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Ankle Arthritis

Overview

The most common cause of ankle arthritis is due to previous trauma although in some patients it may occur as part of the development of rheumatoid arthritis, haemophilia or gout. Ankle arthritis is the loss of the ankle joint’s cartilage lining and usually occurs over a period of years.  Regardless of the cause, the resulting narrowing of the ankle joint space between the shinbone and ankle bone and development of bony spurs, is the same.  The ankle becomes stiff, painful and may lock or grind.  Even though arthritis of the ankle is less common than that affecting the hip or knee, the results can be equally painful and debilitating.

If your arthritis is not too severe, simple measures such as losing weight, using walking aids and avoiding high impact activities can effectively treat it. Activities such as cycling, swimming and walking are encouraged.

When it becomes more severe, the next step is anti-inflammatories, painkillers, physiotherapy, orthotics, ankle bracing or a custom fitted splint.  Sometimes cortisone injections or a lubricant will be offered and may offer relief.

Process

When the above measures fail there are 3 main surgical options:

• Arthroscopic debridement
• Joint arthrodesis (fusion)
• Joint replacement

Arthroscopic debridement

This is a day procedure using keyhole surgery with a recovery time of around 6-12 weeks.  It is generally most suitable for early arthritis. Bone spurs and loose bodies are removed and irregularities in remaining cartilage tidied up. There is around a 70% improvement rate but in 2% of patients, the process may actually accelerate the deterioration requiring further surgery sooner than expected.

Ankle arthrodesis

If you have severe arthritis this surgical technique is the most suitable.  It involves removing bone from the both the shin and ankle bones and holding them together with screws. The ends of the bones then grow or fuse together.  Even though ankle motion is eliminated, the adjacent joints compensate and allow up to 30% of motion to return.  The increased load across the other joints can cause arthritis to develop in those as well and some patients will require additional fusion in the future.

Recovery Times

Hospital stay	1-2 nights
Rest & elevation	10-14 days
Moon boot (non-weight bearing)	2 weeks
Moon boot (non-weight bearing)	4 weeks
Moon boot (full weight bearing)	6 weeks
Crutches/frame	6-8 weeks

Time off work

Seated	4-6 weeks
Standing	3 months
Walking well	3 months
Swelling settles	6 months
Final result	12 months

Benefits

• Fusion is reliable in providing long term pain relief for younger patients with high physical demands. It results in a limp free gait and allows return to more physical work
• Preserves ankle motion
• Relieves painful symptoms
• Allows return to physical activities

Risks

• There can be wound problems depending on age and general health
• Further surgery may be required sooner than expected
• There is a failure rate of 2%
• You may require adjustment surgery in first 5 years
• Time off work may be extended depending on recovery

Dr. Rodda does not perform ankle replacement surgery. He prefers the more reliable and durable results of ankle arthrodesis (fusion).

Ankle Arthroscopy

Overview

Ankle arthroscopy refers to keyhole surgery which is used to treat a variety of ankle problems including:

• Bony spurs (osteophytes)
• Arthritis
• Ligament damage or scarring
• Loose chips of bone or cartilage
• Bone or cartilage damage or lesions
• Small fractures
• Ankle impingement
• Other connected/combined surgery

Process

Surgery is usually performed as a day procedure and will involve both a general anaesthetic and a local anaesthetic placed into the incisions to numb some of the pain following surgery.  Two or three keyholes are made for small telescopic cameras and instruments to see into the joint and clean up or treat the lesions. Surgery usually takes around 45 minutes to 1 hour.

Crutches are required for the first few days until it is comfortable to walk unaided.  Generally you are allowed to be full weight bearing (although Dr Rodda and Dr Connon may advise you to be non-weight bearing depending on your procedure).
The foot should be rested and elevated for 36-48 hours and then mostly rested and elevated for the first week. Icing for 20 minutes two or three times daily for the first 3-5 days can help with swelling and pain.
The outer soft bandage can be removed after 48 hours and an elastic bandage applied to help control swelling.  Stick-on dressings should remain until your first check-up. If they fall off please replace them with a Bandaid.  A small amount of blood on the dressings is normal.
The foot and ankle should be moved up and down and in circles to prevent stiffening and blood clots. Physiotherapy may be started after 10 days if required. Station bike exercise can start 5-7 days after your surgery.
Driving is not recommended for at least 1 week.

