FAQ Category: Ankle

Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. It is possible to take baseline measurements and to measure the impact of ankle arthritis on function. Limitations in function during daily activities is referred to as impairment of function.

There are several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements can be compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems or to your other ankle if it isn’t damaged. It might be better to use adult controls instead of your unaffected ankle because if your walking (gait) pattern is affected on one side, it’s likely there will be compensations on the other side even if it is normal and without injury.

Choosing between ankle fusion (called arthrodesis) and ankle replacement (arthroplasty) is always a challenge. Fusion limits pain because it stops ankle motion. But loss of ankle and foot motion causes changes or alterations in the walking (gait) pattern. That in itself can cause further problems later on. Ankle replacement restores ankle motion and takes the pressure and load off the other nearby joints. But long-term studies of ankle replacement are not showing outstanding results at this time.

The question then becomes: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions have been answered yet. But researchers have at least gotten a start on evaluating which tests and measures provide the most information about function and activity limitations. And they are beginning to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients.

Average walking speed, number of steps taken each day, and length of steps can be correlated with physical function. These tests can help identify problems with ankle motion and function. It is likely that these same measures could be used in future studies. They can be used to determine when treatment should begin and what type should be provided.

Right now, that information isn’t available to help you make your decision. Your surgeon will be the best one to advise you about the use of conservative (nonoperative) care. He or she will also guide you as to when to consider surgery and what type of surgery is best for you.

Ankle sprains are a common occurrence, especially among athletes and sports participants. More and more orthopedic surgeons are recognizing and reporting the fact that ankle sprains often come with other injuries as well. In fact, in about half of all cases, there is this type of osteochondral lesion you are describing where the sprain is severe enough to cause a piece of cartilage and bone to detach.

Treatment for this problem does follow techniques used for similar defects in the knee. Bone marrow stimulation, chondrocyte (cartilage) implantation, and osteochondral autologous transplantation (OAT) are three of the most commonly used treatments.

The type of treatment used depends on many different factors. For example, your age and activity level as well as your personal goals for activity and sports participation are vitally important variables. But the location of the lesion and the size/depth of the defect are important considerations, too.

There are some known risk factors that can contribute to treatment failure that should be kept in mind.
Previous studies have shown that people who are morbidly obese experience significant knee pain from the harvest site. Significant ankle deformity or poor alignment of the ankle axis for rotation or other movements is another risk factor that can result in poor outcomes following the OAT procedure.

Patients with ankle osteoarthritis or ligamentous instability of the ankle are not good candidates for this procedure either. And anyone young enough to have open growth plates should also not be treated with osteochondral autologous transplantation (OAT).

Surgeons generally advise young, active patients who are thinking about having osteochondral transplantation just what to expect after surgery. There may be a risk that the outcomes won’t be as expected. The patient may have to reduce activity level and possibly change type of sports participation. Surgeons should select patients carefully for this procedure keeping risk factors (especially obesity) in mind.

Ankle sprains make up almost one-third of all sports-related injuries so you are not alone in this. About half of all ankle sprains have an associated injury, such as the defect you described. The hole you mentioned is likely called an osteochondral lesion, indicating that both cartilage and a layer of bone have pulled away from the talus. The talus is the major ankle bone located between the heel bone and the lower leg bone (shin).

A recent study was done on 131 young, active adults engaged in recreational activities and sports. The goal was to see what kind of activity and level of activity these patients were able to return to after a procedure called osteochondral autologous transplantation (OAT). In this procedure, a piece of bone is harvested from the knee and moved to fill in the hole in the talus (or other damaged bone).

In this study, (after the OAT procedure), everyone was followed for a minimum of two years (some were followed for as long as 12 years). The primary area of interest was the ability to return-to-sports. Pain, activity levels in general, and patient satisfaction were also measured.

They found a significant change in activity type and level from before to after surgery. Patient satisfaction was not high, possibly due to the fact that these athletes expected more after this type of surgery. Many of them altered their activity level and started avoiding high-impact activities such as jumping and contact sports.

It’s likely (but not confirmed) that the athletes were afraid of injuring or reinjuring the ankle. By limiting the amount of time they played and the intensity of play, they may have believed that they could further prevent deterioration of the ankle joint.

