Next week I am having arthroscopic surgery to remove a tiny bone caught between the lower leg bone and the heel bone. I expect to have a full and easy recovery. But I would like to know more about other patients’ experiences. Does anyone “fail” with this kind of operation? What happens then?

It sounds like you may have an os trigonum. This bone is located on the talus, which is part of the ankle. When the foot and ankle are plantarflexed (toes pointed downward), the os trigonum (and soft tissues attached to it) get pinched between the tibia (lower leg bone) and the calcaneus (heel bone).

Ankle pain can develop that is so severe, the athlete must stop all activities and motions that aggravate the problem. Running and jumping are out of the question until the inflammation has subsided. Physical therapy may be needed to address postural and alignment issues that could be contributing.

If conservative (nonoperative) care is not successful in treating the problem, then surgery to remove the bone may be needed. Minimally invasive procedures are available now to take care of this problem. The surgeon uses a small, thin scope (either an arthroscope or an endoscope) with a tiny TV camera on the end to enter the joint and see what’s going on.

The surgeon then excises (takes out or removes) the os trigonum. Most patients improve significantly and are pleased with the results. The technique is considered “safe and effective.”

The choice between surgical instruments and techniques used (arthroscope versus endoscope) may depend on the level of surgeon experience and expertise. Large os trigonums are more difficult to remove using the arthroscopic approach. There is very little room inside the subtalar joint where the scope enters. It’s also difficult to see inside this area. Using the endoscopic approach from the back side of the ankle requires cutting the flexor hallucis longus tendon but gives the surgeon more room to work in and greater visibility.

Open surgery may be needed if arthroscopic and/or endoscopic techniques are not successful in eliminating the problem. But this happens very infrequently when it is a simple os trigonum exicision. Studies show that more serious complications occur when complex surgery is required (e.g., os trigonum excision AND ankle fusion).

I am a dance instructor in a large city. I’ve always known I have an extra bone (os trig?) in my ankle that should come out but I haven’t wanted to be off work for any length of time. Now it looks like I’ll be forced to have it done because I can hardly walk on it much less dance. I see that most of these procedures leave only a tiny scar. The surgeon I spoke with called it “minimally invasive.” That doesn’t matter to me now so much as the recovery time. Is there any kind of surgery that can get me back on me feet faster (fastest)?

Many people are born with that extra little bone in the ankle called the os trigonum or os trig for short. Studies show that up to 50 per cent of all people have this anatomic anomaly.

Without an X-ray or other imaging study, they might never know about it. It doesn’t cause any problems until and unless the person is involved in activities that require full and repeated foot and ankle plantarflexion (toe pointed downward). Ballet dancers and soccer players fall into this category most often.

When the foot and ankle is plantarflexed, the os trigonum (and soft tissues attached to it) get pinched between the tibia (lower leg bone) and the calcaneus (heel bone). Ankle pain can develop that is so severe, the dancer must stop all activities and motions that aggravate the problem. Running, jumping, and rising up on toes are out of the question until the inflammation has subsided. Physical therapy may be needed to address postural and alignment issues that could be contributing.

If conservative (nonoperative) care is not successful in treating the problem, then surgery to remove the bone may be needed. In the past, surgeons used an open incision technique to cut the bone out but problems developed. Permanent nerve damage occurred in some patients and the large, visible scar was a problem for professional dancers.

As smaller surgical instruments became available and more precise surgical techniques were developed, it became possible for this procedure to be done using an arthroscope. That is the minimally invasive method your surgeon mentioned.

In 2000, a new technique called posterior endoscopy was introduced. Surgeons can choose between using the arthroscopic or endoscopic technique to excise (take out or remove) the os trigonum.

In a recent study, surgeons from Korea reported their results comparing these two surgical techniques. It is the first study published making direct comparisons. Their goal was to “clarify the efficacy and safety of each surgical procedure.” Patients between the ages of 17 and 55 who had this surgery (os trigonum excision) were followed for three years. Results were measured using a variety of outcomes including pain, motion, function, length of time in surgery, time to return to sports participation, and patient satisfaction.

Patients in both groups improved significantly and were pleased with the results. Both techniques were considered “safe and effective.” Certainly, the length of time for the surgery and recovery were much shorter when compared with the open incision technique. In fact, these minimally invasive methods reduced full return to sports (or dance) from five months down to three months. Some patients are able to participate fully in a month’s time. And the dancers in the study were able to dance up on pointe with full motion and without pain.

Next week I am having arthroscopic surgery to remove a tiny bone caught between the lower leg bone and the heel bone. I expect to have a full and easy recovery. But I would like to know more about other patients’ experiences. Does anyone “fail” with this kind of operation? What happens then?

It sounds like you may have an os trigonum. This bone is located on the talus, which is part of the ankle. When the foot and ankle are plantarflexed (toes pointed downward), the os trigonum (and soft tissues attached to it) get pinched between the tibia (lower leg bone) and the calcaneus (heel bone).

Ankle pain can develop that is so severe, the athlete must stop all activities and motions that aggravate the problem. Running and jumping are out of the question until the inflammation has subsided. Physical therapy may be needed to address postural and alignment issues that could be contributing.

If conservative (nonoperative) care is not successful in treating the problem, then surgery to remove the bone may be needed. Minimally invasive procedures are available now to take care of this problem. The surgeon uses a small, thin scope (either an arthroscope or an endoscope) with a tiny TV camera on the end to enter the joint and see what’s going on.

The surgeon then excises (takes out or removes) the os trigonum. Most patients improve significantly and are pleased with the results. The technique is considered “safe and effective.”

The choice between surgical instruments and techniques used (arthroscope versus endoscope) may depend on the level of surgeon experience and expertise. Large os trigonums are more difficult to remove using the arthroscopic approach. There is very little room inside the subtalar joint where the scope enters. It’s also difficult to see inside this area. Using the endoscopic approach from the back side of the ankle requires cutting the flexor hallucis longus tendon but gives the surgeon more room to work in and greater visibility.