Time off work

Desk work	4-7 days
Light duties	1-2 weeks
Standing/heavy work	3-5 weeks
Sports	6-12 weeks
Full recovery	3-4 months

Benefits

• Removal of ankle problems and associated pain
• Ability to return to work and normal everyday activities
• Prevention of further complications if not treated

Risks

The risks with arthroscopic surgery are rare but include:

• Complications from the anaesthetic
• Infection
• Nerve damage
• Blood clots
• Resultant stiffness

Ankle Reconstruction – Postoperative Physiotherapy

Overview

When you are recovering from ankle surgery there is a rehabilitation protocol to be followed which may vary slightly depending on the severity of the injury. Dr Rodda and Dr Connon will prepare a program for you depending on the nature of your surgery. Treatment options listed below are guidelines and will be adapted to suit each individual patient depending on age, function, sport, occupation and rehabilitation goals.

Process – Management Instructions

First 2 weeks (Goals – prevent complications; maintain movement and strength in unaffected joints)

Wear half-cast or CAM boot

Keep to non- weight bearing activities

Perform a range of hip and knee motion exercises

Exercise your quadriceps, hamstrings and gluteal muscles

Perform deep breathing exercises

Weeks 2-4 (Goals – control pain and swelling; regain active movements)

Transfer to CAM boot or ankle brace

Commence weight bearing, PWB or WBAT depending on Dr Rodda and Dr Connon’s instructions

Perform theraband strengthening exercises in all directions

Do double leg calf raises, then progress to single leg calf raises

Perform advanced balance/proprioception exercise e.g. wobble board, foam

Stretch calves

Swim with gentle kick

Cycle as much as is comfortable

Return to Sport (Goals – single leg balance for 1 minute with eyes open; single leg calf raises 3 x 30; single leg squat to 900; lunge +6cm; hopping on the spot; normal lower limb mechanics including pelvis/hip/knee control; direction change tests within 10% of other side; wean off brace)

Perform single leg heel raises

Stretch calves

Perform theraband strengthening, focusing on dorsiflexion and eversion

Hop and land

Perform ladder and lateral hopping

Run, swim and cycle

Prevention of recurrence (Goals – normal mechanics; high level balance; landing strategies; direction change strategies)

Perform advanced landing drills e.g. catching, marking, feed forward training

Practice balance integration i.e. strength work on BOSU ball

Perform plyometric training

Hallux Valgus (Bunions)

Overview

These are a common problem affecting millions of people worldwide. They are thought to occur due to a muscle imbalance that is often inherited.  Wearing the wrong kind of shoes, especially shoes that are too tight or small, may exacerbate the problem however this is not the actual cause.  Bunions get worse with age and can eventually cause pain and deformity.  It may also result in damage to other parts of your feet.  You feel pain from bunions because of their size and their abnormal biomechanics.

Process

Many operations have been tried over the years but the one with the highest success rate and used by Dr Rodda and Dr Connon is the Scarf and Akin osteotomy.   The key to its success are that it restores foot mechanics and allows the early return of joint motion. The recurrence rates are also low.

The procedure has 5 components performed through 2 incisions. Initially, one of the tight ligaments and the tight muscle are released and the bunion is shaved. The metatarsal bone is cut and adjusted to narrow the foot and realign the joint and 2 small screws are placed in the bone to fix it solidly.  Following this a wedge of bone is removed from the phalanx bone to straighten the big toe and a small staple or screw is used to hold the bone in place.  The joint capsule is tightened and the skin is closed. The metalwork does not usually need to be removed. The procedure is performed under general anaesthetic along with a nerve block which puts the foot to sleep for around 12-18 hours.

Plaster is not required as the toe is held in place with a bandage for 4-6 weeks.  As with all surgery some swelling occurs.  This may limit your activity and choice of footwear.  Swelling can increase initially then subside as your toe heals.  You can take simple oral pain relief as required.

