The Advantage of Conservative Care for Achilles Tendon Rupture

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.

In this meta-analysis, the authors combined the results of 10 studies that measured the same things. 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.

These patient outcomes were compared between early range of motion and bracing (the conservative care) and surgery. This type of conservative care is referred to as functional rehabilitation. It is not offered at every health center so the results of this study are especially important if it should be.

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.

The first important finding is the risk of complications other than rerupture with surgery: 15.8 per cent higher with surgery compared with conservative care. 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.

Best Surgery for Unstable Ankle Sprain

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, 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 the authors of this study came up with a new hybrid technique to reconstruct the torn ligaments in the ankle.

As the name suggests, they took two different surgical procedures and combined them together to create this new approach. The goal was to provide a more anatomic repair with fewer problems. These surgeons recognized the need to reduce problems with donor sites, position the graft with correct anatomic alignment, and avoid weak suture anchors that often pull-out easily before healing has taken place.

This hybrid procedure involves the peroneus longus tendon. They take one-third of the diameter of this tendon and transpose 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 athletes in getting back into action on the playing field.

They tested this procedure on 57 patients ranging in age from 17 to 65. Everyone was followed for at least a year. Data is available for some patients who were in the study for up to four years. Clinical tests of ankle joint mechanical stability were done (e.g., anterior drawer test, valgus stress test, Romberg balance test). Patients answered questions about pain, motion, activity, and function.

At six weeks postop, patients were able to put their full weight on the ankle. Physical therapy began at that point. By 10-weeks after surgery, patients were started on sports-specific drills. At the end of one-full year, everyone had a mechanically stable joint. But 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.

These individuals were mostly recreational athletes who chose not to return to a preinjury level of sports participation. They were worried about reinjuring themselves more than aware of any true instability. Follow-up MRIs showed tendon remodeling in the donor graft but also some signs of joint changes that could eventually lead to arthritis. Long-term follow-up is intended in order to further evaluate outcomes.

The surgeon who performed all of these procedures summarized this article in two ways. First, he said that the reconstructive surgical technique for chronic, unstable lateral ankle sprains (known to surgeons as the Broström-Gould procedure) remains the gold standard. This new hybrid approach proposed and tested out is useful when the anterior talofibular ligament (ATFL) is too short to use, too frayed or damaged, or missing altogether.

In all cases, the decision to use this modified technique wasn’t made until the surgeon was able to use an arthroscope and look inside the joint to see how much and what kind of damage was present. Quality of the ATFL was the determining deciding factor. Arthroscopic examination also made it possible to see if there were areas of joint capsular or synovial thickening, a sure sign of chronic instability.

For surgeons who are interested, the article contains a series of drawn figures demonstrating the necessary steps in this hybrid procedure. Incision point, access to the tendon graft, drill holes in the bone, attachment of the graft, and layering of the soft tissues over the graft are shown. A written step-by-step description is also provided. Functional rehabilitation under the supervision of a physical therapist is strongly advised.

Understanding End-Stage Ankle Arthritis

Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. So say researchers at the VA Medical Center in Seattle Washington. Researchers from the Mechanical Engineering and Orthopaedics and Sports Medicine centers at the University of Washington assisted in this study.

They studied 37 patients (men and women) who were expected to have ankle surgery for severe arthritis classified as end-stage arthritis. All patients in the study had failed to achieve pain control or improved function with conservative (nonoperative) care. Surgery to either fuse the ankle or replace it was scheduled.

The purpose of the study was to measure the impact of this type of ankle arthritis on function referred to as impairment of function. They used several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements were compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems.

Some of the considerations in this study were the fact that many of the patients developed severe ankle arthritis as a result of a traumatic injury. And they were younger than the typical older patient who develops degenerative arthritis as a result of the aging process.

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 were answered by this study. But the researchers at least got a start on evaluating which tests and measures provide the most information about function and activity limitations. And they began to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients.

Analysis of the data showed that everyone had decreased ankle motion and power compared to the unaffected side. Average walking speed, number of steps taken each day, and length of steps were less than those of normal (control) adults. These measures were also correlated with physical function. Just moving around a room took more energy, more steps, and more time compared with normal, healthy adults. Those patients who had better physical function also had less pain and a better mental attitude.

In summary, the tests used in this study did help identify problems with ankle motion and function. It is likely that these same measures could be used in future studies. They could be used before and after treatment to see the effects or value of each treatment provided.

Rare But Important Ankle Injury

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 and is the topic of this article from Germany.

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.

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.

A relaxed tendon is more likely to remain in the groove. Any active movement of the ankle will force the tendon out of its protective tunnel. If the ankle is relaxed and the tendon is repositioned correctly at the time of the imaging study, then diagnosis can be delayed. Dynamic ultrasound tests are the best diagnostic tests because they will reveal the movement of the unstable tendon.

