FAQ Category: Ankle

Blood injection therapy is a medical treatment being used for a wide range of musculoskeletal problems. It is also referred to as platelet-rich plasma (PRP) therapy because a sample of serum (blood) plasma that has much more than the normal amount of platelets is used.

Blood is taken from the patient and prepared for use by removing the platelets and injecting them in a higher concentration into the damaged area. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Recovery time may vary depending on the area of the body affected. In the case of the Achilles tendon, this particular tendon does not heal well. It takes a long time to recover from an Achilles tendon rupture. And the risk of rupturing it again is fairly high. For all those reasons, finding a more effective treatment with better long-term results would be a great boon to all.

Post-operative care for a repaired ruptured Achilles tendon is fairly standard with or without platelet-rich plasma (blood) injections. The patient is placed in a short leg cast (below the knee but covering the lower leg, ankle, and foot). The foot and ankle are placed in a slightly plantar flexed position (toes pointing down).

This position takes pressure and load off the healing Achilles tendon. After three and a half weeks, the foot and ankle were re-cast in a more neutral position. At the end of seven weeks post-op, usually no further casting is needed. Patients wear shoes with a slight heel (again to avoid overstretching the healing tendon) for a month.

During all this time, they are allowed to put as much weight on the leg and foot as they can comfortably tolerate. When all casting is completed, a physical therapy rehab program comes next. The therapist helps patients regain normal motion, sensory awareness of joint movement, and strength. A major part of the recovery process involves a home exercise program.

Activities are progressed according to each patient’s abilities and response to treatment. You’ll move through toe raises and balance exercises to jumping and jogging activities. Sports athletes report being back at full capacity in their sport of choice by the end of five months.

If the university where you are having treatment is running studies on the use of platelet-rich plasma for Achilles tendon healing, they may have some data collected that offer more specific timelines for you. Be sure and ask them the same questions you posed here and good luck!

Diagnosis of joint implant infections after hip replacement can be difficult. The bacteria can hide in many nooks and crannies of the joint. Efforts have been made to provide surgeons with guidelines to aid in the diagnosis of periprosthetic (around the joint) infections.

In fact, in 2010 the American Academy of Orthopaedic Surgeons (AAOS) published what they call Clinical Practice Guidelines (CPGs) for the diagnosis of such infections. Here’s a quick summary of the 15 guidelines. This information should give you a spring board for talking with your surgeon.

Anyone suspected of a periprosthetic joint infection (PJI) should be screened using two tests: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

The use of platelet-rich plasms (PRP) as a potential treatment for tendon and ligament healing is fairly new. Scientists have discovered that human blood contains key ingredients for healing. The plasma portion of human blood (the clear liquid) has parts called components that may come to our aid.

In particular, tiny platelets circulate every minute of every day in the blood — they are always there in case of an injury. Platelets help form blood clots to stop bleeding. When the body signals that there is a need for platelets, they become activated and rush to the area of injury. Once there, they clump together to form a clot and then release tiny chemicals called growth factors.

It’s those growth factors that turn stem cells into tendons. Stem cells are basic cells that haven’t formed a specific type of cell (e.g., heart, muscle, joint, organ). The body can turn a stem cell into any kind of cell needed including tenocytes (tendon cells).

Injecting blood plasma with its rich supply of platelets into a damaged tendon has been shown to stimulate the growth of new tendon cells. But there are more things we don’t know about it than things we do know about it. We know that it does help soft tissues like tendons and ligament heal. Scientists are still trying to unravel the ‘why’ and the ‘how’ of it.

There aren’t a lot of studies out yet to give us an answer for your particular situation that is certain. Some studies have shown that a single injection may not be enough to get the healing response needed.

There’s a difference between making more tenocytes (tendon cells) and having enough that are strong and able to withstand mechanical forces placed on the area when walking, running, or jumping. In other words, more may not be enough unless there is mechanical strength to the new cells.