The authors did not test out this hypothesis but just offered their theories on the athletes’ behaviors. The decreased patient satisfaction may be the result of athletes who were disappointed that they could no longer train or play at the high level they participated in sports before the injury and subsequent ankle surgery. Pain at the bone donor site (knee) may also adversely affect activity and sports play as well as attitude and level of satisfaction.

As a result of these findings, the authors suggested surgeons advise young, active patients having osteochondral transplantation of the talus what to expect after surgery. There may be a risk that the outcomes won’t be as expected. The patient may have to reduce activity level and possibly change type of sports participation.

Having this kind of information will help you in talking with your surgeon. Be sure and bring up your question and see what you find. Each patient has some individual differences in age, body type, goals, and extent of injury that may impact treatment decisions and treatment results.

You may have an unusual lateral ankle sprain with a condition called peroneal tendon instability. A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.

When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation such as you mentioned.

Conservative (nonoperative) care is only possible when the unstable tendons can reposition inside the retromalleolar groove. A cast or boot placed on the lower leg will give the tendon a chance to heal. If conservative care is unable to achieve a stable gliding tendon or if the tendon displacement is unstable from the start, then surgery is necessary.

There are several different surgical options to consider. The fibrous protective sheath (retinaculum) can be reinforced or reconstructed. The groove can be reshaped (deepened) and rebuilt. The surgeon will probably suggest some additional imaging studies to determine the extent of the damage and the best way to surgically treat it. If you are still uncertain about the need for surgery, you always have the option of seeking a second opinion. There is nothing wrong with asking questions and seeking further advice.

Ankle sprain is a common injury in athletes as well as the active adult. Most of the time, the ankle heals with a little care (rest, taping, ice). But one rare complication of lateral ankle sprains is a condition called peroneal tendon instability. It sounds like this may be what you are experiencing.

A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.

When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. Traumatic displacement of the peroneal tendons is a rare but painful complication of some lateral ankle sprains. Some people have a naturally shallow groove, which contributes to the likelihood of tendon displacement after ankle sprain.

The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation. Swelling may mask the symptoms of tendon displacement at first. It’s only weeks to months later when the painful symptoms don’t go away that the additional tendon damage is recognized. Early MRIs may not show peroneal tendon instability, especially if the tendon pops in and out of the groove spontaneously. Dynamic ultrasound tests are the best diagnostic tests because they will reveal the movement of the unstable tendon.

You are probably referring to the use of hyaluronic acid injections for the treatment of joint osteoarthritis. Hyaluronic acid is a substance naturally found in the body in small quantities. It seems to have a role in the multiplication of normal, healthy cartilage cells. Used as an injection into the joint, it is designed to rebuild the protective joint cartilage.

Fifteen years ago, the Food and Drug Administration (FDA) approved the use of an injection of hyaluronic acid for knee arthritis. This approval was based on enough studies that showed it was safe and effective for this type of use. It has been used ever since for the effective relief of (knee) arthritis pain in some carefully selected patients.

Surgeons are starting to look at the possible use of this same injection for ankle arthritis. As you have discovered, it has not yet been approved for this type of use by the FDA. Even so, studies are starting to trickle in. So far, it looks like the procedure is well tolerated by patients with very few side effects or complications. But the question arises: does it work any better than a placebo treatment?

Surgeons from the Newton-Wellesley Hospital in Massachusetts set up a study to find out. They injected one group of patients with ankle arthritis using the hyaluronic acid. A second (control) group received the placebo injection of saline solution.

Patients were carefully selected for this study with limited inclusion criteria. Adults 18 years or older who had been formally diagnosed with ankle arthritis were included. They had to be willing to stop taking all pain meds during the study. Anyone who was pregnant, diabetic, or had circulation problems was not allowed to participate. Other exclusion criteria included the use of anticoagulant medication (prevents blood clotting) and the presence of sciatica, skin rash, plantar fasciitis, or ankle sprains.