Since this problem is rare, not much is known about the best way to treat it. That’s why the authors decided to offer their advice on how they handle this injury. They suggest 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 must be careful not to destroy or disrupt the smooth gliding surface of the bone that helps form the retromalleolar groove.

The authors provide a detailed description of their own preferred surgical treatment for peroneal tendon instability. The retinaculum is repaired or reconstructed depending on the severity of the damage. Incision shape, drill holes, suture type and placement, and method for protecting the groove surface are discussed. Photos of each step in the surgical procedure are provided.

In summary, traumatic displacement of the peroneal tendons is a rare but painful complication of some lateral ankle sprains. Pain and swelling may mask the presence of this problem at the time of the injury with a delayed diagnosis. A careful examination with tenderness palpated over the torn retinaculum is the best way to accurately identify the injury. Treatment is usually surgical with the author’s own preferred treatment presented.

Return to Sports After Osteochondral Autologous Transplantation of the Ankle

In this study, surgeons measured the frequency, intensity, and sports choices of recreational sports athletes following bone grafting for an ankle injury. In all cases, the athletes had sprained their ankles with an associated bone lesion.

Ankle sprain with an osteochondral lesion refers to a sprain severe enough to cause a piece of cartilage and bone to detach. In these patients, the talus ankle bone was the area of specific injury.

Treatment was with a bone graft from the ipsilateral knee to the talus bone of the ankle. Ipsilateral means the bone graft was harvested from the knee on the same side as the injured ankle. The donor bone is carefully shaped to fit the defect or hole in the talus bone.

Patients were selected for this treatment technique with the following risk factors 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.

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).

In this study, 131 young, active adults engaged in recreational activities and sports were included. After the osteochondral autologous transplantation (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 suggest 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. Surgeons should select patients carefully for this procedure keeping risk factors (especially obesity) in mind.

Surgeons Try Hyaluronic Acid Injection for Ankle Osteoarthritis

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. 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 injection with saline?

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.

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.

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.

The authors did discuss why hyaluronic acid injections seem to work so well for some patients with knee osteoarthritis but these patients with ankle arthritis didn’t get the same improvements. 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.

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

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, the authors recommend further study to find new types of nonsurgical treatment for ankle osteoarthritis that are cost effective and economical.

How Do Patients Rate Ankle Replacements?

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 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) 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.

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.

In summary, 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, 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.

Planning Health Care Services to Treat Foot and Ankle Pain

Ever see someone shuffling along without picking up their feet? Wonder what’s wrong with that man or that woman in a wheelchair or on a scooter who looks perfectly able bodied? In fact, the body may be fine but it’s the feet that are the problem. And without healthy, pain free feet and ankles, it’s plenty hard to get around easily.

Health care professionals such as podiatrists, physical therapists, and orthopedic surgeons are very aware of just how common foot and ankle pain has become in the adult population. And it’s not just the very old but also the middle-aged groups.

To find out just how prevalent (common) the problem of disabling foot and ankle pain has become researchers conducted a systematic review. They pooled together the data from eight comparable studies to get an estimate on prevalence, severity, and demographics associated with this condition. This is the first study of its type (an epidemiologic study) for this particular problem.

Epidemiologic studies provide a broad spectrum of information about conditions in order to direct or expand health care resources. The data gathered helps identify how many people are affected, where they are located geographically, and what these folks are like (age, gender, occupation, education level). The information is then used to target people at risk in hopes of preventing the problem or at least preventing disability from the pain.

The authors actually ran into a bit of trouble finding enough high-quality, comparable studies for this review. Just being able to define “foot and ankle pain” was a challenge. The ankle-foot complex has many parts (bones, joints, ligaments, tendons, muscles) and locations (top, bottom, inside edge, outside edge, toes, forefoot, hind foot, ball, heel, arch). It was difficult to find consistency in exactly which part of the involved foot and ankle was studied and reported.

Then the problem of categorizing pain was quickly obvious. If the pain isn’t present on the exact day the study was conducted but the person has been having pain, does it count? How do researchers compare occasional pain with constant pain or mild versus severe pain? Location, frequency, intensity, duration, and timelines for pain are all important variables. This is why they only ended up with eight useable studies out of the initial potentially relevant 6,261 studies published on foot and ankle pain.

Even so, the authors were able to drill down through the material and come up with some interesting findings. First, there was an overall prevalence of foot/ankle/toe pain in 20 per cent of the adult population. That’s one in five people.

In general, there was a greater prevalence of foot/ankle/toe pain in people aged 45 and older. And it turns out that foot pain is a bigger problem than ankle pain. The forefoot and toes seem to create the greatest pain and dysfunction. By age 50, over 50 per cent of the people polled reported disabling foot pain. Disabling pain refers to significant enough discomfort as to interfere with daily activities.