And it’s clear that platelet-rich plasma needs a place to hang its hat. Just injecting this solution into the damaged area without a scaffold for it won’t work either. The cells need a place to cling to — without such a place, the cells dissipate or scatter and disappear without the intended effect.

With only one injection behind you, it may be time to head back to the physician treating you and see what is the next step. It could be that a series of injections is planned and you’ve only completed the first step. Or perhaps a different dosage of platelet-rich plasma is needed for the type of healing your Achilles tendon needs.

This is a new treatment that probably won’t always work 100% in every patient the first time. Until we know who is likely to benefit the most and what dosage is needed for each type and degree of injury, it’s likely that some trial-and-error will occur.

Tendons and ligaments don’t heal quickly even in younger adults. The healing response is complex and involves several stages or phases of repair. The body can’t just conjure up new tendon tissue and send it to replace the damaged tendon.

First, the innate healing wisdom of the body calls for more tendon cells called tenocytes. While that is taking place, a special scaffold is prepared at the injured site. The scaffold is like a trellis that flowers or vines cling to and spread to fill in all the spaces. Only in this case, its the new tissue that is being deposited on the scaffold.

And once healed, the tissue just doesn’t have the elasticity and spring of muscles. Once they are torn, the injured area tends to fill in with scar tissue. And as you might suspect, scar tissue is firm to hold but doesn’t have much give to it. That means the area is at increased risk for reinjury — especially if it is stressed with too much load before it is ready.

Many athletes of all ages experience tendon injuries. That’s why efforts are being made to find ways to speed up and enhance the healing process. Scientists have discovered that human blood contains key ingredients for healing. The plasma portion of human blood (the clear liquid) has parts called components that may come to our aid.

In particular, tiny platelets circulate every minute of every day in the blood — they are always there in case of an injury. Platelets help form blood clots to stop bleeding. When the body signals that there is a need for platelets, they become activated and rush to the area of injury. Once there, they clump together to form a clot and then release tiny chemicals called growth factors.

It’s those growth factors that turn stem cells into tendons. Stem cells are basic cells that haven’t formed a specific type of cell (e.g., heart, muscle, joint, organ). The body can turn a stem cell into any kind of cell needed including tenocytes (tendon cells).

The use of platelet-rich plasma injections into torn or damaged tendons isn’t in routine use yet. In any case, Achilles tendon ruptures do take time to heal. We’re not even sure yet whether it’s best to surgically repair the torn tendon or follow the old-fashioned method of letting it heal on its own by following a nonoperative approach (rest, heel lift, nonweight bearing standing and walking).

If you are under a physician’s care for your injury, the rehab process can be between six and 12 months for this type of injury. It’s best to let an orthopedic surgeon guide you through the process. In this way, you’ll know how to protect the healing tissue and avoid reinjury.

You are right in thinking that the word “sprain” doesn’t adequately describe the type of damage that is present with a high sprain. But to fully appreciate what’s going on, a little anatomy review might be helpful.

A high ankle sprain refers to tearing of the connective tissue that connects the lower part of the tibia to the fibula. The tibia is the larger of the two bones in the lower leg. Your shin is the front of the tibia.

The fibula is the smaller bone (along the outside of the leg). Syndesmosis is the name of the connecting tissue between these two bones. Another word used to describe high ankle sprains is syndesmotic.

The syndesmosis is actually more than just a single layer of connective tissue between the tibia and fibula. That’s certainly part of it but there are also four strong ligaments involved (anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, interosseous ligament, transverse tibiofibular ligament).

When surgery isn’t needed, a plan of conservative (nonoperative) care is suggested. A three-phase rehab program is made up of 1) the acute phase, 2) subacute phase, and 3) advanced training phase. Each phase has its own goals, treatments, and criteria for progression (moving along to the next phase or getting back into sports participation).

Every athlete is evaluated individually in order to determine the best treatment approach. Once the three-phase program is tailored for the athlete, the therapist carefully monitors symptoms, concerns, goals, and each part of the program.