Open surgery may be needed if arthroscopic and/or endoscopic techniques are not successful in eliminating the problem. But this happens very infrequently when it is a simple os trigonum exicision. Studies show that more serious complications occur when complex surgery is required (e.g., os trigonum excision AND ankle fusion).

I am a dance instructor in a large city. I’ve always known I have an extra bone (os trig?) in my ankle that should come out but I haven’t wanted to be off work for any length of time. Now it looks like I’ll be forced to have it done because I can hardly walk on it much less dance. I see that most of these procedures leave only a tiny scar. The surgeon I spoke with called it “minimally invasive.” That doesn’t matter to me now so much as the recovery time. Is there any kind of surgery that can get me back on me feet faster (fastest)?

Many people are born with that extra little bone in the ankle called the os trigonum or os trig for short. Studies show that up to 50 per cent of all people have this anatomic anomaly.

Without an X-ray or other imaging study, they might never know about it. It doesn’t cause any problems until and unless the person is involved in activities that require full and repeated foot and ankle plantarflexion (toe pointed downward). Ballet dancers and soccer players fall into this category most often.

When the foot and ankle is plantarflexed, the os trigonum (and soft tissues attached to it) get pinched between the tibia (lower leg bone) and the calcaneus (heel bone). Ankle pain can develop that is so severe, the dancer must stop all activities and motions that aggravate the problem. Running, jumping, and rising up on toes are out of the question until the inflammation has subsided. Physical therapy may be needed to address postural and alignment issues that could be contributing.

If conservative (nonoperative) care is not successful in treating the problem, then surgery to remove the bone may be needed. In the past, surgeons used an open incision technique to cut the bone out but problems developed. Permanent nerve damage occurred in some patients and the large, visible scar was a problem for professional dancers.

As smaller surgical instruments became available and more precise surgical techniques were developed, it became possible for this procedure to be done using an arthroscope. That is the minimally invasive method your surgeon mentioned.

In 2000, a new technique called posterior endoscopy was introduced. Surgeons can choose between using the arthroscopic or endoscopic technique to excise (take out or remove) the os trigonum.

In a recent study, surgeons from Korea reported their results comparing these two surgical techniques. It is the first study published making direct comparisons. Their goal was to “clarify the efficacy and safety of each surgical procedure.” Patients between the ages of 17 and 55 who had this surgery (os trigonum excision) were followed for three years. Results were measured using a variety of outcomes including pain, motion, function, length of time in surgery, time to return to sports participation, and patient satisfaction.

Patients in both groups improved significantly and were pleased with the results. Both techniques were considered “safe and effective.” Certainly, the length of time for the surgery and recovery were much shorter when compared with the open incision technique. In fact, these minimally invasive methods reduced full return to sports (or dance) from five months down to three months. Some patients are able to participate fully in a month’s time. And the dancers in the study were able to dance up on pointe with full motion and without pain.

I can’t believe this but I helped a friend push his car off the road and got a ruptured Achilles tendon for my efforts. Didn’t know how bad it was until it was too late to repair. Now I’m facing major surgical reconstruction. What are my chances or a full recovery?

Adults of all ages can experience a rupture of the Achilles tendon. A simple event like running to catch a bus, stumbling on the floor, or playing with children can lead to this type of injury in the nonathletic adult. And yes, even helping a friend push a car can be an activity at the time of rupture.

It is estimated that one-fourth of all acute Achilles tendon ruptures are missed resulting in a delayed diagnosis. Eventually, the acute problem becomes a chronic one that can no longer be repaired (by sewing the two ends of the tendon back together). Instead, tendon reconstruction is required. Evidently, this is where you find yourself today. Here’s a little information that may help you.

The torn end of a tendon is referred to as a “stump.” In chronic ruptures, the ruptured end of the tendon pulls away or “retracts” from the bone. There can be a large gap between the end of the torn tendon and the place where it is supposed to attach to the bone. In chronic cases, the ruptured tendon stump is often thin and atrophied. It can no longer be pulled back up and reattached. That’s when reconstruction surgery becomes the necessary treatment approach.

But which surgical technique (there are several) works the best remains unknown. And recovery is often linked with severity of the problem, type of surgical management, and occurrence of complications after surgery. In a recent study, surgeons at a single-center reviewed the results of their 28 patients after using a tendon graft from the hamstring muscle to reconstruct the Achilles tendon. The patients ranged in age from 28 years old up to 66 years old. Two-thirds of the group were men and the remaining one-third were women.

Patients in the case series were followed for two to three years. The mid-term results were reported based on improvement of overall function and rate of complications. Calf circumference and strength were also measured and compared from before surgery to after surgery. Outcomes of surgical management are summarized in a table. Twenty of the 28 patients had no pain after surgery. The remaining eight people had mild to moderate pain; no one reported severe pain.

Daily activities were resumed by all but two patients. Some patients reported limited recreational activity. Only two people were bothered by shoes (usually the more fashionable, less supportive type of footwear). And in the end, 22 of the 28 patients were satisfied with the results. No one was dissatisfied; a few were happy with the results but had a few reservations.

In terms of post-operative problems, there were no infections, nerve injuries, reruptures, or blood clots to complicate matters. There was significant overall improvement of symptoms and function. But the authors also reported that calf circumference of the affected side did not fully return and ankle plantarflexion strength (pointing toe downward or rising up on toes) did not recover fully either. It should be noted that the loss of full strength did not affect patients’ ability to walk normally, rise up on toes, or return to work and recreational activities.

The best approach to the surgical management of chronic Achilles tendon ruptures remains unknown. Using hamstring tendon grafts results in good clinical outcomes. The hamstring tendon is long enough to bridge the wide Achilles tendon gap. It is easy to harvest with quick recovery for the patient. The knee does not suffer significant loss of function in terms of strength and power. And the semitendinosus can grow back in time. The entire procedure can be done with minimally invasive techniques and few (if any) complications.

Once you meet with your surgeon and find out more about the type of reconstructive surgery that is planned, you may have more questions. The information here about hamstring tendon graft will give you a starting point for discussion.