Although the treatment with hyaluronic acid for joint osteoarthritis is usually three to five injections, patients in this study were only given a single injection (of either solution). Six and again 12 weeks after the injection, they were re-evaluated. Pain, motion, and function were the main before and after measures used to assess results.

They found that patients in both groups got much better by the end of 12 weeks. But there wasn’t a significant difference between the groups to suggest one treatment was superior to the other. The equal results did show that at least for one injection, hyaluronic acid isn’t any better than a placebo treatment.

The fact that everyone improved by the end of the study could demonstrate the natural process of healing, the effect of just inserting a needle through the skin, or it could have some other unknown meaning. The power of the placebo effect (patients expect to get better so they do) must be taken into consideration.

Until there is enough evidence that hyaluronic acid is an effective treatment for ankle arthritis, it is unlikely that the use of hyaluronic acid injections for the treatment of ankle osteoarthritis will be approved any time soon.

Further studies are needed with a series of injections to see if one just isn’t enough to have an effect. It will be necessary to try different hyaluronic products commercially available and compare results. It’s possible that some formulations of the product work better than others. Different dosages need to be evaluated as well.

It sounds like maybe you had a series of injections using hyaluronic acid. Hyaluronic acid is a substance naturally found in the body in small quantities. It seems to have a role in the multiplication of normal, healthy cartilage cells. Used as an injection into the joint, it is designed to rebuild the protective joint cartilage.

Fifteen years ago, the Food and Drug Administration (FDA) approved the use of an injection of hyaluronic acid for knee arthritis. It has been used ever since for the effective relief of arthritis pain in some carefully selected patients.

Now surgeons are turning their attention to the possible use of this same injection for ankle arthritis. Although it has not yet been approved for this type of use by the FDA, studies are starting to trickle in. From what has been reported so far, there isn’t a clear benefit to these injections for the ankle. In fact, according to one random controlled trial, hyaluronic acid didn’t work any better than a placebo injection using saline (salt) solution.

The question comes up: why do hyaluronic acid injections seem to work so well for some patients with knee osteoarthritis but patients with ankle arthritis don’t’t get the same benefit? It’s possible that because most ankle arthritis is the result of trauma (and knee arthritis is not), there is a difference in the response to hyaluronic acid. Ankle cartilage is also a lot stiffer, denser, and less elastic compared with knee cartilage. Maybe that makes a difference.

Until there is enough evidence that hyaluronic acid is an effective treatment for ankle arthritis, it is unlikely that insurance companies will reimburse for its use. With the high cost of this product, further study is needed to find new types of nonsurgical treatment for ankle osteoarthritis that are cost effective and economical.

Surgeons agree that a total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, it is a reasonable approach for some patients and is still considered an acceptable alternative to ankle fusion (or amputation).

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn’t a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) also remains a problem.

And studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It’s a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

Patients are selected carefully for this procedure. Your surgeon may have some specific reasons why he or she thinks you are not a good candidate. But it’s also possible your surgeon doesn’t do this type of surgery.

It may be a good idea to find a surgeon who does perform total ankle replacements on more than an occasional basis and get a second opinion. You may get the same answer in which case it would be good to explore your options for better pain management so that you can become more functional. It’s possible there are some conservative treatment approaches that could really help.

There is one recent study from Duke Medical Center that may have the answers you are looking for. In this study, one surgeon from Duke University Medical Center shares the results of 82 patients who received the STAR total ankle replacement.

This surgeon performed all of the procedures himself using the Scandinavian Total Ankle Replacement (STAR) over a 10-year-period of time. The STAR prosthesis has been in use since the early 1980s with good results. It remains one of the most widely used ankle implants.

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn’t a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) can also develop causing some difficulties.

Studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It’s a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

The surgeon who conducted this study was particularly interested in knowing how the patients viewed the results. Measurements were taken before surgery and compared to the same measurements after surgery. Pain, ankle motion, and function were the main areas assessed. Patients’ satisfaction with the results and self-reported quality of life were important means of determining patient reaction to the outcomes.

After analyzing all the data, he found there were improvements in all areas measured but especially in patient quality of life and satisfaction. Everyone was followed for at least two years and some patients were in the study for almost 10 years. This is probably one of the most comprehensive, long-term studies of patient perceived outcomes currently available.