In the acute phase, the goal is to protect the joint and decrease symptoms, especially pain, swelling, weakness, and loss of motion. A variety of tools are used to accomplish these goals such as immobilization in a cast or brace and limiting weight-bearing if needed. Modalities such as ice, compression, electrical stimulation, manual therapy, and/or complementary therapies (e.g., acupuncture) may be used.

When the patient can walk with minimal difficulty on different types of surfaces (uneven ground, stairs, grass, curbs), then they are progressed to the subacute phase. Now the goal is to get normal joint motion, strength, and motor control back.

The early phase of a strength-training program is started during the subacute phase. The foot and ankle will be challenged with balance activities (e.g., rocker board, wobble board, air cushion). A foot cycle, aquatic therapy, ankle weights or elastic resistance, and weight machines are just a sampling of the many ways training continues.

Advanced training is begun when the athlete can jog and hop with little discomfort and can perform all daily activities. The goal, of course, is to get back into sports action. Running, hopping, figure-8, and jumping drills are an important first step in the advanced training series of exercises.

The athlete will progress through advanced strengthening, plyometrics, speed drills, and running patterns. Plyometrics involve making fast changes with momentum (speed). This is kept up until they can perform sport tasks at game speed without pain or discomfort. Correct movement patterns and quality motor control are also required. That’s when they are released to return to full participation in whatever sport they want to participate in.

This progression from acute phase to return-to-sports can take anywhere from weeks to months. Each athlete should be prepared to make a concerted effort to get back into shape before setting foot on the basketball court, football field, soccer field, or as in this case, the ice rink.

A high ankle sprain refers to tearing of the connective tissue that connects the lower part of the tibia to the fibula. The tibia is the larger of the two bones in the lower leg. Your shin is the front of the tibia.

The fibula is the smaller bone (along the outside of the leg). Syndesmosis is the name of the connecting tissue between these two bones. Another word used to describe high ankle sprains is syndesmotic.

The syndesmosis is actually more than just a single layer of connective tissue between the tibia and fibula. That’s certainly part of it but there are also four strong ligaments involved (anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, interosseous ligament, transverse tibiofibular ligament).

With that much ligamentous support, you can imagine the kind of force it takes to tear them. Most of these high ankle sprains occur when the player collides with another player or gets hit with enough speed and force to fracture one or both of the bones and the ligaments. In all cases, the foot is planted on the ground while load is applied above the ankle.

A similar mechanism (pathway to injury) occurs in skiers or skaters who have the foot planted firmly, then twist or torque suddenly. Pressure applied along the top of the rigid boot from the sudden force is enough to tear the stabilizing soft tissues (ligaments and connective tissues) just described.

Without a normal, healthy, intact syndesmosis, the ankle becomes unstable. Of course the athletes who need a stable ankle the most are the very ones who injure this area: ice hockey players, soccer players, and football and rugby players.

Recovery takes time. As the tissues are healing, the skater (or other injured athlete) must be careful not to strain or overstrain the injured area. A carefully controlled and monitored rehab program is usually supervised by a physical therapist. Unless you hear differently, most likely, the skater is off the ice for the rest of the season.

Footballer’s ankle is also known by the medical term: medial ankle impingement. Medial refers to the side of the ankle closest to the other leg. The term “impingement” always tells us something is getting pinched.

With footballers ankle or medial ankle impingement, there are often bone spurs (osteophytes) on opposite bones that form the ankle (talus bone in the foot and tibia in the lower leg).

With certain movements of the ankle (e.g., dorsiflexion or moving the ankle toward the face), the opposing bumps of bone butt up against each other, stopping motion. Sometimes the deltoid ligament gets caught between the two bone spurs, another example of impingement.

Typical symptoms of impingement include ankle pain, a clicking sensation when moving the ankle, and loss of ankle motion. One other factor in the development of medial ankle impingement is a foot deformity called cavus. Cavus means high arch. The high arch is accompanied by a shift in the foot, which contributes to the problem.