Have you ever heard of using the hamstring muscle to repair the Achilles tendon? This is the type of surgery my surgeon wants to do on me. But I can’t see injuring another area of the body (hamstring muscle) to fix the first problem (Achilles tendon rupture). What do you think?

There are many different ways to approach the problem of a chronic Achilles tendon rupture. Surgery is usually necessary when there is a large gap between the tendon “stump” (end of tendon that ruptured and pulled away) and the bone where the tendon is supposed to attach.

After an acute injury, repair of the torn tendon may be possible. But in the case of older injuries (referred to as chronic ruptures), the ruptured tendon stump becomes thin and atrophied. It can no longer be pulled back up and reattached. That’s when reconstruction surgery becomes the necessary treatment approach. But which surgical technique (there are several) works the best remains unknown.

The results after using a hamstring tendon graft in a series of 28 patients was recently reported. In this study, surgeons at a single-center reviewed the results of their 28 patients. The patients ranged in age from 28 years old up to 66 years old. Two-thirds of the group were men and the remaining one-third were women.

Each patient was treated for chronic closed rupture of the Achilles tendon. The surgeons chose to use a tendon graft from the hamstring muscle (the semitendinosus portion of the hamstrings). The hamstring tendon is long enough to bridge the wide Achilles tendon gap. It is easy to harvest with quick recovery for the patient. The knee does not suffer significant loss of function in terms of strength and power. And the semitendinosus can grow back in time. The entire procedure can be done with minimally invasive techniques and few (if any) complications.

Patients in the case series were followed for two to three years. The mid-term results were reported based on improvement of overall function and rate of complications. Calf circumference and strength were also measured and compared from before surgery to after surgery. Outcomes of surgical management are summarized in a table. Twenty of the 28 patients had no pain after surgery. The remaining eight people had mild to moderate pain; no one reported severe pain.

Daily activities were resumed by all but two patients. Some patients reported limited recreational activity. Only two people were bothered by shoes (usually the more fashionable, less supportive type of footwear). And in the end, 22 of the 28 patients were satisfied with the results. No one was dissatisfied; a few were happy with the results but had a few reservations.

In terms of post-operative problems, there were no infections, nerve injuries, reruptures, or blood clots to complicate matters. There was significant overall improvement of symptoms and function. So although the best approach to the surgical management of chronic Achilles tendon ruptures remains unknown, this study added some perspective on the subject by showing that using hamstring tendon grafts results in good clinical outcomes.

How safe is the use of hyaluronic acid for ankle arthritis? Is it better to take the supplements in pill form or to have the injections directly into the joint?

Ankle osteoarthritis (OA) is not as common as hip or knee OA. But it affects enough people (especially young adults who injured their ankles during their teen years) that interest in treatment like hyaluronic acid (HA) has increased over time. Some of this interest may be because HA has been used successfully with hip and knee problems.

Hyaluronic acid is a normal part of the matrix that makes up cartilage. It has two distinct properties that make it so important for smooth joint motion. It is both viscous (slippery) and elastic.

The viscosity allows the tissue to release and spread out energy. The elasticity allows for temporary energy storage. Together, these two properties protect the joint, help provide joint gliding action (especially during slow movement), and act as a shock absorber during faster movements.

Hyaluronic acid (HA) injected into a joint has some additional benefits. The HA replaces unhealthy synovial fluid, reduces inflammation of the synovium (lubricating fluid inside the joint), and therefore has an analgesic (pain relieving) effect. It also has a direct effect on the pressure inside the joint to separate the joint capsule where it is stuck together. Hyaluronic acid may be protective of the joint cartilage and prevent the formation of adhesions that keep the capsule from the smooth gliding action needed for normal joint motion.

Studies comparing oral supplementation with injection therapy using hyaluronic acid have not been done. But a recent systematic review of studies from 1995 to 2012 on the use of the injected form offered the following observations and recommendations:

  • Significant pain reduction is possible using intra-articular hyaluronic acid injections for the treatment of ankle osteoarthritis.
  • There may be some minor, temporary adverse effects (e.g., increased ankle swelling, local itching at the injection site, lymph node enlargement in the groin area); 15 per cent of the patients in the studies included reported these kinds of after effects.
  • Increased pain relief was noted with more injections but not with more volume per dose. The ankle joint is fairly small and cannot accommodate large injection volumes. Too much fluid pushed into the joint can cause swelling and more pain instead of less.
  • Further studies are needed to identify appropriate and optimal dosing of injections.
  • The injection itself accounted for 87 per cent of the improvement in symptoms; this suggests that it isn’t the hyaluronic acid as much as it is the placebo effect of the injection procedure on pain. This phenomenon bears further study as well.

    A simple summary of this systematic review would say: hyaluronic acid injections for the treatment of painful ankle osteoarthritis may be most effective when given in the right dosage (volume and number of injections). Optimal values for dosage remain undetermined except to say that lower volume and higher number of injections seem to have the best results so far.

  • I had a very bad ankle injury when I was a teenager and now in my early 30s, I’m starting to have some significant pain and loss of motion in that ankle. Could this be early arthritis? (I hope not…)! What should I expect now?

    Ankle osteoarthritis (OA) is not as common as hip or knee OA but it still occurs. And the people affected most often are indeed individuals who had a previous injury or trauma of some sort. Most are younger like yourself who were not expecting such a decline in function so early in life.

    The natural history (what happens over time) of ankle osteoarthritis following an earler trauma is one of accelerated functional decline. This means that the older the person becomes, the faster and greater the loss of motion and function in that joint. Teens who had ankle injuries suddenly discover in their mid-30s that they have reached a stage of severe ankle osteoarthritis (OA) referred to as end-stage OA.

    Conservative care with medications, physical therapy, and injection therapy tends to help more earlier on. The closer the patient comes to end-stage OA, the more likely that nonoperative care will fail to help. It is at that point that other approaches may be considered such as ankle fusion or ankle replacement. That’s why researchers are continuing to search for more effective ways to treat ankle osteoarthritis.