The surgeon reminds the reader that these are self-reported results for a particular ankle implant (the STAR prosthesis). The more objective measures (number of patients requiring further surgery, number of failed implants, and implant survival rate) were also favorable. There was a revision rate of four per cent early on that increased over time. The survival rate was 88.5 per cent after 10 years.

It should help you to know that surgeons agree total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, as this study showed, it is a reasonable approach for some patients. And is still considered an acceptable alternative to ankle fusion (or amputation). As the patients in this study report, function and quality of life are improved. Patient satisfaction is ranked high enough to make this a procedure worth considering.

Physical therapists and athletic trainers working with high school football players are concerned about the high number of players benched because of ankle injuries. Recently, they conducted a study to compare the number and severity of ankle injuries in players with and without a lace-up ankle brace. They also looked to see if there were more knee injuries in athletes who did not wear the brace. What they found might be of interest to you.

Over 2000 football players from 50 high schools participated in this study. They were divided into two groups: those who wore a lace-up ankle brace and those who did not wear a brace (the control group). The study was conducted over one football season.

The brace was worn on both ankles by players in the brace group. Athletic trainers made sure the braces fit properly and were worn during practice, conditioning sessions, and games. The players could wear their own shoes (low- or mid-top height) and their preferred cleat type (molded or detachable).

Injuries were reported along with information about the field surface (grass or synthetic) and the type of injury (ligament sprain, muscle strain, contusion, fracture). Only injuries that occurred during sports activities were counted.

Records were kept to show whether the athlete was seen by a physician, required surgery, and/or suffered other bodily injuries as well. Severity of ankle injuries was measured by the number of days the athlete was unable to play.

By the end of the season, between one-fourth and one-third of the players (27 per cent) suffered some type of injury. Injury rates for the ankle and knee were much higher in the non-braced (control) group. In fact, there were 70 per cent fewer ankle injuries for players who had a prior history of ankle injuries. And there was a 57 per cent reduction in ankle injuries measured in players who had never had a previous ankle injury (like you). These rates were calculated based on comparing results to the control group.

The severity of these injuries was not different from players injured while wearing the brace as compared to players injured in the control group (no brace). There was no difference in number or severity of knee injuries (or other leg injuries) between the two groups.

In summary, the results of this study showed that lace-up ankle braces do reduce the number (but not severity) of acute ankle injuries in high school football players. Something to think about! More studies are needed to help identify players who might be at increased risk of ankle injuries.

Other studies show neuromuscular training programs work well to prevent ankle injuries. So for players who are motivated to do a few extra exercises, the brace may not be needed at all. And there are concerns that an ankle brace reduces ankle motion and may increase the risk of stress fractures, low back injuries, or upper leg and hip injuries. This is another area for future study.

It sounds like you have the DonJoy Ankle Stabilizing Brace. It is designed so it can be worn on either foot (there is no right or left). As you can see, it laces up the front like a shoe. There should be two velcro straps that wrap around the ankle and one wide strap around the top of the ankle.

Most ankle supports (including the DonJoy brace) are meant to be worn over a single layer of sock or fabric (e.g., legging or stockinette). The material will absorb perspiration and protect the skin from any pressure or rubbing.

You will want to fasten the straps with equal tension throughout. The straps are meant to be pulled firmly but not tightly. If your toes turn white or blue or feel cold, you may have the brace on too tight. When you take the brace off, check the skin immediately for any red areas. This may be an indication that the brace does not fit properly or that the straps can be loosened a bit. Any red marks that do not go away in five to 15 minutes should get your attention.

There is really nothing wrong with asking your coach (or an athletic trainer if your team has one) to make sure you have the right size and fit. If the intent is to prevent injuries, it makes sense to ensure a proper brace fit.

Having diabetes heads the list of potential risk factors for joints “freezing up”, especially the shoulder. In fact, up to 40 per cent of adults with Type 1 diabetes and 10 to 36 per cent of folks with Type 2 diabetes develop adhesive capsulitis of the shoulder. Adhesive capsulitis is the medical term for this condition.