Women were more likely to report pain. That’s not surprising since fashionable footwear often includes narrow shoes and high heels, which have a distinct affect on the feet. But there’s more to it than just fashion footwear. As we get older, our feet tend to spread out and get wider. But shoe manufacturers have not altered shoes to accommodate for this change. And many people continue to wear the same size they have always worn putting up with the discomfort of a too-small or too-tight shoe rather than admit they need a larger size.

The conclusion offered from this systematic review is that foot (and ankle) pain is a bigger problem than we imagined. Some reasons for this could be identified (e.g., footwear, anatomical changes associated with aging). It is possible that there is a correlation between foot pain and other musculoskeletal problems (e.g., knee, hip, or low back pain).

There is a need for further study in the future to get some agreement on what’s going on with foot and ankle pain in middle-to-older age groups and why it’s happening. Then we can address the need for more health care services directed at the feet and identify what those services should be to best serve our seniors (or should we say our “middlers” and our seniors?).

Do Lace Up Ankle Braces Prevent Injury?

Physical therapists and athletic trainers working with high school football players are concerned about the high number of players benched because of ankle injuries. They conducted this 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.

Over 2000 football players from 50 high schools participated in this study. They were divided into two groups: those who wore a DonJoy 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. Two-thirds of the players were treated on the field while the remaining one-third was sent to the hospital or to a physician for follow-up.

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. 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.

Before coming to any conclusions, the researchers pointed out a few limitations in their study. The most notable was the fact that shoe brand and type (mid- versus high-top) could have made a difference in outcomes. The shoe as a factor in injuries was not investigated.

The second important limitation was the fact that other studies show neuromuscular training programs work well to prevent ankle injuries. The brace was not compared with this type of exercise program either directly (one against the other) or when combined together (brace plus neuromuscular rehab versus brace alone or rehab alone).

And a third consideration was the notion that an ankle brace reduces ankle motion and may increase the risk of stress fractures, low back injuries, or upper leg and hip injuries. These topics will be potential areas for future study.

The results of this study as it was designed and carried out can be summarized by saying lace-up ankle braces do reduce the number (but not severity) of acute ankle injuries in high school football players. The authors point out that there are financial savings to consider from this study.

Reducing the number of ankle injuries and especially the number of injuries that require hospitalization or medical care also lowers overall health care costs. With the high number of high school football injuries in the U.S. every year, this could add up to millions of dollars in savings.

Understanding the Frozen Ankle

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 the patient is in the early, mid, or late stage of the condition. If there’s been an ankle fracture, treatment begins with the lower leg being immobilized in an air splint or cast for six to eight weeks.

Physical therapy is a key feature of treatment in all stages of adhesive capsulitis but especially after immobilization. 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. The patient may be given an antiinflammatory medication or steroid injections. The patient is encouraged to keep moving the joint in order to maintain full joint range-of-motion. Of course, this type of treatment begins after the cast or splint has come off for those patients who fractured their ankles.

Failure to respond to conservative (nonoperative) care may mean surgery for that patient. 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.

As the author of this review on adhesive capsulitis of the ankle points out, most of what we know about the diagnosis and treatment of ankle adhesive capsulitis comes from our understanding of the same process in the shoulder. But adhesive capsulitis occurs far less often in the ankle than in the shoulder. Not that much is known or has been reported on this problem. This may be one of the first articles to address the problem.

More studies are needed to set up specific diagnostic criteria for ankle adhesive capsulitis. Likewise, evidence-based treatment needs to be developed. Treating a frozen ankle as if it were a frozen shoulder may not be the best approach. But we won’t know that until proper studies have been conducted and evidence presented.

Navigating the Complexity of Pilon Fractures

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.

Pilon fractures are 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.

But advances in surgical management are ongoing and in this article, orthopedic surgeons from the University of Missouri bring us up-to-date on this problem. Using X-rays, MRIs, illustrations, and written descriptions, the reader gets a clear picture of all that goes into the treatment of these fractures.

Surgical management begins with careful preoperative planning. Preoperative planning often requires assessing patient risks for success or failure of surgical management. For example, malnutrition, diabetes, tobacco use, osteoporosis (brittle bones), and alcohol abuse are key risk factors that can contribute to extra complications and poor results.

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.

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 around the fracture sites. Special surgical struts are often used to buttress metal plates and prevent deformities such as bone angulation and bone rotation.

Two key changes in today’s surgical routine are mentioned for pilon fractures. The first is the timing of the surgery. Timing also directly impacts the second factor and that is the amount of soft tissue injury that accompanies these high-energy injuries.