What can be done about this problem? First, the cavus foot can be treated with a special shoe insert called an orthotic. This firm piece of plastic is molded in such a way to support the arch in a slightly lower position than normal for that person. Dropping the arch down this way helps realign the ankle and foot and may help resolve the impingement problem.

For patients who have an unstable ankle, bracing may be necessary. And for those who don’t get better with orthotics or bracing, surgery to remove the bone spurs and any loose pieces of bone or cartilge may be needed.

The surgeon may tighten up loose ankle ligaments at the same time. In all cases, a reduction in exercise helps decrease the symptoms. And the reverse is also true: increased exercise makes things worse.

Results are usually very good and most people can get back to their daily activities fairly quickly. Athletes can anticipate a return to full sports participation in time. It will probably always be necessary to use at least the shoe orthotic if there is a cavus foot present. Supporting the foot in proper alignment may help prevent the bone spurs and resulting problems from coming back.

Athletes involved in running and jumping sports can develop a condition called footballer’s ankle or medial ankle impingement. Medial refers to the side of the ankle closest to the other leg.

Typical symptoms include ankle pain, a clicking sensation when moving the ankle, and loss of ankle motion. These symptoms are the result of “impingement”. The term “impingement” always tells us something is getting pinched.

In cases of medial ankle impingement, there are bone spurs (osteophytes) opposite one another (hence, the term “kissing osteophytes”). With certain movements of the ankle (e.g., dorsiflexion or moving the ankle toward the fact), the opposing bumps of bone butt up against each other, stopping motion. Sometimes the deltoid ligament gets caught between the two bone spurs, another example of impingement.

Football players aren’t the only ones who can develop this condition. Other athletes engaged in sports like basketball, soccer, distance running, and gymnastics have developed medial ankle impingement. Most of the affected individuals have a subtle (mild) cavus foot (high arch). Changes in foot position after nonsporting injuries such as ankle and foot fractures can also lead to medial ankle impingement.

Treatment is usually quite successful for this problem but it may mean surgery and time in recovery. Most athletes are able to get back into action and return to full participation in their sport(s).

The cost of ankle sprains and repeated (recurrent) sprains is the focus of a recent study from The Netherlands. Though this comes from across the ocean, the information is still very easily applied to the American population as well.

Everyday 23,000 Americans sprain their ankles. The cost in terms of work absenteeism, lost productivity, and medical expenses is in the millions each year. With health care reform being a hot topic these days, researchers are turning their focus and attention on finding ways to cut costs.

One of those ways is to prevent re-injuries like ankle sprains. Early efforts to investigate this particular problem has shown that a program of proprioceptive training can reduce the risk of repeated ankle sprains by 50 per cent or more.

Proprioceptive exercises are designed to restore the joint’s sense of position change. Finely tuned proprioception is important so that the foot and ankle respond to tiny changes in position.

Good proprioception allows the ankle to readjust its position when you walk on uneven ground, step on a rock, or get pushed off balance suddenly. Without an accurate sense of position, the ankle may twist or rotate too far in one direction before pulling back. And by that time, it’s too late and another sprain has occurred.

Ankle rehab has a major role in restoring normal joint function. A physical therapist can help you regain proprioceptive sense, motion, and strength. Specific training for balance, postural control, and proprioception is essential. To avoid further sick leave, you can ask the therapist for a home program to work out on your own as much as possible.

That’s a very good question. Studies have shown that proprioceptive training to help the joint regain its finely tuned sense of position does help prevent repeated ankle sprains.

But preventive measures such as taping, bracing, and proprioceptive training don’t seem to help with first time sprains. These approaches seem to work best for those individuals who have already sprained their ankles at least once.

That’s not to say ankle sprains can’t be prevented. Researchers haven’t found a foolproof method yet, but proper shoe wear, good postural alignment, and muscle strengthening may help. Flexibility is also considered important, so including a stretching program may be a good idea. Balance work makes up the final piece of prevention.

We are far from knowing everything that would help us predict who might be at risk for ankle sprains. But with the large numbers of people (from children to older adults) engaged in sports activities, injury prevention is becoming the focus of more and more studies.