Being a woman or an older adult (40 to 60 years old) also increases the risk of adhesive capsulitis. Injury or trauma to the affected joint may be the cause of secondary adhesive capsulitis. Treatment is based on whether the patient is in the early, mid, or late stage of the condition.

Physical therapy is a key feature of treatment in all stages of adhesive capsulitis but especially when the condition is just developing. The physical therapist mobilizes the ankle joint. Mobilization is a hands-on technique. The therapist moves (slides and glides) the joint surfaces in different directions to lubricate and stretch the joint capsule and move the joint.

In the early stages of acute adhesive capsulitis, joint mobilization may help decrease inflammation and prevent the formation of fibrous adhesions. You may be given an antiinflammatory medication or steroid injections. The therapist will encourage you to keep moving the joint in order to maintain full joint range-of-motion.

Failure to respond to conservative (nonoperative) care may mean surgery. The surgeon inserts an arthroscope into the joint to see what’s going on and to correct the problem. This may mean removing loose fragments of bone or cartilage from inside the joint. This type of procedure is called arthroscopic debridement.

Prevention is definitely the key to avoiding joint problems. If you haven’t already seen an orthopedic surgeon, it would be a good idea to get a difinitive examination and diagnosis. If there are no fractures, infection, or loose fragments inside the joint, then you may be an immediate candidate for physical therapy.

The joint may still progress through all three phases (the painful, “freezing” phase, the stiffening phase, and the “thawing”) recovery phase. But with a good home program, you should be able to complete the process with minimal discomfort and maximum outcomes (motion, strength, function).

Most people have heard of the condition known as a frozen shoulder. The medical term for a “frozen” joint is adhesive capsulitis. The diagnosis of adhesive capsulitis can apply to any joint that is painful and stiff with significant loss of motion. In this article, the concept of a frozen ankle or adhesive capsulitis of the ankle is reviewed.

One of the key features of adhesive capsulitis is the overall loss of both active and passive motion. Active motion refers to your ability to move the ankle up, down, and all around. Passive motion occurs when someone else (your physician, physical therapist, athletic trainer) moves the foot and ankle through the available range-of-motion without your help.

What causes a frozen ankle? Like adhesive capsulitis of the shoulder, the exact cause may be unknown. This is called primary or idiopathic adhesive capsulitis. Even though it is said that the cause is unknown, with primary adhesive capsulitis, there are some factors that increase your risk for joint problems like this.

Having diabetes heads the list of potential risk factors. In fact, up to 40 per cent of adults with Type 1 diabetes and 10 to 36 per cent of folks with Type 2 diabetes develop adhesive capsulitis of the shoulder.

Being a woman or an older adult (40 to 60 years old) also increases the risk of adhesive capsulitis. Injury or trauma to the shoulder may be the cause of secondary adhesive capsulitis. As the term secondary suggests, the shoulder condition occurs as a direct result of another problem like trauma.

The incidence of adhesive capsulitis of the ankle is much less than in the shoulder. And most of the time, adhesive capsulitis of the ankle is secondary to repeated ankle sprains or an ankle fracture. Risk factors for primary (idiopathic) ankle adhesive capsulitis do include diabetes as well as infection, heart disease, or autoimmune disorders.

All in all, a frozen ankle is a lot like a frozen shoulder. The symptoms are very similar. The underlying pathologic processes within the tissues appear to match up as well. Treatment is based on whether you are in the early, mid, or late stage of the condition.

It sounds like you are in the early phase when there is considerable inflammation that might respond to antiinflammatory medications. Physical therapy is often a good idea in order to keep the joint moving and prevent stiffening and thickening of the joint capsule.

All of the major joints can be replaced now: the shoulder, hip, knee, and ankle. Surgeons have the most practice with hips and knees. Ankles remain more difficult because of the complexity of the joint itself. Patients may get good pain relief with ankle joint replacement but they don’t always get better ankle motion.

Lining up all the bones and parts of the implant can be very challenging. Experts say there is a “steep learning curve” for the surgeons doing this procedure. That means their early attempts aren’t as good as their later cases after they’ve had the chance to do many ankle joint replacements. They do practice on cadavers and that is an important step in learning how to do these procedures.