Recovery Times

The final result can be expected 3 months after surgery but your body may continue to adapt for up to 12 months. Wide shoes will have to be worn for up to 12 weeks.

Hospital stay	1 night
Rest & elevation	10 days
Crutches/frame	1-2 weeks
Foot swelling	12 weeks

Time off work

Seated	3-4 weeks
Standing	6-8 weeks
Lifting/carrying	8-12 weeks

Benefits

• Relieves painful symptoms
• Allows return to physical activities
• Allows patient to wear normal footwear

Risks

No surgery is risk free. Please be aware of the following:

• Infection
• Blood clots
• Reaction to the anaesthetic
• Recurrence of the deformity
• Overcorrection of the big toe
• Problems with bone fixation
• Numbness or hypersensitivity of the toe

Hammer or Claw Toes

Overview

Hammer or claw toes are the most common toe deformities and can cause problems in a number of ways.  They often require surgery as they can cause problems relating to the prominent knuckle joint on the toe sticking up and rubbing on your shoe, causing wear and corn formation or ulcers. The deformity of the toe itself may cause pain from inflammation in the main joint at the base of the toe or because of damage and stretching of the ligament under the toe and ball of the foot. You can feel as if you are walking on a pebble.

Hammer toe can be genetic, caused by wearing too tight shoes, the result of the presence of a bunion, from a neurological cause, from rheumatoid or other types of arthritis, overuse and ligament damage or simply be the particular shape of your foot.

Non-surgical methods of treatment should always be considered before surgery.  Orthotics and insoles may be an option to assist with pain under the ball of the foot; taping or strapping the toe may prevent ligament damage; silicone sleeves or padding over the toe may cushion it and an appropriate wide and roomy shoe selection will prevent further pressure.

If these measures fail to work then surgery can be performed to straighten the toe.

Process

Surgery can involve a number of small procedures depending on the problem.  Usually the bent knuckle in the middle of the toe will need to be straightened and possibly fused. This is performed as day surgery unless it is combined with treatment for a bunion or other problems which may require an overnight stay.

You may require a pin in the toe which is left 5mm outside the toe and removed after 4-6 weeks.  Removal of the pin is straightforward and takes just a few seconds with no need for anaesthetic.  Sometimes a dissolvable pin or internal pin can be used instead.  Other adjustments include lengthening tight tendons or shortening the Metatarsal head (knuckle bone at the bottom of the toe joint).

Weight bearing is allowed in a post-operative sandal. Elevation is required for 5-7 days and you can expect to be mostly recovered by 4-5 weeks once the bones are healing. The toe can remain swollen for several months however it will recover.

Some stiffness may occur in the toe following surgery. This is normal and cannot be helped as the previous damage cannot be fully corrected. However the toe will be straighter and more comfortable.

Plantar Fasciitis

Overview

Plantar fasciitis is a common inflammation of the heel bone. It is a result of a repetitive strain/tear and repair of the fascia from traction that has worn it out. The plantar fascia runs along the length of the sole of the foot and assists in maintaining the inner arch. Like an elastic band left in the sun it can lose its stretch and develop many micro tears.

Heel spurs which form just beneath the plantar fascia, were originally thought to be the cause however it has been proven that they are NOT responsible and therefore don’t need to be removed.  It is possible they form because of the inflammation in the soft tissue.

Initial treatment should include analgesics, anti-inflammatories, massage, the application of ice and exercises that stretch the fascia and strengthen the muscles.  Cushioning heel pads and night splints may also help.  Ultrasound and shock wave therapy and cortisone injections can also be considered.

Process

If surgery is thought necessary it is performed either through an incision on the in-step of the foot.

Recovery Times

Hospital stay	Day surgery
Rest & elevation	7 days
Crutches/frame	5-7 days
Foot swelling	4 weeks
Sport	6-12 weeks

Time off work

Seated	1 week
Standing	3-4 weeks

Benefits

• Less pain
• Return to sport and every day activities

Risks

Complications are rare with this procedure although as with all surgery there can be a risk of infection, blood clots, nerve injury and a reaction to the anaesthetic.

• Persistence of pain
• Discomfort outer part of top of foot