It may be best to just do what you can to follow your doctor’s advice and return to work as soon as you are released to do so. Trying to educate employers who are already convinced that employees out on Workers’ Compensation are taking advantage of the system can be a difficult task.

There is some evidence that Workers’ Compensation patients are treated differently than patients on standard health insurance. The differences may be the result of government and legal requirements. Patients like yourself are ready to have surgery but surgeons know they must document everything more carefully with more tests.

Sometimes letters of justification must be written by the surgeon. Or a letter of approval from the employer’s risk management firm may be necessary. In some cases, a second opinion is required by the Workers’ Compensation board. All of this adds to the time between diagnosis and treatment and can make it look like the patient is the problem when in fact, the system is the culprit.

As you might expect, ankle sprains are the most common injury in athletes and people who participate in competitive sports. That may describe your son, but probably isn’t as likely with your neighbor or your 85-year-old mother.

We don’t know a lot about ankle sprains in the general population. But a recent study looking at records from emergency departments reported ankle sprains as accounting for two million patient visits to the hospital. That translated into two billion dollars worth of costs.

After digging a little further, they found that men and women sprain their ankles in equal numbers. Some specific age patterns are evident: there is a peak incidence of ankle sprains in women over 30 and men between the ages of 15 and 24.

Ankle sprains occur most often during athletic activities, in particular, during basketball, football, and soccer (in that order). Athletes involved in other sports such as gymnastics, volleyball, and running are also at increased risk of ankle sprains.

Not too surprising is the fact that the peak of sprains occurs in children between ages 10 and 19 as a result of sports, athletics, or other physical activity. But half of all ankle sprains occur while people are at home from falls on stairs or a stumble on a ground-level surface.

There may be other important factors that haven’t been identified or linked yet with ankle sprains. For example, there may be an important role of race, obesity, anatomy, or nutrition. Any one of those could be a common factor for the three people you mentioned. Or, as you suggested, it could be completely coincidental.

But by identifying risk factors, health care professionals hope to be able to reduce the numbers of people experiencing this potentially disabling injury. Finding a way to prevent ankle sprains will be the focus of future studies. Stay tuned!

You might be interested in the results of a recent epidemiologic study. An epidemiological study is one that looks at the patterns of health and illness. By looking at who sprains their ankle, it is possible to identify associated risk factors with the idea of preventing the problem.

Every year two million Americans suffer an acute ankle sprain. About half of those people hurt themselves during an athletic event — but not everyone. The other half were ordinary men and women.

And these figures don’t even represent the numbers of teens and adults who see their primary care physician for an ankle sprain. And they certainly don’t represent the numbers of people who don’t see anyone but just try and treat it themselves. The lack of health insurance (a hot topic in the U.S. right now) may be a factor as well.

The economic (health care) cost of ankle sprains each year in the United States is two billion dollars! And that doesn’t even include the cost of time lost at work, loss of productivity on-the-job, or the cost of long-term disability.

Ankle sprains is a great topic for your presentation since this is one of the most common musculoskeletal injuries around. Given the large numbers of people of all ages who have had an ankle sprain, you probably won’t have any trouble drawing a crowd. we hope this information will help. Good luck!

Many surgeons work with a decision-making tree referred to as an algorithm. In the case of ankle pain, it’s important to determine the cause before assigning a specific treatment.

Getting weight off the joint and giving it time to heal is a wise first step for many problems. In the case of damaged joint cartilage, there isn’t a good blood supply to the area, so healing can be delayed if it occurs at all.

Damage to the cartilage can cause fissures (cracks), pits, holes, and even displace fragments of cartilage. Depending on how deep, wide, and long the lesion is, the osteochondral (bone and cartilage) defect is classified as stage one through four.

X-rays, MRIs, and CT scans each have their own grading scale but the end-result is a diagnosis that is used to determine the most appropriate treatment. With mild (early stage) disease, it may be possible to treat the problem conservatively with nonoperative care (rest, immobilization in cast or splint). Deep fissures or displaced fragments require more extensive surgical procedures.