But getting the right alignment, correcting any anatomic deformities, and repairing damaged soft tissues can be very complex and challenging — even for the most seasoned surgeon. For example, the axis of rotation depends on perfect alignment of the talus (one of the major bones replaced). But even in normal ankle joints, this axis changes during motion. Duplicating normal anatomic alignment and function is a complex and demanding step in the ankle joint replacement procedure.

Skillful use of fluoroscopy (real-time X-rays) is required for this procedure. The surgeon works hard to achieve a zero anteroposterior offset ratio. Patients have much better outcomes (pain, ankle motion, and ankle function) when this ratio is zero.

What is the anteroposterior offset ratio? It is a measure of the relationship between the two key components of the ankle joint implant. There is the flat piece that goes at the base of the tibia (shin bone) called the tibial plafond and the replacement for the talus (the bone at the top of the ankle that moves against the tibia).

When the center of the talus lines up with a vertical line drawn down the side of the tibia, the anteroposterior offset ratio is zero. That is a perfect line up of the two component parts. If these two points don’t line up, then there can be a positive ratio (measure greater than zero) or negative ratio (measure less than zero).

The key to a good result is improving the alignment and mimicking normal biomechanics as much as possible. Patients are advised before surgery that even with the newer improved implants, results aren’t always as expected. The change in ankle motion can be very small. Pain may be reduced and even gone but there is the chance that pain will persist.

Studies show that even in the hands of experts, zero anteroposterior offset ratio is possible in less than half the cases. Small malalignments can cause stress on the soft tissues around the ankle and the other bones of the ankle and foot. Even minor increases of strain on the ligaments can cause pain and loss of motion.

Having the right expectations and understanding of the possible outcomes before having this procedure done is important. It sounds like you have been well-educated on the pros and cons of ankle joint replacements. We hope this added bit of information will help you discuss your situation with your surgeon and make the best choice for you.

A study from Switzerlan may have the answers you are looking for. Surgeons at the Clinic of Orthopaedic Surgery in Liestal, Switzerland studied the results of 317 ankle joint replacements. They measured one factor in particular and looked at results in relation to this one variable.

They studied something called the anteroposterior offset ratio. They found that when this ratio is zero, patients had much better outcomes. They measured pain, ankle motion, and ankle function to compare results.

What is the anteroposterior offset ratio? It is a measure of the relationship between the two key components of the ankle joint implant. There is the flat piece that goes at the base of the tibia (shin bone) called the tibial plafond and the replacement for the talus (the bone at the top of the ankle that moves against the tibia).

When the center of the talus lines up with a vertical line drawn down the side of the tibia, the anteroposterior offset ratio is zero. That is a perfect line up of the two component parts. If these two points don’t line up, then there can be a positive ratio (measure greater than zero) or negative ratio (measure less than zero).

Putting the talus in just the right position to obtain a zero anteroposterior offset ratio is a challenge even for the most seasoned surgeon. The surgeon must contend with changes in the joint from degenerative arthritis as well as any other positional or alignment deformities. Skillful use of fluoroscopy (real-time X-rays) is required for this procedure.

But as these Swiss surgeons showed with 317 patients, this ratio represents component position. And any malposition of the talus has a direct effect on outcomes. Positive or negative ratios result in increased ankle pain, reduced ankle motion, and worse function compared with a zero ratio.

Only 40 per cent of their group had a zero anteroposterior offset ratio. As their results showed, small malalignments can cause stress on the soft tissues around the ankle and the other bones of the ankle and foot. Even minor increases of strain on the ligaments can cause pain and loss of motion. Improving the alignment and mimicking normal biomechanics as much as possible is likely to yield the kind of results patients are looking for.

This ratio may be something your surgeon can take a look at and see if it is part of the problem. There may be other (unknown) factors as well. More study is needed in this area to help the many patients like you who do not get the pain relief and improved motion they expected.

What you have just described sounds like what we would call a pilon ankle fracture. The term pilon fracture (also known as a hammer) fracture occurs when one bone is driven into another bone with force. The bone may be broken into more than one piece. This is a comminuted pilon fracture. Pilon fractures can affect the spine and either bone in the lower leg (tibia or fibula).