    For example, there is evidence to support the use of hyaluronic acid injections into the ankle joint to reduce the painful symptoms of osteoarthritis (OA). Hyaluronic acid is a normal part of the matrix that makes up cartilage. It has two distinct properties that make it so important for smooth joint motion. It is both viscous (slippery) and elastic.

    The viscosity allows the tissue to release and spread out energy. The elasticity allows for temporary energy storage. Together, these two properties protect the joint, help provide joint gliding action (especially during slow movement), and act as a shock absorber during faster movements.

    Hyaluronic acid (HA) injected into a joint has some additional benefits. The HA replaces unhealthy synovial fluid, reduces inflammation of the synovium (lubricating fluid inside the joint), and therefore has an analgesic (pain relieving) effect. It also has a direct effect on the pressure inside the joint to separate the joint capsule where it is stuck together. Hyaluronic acid may be protective of the joint cartilage and prevent the formation of adhesions that keep the capsule from the smooth gliding action needed for normal joint motion.

    Optimal values for dosage of HA remain undetermined. From studies done so far, it appears that lower volume and higher number of injections seem to have the best results so far. With the new onset of painful symptoms, it may be a good time to see your orthopedic surgeon and determine the best treatment for you. A discussion of all the possibilities may include the use of hyaluronic (and other) conservative treatments.

    I’m doing some looking on-line about stress fractures and how they should be treated. My situation is a little bit more complicated than a simple stress fracture because I have an ankle joint replacement and the fracture is in the bone around the implant. What can I expect when I see the orthopedic surgeon about this?

    It doesn’t happen very often but as you have discovered, an ankle fracture after a total ankle replacement (TAR) is possible. Treatment depends on multiple factors such as your age, your activity level, the location of the fracture, the stability of the implant, and the presence of damage to other areas around the joint.

    Thanks to a recent study from Germany, surgeons now have a classification system that will assist them in making decisions about what to do after such a fracture occurs. This classification model is centered around three key factors: 1) cause of the fracture, 2) location of the fracture, and 3) stability of the implant (also known as the prosthesis).

    Using their patient base of 503 people, they divided the classification of periprosthetic ankle fractures based on cause into three categories: Type 1 – intraoperative fracture, Type 2 – postoperative traumatic fracture, and Type 3 – postoperative stress fracture. It sounds like you may have a Type 3 fracture.

    The classification model divides fracture location into four groups (A, B, C, and D) based on whether the fracture occurred in the medial malleolus, lateral malleolus, tibia, or talus. You didn’t mention the exact location of your fracture but this is something your surgeon will take into consideration when planning follow-up care.

    And the last classification variable (implant stability) has two possibilities: stable or unstable. A stable implant is not loose and the fracture does not affect the implant. An unstable implant has signs of loosening with loss of bone around the implant. Each of these three classification parameters (location, type, implant stability) helps determine and guide treatment.

    For example, a nondisplaced stress fracture (the bones have not separated at the fracture site) with no sign of implant loosening can be managed nonoperatively (without surgery). If this is the case for you, your lower leg will likely be placed in some type of immobilizer (cast or splint). You may be told to limit how much weight to put on the foot until healing occurs.

    If there is fracture displacement, implant shifting or loosening, or malpositioning of the implant, then it is more likely that corrective surgery will be recommended. And each one of these problems calls for a different surgical approach ranging from bone graft to joint fusion. Once your surgeon evaluates you, then a more definite plan of care will be developed. Hopefully, these comments will help prepare you for the meeting with your surgeon and discussion of your specific needs.

    My cousin went all the way to Switzerland to have her ankle replacement done. She complains all the time about the pain still continuing and having limited motion on that side. Could she have gotten a better result having the surgery here in the USA?

    In Switzerland, orthopedic surgeons have been working for years to develop and perfect a total ankle replacement referred to as the Scandinavian Total Ankle Replacement (STAR). This is a fairly new system and very favorable early to mid-term results have been published.

    But according to a recent report from a group of Scandinavian surgeons, the long-term results are not as positive. It appears that over time, there are more and more implants that develop problems. In their experience, the need for a second (revision) surgery increased after 10 years and continued to increase as time went by.

    The main reason for implant failure was loosening. Degenerative changes where the implant and bone connected (called the prosthesis-implant interface) was observed. The cause of this degenerative process may be the coating used on some of the component parts of the implant. A single layer of hydroxyapatite was used. Hydroxyapatite can be found in teeth and bones and is commonly used as a coating to promote bone ingrowth into prosthetic implants. It seems the body tends to resorb the coating so that over time, it weakens and then comes off the implant. Then the implant loosens and pulls away from the bone.

    Other problems observed with the STAR system included the formation of bone within the surrounding soft tissues (a condition known as heterotopic ossification), bone cysts, residual pain, and loss of motion.

    Three-fourths of the patients in this later follow-up complained of ongoing pain and ankle motion was limited to about 24 degrees (less than one-third of normal). Surgeons say that improved ankle motion isn’t the main goal of the surgery and patients shouldn’t expect full or normal motion. Instead, pain relief and saving the ankle joint are the main goals. Without the ankle replacement, the joint would have to be fused resulting in complete loss of motion.

    But despite low functional outcomes, patient satisfaction remains high. The same level of patient satisfaction has been reported in other studies where function was progressively worse over time.

    Anyone who has any type of joint replacement (including ankle) and continues to experience residual pain should return to the surgeon for a follow-up evaluation. There may be a simple solution to your cousin’s pain that could be addressed. More complex problems may require a second surgery but that cannot be determined without further assessment.

    I am thinking about having an ankle replacement. What do you think of the Scandinavian version (called the STAR prosthesis)?

    In Switzerland, orthopedic surgeons have been working for years to develop and perfect a total ankle replacement. In a recent article, long-term results of the Scandinavian Total Ankle Replacement (STAR) were reported, which may help answer your question. It was the second report from a group of patients who received the implant 10 to 15 years ago.

