UK. MethodsWe searched available national diagnosis databases and also sent out a questionnaire-based survey to all Consultant members of the British Orthopaedic Foot & Ankle Society (n=180). Results123 completed survey questionnaires were returned (68%) with each surgeon seeing on average 160 cases of symptomatic ankle arthritis and performing on average 20 definitive procedures for end-stage ankle osteoarthritis per year. There are no internationally agreed diagnostic or treatment codes specific for ankle osteoarthritis. ConclusionThere are an estimated 29,000 cases of symptomatic ankle osteoarthritis being referred to specialists in the UK, representing a demand incidence of 47.7 per 100,000. 3000 definitive operations to treat end stage ankle osteoarthritis take place in the UK annually. We recommend that specific codes pertaining to ankle arthritis and its treatment be included in any future revisions of the WHO International Classification of Diseases (ICD) and operative procedure coding systems.

Total Ankle Arthroplasty Outcome Comparison for Post-Traumatic and Primary Osteoarthritis

Mobile-bearing total ankle arthroplasty designs have achieved good clinical results for the treatment of ankle osteoarthritis. However, no direct comparison of the outcomes of total ankle arthroplasty has been made between post-traumatic and primary osteoarthritis. The purpose of the present study was to compare the clinical and radiographic outcomes of total ankle arthroplasty in patients with post-traumatic and primary osteoarthritis. The HINTEGRA total ankle arthroplasty was carried out in 65 patients (67 ankles) with symptomatic ankle osteoarthritis. Group A included 37 patients (37 ankles) with post-traumatic osteoarthritis, whereas Group B included 28 patients (30 ankles) with primary osteoarthritis. Patients were assessed clinically and radiographically at a mean followup of 38 months. No significant differences were found between the two study groups in terms of American Orthopaedic Foot and Ankle Society ankle-hindfoot scales, range of motion, or radiographic values at final followup (p > 0.05). The incidence of complications (38% in Group A, 27% in Group B) and additional procedures (54% in Group A, 27% in Group B) was significantly higher in Group A (p = 0.014 for complications, p = 0.013 for additional procedures). One ankle was revised in Group A for a deep infection. The clinical and radiographic outcomes of total ankle arthroplasty for post-traumatic and primary osteoarthritis were comparable, although the incidence of complications after total ankle arthroplasty was higher in the post-traumatic osteoarthritis group. More preceding or concomitant surgeries were required in order to make the post-traumatic cases suitable for total ankle arthroplasty.

Treatment of Osteoarthritis of the Ankle by Intra-articular Injections of Hyaluronic Acid

Treatment of osteoarthritis of the ankle is similar to that of any other large joint and includes conservative and surgical options. Surgical treatment in severe cases is fusion or joint replacement, whereas conservative treatment is limited and includes mainly ankle supports and physiotherapy. Hyaluronic acid was discovered by Meyer and Palmer in 1934 and has recently been widely used in the treatment of knee osteoarthritis. We evaluated the efficacy of an intra-articular preparation containing sodium hyaluronate in the treatment of osteoarthritis of the ankle. We studied 16 patients aged 31 to 79 years (mean age, 43 years) with symptomatic ankle osteoarthritis of 9 months' to 27 years' duration. The radiographic severity of the ankle osteoarthritis was graded II, III, or IV according to Kellgren and Lawrence. Arthritic ankles underwent intra-articular injections of 25 mg of sodium hyaluronate for 5 consecutive weeks. Follow-up visits were performed 4, 8, 11, 17, and 32 weeks after treatment and included clinical evaluation and objective scoring. Global assessment showed improvement in 13 of 15 patients who completed the study. There was improvement by 20% in range of motion and a significant reduction in pain assessed by visual analog scale and ankle-hindfoot scores, all statistically significant. Seven months after treatment, no decrease in efficacy was shown. Two patients did not show any significant improvement in global assessment after treatment. One patient was dropped from follow-up owing to concurrent back surgery. Symptomatic relief of signs and symptoms of osteoarthritis of the ankle was achieved by injection of an intra-articular preparation containing sodium hyaluronate. There were significant improvements, in objective and subjective parameters, that lasted for more than 7 months. Ankle intra-articular injection of sodium hyaluronate is a valid conservative treatment for ankle osteoarthritis.