Surgery that is done too soon may compromise underlying soft tissue injuries that are not recognized in advance. Studies show that surgery performed too soon to fix the bone fractures actually results in much higher rates of complications with wound infections and poor wound healing. Amputation from nonunion of the fractures and deep infection are additional serious complications.

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.

How long should the surgeon wait then before attempting to repair the fractures? These authors recommend the following:

  • All bruising over the surgical site should be gone before cutting the leg open.
  • Fracture blisters and open fracture wounds should be healed without infection.
  • Swelling should go down enough to create a positive skin wrinkle test (skin wrinkles form at the front of the ankle when the patient moves the foot toward the face).
  • The typical waiting time from injury to surgery is between 10 days and three weeks.

    All of these guidelines are made even more difficult to gauge and follow when the smaller bone in the lower leg (the fibula) along the outside of the leg is also broken. If that occurs, then the surgeon must identify the optimum surgical timing and approach to repair both areas. Limb length depends on having both bones in the lower leg (fibula and tibia) lined up and working together.

    That brings us to the next decision moment for the surgeon: what surgical approach to take? Should the surgeon make the incision in the front (anterior) or back (posterior) aspect of the joint? Or should the first cut be made halfway between and on which side (inside or outside of the ankle)?

    Each approach has its own pros and cons, advantages and disadvantages. The location and severity of the fractures and presence and type of soft tissue damage will also affect the decisions made. The surgeon also takes into consideration the type of fixation that will be used. For example, metal plates take a different angle and approach than screws or pins.

    The more complex the problem, the more likely the surgeon will have to plan multiple surgical steps that may involve more than one approach. There has to be enough skin to cover the surgical site so that’s another consideration. And the health of the surrounding soft tissues can make a big difference in the surgical planning.

    On the plus side are the new and improved options for fixation. Locking plates that are preshaped to conform to the curve of the bones are now available. Another advance in surgery for pilon fractures is the ability to place some plates using a minimally invasive approach. The surgeon can actually slip the plate through the skin and put it in place with tiny incisions that don’t disturb already damaged soft tissues.

    Surgeons who are interested in details of outcomes reported with each surgical approach and fixation type will find the last section of this article of interest. Treatment comparisons and outcomes from studies already published are reviewed and summarized. The information is helpful but doesn’t provide a one-approach-fits-all guideline. Most of the studies have a small number of patients and final results are often measured differently from one study to the next.

    In general, there is a consensus from these studies that the final results of treatment for pilon fractures (regardless of the surgical approach used) vary greatly from patient-to-patient. It isn’t easy to predict who should have what type of surgery or to predict complications and outcomes. And surgeons are finding that having a perfectly lined up joint doesn’t always mean a pain free, full return-to-function result.

    Further studies to find ways to reduce complications and improve results are clearly needed. Surgeons can expect to see continued reports of new treatment strategies (or at least comparison of results for current surgical approaches). Having updated information will be helpful when dealing with the technically demanding nature of these injuries and need to consider so many different patient, injury, and surgery factors.

  • Getting Better Results with Ankle Joint Replacements

    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.

    The surgeons who conducted this study may have found the reason why improvement in ankle motion is small after joint replacement. 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.

    The axis of rotation depends on perfect talar alignment 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.

    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.

    The surgeons who performed these procedures and reported on them in this study intend to follow these 317 patients over time. They hope to evaluate the effect of the anteroposterior offset ratio on long-term outcomes. There may be other reasons why patients’ results aren’t satisfactory. These factors will be explored and investigated as well.

    And finally, with only 40 per cent of the group having a zero anteroposterior offset ratio, the authors hope to find ways to improve these results. As their study 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 implant alignment and mimicking normal biomechanics as much as possible is likely to yield the kind of results patients are looking for.

    Should Athletes Wear Ankle Brace to Prevent Sprains?

    This may be the first study to look at preventing ankle sprains (and other leg injuries) by wearing a soft, lace-up ankle brace. Ankle sprains may seem like a minor problem but they put many athletes on the bench every year. And the effects can catch up with you much later in life. Chronic ankle stability, decreased physical activity, and ankle osteoarthritis head the list of potential long-term effects of ankle sprain.

    Can a simple lace-up ankle brace really prevent ankle sprains? To find out, a group of researchers from the University of Wisconsin (Madison) enrolled 1460 high school athletes in this study. 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.

    Number and severity of all injuries affecting the lower extremity were recorded. This included ankle sprains, other ankle injuries, as well as knee injuries. An injury was defined as any event that caused the athlete to quit playing for 24 hours (or more). Severity of the injury was determined by the number of days the athletes couldn’t practice of play basketball in competition because of the injury.

    There were a number of other variables that the athletic trainers involved in the study kept track of. For example, player compliance with wearing the brace was recorded. The use of tape in addition to bracing was noted. Type of shoes (low, mid- or high-top) was included as well. As it turned out, everyone wore the same type of court shoes (mid-tops).