    The first reported results for these 72 patients came after the initial two to four years. At that time, the short-term survivorship of the implant was very high. But over time, there were more and more implants that developed problems. The need for a second (revision) surgery increased after 10 years and continued to increase as time went by.

    The main reason for implant failure was loosening. Degenerative changes where the implant and bone connected (called the prosthesis-implant interface) was observed. The cause of this degenerative process may be the coating used on some of the component parts of the implant. A single layer of hydroxyapatite was used. Hydroxyapatite can be found in teeth and bones and is commonly used as a coating to promote bone ingrowth into prosthetic implants. It seems the body tends to resorb the coating so that over time, it weakens and then comes off the implant.

    Other problems observed in these patients included the formation of bone within the surrounding soft tissues (a condition known as heterotopic ossification), bone cysts, residual pain, and loss of motion.

    Three-fourths of the patients in this later follow-up complained of ongoing pain and ankle motion was limited to about 24 degrees (less than one-third of normal). But despite these low functional outcomes, patient satisfaction remained high (reported as “satisfied” or “very satisfied”). The authors did not speculate as to why this may occur. They noted that the same level of patient satisfaction has been reported in other studies where function was progressively worse over time.

    Most of the patients needed the ankle replacement because of severe end-stage osteoarthritis from a previous traumatic injury. A few patients had primary osteoarthritis, rheumatoid arthritis, or in one case, hemophilia (bleeding disorder). The diagnosis did not seem to be linked with implant failure. Instead, younger age at the time of the surgery was the biggest risk factor. This is not surprising since younger people tend to be more active and survive longer with the implant in place.

    One other risk factor for implant failure identified in other studies is malalignment. Implants that are not anatomically correct can cause increased contact pressures. The result is a wearing away of the polyethylene (plastic) insert and eventual fracture of the insert. There were no cases of this type of problem in the patients in this study.

    The authors concluded that the long-term results of the Scandinavian Total Ankle Replacement (STAR) are not nearly as good as the short-term results. They suggest the single-coating of hydroxyapatite may be the cause and should be investigated further. For those patients who did not need revision surgery (i.e., they kept the original implant), results were reported as “generally good.”

    I suspect my sister may be suffering an ankle fracture that actually occurred during surgery (she had an ankle replacement) but nobody’s talking. Should I say something before she goes back to this same surgeon? Maybe she should be seeing someone else for her follow-up care.

    It doesn’t happen very often but ankle fracture during (or after) a total ankle replacement (TAR) is possible. Every effort is being made to reduce the number of these cases. For example, in a recent study from Germany, surgeons reported that their own work improved over time. There were a total of 503 patients who received one of two different types of ankle replacements.

    In the first 100 cases, the rate of intraoperative fractures (those that occurred during the surgery) went from three out of every four patients down to one of every three. By the end of the study, only two per cent of the last 100 patients experienced an intraoperative periprosthetic (around the implant) fracture. These may have occurred as a result of improper implant size or position, mechanical overload of the implant, or weakening of the bone from the surgery.

    What made the difference for the two surgeons who performed these 503 ankle replacement procedures? There were several possible factors contributing to the improved results. The surgeons did gain experience over time. Operative techniques improved as did surgical instruments. And even the implant designs improved over time. Some patients still developed post-operative fractures but these were from stress (overload) and trauma (injury).

    As results following total ankle replacement continue to improve, more and more surgeons will choose ankle replacement over ankle fusion (called arthrodesis). Preserving motion and function (especially in younger, active patients) is the number one reason for this choice. And along with the increasing number of candidates for total ankle replacement may come an increasing number of periprosthetic ankle fractures (both intraoperative and postoperative).

    Your sister can always ask the surgeon for more details about her own fracture (cause, location, type) and the proposed treatment. There is nothing wrong in getting a second opinion either. The decision whether to stay with the original surgeon for follow-up may depend on the information she receives at her follow-up appointmant and her confidence in the current surgeon.

    I am a dedicated long-distance runner with a slight problem. I sprained my ankle in the last marathon really badly and ended up with an OLT lesion. If I have microfracture treatment and it works, will it hold up so that I can run long distances again?

    Many people who sprain (or even break) their ankle end up with an additional injury known as an osteochondral lesion of the talus (OLT). Osteochondral refers to the layer of cartilage over the bone. The talus is one of the ankle bones between the heel and the lower leg bone. This type of defect in the bone can result in deep ankle pain, a clicking or locking sensation of the joint, and loss of motion and function. It certainly can put a damper on your ability to run long distances.

    Treatment is often with the technique you mentioned known as microfracture. Tiny holes are drilled around the lesion through the bone to the bone marrow. Breaching the bone in this way releases stem cells from inside the bone to improve blood circulation to the area. The stem cells form fibrocartilage and fill in the hole. Defects (holes) that measure less than one-half inch (15 millimeters) can be treated this way.

    The hope for this treatment is that the new fibrous cartilage will act as a shock absorber and protect the bone underneath. But no one really knows if the fibrocartilage that forms can hold up under constant load through the ankle — especially in athletes or active adults.

    In fact, there have been a few studies that suggest the fibrocartilage starts to break down over time. Patients who once experienced pain relief and improved function suddenly find themselves back where they started from. A recent study done to help compile long-term data and see if studies on this topic are consistent enough to pool the information together. This could give you a better idea of the long-term results for many different people. Such a review is referred to as a systematic review and helps give a better picture of what happens down the road.

    The authors searched all the studies on osteochondral talus lesions (OTL) where microfracture was used as the main treatment. Over a period of 45 years (from 1966 to 2011), they found a total of 24 studies that could be included. But the data collected in these studies was NOT consistent enough to combine together for a big picture analysis.

    It was clear from this study that a set of guidelines is needed to aid researchers in collecting and then reporting information from their studies on the treatment of OLT. In this way, data collected is standardized and can be organized and used to assess short- medium- and long-term results. Patients benefit by receiving the best treatment based on evidence that it works and has long-lasting effects.