Intra-articular sodium hyaluronate injections in the osteoarthritic ankle joint: Effects, safety and dose dependency

To determine the efficacy, safety and dose dependency of intra-articular Orthovisc(®) hyaluronic acid injections in the ankle. A prospective single blinded study in patients with symptomatic ankle-osteoarthritis. Patients were randomly allocated to 1, 2, 3 ml, or 3 weekly injections of 1 ml (3 × 1 ml). Primary outcome was 'pain during walking' at 15 weeks measured on a 100mm VAS. Twenty-six patients (ITT) participated. The 3 × 1 ml dose group showed statistically significant decreases at week 7 for 'pain during walking' and 'pain at rest' (p=0.046). At week 15 decreases were significant for 'pain at rest' (p=0.046). There was no significant decrease of VAS-scores in any of the single dose groups. Seven patients experienced temporary local swelling and increased pain in the injected ankle. Orthovisc(®) viscosupplementation in the ankle joint is effective and well tolerated. The 3 × 1 ml dose regimen shows the best results.

A prospective multi-centre, open study of the safety and efficacy of hylan G-F 20 (Synvisc®) in patients with symptomatic ankle (talo-crural) osteoarthritis

To evaluate the safety and efficacy of hylan G-F 20 in patients with ankle osteoarthritis. A prospective, open study in patients with symptomatic (>or=50 mm and <or=90 mm on a 100 mm VAS) ankle osteoarthritis. Patients received 1 ml x 2 ml intra-articular injection of hylan G-F 20, plus an optional, second injection if pain remained at baseline levels after 1, 2 or 3 months. The primary efficacy endpoint was the change from baseline in the pain VAS score at 3 months. Fifty-five patients received the first injection; 24 patients received a second. There were no serious or severe adverse events (AEs) related to the treatment. Seventeen patients experienced mild or moderate local, treatment-related AEs. The mean pain VAS score decreased from 68.0 mm (baseline) to 33.8 mm at 3 months (p<0.001), which was maintained to 6 months (34.2 mm, p<0.001). Hylan G-F 20 is well-tolerated and effective for up to 6 months in the treatment of symptomatic ankle osteoarthritis.

Unterschenkel-Muskelatrophie bei Arthrose des oberen Sprunggelenks und deren Rehabilitation nach Implantation einer Sprunggelenksprothese

The aim of this orthopaedic-biomechanical study was to evaluate lower leg muscle function in ankle osteoarthritis (OA) patients and muscle rehabilitation after the implantation of a total ankle replacement (TAR). Patients with a severe unilateral ankle OA were assessed with an orthopaedic and biomechanical examination before and one year after TAR surgery. Visual analogue pain score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, ankle range of motion for dorsi- and plantar flexion (ROM DF/PF), and calf circumference difference between affected and contralateral healthy leg were measured. Isometric maximal voluntary torque for ankle dorsiflexion and plantar flexion were measured simultaneously with surface electromyography (EMG; mean frequency and intensity) of the anterior tibial, medial gastrocnemius, soleus, and peroneus longus muscle. Data were compared to a group of age- and gender-matched normal subjects. The mean calf circumference difference between legs did not significantly decrease from preoperative to one year follow-up. The mean dorsiflexion torque and plantar flexion torque of the affected ankle increased significantly. The atrophic muscles were characterized by a reduction of the mean EMG intensity and mean EMG frequency. In the rehabilitation process, the mean EMG intensity recovered and was not significantly different for all muscles, however, not for EMG frequency, which remained low and unchanged. This study reports for the first time in the literature the clinical and biomechanical facts of lower leg muscle atrophy in ankle OA as well as the amount of the muscle rehabilitation after a total ankle replacement. Patients with a symptomatic ankle OA achieve better function with a total ankle replacement; however, one year after the operation neuromuscular and biomechanical deficits may still be present.