How To Treat An Arthritic Ankle In A Young Patient
Forefoot issues related to rheumatoid arthritis (RA) are well noted with fusion of the great toe being a standard procedure in association with relocation or resection of the lesser metatarsophalangeal joints, and fusion of the proximal interphalangeal joints. Surgeons have also been successful in treating the rearfoot with fusion procedures once the arthritis is not tolerable with bracing and medication.
As a patient grows older, it is easier to address the issues of RA in the ankle. In the thin and fairly sedentary patient, ankle replacement is a good option and allows for continued motion of the ankle. In these cases, the benefits are rapid recovery and the potential to combine an ankle replacement with rearfoot fusion in severe hindfoot arthritis.
When it comes to treating the active older rheumatoid patient or one who is heavyset, I still prefer to perform an ankle fusion. However, if a full hindfoot and ankle fusion is necessary, I may consider an ankle replacement in certain select cases.
These cases are not very difficult to evaluate and treat. However, the one difficult issue to deal with is moderate arthritis of the rearfoot and ankle in a young patient with rheumatoid arthritis, who is active and in chronic pain.
This condition is far more common than one might think. There have been improvements in medications for RA and they allow patients to stay active and control the pain in their joints. However, these medications do not always keep the joints from being destroyed.
What are the available treatment options for a young rheumatoid patient who is 30 to 40 years old, has an active lifestyle and moderate to severe debilitating hindfoot and ankle arthritis? This is a very difficult problem and poses few good options.
Counseling The Patient On The Benefits And Risks Of Treatment
When it comes to ankle replacements, one would usually reserve these for patients over the age of 55 and this is what the manufacturer of this device recommends. This is not to say one cannot replace an ankle on a younger patient but there are issues with revision of the ankle replacement prostheses so using them for a young patient is somewhat controversial.
A somewhat more difficult situation is performing a fusion in either the hindfoot or ankle of a young rheumatoid patient. In such cases, it is inevitable that the surrounding joints will undergo increased stress, leading to the potential need for a pantalar fusion, which can make it very difficult for patients to have comfortable ambulation.
When a young patient presents with moderate ankle and hindfoot arthritis, I give him or her a complete explanation of the treatment options. Instead of doing this during a normal office visit, I go over the options during a meeting that lasts an hour or so with the patient. I explain the short-term, mid-term and long-term progressive treatments to the patient. I explain the thinking behind each option as well as the benefits and risks. Finally, I allow the patient to decide the level of treatment at which he or she would like to begin.
Exploring The Initial Treatment Options
When treating this condition, I start with injection therapy and orthotics or bracing. The type of injection depends on the financial status of the patient. If a patient can afford materials such as Hylan G-F 20 (Synvisc, Genzyme), which helps to lubricate and calm the edema of the involved joint or joints, I think this is the best option as there is less risk than one would have with cortisone injection. Have the patient sign a consent form. Also provide a secondary paper that acknowledges the off-label use of the product and the fact that it is not officially approved by the FDA. Do this with care on select patients. One would perform the procedure over five to six weeks with weekly injections and repeat it every six months or so for best results.