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Diagnostic Dilemmas

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.    In regard to bracing, I prefer to use a flat-posted rearfoot orthotic with additional padding and a very deep heel cut. I may also employ a custom ankle and foot orthotic that is well padded and also flat-posted. If the ankle is not very arthritic, I will begin with a hinged device to prevent stiffening of the hindfoot and ankle. If there is early arthritis and I need to add some control, I will make a non-hinged device that has some flex at the ankle to allow slight motion. In the moderate to severe cases, I will make a stiff non-hinged device with rearfoot posting in order to prevent as much motion as possible.    Once one has exhausted the injection and bracing options, podiatrists may begin to consider arthroscopic options for possible synovectomy, spur resection and cartilage drilling or fenestration in order to allow fibrocartilage ingrowth. In these cases, I have begun to distract the joint in order to allow some relief on the articular surfaces and reduction of joint stress. I have found this option effective in cases of early to moderate arthritis as there is less localized degeneration and generally less loss of articular cartilage than one would see in cases of severe arthritis.    I prefer to use a circular frame and keep the joint distracted for two to four months. Furthermore, I continue the joint injections with either weekly lubrication injection for six weeks or two to three cortisone injections at monthly intervals.    This procedure is excellent for any hindfoot joint although it is more common to perform this at the ankle level. It is also effective for the talonavicular, calcaneocuboid or subtalar joints although ring fixation techniques are more difficult in distraction of the tarsal joints. In most cases, there is arthritis of more than one joint and distraction of multiple joints is required.

Should You Opt For Fusion Or Ankle Replacement?

   The greatest dilemma in my hands is what to do next. When there is severe arthritis and pain in a young patient, and you have already provided an exhaustive amount of joint sparing care, should you proceed to perform fusion or ankle replacement surgery?    It depends on various factors. The primary issue is not how long the ankle replacement will last. Indeed, the key considerations are how heavy and active the patient is and what other joints are arthritic.    If a patient has hindfoot and ankle arthritis, is not heavy and not very active in his or her daily activity, I would suggest a rearfoot fusion and ankle replacement. The only company with an ankle replacement device on the market at this time has begun to produce ankle products that allow for revision if necessary. This allows the option of a possible secondary replacement if one needs to perform this procedure in the future. My thinking in such a case is to preserve some semblance of normal walking ability in order to prevent the leg from being a stiff plank. I fully discuss the hazards of failed replacement surgery with the patient.    If a patient is heavy or very active, I still prefer fusion. I stay away from being a hero in such cases as the replacement procedures cannot endure heavy stress or activity for an extended number of years. If the rearfoot is severely arthritic but the ankle is tolerable, I will perform a hindfoot fusion and continue with bracing. If the ankle is arthritic and the rearfoot is stable, I will fuse the ankle and use an orthotic to control the rearfoot.

In Conclusion

   I believe we owe it to our patients to try to provide state-of-the-art care by using the latest time-tested techniques and not merely resort to what is comfortable. Young patients with RA have a great deal of life in them even though their joints may not show it. It is essential to try to preserve motion for as long as possible and not think of the fusion as the only option. Dr. Baravarian (shown here) is Co-Director of the Foot and Ankle Institute of Santa Monica. He is an Associate Professor at UCLA Medical Center and is the Chief of Podiatric Surgery at Santa Monica/UCLA Medical Center. Dr. Baravarian may be reached via e-mail at

Diagnostic Dilemmas
By Babak Baravarian, DPM
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