    There were a total of 265 injuries (all types). About 16 per cent of the entire group was affected. Most of the injuries were acute, traumatic (rather than slow and gradual). Basketball requires frequent stops, starts, turns, and cutting movements that increase the risk of acute injuries (especially of the knee and ankle). But handling the ball also lends itself to wrist, hand, and finger injuries. And falls resulting in head injuries (concussions) are also common.

    Of course the real interest is in knowing how many of the injuries occurred to athletes wearing the lace-up ankle brace compared with those who did not wear a brace. 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.

    The authors conclude by saying that future research is needed. First, to repeat these same results in athletes of all kinds. Then, to compare various bracing options to find the one with the best protective effects. Comparing bracing with and without a neuromuscular training program is also called for. And they plan on taking a closer look at the trend for other types of injuries of the lower extremity (leg) observed in this study.

    Treatment Alternative to Surgery for Ankle Arthritis

    What do you do if you have severe pain from an arthritic ankle and you aren’t a good candidate for surgery? You need relief from the pain and some way to improve function in that ankle. You are overweight and haven’t been able to lose it. Or you’ve tried antiinflammatories but couldn’t tolerate the side effects and exercise helped but not enough. On the other hand, what if you are accepted for surgery but you don’t want surgery? What are your options?

    In this study, physicians from Taiwan investigate the use of hyaluronate injections into the ankle 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.

    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 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 looking for an alternative approach to surgery.

    Taking a Step Back to Look at Ankle Joint Replacements

    In this review and update, orthopedic surgeons at Duke University Medical Center take a look at the results of ankle joint replacement called total ankle arthroplasty or TAA. They present a thorough examination of all aspects of TAA from studies published and evidence gained so far on this topic.

    Total ankle arthroplasties have been around long enough now to be in what is referred to as second-generation implants. Second-generation means the original design has been improved and changed in a significant way. Along with improved implants come better surgical techniques and surgical tools.

    But are the results matched in terms of implant performance and survival? What about patient satisfaction, which is usually based on reduced pain levels and restoration of ankle joint motion and function?

    In other words, what’s the evidence to support this treatment for end-stage ankle arthritis? And are there real advantages to ankle replacement over the current standard procedure of ankle arthrodesis (fusion)? Should the various types of ankle arthritis (inflammatory, post-traumatic, osteoarthritis) be treated differently?

    There are many individual (small) studies on total ankle arthroplasty (TAA). Surgeons explore the results of their own techniques or results of a specific implant. There are a couple meta-analyses (multiple small studies combined together for greater statistical significance). But an analysis of most of the studies reveals problems with study design and research standards.

    Based on their review of current published analyses of total ankle arthroplasties, the authors of this report give a C grade of recommendation for the treatment of end-stage ankle arthritis with TAA. A C grade means the evidence is of poor quality and conflicting. Does this poor grade mean no one should get an ankle joint replacement?

    No — a closer look at the details of various studies still gives some good information. But the need for better study designs and comparisons is pretty clear. Here are a few of the observations the authors made as they summarized study findings.

  • Implants last up to 12 years so far in 95 per cent of the patients. Younger age (less than 50 years old) and higher activity level may be linked with risk of implant failure.
  • As with other types of joint replacements, loosening and subsidence (sinking down into the bone) are the two most common problems.
  • There isn’t one brand of implant that has tested superior to all others.
  • Patients often still experience some ankle pain after an ankle joint replacement. The reason(s) for this remain unclear.
  • Technical errors are more common as the surgeon is first learning to perform this surgical procedure. Complication and revision (second surgery) rates are higher and implant survivorship is lower for patients when the surgeon is new to this procedure.
  • Active adults can expect to return to light recreational sports and activities. Hiking, biking, and swimming seem the most popular activities. High impact or strenuous activities are not advised.
  • It is possible to convert a fused ankle to a moveable ankle with an ankle prosthesis. Patients must be selected very carefully for this procedure. Guidelines for patient selection for this conversion have not been published.

    As surgeons become more familiar with ankle arthroplasty procedures, the criteria for who qualifies to receive these implants will continue to expand. Survivorship of implants can be extended by minor surgeries to improve alignment, relieve impingement if anything is being compressed, and/or replace the plastic liner that is part of the implant when it wears out.

    Future research that uses standardized patient outcomes will make it easier to compare results of total ankle arthroplasty (TAA) with ankle arthrodesis (fusion). Likewise with consistent reporting of results, it will be possible to compare one type of TAA to others.

    The goal will be to find out which one works best for different patient problems (inflammatory arthritis versus post-traumatic arthritis or degenerative osteoarthritis). And finally, long-term studies (10, 15, 20-year follow-up) are really needed to see what happens over time for these patients. This type of information will help surgeons advise and guide patients through the decision about what type of treatment is best.