    I may be having buyer’s remorse in a weird way. I had an operation called microfracture to help heal a hole in my ankle bone. But now I’m regretting doing it and thinking it could have just healed on its own if I waited a bit longer. And I’m worried that after spending all this money, the repair won’t last. What do you think?

    Microfracture is a way to treat defects, lesions, or ‘holes’ that go all the way through the protective cartilage to the bone. In this procedure, tiny holes are drilled around the lesion through the bone to the bone marrow. Breaching the bone in this way releases stem cells from inside the bone to improve blood circulation to the area. The stem cells form fibrocartilage and fill in the hole.

    Defects (holes) that measure less than one-half inch (15 millimeters) can be treated this way. In fact, size and location of the defect are two of the most important factors that predict results. Your activity level and body size (body mass index or BMI) are also important variables that help determine long-term outcomes.

    The hope for this treatment is that the new fibrous cartilage will act as a shock absorber and protect the bone underneath. But no one really knows if the fibrocartilage that forms can hold up under constant load through the ankle — especially in athletes or active adults.

    There have been a few studies that suggest the fibrocartilage starts to break down over time. Patients who once experienced pain relief and improved function suddenly find themselves back where they started from. Other injuries suffered at the same time (and treatment for those injuries) can also impact how well microfracture works.

    Efforts have been made to study and report the long-term results for microfracture to treat osteochondral lesions (holes in the bone). Most of the studies include complete demographic information about the patients (e.g., age, sex, body size, duration of symptoms, type of injury). But clinical information (e.g., size of lesion, location of defect, presence of other injuries, rehabilitation protocol) is often limited. And imaging data (e.g., results from X-rays, MRIs, CT scans) has been very poorly reported.

    Patient-reported outcomes (e.g., pain, function, activity, satisfaction) is an important part of any patient-centered study. A recent study showed that 87 per cent of the studies on microfracture for osteochondral lesions of the ankle included this information. But they all used different assessment tools to judge results. Without a consistent scoring system, these results cannot be compared.

    We do know that injuries of this kind do not heal on their own. Treatment is usually necessary and often includes microfracture. When you see your surgeon for the next follow-up appointment, don’t hesitate to bring up your concerns and questions. Sometimes just reviewing why the surgeon thought you were a good candidate for this type of procedure can be very helpful to allay fears and worries.

    I think I’m probably not a good person to have a knee replacement but maybe you can tell me for sure. I have what they call fear avoidance. I’m afraid to do much because if I do, the pain shoots up from a three to a 10 immediately. My husband thinks if I just have the knee replaced, I’ll be fine. But I’m secretly worried I won’t be any be any better off after surgery than before. You probably know about these things. What can you tell me?

    Before reaching the point of needing, wanting, and accepting a total knee replacement for joint arthritis, like you, many people become fearful of movement (kinesiophobic). Their level of pain causes them to start avoiding certain movements and activities at home and work. As you have found out for yourself, this pattern of behavior is called fear-avoidance.

    Long periods of time in the fear-avoidance mode of thinking and acting can eventually lead to loss of function and disability. Without movement, knee osteoarthritis is known to get worse, causing more pain. Before you know it, you become kinesiophobic (afraid to move), sacrificing everyday activities and tasks. A viscious cycle of pain-fear-disability-pain develops that can be hard to break.

    In fact, just as you susptected, this pattern of pain-related fear does not automatically go away after the joint is replaced. But the good news is that it is possible to restore full motion and function without the element of fear preventing recovery. You can return to all your previous activities.

    A study was done in Italy comparing two different ways to approach this problem. The first was to provide patients with a functional exercise program. This refers to a type of program designed to do more than just regain 90-degrees of knee flexion or lift the leg off the bed ten times. Functional exercise-based rehabilitation programs are geared toward improving motion and strength while preventing blood clot formation and while restoring specific activities. Walking; climbing stairs; and making sudden starts, stops, and turns are just a few examples of the skills functional exercises work to restore.

    The exercise group also received a book designed to help them understand their own unwillingness to go out shopping, go for a walk, return to work, or ride a bike. By practicing physical activities and movements at home, the patients in this group were encouraged to perform all these things without fear. The goal was to increase activities previously considered “dangerous” (i.e., before surgery). This was to be done slowly but steadily over the six months’ period of time after surgery.

    The second (control) group was just advised to stay active. They were told to gradually increase their activity level until they returned to normal (defined as their “usual” activities). Patients were randomly assigned to one of these two groups (experimental or control).

    After six months, it was clear that the experimental group had much better results compared with the control group. Disability level was much lower and quality of life was much higher in the experimental group. Fear-avoidance behaviors were also less common among the exercise group. Based on their findings in this study, the authors proposed the following:

  • Before knee replacement, all patients should be screened to identify those individuals who have pain-related fear of movement.
  • Anyone at risk for problems after total knee replacement because of fear-avoidance behaviors should receive education about kinesiophobia and a special rehab program.
  • Specific “graded” (in other words, slowly progressed) functional exercises should be prescribed and supervised until knee motion, daily activities, and physical function can be done with confidence and without fear.
  • Such a program can be taught to the patient while still in the hospital for the surgery. A follow-up home program may be enough to take care of the problem. Future studies are needed to know for sure exactly what type of rehab program (and for how long the program) should be provided.

    So, it is possible to pre-identify (before surgery) patients whose recovery from a total knee replacement may be compromised by fear-avoidance thinking and behaviors. Education and exercise can help correct these behaviors and aid in overcoming barriers to full recovery.

    Addressing and treating kinesiophobia in this way puts the burden of responsibility for recovery from mistaken beliefs and thoughts squarely on the patient’s shoulders. But since you are asking the question, it sounds like you are already aware of (and concerned about) the problem. And that’s the first step toward full recovery!

    Let your surgeon know about your fears and worries right up front. He or she should be able to guide and direct you through this process toward a successful knee replacement!

  • I am looking at putting an end to my chronically cranky and very painful ankle. The surgeons says according to the X-rays and CT scan I have end-stage osteoarthritis. She is recommending an ankle fusion using the newer arthroscopic method. Call me old-school but I’m not always convinced new is better. In this case, is it?