The most common pilon fracture affects the lower end of the tibia. The break occurs across the entire bone and into the ankle joint. It results from a high-energy, loading injury from the foot up into the bone. Car accidents, skiing injuries, and falls during horseback riding are the most commonly reported cause of pilon fracture.

Surgery is needed but the timing of the procedure can be extremely important in saving the foot. Making incisions into swollen, infected, and/or damaged soft tissues can set off a chain of events that result in very poor outcomes. Amputation from nonunion of the fractures and deep infection are two potential serious complications. Surgeons have learned that a wait-and-see approach might be best.

Unless the surgeon is able to bring the joint surfaces back together and match them up evenly, the risk of joint arthritis is much greater. Likewise, if the alignment of the ankle joint isn’t normal, there may be a loss of stability, uneven wear, inability to walk without a limp, and early development of osteoarthritis. Some experts in this area recommend the following:

The term pilon fracture (also known as a hammer) fracture occurs when one bone is driven into another bone with force. The bone may be broken into more than one piece. This is a comminuted pilon fracture.

The most common pilon fracture affects the lower end of the tibia. The break occurs across the entire bone and into the ankle joint. It results from a high-energy, loading injury from the foot up into the bone. Car accidents, skiing injuries, and falls during horseback riding are the most commonly reported cause of pilon fracture.

Pilon fractures are indeed difficult to manage. There is often damage to the joint surface, soft tissue complications, and poor outcomes. It often requires one or more operations to repair the damage. In 10 percent of cases, fusion of the joint is needed.

Advances in surgical management are ongoing and it sounds like your surgeon is keeping abreast of the changing times. As you have seen, surgical management for pilon fractures begins with careful preoperative planning. Preoperative planning often requires assessing patient risks for success or failure of surgical management.

The surgeon also examines the fracture from every angle trying to see where all the damage has occurred and preparing a plan of action. It may be helpful to trace the X-rays and create an overlay that can be used to plan out the surgical approach. Computer computations can be used to calculate the best way to align the bones and joints while taking into consideration the condition of the surrounding soft tissues.

Surgical fixation will be needed. This requires the use of pins, screws, wires, cages, and/or plates to hold the bones together until healing takes place. Strategic placement of fixation devices may improve the results. Bone graft may be used to prevent bone collapse and help stimulate bone growth. Planning ahead how to best use these resources (as your surgeon has done) is really the best way to assure a good result with this type of injury. Sounds like your daughter is in good hands.

Scientists are just beginning to investigate the use of hyaluronate injections to treat ankle osteoarthritis. The procedure is referred to as viscosupplementation. The injection helps restore the normal flow of fluid inside the joint. It is a joint lubricant. The natural result is to reduce pain and improve motion and function.

As you know from personal experience, viscosupplementation of this type with hyaluronate has been done successfully with the knee. After three to five (once a week) injections, patients report considerable relief from pain. And with pain relief and improved ability for the joint to slide and glide comes a return in the ease of motion. These researchers wondered how well does this technique work for the ankle?

They gave each of 50 patients with ankle arthritis in one ankle one injection every week for three weeks. Then they measured results one to six months after the last injection. Standardized tests of pain, motion, and balance were completed. Patients were asked to rate their level of satisfaction. Complications and use of pain relievers were also recorded.

The results were very encouraging. Patients improved in all areas, used less pain medication, and rated their satisfaction high. There were no serious side effects either! In particular, the improvement in balance was consistent when measured with four different tests. The possibility of fewer falls and reduced risk of additional injuries are added benefits of viscosupplementation. There is also a cost savings in not having the expense of surgery.

All positive changes occurred within the first month following the injections. And the benefits remained when patients were checked at the end of six months. Younger patients (55 years old and younger) seemed to improve more than older adults.

The authors concluded that the use of hyaluronate injections for ankle osteoarthritis is safe and effective. Further studies are needed as this was the first one published in the area of viscosupplementation for ankle arthritis. It wouldn’t hurt to talk with your physician about your ankle. Caught early enough, there may be other forms of conservative (nonoperative) care that could benefit you now.