  • Long-Term Results of Finger Joint Replacements

    You never really know or appreciate just what one little finger joint can do for you — until you lose the ability to move it. But patients with osteoarthritis of the interphalangeal (IP) joint can testify that pain limits function and even movement of the other finger joints.

    It is possible to replace damaged joints these days — even finger joints like the interphalangeal (IP) joint. That’s the middle finger joint between the large knuckle and the tip of the finger. But does replacing the degenerated IP joint restore normal motion and function?

    Early reports after interphalangeal (IP) joint replacements said, ‘Yes! Good results!” But the authors of this report suggest differently. One surgeon replaced 31 IP joints in the hands of 17 patients and then followed them for at least two years. Most were followed for an average of four years (or more).

    Results were measured using pain, finger joint motion, finger and hand function, and X-ray findings. X-rays were used to look at alignment of the implants including subsidence (sinking of the implant down into the bone) and implant failure (fracture, dislocation). Activities of daily living and patient satisfaction were also assessed as important outcome measures.

    What they found was that like the results reported from other studies, in the early months, patients experienced significant improvements in pain, motion, and function. But over time, significant problems developed.

    Pain persisted. Complications occurred that required additional surgeries. For example, there were five joint dislocations, one fracture, and 11 complaints of finger squeaking. Some joints just wouldn’t move at all while in others the implant loosened creating an unstable joint. In quite a few cases, the implant shifted and moved until it had migrated right out of the bone!

    The surgeon performing the study attributed these complications to the particular type of implant he was using (a pyrolytic carbon resurfacing joint replacement). When he tallied up all the problems and saw how unhappy his patients were with the results, he stopped using this particular type of implant.

    The material (pyrolytic carbon) is supposed to wear well and last a long time. It has the added advantage of stimulating bone growth, which is important to help the body create a stable implantation. But as the results of this study show, the benefits didn’t last.

    With 60 complications in 28 joints, a different strategy is needed. The need for good finger pinch and grip strength in everyday activities is just too important. Good short-term results aren’t enough if long-term results aren’t as good if not better.

    In this study group, the patients who received the pyrolytic carbon resurfacing interphalangeal implant either had a revision surgery with a different type of implant (silicone) put in place or they had the joint fused.

    Fusion of the IP joint is unfortunate because the result is often the inability to pick up and/or handle small objects. Try going a day without being able to do that and you’ll appreciate how disabling it can be to lose IP motion and function.

    The authors hope the pyrolytic carbon implant will be improved upon and yield better results in the future. The results of this long-term study may assist in showing the manufacturers of the device just what the problems are and how to address them.

    Preventing Accidental Overdose of Meds for Children

    Any medication (even over-the-counter drugs) can become deadly when taken in large amounts or in combination with other chemicals. Liquid medications taken by mouth (called oral dosing) are formulated for ease of swallowing. This is helpful for the elderly, anyone with difficulty swallowing, and children.

    With liquid drug products, there is a grave concern that children will be given too much of a good thing. There are printed directions with each bottle but not all parents and caregivers can read or understand the directions. Older adults (when taking the medication or giving it to a child) may not be able to see the small print.

    That’s why the Food and Drug Administration (FDA) has provided guidance for dispensing over-the-counter drugs. Drug companies that make liquid medications follow these guidelines by providing a cup, dropper, syringe, or spoon to measure out the right dose.

    Devices provided in the package must have clear markings with dosage directions properly labeled. In fact, the labeling must still be clearly visible even after the medication has been put into the device.

    Warnings must be provided that these devices (spoons, syringes, cups, droppers) must not be used for any other medication. The dispensing device must only be used with the medication it comes with.

    Pharmacists, physicians, and other health care professionals who dispense medications are advised to pass on these important safety tips to their patients (or the patient’s caretakers):

  • Before dispensing any medication, read the labels carefully. If the print is too small to see easily, use a magnifying glass. Read and review directions three times before taking them yourself or giving them to someone else.
  • Make sure the medication being given is the right one for that person. It is very easy to put drops meant for the ears into the eyes by mistake or to give someone a digestive aid instead of a cold medicine.
  • Never take yourself or give to someone else a medication that was not prescribed or intended for that person. Don’t give or take more than is recommended. Doubling or tripling the dose is a big No-No without your physician’s direct approval.
  • Never mix drugs (take two or more at the same time) without first discussing this with your pharmacist or physician. The unintended consequences can cost a life.
  • Use child-resistant caps on all drugs kept anywhere in the house where children live (even if the medication isn’t for the child). Store all medicines in a safe (inaccessible to children) place.
  • Do use the dosing device provided (spoon, dropper, syringe, cup). Use it exactly as described by the pharmacist, physician, or according to the written instructions.
  • If you don’t remember what you were told, you don’t understand the directions, or you have any questions at all, contact your pharmacist, and/or physician first before taking or giving the drug. This step takes time but it could save a life.