    In this case, the term “new” may not be exactly the right word to use. Arthroscopic ankle arthrodesis (fusion) has been around for 30 years. That’s long enough to have gathered enough data from studies to track short-, mid-, and long-term results.

    What we don’t always have are comparative studies where one group of patients is treated one way and a second group is treated differently. For example, in the case of ankle arthrodesis, there aren’t oodles of studies comparing the results when the procedure is performed arthroscopically versus using an open incision approach.

    Surgeons from Canada recently published the results of their two-year study of 60 patients in a comparative case series. They treated 30 adults (men and women) with ankle osteoarthritis using the arthroscopic arthrodesis and compared the results to 30 adults (similar in age, sex, weight, and diagnosis) treated for the same problem using an open approach. Everyone was re-evaluated at one and two years after the procedure.

    They assessed which technique worked better when measured by improvement in pain levels, function, and costs (hospital stay). A special self-reported survey designed to measure disability and pain from ankle osteoarthritis was used as the main outcome measure. This tool is known as the Ankle Osteoarthritis Scale or AOS.

    They found that all the patients in both groups improved significantly both at the end of one year and at the end of the second year of follow-up. But the arthroscopic group did show even greater improvement (statistically better) compared with the open incision group. And the arthroscopic group was in the hospital on average 1.2 fewer days.

    There was no difference between the groups in terms of length of time (number of minutes) to do the surgery or quality of alignment of the bones (as viewed on X-ray). The number and type of complications (e.g., nonunion of the bone, delayed wound healing, painful hardware that had to be removed) were also the same between the two groups.

    The authors concluded that surgical treatment for end-stage osteoarthritis of the ankle can be safely done arthroscopically. Compared with open incision procedures, arthroscopic arthrodesis provides better overall results faster and without an increase in postoperative problems or complications.

    I’m scheduled to have an ankle fusion next week. The surgeon I’m seeing didn’t answer all my questions today. He says “don’t overthink this.” But I would still like to know what kind of problems I could potentially run into after surgery. I did read the patient disclosure form with all the usual blood clots that can kill you kind of stuff. What about the actual ankle? Will it work? Will I be better?

    When ankle pain from osteoarthritis is severe, function is low, and conservative care isn’t helping, surgeons turn to a fusion procedure known as an arthrodesis. There are two ways to do this surgery: open ankle and arthroscopic. As the names suggest, open ankle involves large incisions. Arthroscopy can be done with tiny incisions or just puncture holes where the scope is inserted into the joint.

    Naturally, the question arises: which technique works better? Which one is preferred when measured by improvement in pain levels, function, and costs (hospital stay)? Perhaps you discussed some of these details with your surgeon. It is likely you will have another chance to ask a few more questions either during the pre-operative exam (unless this was it) or the day of the surgery.

    Most of the time, patients do sail through this procedure. Whether performed arthroscopically or with an open incision, the rate of problems or complications is fairly equal between the two groups. According to a recent study from Canada comparing results of ankle arthrodesis when done arthroscopically versus open incision, 60 patients (30 in both groups) all improved significantly.

    The arthroscopic group did show even greater improvement (statistically better) compared with the open incision group. And the arthroscopic group was in the hospital on average 1.2 fewer days.

    There was no difference between the groups in terms of length of time (number of minutes) to do the surgery or quality of alignment of the bones (as viewed on X-ray). The number and type of complications (e.g., nonunion of the bone, delayed wound healing, painful hardware that had to be removed) were also the same between the two groups.

    The authors concluded that surgical treatment for end-stage osteoarthritis of the ankle can be safely done arthroscopically. Compared with open incision procedures, arthroscopic arthrodesis provides better overall results faster and without an increase in postoperative problems or complications.

    Previous studies reported difficulty correcting a particular ankle deformity (coronal plane deformity) using arthroscopic techniques. But these surgeons say it’s just a matter of repositioning the talus bone in the ankle to restore normal alignment and that can be done arthroscopically as well.

    After tearing my Achilles tendon, I’ve been put on a special program of wearing a removable brace and gently moving my ankle through part of the motion twice a day. I feel really apprehensive about the movement. I’m worried I’ll retear the healing tissue. The surgeon assures me I’ll be fine if I follow his instructions exactly. What do you think?

    You have been put on a program referred to as functional rehabilitation. This involves early range of motion to stimulate tendon healing and bracing to protect the healing tissue. This type of conservative care offers the best of both approaches.

    Instead of putting the lower leg in a cast for six weeks, the brace is used. The cast would hold the ankle in a slight amount of plantar flexion (toes pointed down) with no movement allowed. The brace can be removed so you can actively plantar flex the ankle every day (usually from day 10 on). As mentioned, the idea is to use early range-of-motion to stimulate tendon healing without putting any stress on the tear.

    Results of this approach have been very successful. The rerupture rate is the same between surgery and functional rehab. And of course, there are none of the potential associated risks that come with surgery (e.g., blood clots, nerve damage, skin infections).

    However, on the plus side for surgery, patients go back to work sooner after surgery compared with functional rehab. All other factors (ankle motion, function, and calf size) are the same regardless of treatment.

    If all other factors are equal, functional rehab is a good place to get started. If you are having symptoms of apprehension, it would be a good idea to ask your surgeon for a closer follow-up schedule. You can also request the opportunity to work for a short time under the supervision of a physical therapist until you feel comfortable with the program. With a little guidance, you will be able to tell the difference between acceptable and unacceptable ankle motion and tension on the tendon. The goal is to get a good result without rerupture and without the need for surgery.

    I am reading conflicting reports about how to treat an Achilles tendon rupture. Even on your website there are some studies that say surgery is better and others that recommend a nonsurgical treatment plan. What’s the overall big picture view?

    You are correct that there are some conflicting results published in the medical literature about the treatment of Achilles tendon ruptures. Some of the differences depend on the type of treatment applied. Not all surgical treatment and not all nonsurgical care are the same. For example, surgical repair can be done with an open incision, with a minimally invasive approach (very small incision), or percutaneously (through the skin). Results can vary just based on those differences.