There are some possible treatment ideas for ankle arthritis you may want to explore. Physical therapy to help you regain strength, restore normal alignment, and even lose weight may not be a bad idea. Pain control through the use of medications, hypnosis, relaxation, and other alternative approaches have helped some people.

There is also a nonoperative approach called viscosupplementation that might be a good option for you. An injection of a substance called hyaluronate into the joint helps restore the normal flow of fluid inside the joint. It is a joint lubricant. The natural result is to reduce pain and improve motion and function.

Viscosupplementation of this type with hyaluronate has been done successfully with the knee. After three to five (once a week) injections, patients report considerable relief from pain. And with pain relief and improved ability for the joint to slide and glide comes a return in the ease of motion.

The first study to try this out on painful arthritic ankles has been published. The authors of the study gave each of 50 patients who had ankle arthritis in one ankle one injection every week for three weeks. Then they measured results one to six months after the last injection. Standardized tests of pain, motion, and balance were completed. Patients were asked to rate their level of satisfaction. Complications and use of pain relievers were also recorded.

The results were very encouraging. Patients improved in all areas, used less pain medication, and rated their satisfaction high. There were no serious side effects either! In particular, the improvement in balance was consistent when measured with four different tests. The possibility of fewer falls and reduced risk of additional injuries are added benefits of viscosupplementation. There is also a cost savings in not having the expense of surgery.

All positive changes occurred within the first month following the injections. And the benefits remained when patients were checked at the end of six months. Younger patients (55 years old and younger) seemed to improve more than older adults. Weight loss was not required for good results.

The authors concluded that the use of hyaluronate injections for ankle osteoarthritis is safe and effective. Further studies are needed to determine the optimum number of injections needed for the best results. It’s possible that some patients would do better with five injections instead of three (and vice versa).

Longer follow-up is also needed to see if the benefits last more than six months. With larger study groups, it might be possible to determine which patients with ankle arthritis are the best candidates for this type of treatment.

It would be helpful to know the best timing of treatment. Earlier use of hyaluronate to lubricate the affected ankle might help patients maintain balance, strength, and proprioception (fine tuning that signals even the smallest change in joint position).

And finally, hyaluronate injections must be compared to other conservative (nonoperative) treatment methods (e.g., physical therapy, antiinflammatories, weight loss, orthotics, activity modification). The result of different treatments combined together versus just viscosupplementation will be necessary. Perhaps comparing surgical results to hyaluronate injections would yield some additional helpful information for patients like yourself who are looking for an alternative approach to surgery.

There was a study done recently in your area that might offer you the kind of information you are looking for. A group of researchers from the University of Wisconsin (Madison) enrolled 1460 high school athletes in a study designed to determine the effect of lace-up ankle braces on injury rates in athletes.

This may be the first study to look at preventing ankle sprains (and other leg injuries) by wearing a soft, lace-up ankle brace. All participants were basketball players. The study included males and females involved in high school basketball during the 2009-2010 season.

The athletes were randomly divided into two groups. One group received the ankle brace. The other group was the control group (no brace). Athletes in the brace group wore the McDavid Ultralight 195 brace during any conditioning session, practice, or game throughout the season. This particular brace was chosen because it happens to be one that is used by many high school and college-level athletes.

As you might expect, the braced group did have fewer injuries. But the brace did not reduce the severity of the ankle injuries. Bracing did not prevent knee injuries either. The number of acute knee injuries was similar between the two groups.

What do the results of this large study really tell us? Wearing a lace-up ankle brace is effective in reducing ankle injuries in high school basketball players regardless of age, sex (male or female), or body mass index (body weight for size). The protective effect of this simple device also helps athletes who have already had a previous ankle injury from reinjuring that ankle again. This is good news since ankle reinjury is a common problem in athletes.

There are plenty of other factors to consider when trying to reduce the number of ankle injuries. Type of shoes (low-, mid-, or high-top) may make a difference. Player compliance in wearing a brace could be a key factor. The role of neuromuscular training has also been explored by other researchers and should not be ignored. But it looks like you have taken on an important problem and started with an approach that has some evidence to support it.