A New Solution For The Arthritic Ankle

Start Page: 36
Here is a preoperative X-ray that reveals painful arthritis of the ankle in a 57-year-old male patient.
Here one can see a small wire, circular ring external fixator with distraction applied between the footplate and distal ring.
Here is an intraoperative C-Arm image. After performing distraction, the surgeon injects hyaluronan into the joint.
While this postoperative X-ray resembles the earlier preoperative view, the patient is now pain-free and has returned to regular activity one year after undergoing the procedure.
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Author(s): 
By George R. Vito, DPM, Floyd L. Pacheco, Jr., DPM, Charles Southerland, DPM, Edgardo Rodriguez, DPM, and Shannon Thompson, DPM

   Arthritis of the ankle can be a painful and disabling condition. Clinicians can effectively treat mild or moderate arthritis with conservative therapies and joint preserving surgical procedures.1-5 Advanced cases that do not respond to more conservative measures require aggressive surgery. Traditional procedures for severe ankle arthritis pain include ankle arthrodesis and arthroplasty with implant. These are lengthy, usually invasive procedures that can successfully treat severe ankle arthritis but they also have some serious surgical risks.

   Researchers have reported rates of deep infection and non-union with ankle arthrodesis that range between 5 and 11 percent.6,7 Many patients and surgeons are reluctant to opt for this procedure since eliminating movement at the ankle can produce an aberrant gait and limit the patient’s ability to return to normal activity.

   Ankle joint arthroplasty with total joint replacement has its own drawbacks. Most importantly, ankle implants are not yet a realistic option for many patients. There are specific surgical indications for this procedure and not all patients with severe ankle arthritis are candidates for an ankle implant.8 Additionally, there are few surgeons in the United States who have ankle implant training and who regularly perform the surgery. Although ankle replacement may sound like a desirable option, the literature regarding ankle implants suggests that improvements in implant design are needed.9

   Accordingly, we sought to evaluate two minimally invasive techniques, ankle arthrodiastasis and joint fluid replacement therapy. These procedures are not joint destructive and provide the podiatric surgeon with an option for patients who are in serious pain but are also reluctant to undergo a fusion procedure. Surgeons have used these procedures separately to treat arthritis of many joints in the lower extremity. While these techniques are relatively new, the early research has been promising.10-13

What The Literature Reveals About Arthrodiastasis And Joint Fluid Replacement

   The term “arthrodiastasis” comes from the Greek word “arthros” for joint, and “diastis,” which means a separation or gap. Although the concept was discussed as early as 1978, the use of joint distraction as a means of treating cartilaginous defects became more common in Europe during the late ‘80s and early ‘90s. The term arthrodiastasis was coined around 1993 by Canadell, Gonzalez, Barrios and Amillo. They used the term to describe a procedure, which involved the stretching of hip joints in adolescent patients with Legg-Calves-Perthes disease to relieve intraarticular pressure.10

   In 1995, van Valburg, et. al., studied arthrodiastasis on a series of 11 patients with post-traumatic arthritis of the ankle. They applied distraction with an Ilizarov frame for three months as a means of preventing or delaying the need for arthrodesis. Patients reported pain relief for an average of two years after the removal of the frame.11 Van Valburg, et. al., reported a follow up study in 1999. They found that using an Ilizarov frame to distract the arthritic ankle allowed patients to ambulate during treatment and produced “significant improvement” in two-thirds of patients.14

   Many other authors have subsequently reported on the successful use of arthrodiastasis to restore function of arthritic joints.15-19 Recently, Ploegmakers, et. al., published a seven-year follow-up study that evaluated ankle joint distraction via the Ilizarov method for the treatment of osteoarthritis. They found significant clinical benefit in 73 percent of patients and failures in 27 percent of the patients. While they concluded that arthrodiastasis can be effective for severe ankle arthritis, the authors emphasized the need for further research in order to predict which patients will do well with this approach.20

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