    Likewise, not all conservative care is the same. In some centers, an approach known as functional rehabilitation is offered, whereas other centers continue to use the traditional method of cast immobilization for six weeks.

    Here’s a little more about this concept of functional rehab. Instead of putting the lower leg in a cast for six weeks a brace is used. The cast would hold the ankle in a slight amount of plantar flexion (toes pointed down) with no movement allowed. The brace could be removed so the patient could actively plantar flex the ankle every day from day 10 on. The idea is to use early range-of-motion to stimulate tendon healing without putting any stress on the tear.

    For a long time now, studies have repeatedly shown that surgery is the better way to treat Achilles tendon ruptures. Patients got better faster and returned to work and play sooner. And there were fewer cases of tendon rerupture after surgery compared with conservative care. But surgery always comes with some risks of its own. So there have been continued efforts to compare different types of conservative care against surgical repair. That’s where functional rehab comes into play.

    In a recent meta-analysis, the authors combined the results of 10 studies that compared results after functional rehab versus surgery. The authors looked at rerupture rate as the main measure. But other factors evaluated included the rate of other complications (e.g., infection, skin breakdown, tendon necrosis, blood clots, nerve damage, scarring), return to work, calf circumference (size), muscle strength, and function.

    The first important finding was the risk of complications other than rerupture with surgery: 15.8 per cent higher with surgery compared with functional rehab. However, on the plus side for surgery, patients went back to work almost three weeks sooner after surgery compared with functional rehab. All other factors (ankle motion, function, and calf size) were the same regardless of treatment.

    So what’s the answer then? Should patients have surgery right away for an Achilles tendon rupture? Or should they go with functional rehab if it’s available? There may not be a one-size-fits all kind of reply. Consider these facts: the rerupture rate is the same between surgery and functional rehab. However, the risk of other complications is higher whenever surgery is done. The risk of rerupture is higher after prolonged immobilization (traditional conservative care) compared with surgery.

    If all other factors are equal, functional rehab should be considered first. If functional rehab is not available, then surgery should be the top option but keeping in mind the risk of other complications. Those “other” complications could be something as minor as a skin rash or infection but could be as serious as a life-threatening blood clot to the lungs. There is no way to predict who will have a post-operative problem and whether it will be minor or major.

    In terms of motion, function, and return to full activities, patients in both groups are equally successful. But there is a less than three per cent chance of rerupture after surgery compared with 10 to 12 per cent following nonsurgical treatment. Each patient must discuss with the surgeon the potential benefits, problems, and trade-offs with each type of treatment available.

    Well, it’s getting near the end of the year. Time to make a decision about my poor ankle before my insurance runs out and I have to start my deductible all over again. The surgeon says I have a chronically unstable ankle from a dozen sprains and resprains. It’s all been on the outside of the ankle. Lucky me. But really I guess I am fortunate because this surgeon does something new called a hybrid ligament reconstruction. What do you guys know about this operation? Should I go with it?

    Two million ankle sprains a year have led surgeons to develop a wide range of treatment possibilities. Most of these injuries occur along the lateral (outside — away from the other leg) portion of the ankle. Conservative (nonoperative) care works well for many people. But when the ankle keeps giving way and/or getting resprained, it may be time to consider surgery.

    Once the decision to have surgery has been made (like in your case), then the next step is to consider what type of procedure to do. There are three basic options: a direct repair (take the torn ligament and reattach it to the ankle bone), reconstruct the ligament by replacing it with graft tissue, or a checkrein technique. This last option involves taking a portion of a nearby tendon (the peroneus brevis) and transferring it across the joint to the spot where the torn ligament was pulled off the bone.

    There are many different pros and cons for these three approaches. The best evidence from studies done so far suggest that reconstruction has better results than either a direct repair or the checkrein procedure. By “better results” we mean fewer complications after the surgery, less pain, most normal motion, and improved proprioceptive function. Proprioception refers to the joint’s sense of position, which is often damaged when the joint is injured.

    Even so, there are still concerns about overtightening the joint and problems that arise with even the best reconstructive techniques. Nerve damage during the surgery, poor wound healing after surgery, and joint stiffness postoperatively have been reported with the procedures described. That’s why this new hybrid technique was developed to reconstruct the torn ligaments in the lateral ankle.

    As the name suggests, the surgeon takes two different surgical procedures and combines them together to create this new approach. The goal is to provide a more anatomic repair with fewer problems. This hybrid procedure uses the peroneus longus tendon.

    They take one-third of the diameter of this tendon and transpose or transfer it to the insertion point of the torn anterior talofibular ligament (ATFL). The result is to restore normal contact points of the ankle joint, thus avoiding an overtightening situation. Putting the ankle back together as close to normal as possible may be one way to aid patients who are chronically unstable to regain ankle stability.

    This procedure has been tested so far on 57 patients ranging in age from 17 to 65. Everyone has been followed for at least a year and some up to four years. At six weeks postop, the patients were able to put their full weight on the ankle. Physical therapy began at that point and by 10-weeks after surgery, the patients were started on more specific exercise drills.

    At the end of one-full year, everyone had a mechanically stable joint. Follow-up MRIs showed tendon remodeling in the donor graft but also some signs of joint changes that could eventually lead to arthritis. A fair number of patients (12 per cent) were unstable with the balance tests. They could not do a one-legged stand on the surgical side without support. Long-term follow-up is intended in order to further evaluate outcomes.

    This new hybrid reconstructive surgical technique for chronic, unstable lateral ankle sprains is most useful when the torn, ruptured, or damaged anterior talofibular ligament (ATFL) is too short to use, too frayed, or missing altogether.

    The final decision to use this modified technique isn’t usually made until the surgeon has looked inside the joint with an arthroscope to see how much and what kind of damage is present. Quality of the ATFL is the determining deciding factor. Arthroscopic examination also makes it possible to see if there are areas of joint capsular or synovial thickening, a sure sign of chronic instability.