If the OLT is free of cysts, then a simple debridement (smooth the area, remove frayed edges) may be all that’s needed. Another treatment option early on is called microfracture — after debridement, the surgeon drills tiny holes in the area of the defect down into the bone. This stimulates bleeding and a healing response.

For larger defects (or for any size defect that doesn’t respond to a more conservative approach), the lesion is filled with graft material. The donor graft may come from a bank (allograft) or from the patient (autograft).

Reconstructive procedures are not 100 per cent guaranteed. When patients fail to recover after arthroscopic procedures, it may be necessary to perform a second operation — this time with an open incision. Again, the selection of which approach to use depends on the type of lesion and stage.

Some problems just can’t be treated with reconstructive procedures. That’s when an ankle fusion or joint replacement might be more appropriate. But fusion or replacement are the end points on the algorithm and you are just at step one. Follow your surgeons directions carefully and you should have a good result with the early conservative care outlined for you.

Your daughter may have a condition referred to as ankle impingement. Impingement is another word for “pinching”. This is a fairly common problem among athletes of all kinds, including gymnasts.

Most of the research indicates that surgery to remove the offending tissue is really the only answer. Putting it off only delays the inevitable and can potentially create additional problems.

X-rays and/or MRIs are needed to identify the source of the problem. This helps the surgeon plan the specific steps needed in surgery. Sometimes there are bone spurs called osteophytes that form along the joint line. Every time the foot and ankle move, the extra bone jams up against the joint preventing full motion. T

here can also be an overgrowth of joint synovium (lining with fluid to give smooth movement of the bones) called synovial hyperplasia. And in some cases, the Deltoid ligament of the ankle gets folded over and pinched between two bones.

No amount of rest or conservative care will get rid of the underlying cause of the problem. Most dancers, gymnasts, and athletes with ankle impingement aren’t willing to give up the extra six to eight weeks required for a nonoperative approach. Most surgeons don’t recommend delaying surgery given all the studies that show the unsuccessful results to conservative care.

Ankle pain from impingement in athletes of all kinds is a fairly common problem. Early recognition and treatment of the problem is ideal. Surgery to remove any scar tissue, overgrowth of synovial tissue in the joint, and bone spurs is the gold-standard of treatment.

Basically, all tissue preventing ankle dorsiflexion (motion of pulling toes and ankle toward the face) is resected (trimmed, cut, or shaved away). The surgeon will examine the joint and surrounding soft tissues for signs of any other injuries. Any damage will be corrected at the same time the impingement is taken care of.

Most athletes are back in full action after this type of surgery by the end of 13 weeks (some as early as seven weeks). There can be complications (infection, temporary nerve injury, excess scar tissue formation) that can delay return-to-sports. Some athletes needed additional ankle surgery later for other problems.

Every surgeon knows that sometimes the risks of surgery outweigh the benefits. And the biggest reason for this is because of a little thing we call risk factors. By studying who has a good outcome and who has poor results after any procedure, it’s possible to predict who will do well and who won’t.

Some of the most common risk factors that have the potential to disrupt healing or contribute to post-operative complications are known. These can include patient factors such as age, sex (male versus female), body-size ratio called body mass index, general health, and the presence of conditions such as diabetes.

In other cases, surgical factors are more likely to increase the risk of problems developing. Length of time in the operating room, type of incision used, size of implant, type of surgical procedures used are examples of intra-operative risk factors.

In the case of a total joint replacement for the ankle, the presence of inflammatory conditions (e.g., rheumatoid arthritis) is an important risk factor for infection. And infection is the surgeon’s number one fear after joint replacements because it can destroy the joint.

Given the fact that surgeons do, indeed, like to do surgery, if both surgeons declared you aren’t a good candidate for an ankle joint replacement, you would probably be better off exploring other treatment options.