    Following these simple guidelines can go a long way in preventing accidental overdoses of common over-the-counter (OTC) medications used for colds, digestive problems, pain, and other problems.

    If any problems occur, you can report them to the Food and Drug Administration’s MedWatch Safety Information and Adverse Event Reporting Program. Call 800-332-1088 for the special form to fill out. You can also go on-line and make a report at Any side effects or problems with product quality should be reported in order to prevent similar problems for others.

  • New Finding After Total Ankle Replacement

    Problems that develop after surgery for joint replacement can include heterotopic ossification (bone forms in soft tissue where it doesn’t belong). This complication is not uncommon after hip and knee replacements. Now, we know the same holds true for ankle joint replacement.

    In this study from South Korea, 25 per cent of the 80 adult patients followed after total ankle replacement (TAR) surgery developed heterotopic ossification (HO). In 10 per cent of the cases, it was painful and reduced ankle motion. Stiffness and difficulty with movement were severe enough to require surgery in a small number of patients.

    Why does this problem develop, who is at risk, and what can be done to prevent it? These are three good questions with limited answers at this time. No one knows for sure why or how mature bone forms in the muscles and tendons around the joint. Some experts suggest both local and systemic factors.

    Why do some people end up with heterotopic ossification (HO) after surgery and others do not is also something of a mystery. There are known risk factors but not all patients with those risk factors develop HO.

    Some of the risk factors that have been identified so far include: male sex, older age, and infection. Bone trauma, extensive soft tissue dissection during surgery, and the formation of any hematomas (pocket of blood) during surgery are additional risk factors.

    One more question — how come only 10 per cent of the patients who develop heterotopic ossification have any symptoms? Again, no one knows for sure. If it weren’t for studies like this one, we wouldn’t even know the prevalence rate (25 per cent) is so high.

    The authors of this study take things one step further and developed a classification system for heterotopic ossification following primary (the first) total ankle replacement. Having criteria for severity of the condition is helpful for surgeons following these patients.

    The current proposed classification system is as follows:

  • Class 0 No heterotopic ossification
  • Class I Pieces or fragments of bone called islands within the soft tissue around the ankle
  • Class II Bone spurs form inside the joint; up to half the joint space is reduced by the presence of the extra bone
  • Class III Bone spurs reduce the joint space by 50 per cent or more
  • Class IV Bone forms a bridge between two major bones of the ankle (tibia and talus)

    As you can see, the classification model is based on severity (amount) of new bone formation. X-rays were used to examine each of the 80 patients when rating the severity of their heterotopic ossification (HO). There was a fairly equal number of patients in each of the classes from I to IV. The appearance of early signs of HO was seen in the first months after surgery for some and not until a year later in others.

    Looking back and comparing the patients in this study who developed HO with those who did not, there were several variables that might have made the difference. The first was the condition of the soft tissues before surgery.

    Nine of the 20 ankles with heterotopic ossification had plenty of scar tissue around the ankle (from previous injuries or surgery). These patients had more severe osteoarthritis from trauma as opposed to primary osteoarthritis (without trauma).

  • Fresh Bone Graft Preferred for Ankle

    Holes or defects in the surface of a joint that extend down through the cartilage to the bone are called osteochondral lesions. Various treatment approaches have been tried for this problem with some success. One particularly challenging area of the body to treat these defects is the talus bone of the ankle.

    The very complex ankle joint with its many bones makes it difficult to reach areas of osteochondral lesions. The talus is one of those problem areas. It is sandwiched in between the calcaneus (heel bone) and the tibia-fibula bones of the lower leg.

    The tibia (larger bone of the lower leg) sits over the top of the talus and extends down along one side of the talus creating an area referred to as the talus shoulder. Repairing osteochondral lesions of the talar shoulder is the topic of this study.

    Damaged cartilage in older adults doesn’t make new chondrocytes (cartilage cells) and can’t seem to repair itself. Therefore, the use of bone graft material has been studied as one possible treatment approach. As this study shows, using fresh bone graft placed into the defects along the talar shoulder seems to have good results.

    Fresh allografts (taken from a donor rather than harvested from the patient) can be used as soon as they are released by the bone bank that prepares them for use. Most of the time, there is an average delay of almost a month before donor bone is available. Sometimes delays in implanting the bone graft are related more to the surgeon’s schedule, availability of an operating room, or health, travel, or work schedule of the patient.

    The defect must be large enough to warrant this type of treatment but not so large that a bone replacement is required. The shape of the talar shoulder makes it unlikely that bone plugs inserted into the holes will work — there just isn’t enough structural support for this approach.

    Results of the treatment are measured using patient pain levels, function, and imaging studies (X-ray, CT scans, MRIs showing changes in the bone). For the eight patients in this study, results were good-to-excellent without fragmentation, absorption, or rejection of the donor bone. Pain levels were significantly reduced and function significantly improved.

    There were no graft failures and no cases of the defect filling in with fibrous scar tissue instead of bone. The surgeons cleaned the donor bone carefully before putting it in the defect as a precaution against disease transmission (e.g., hepatitis or HIV). There were no cases of disease transmission in these eight patients.

    Half of the patients did end up having another surgical procedure later. But in all cases, treating osteochondral lesions of the talar shoulder with fresh allograft delayed the need for ankle replacement or fusion. The use of talar allograft transplantation can also be done more than once before considering other more invasive or permanent procedures.

    New Information on Ankle Fractures in Older Adults

    Studies show that more and more older adults are being treated for ankle fractures. Not only are there more of these injuries, but they are more severe. What’s behind this change?

    In the past, osteoporosis (decreased bone density or “brittle bones”) was blamed for most ankle fractures in adults 65 years old and older. Osteoporosis is linked with hip, wrist, and shoulder fractures. But new data suggests there are other possible more important risk factors. One of those risks is taking multiple medications called polypharmacy.

    Being overweight appears to be the most common risk factor. The heavier body mass increases the force on the soft tissue and bony structures when a fall happens. But diabetes, cigarette smoking, and inactivity may be the real underlying culprits.

    A sedentary lifestyle leads to weakness and deconditioning resulting in decreased balance and increased risk of falls. People who have to push up with their arms to get out of a chair are more likely to suffer a fall and broken ankle.

    Many older adults with ankle fractures aren’t doing dramatic things when the injury occurs. They aren’t sliding into home plate or skydiving. More often, these are low-energy injuries involving pressure, load, and a twisting motion of the ankle.

    Even in active seniors who are physically fit, stopping a bike on an uneven surface, stepping down from a curb, or walking along a patch of grass with dips and bumps can do it. The twisting motion is enough to tear one or more of the many supportive ankle ligaments (e.g., anterior and posterior talofibular ligaments, calcaneofibular ligament, deltoid ligament, tibiocalcaneal ligament, tibiotalar ligament).

    Without this important soft tissue structure, the force continues through the bone causing a spiral or oblique (at an angle) break in one or both of the bones along side the ankle.

    The areas affected are the distal (bottom end) of the tibia (large bone in the lower leg) and the fibula (smaller bone in the lower leg). The fractures occur right where the “bumps” are located on either side of the ankle — what most people call their “ankle bones.” The anatomical term for this area is malleolus (malleoli, plural).

    Once the deed is done, how should the fracture be treated? The first step is to determine if the fracture is stable (nondisplaced) or unstable (displaced or separated, bones shifted apart).

    The primary care physician or orthopedic surgeon visually inspects the injury, palpates (feels) for broken bones, and (if possible) tests ankle motion. X-rays and other imaging studies (e.g., CT scans, MRIs) are used to confirm the diagnosis.

    A broken but stable ankle can be put in a cast brace or walking cast. The patient is allowed to put full weight on the bones. An unstable fracture must be reduced — meaning the two ends of the bones are separated apart if they are jammed together and overlapping.

    If the bones are separated apart, the ends are realigned and matched back up as closely as possible. Sometimes a closed reduction is possible (without surgery using traction). Most of the time, surgery is required. That all sounds like it’s very simple — a cut and dried decision. But it’s not.

    There are many factors that impact the treatment decisions whether or not to have surgery. And if surgery is done, what’s the best way to approach the problem? Should the bones be wired back together? Should screws be used instead? When should the surgeon reinforce the screws with glue to hold them in place?

    What if the patient does have osteoporosis? Does that affect the way treatment is carried out? Some surgeons are trying the new locked plating system to hold bones together that are weakened by osteoporosis and may not otherwise be able to handle screws placed through the bone.

    The locked plating system is a new technology still being investigated. But the fact that it doesn’t have to be compressed onto the bone yet can withstand torsional and bending forces are major advantages of this system.

    All risk factors for poor recovery should be identified. Physicians and patients should be prepared for possible complications. The most likely problems include delayed wound healing, infection, pain from the hardware (which is often sticking out), and malunion (bones don’t heal properly lined up).

    Management of the condition may include reducing risk factors for future ankle fracture injuries. Consideration is given to the fact that any hardware put in to stabilize the joint must be taken out later. That requires another operation, which costs more money and puts the older at-risk patient at greater risk for additional complications and problems.

    In summary, there are many questions being studied right now about the optimal treatment of ankle fractures in older patients. No definitive (“for sure”) answers are ready. Physicians are advised to review each case individually and carefully.