Surgeons know that replacing the ankle joint (a procedure called total ankle arthroplasty or TAA) is more successful for some patients than for others. This particular operation requires selecting patients carefully for the best outcomes.

There are all kinds of potential reasons why one patient might develop complications (such as infection) while others do not. Factors such as age, sex (male versus female), body-mass index (BMI), and general health may make a difference. Some studies show results are compromised most often when the patient has rheumatoid arthritis.

In a recent study from Thomas Jefferson University Hospital in Philadelphia, the orthopedic surgeons were interested in narrowing down risk factors associated with complications following total ankle arthroplasty. They specifically focused just on wound infection of the incision used to open the ankle up. By doing a retrospective (looking back) chart review of 106 patients, they were able to see who had problems and why. This information might help you understand your own situation.

The authors collected, compared, and analyzed data recorded in their patients’ charts. For example, they looked at implant size, the use of medications, smoking (tobacco use) status, and type of sutures used to close the wound. They also separated the patients into three basic groups based on severity of complications. They compared the presence of each of these factors based on which group the patients were in.

The first group had no wound complications or only mild/minor problems with the healing incision. Group two had minor complications that could be easily treated with local care and possibly some oral (taken by mouth, usually in pill form) antibiotics.

The most difficult and severe group (group number three) had major complications that meant having another operation. The second procedure could be as simple as returning to the operating room and cleaning the joint out, a procedure referred to as irrigation and debridement. More complex operations might include removing the implant or even amputation (removing the foot).

As it turns out, the main difference between the groups with no complications or only mild complications and the group with major complications was the presence of diabetes mellitus. The biggest threat to healing without complications was the presence of rheumatoid arthritis (RA). In fact, patients with RA were 14 times more ikely to develop severe enough complications at the incision site to require another operation.

Why is rheumatoid arthritis such a big problem? It is an inflammatory condition that is often treated with medications that suppress (decrease) the immune system’s response. So any bacteria present at the surgical site aren’t always taken care of by the immune system. They can quickly mount an attack on the body. With limited immune capability, the body can’t fend off the growing bacteria and a full-blown infection breaks out.

Extrasynovial means the problem has to do with synovial fluid being outside of a joint. Synovium is the fluid that keeps the joints lubricated and moving smoothly. It is a viscous (slippery) membrane that lines the cartilage (cartilage covers the bone).

Normally, the synovial fluid stays inside the joint. Any synovial fluid outside the joint is considered extrasynovial. Now for osteochondromatosis: osteo refers to bone, chondro is the cartilage, and osis at the end of a word just tells us something is wrong. In this case, the synovium has started to proliferate or grow too much.

It clumps together with the cartilage forming small nodules that eventually harden. These tiny osteocartilaginous (bone and cartilage) bodies can stick to the synovium inside the joint. They can also move outside of the joint and become loose bodies floating around the various bones that form the ankle joint.

No one knows for sure why the synovium starts to overgrow. There is often a history of trauma or injury to the joint involved. But it can happen spontaneously, too. Sometimes the body breaks down and absorbs these tiny masses. In other cases, they get stuck between two bones or embedded in a tendon. The clinical picture is one of pain, loss of motion, and a joint that locks up with movement.

Synovial osteochondromatosis occurs in three phases. First, there is the overgrowth of the synovium, the slippery fluid that keeps your joints moving smoothly. Next, the extra synovium begins to form bumps and lumps that can stick to the cartilage. And finally, these masses can break loose and move out of the joint.

What happens over time is called the natural history of a condition. In the case of synovial osteochondromatosis, the body can break down and absorbs these tiny masses. Most of the time, they interfere with motion and have to be surgically removed. Whether they are resorbed naturally by the body or surgically removed, osteochondral masses can grow back.

They can even become malignant. That only happens about five per cent of the time but it’s something to watch out for. No one knows why this transformation from benign mass to malignant tumor (chondrosarcoma) occurs. There isn’t a way to predict who might develop a malignancy. That’s why the masses are removed and then observed closely afterwards.