Foot and ankle structured oral questions2: Ankle arthritis
Foot and ankle structured oral questions2: Ankle arthritis
EXAMINER: Describe the findings on this X-ray. (Figure 4.2.)![]()
CANDIDATE: This is an AP weightbearing radiograph of a left ankle showing narrowing of the joint space and some subchondral sclerosis consistent with post-traumatic arthritis. There is evidence of a previous fibula fracture superior to the syndesmosis and varus angulation of the ankle.
EXAMINER: Excellent, what are the most common causes of endstage arthritis of the ankle?
CANDIDATE: Primary osteoarthritis is thought to be relatively uncommon and the most common cause of ankle arthritis is probably post-traumatic arthritis. Other causes are inflammatory arthritis and septic arthritis.
Figure 4.2 X-ray showing ankle arthritis.
EXAMINER: How is this patient likely to present?
CANDIDATE: They are most likely to complain of pain, however they may also present with restriction of movement, deformity and difficulty in performing activities of daily living (ADLs).
EXAMINER: Are you aware of any classification systems for arthritis of the ankle?
CANDIDATE: No, I am not aware of any classification systems specific to the ankle. The Kellgren and Lawrence Radiographic Criteria can be used.1
EXAMINER: The X-ray you have been shown belongs to a 42year-old manual worker who had an ankle fracture 7 years ago which was managed non-operatively. Describe your management strategy for this patient.
CANDIDATE: I would first want to perform a full history and examination, and obtain a lateral radiograph.
EXAMINER: Absolutely. Tell me about the management options available for ankle arthritis.
CANDIDATE: I would start with conservative measures and optimize the patient’s analgesia adding in NSAIDs, and suggest activity modification. He could try footwear modification with a cushioned sole and rocker-bottom shoe which may improve his symptoms as may use of an ankle brace or AFO. Similarly an injection of intra-articular steroid or viscosupplementation may be of symptomatic benefit. Physiotherapy could be an adjunctive treatment in patients with symptoms of instability or weakness but may aggravate symptoms.
EXAMINER: What surgical options are available?
CANDIDATE: There are two types of surgical option available, those aimed to ‘buy time’ or provide temporary relief and definitive treatments. The temporizing measures are debridement of the joint which can be performed arthroscopically or open depending on the extent of disease and should be aimed at treating identifiable causes of symptoms such as removing loose bodies, trimming anterior osteophytes which may give impingement symptoms, or debriding loose areas of articular cartilage and areas of synovitis. The other option is distraction arthroplasty.2 The definitive surgical options are ankle fusion or ankle replacement.
EXAMINER: Isn’t fusion an outdated treatment now that ankle replacements are available?
CANDIDATE: No, total ankle replacements are not suitable for every patient and ankle fusion is still considered the ‘gold standard’.
EXAMINER: So which patients should be considered for ankle replacement surgery?
CANDIDATE: Ankle replacement surgery could be considered in low-demand patients over the age of 60 years who have inflammatory arthritis or osteoarthritis. Bilateral disease or arthritis affecting adjacent joints is a relative indication. Contraindications would include younger, more active patients, significant ankle instability, particularly deltoid ligament insufficiency, significant deformity, especially varus or valgus of more than 10, peripheral vascular disease, a poor soft tissue envelope, marked osteoporosis or avascular necrosis of the tibial plafond or talar dome.
EXAMINER: Do you know anything about the types of ankle replacement available?
CANDIDATE: The earlier designs involved a two-component design such as the Agility total ankle replacement, which required fusion of the distal tibiofibular joint. Most modern designs are three-component uncemented mobile bearing prostheses.
EXAMINER: A patient wants to know how long an ankle replacement will last. What will you tell them?
CANDIDATE: The 10-year survival is approaching 85% but there are fewer data available than for knee and hip replacements. Many series are small.2–5
EXAMINER: The 42-year-old patient we began by discussing wants an ankle replacement. What would you tell him?
CANDIDATE: He is a young patient, in a manual job. He wouldn’t be a candidate for total ankle replacement and I would explain to him that if his symptoms have failed to be controlled by non-operative measures and he requires definitive surgical treatment then an ankle fusion would be a better option for him.
EXAMINER: He still wants a replacement, as he is keen to get back to hill walking and sports and doesn’t want a stiff ankle. What will you tell him now?
CANDIDATE: He would be at risk of early failure with an ankle replacement due to his young age and level of activity. A fusion would provide a stable pain-free ankle that would allow him to return to the majority of activities that he wishes to do. I would explain that many patients return to sports after ankle fusion. I would also explain that an ankle fusion would only sacrifice the residual movement that he has at his ankle joint and that his subtalar, midfoot and forefoot movements would still be present.
EXAMINER: What position should his ankle be fused in?
CANDIDATE: The foot should be plantigrade with a physiological 5 of hindfoot valgus and 5 of external rotation.
EXAMINER: What complications will you warn him about?
CANDIDATE: Non-union, malunion, delayed union, infection, wound-healing problems, nerve or vessel damage, DVT/PE, risk of exacerbating or developing arthritis in other joints.
EXAMINER: Thank you.
-
Kellgren JH, Lawrence JS. Radiological assessment of osteoarthrosis. Ann Rheum Dis 1957;16:494–501.
-
van Valberg AA, van Roermund PM, Marijnissen AC et al. Joint distraction in treatment of osteoarthritis: a two-year follow-up of the ankle. Osteoarthritis Cartilage 1999;7:474–479.
-
Wood PLR, Prem H, Sutton C. Total ankle replacement: medium term results in 200 Scandinavian total ankle replacements. J Bone Joint Surg Br 2008;90-B:605–609.
-
Bonnin M, Gaudot F, Laurent JR et al. The Salto total ankle arthroplasty: survivorship and analysis of failures at 7 to 11 years. Clin Orthop Relat Res 2011;469:225–236.
-
Mann JA, Mann RA, Horton E. STAR ankle: long-term results. Foot Ankle Int 2011;32(5):473–484.
-
Labek G, Klaus H, Schlichtherle R et al. Revision rates after total ankle arthroplasty in sample-based clinical studies and national registries. Foot Ankle Int 2011;32 (8):740–745.
Foot and ankle structured oral questions2: Ankle arthritis
EXAMINER: Describe the findings on this X-ray. (Figure 4.2.)
CANDIDATE: This is an AP weightbearing radiograph of a left ankle showing narrowing of the joint space and some subchondral sclerosis consistent with post-traumatic arthritis. There is evidence of a previous fibula fracture superior to the syndesmosis and varus angulation of the ankle.
EXAMINER: Excellent, what are the most common causes of endstage arthritis of the ankle?
CANDIDATE: Primary osteoarthritis is thought to be relatively uncommon and the most common cause of ankle arthritis is probably post-traumatic arthritis. Other causes are inflammatory arthritis and septic arthritis.
Figure 4.2 X-ray showing ankle arthritis.
EXAMINER: How is this patient likely to present?
CANDIDATE: They are most likely to complain of pain, however they may also present with restriction of movement, deformity and difficulty in performing activities of daily living (ADLs).
EXAMINER: Are you aware of any classification systems for arthritis of the ankle?
CANDIDATE: No, I am not aware of any classification systems specific to the ankle. The Kellgren and Lawrence Radiographic Criteria can be used.1
EXAMINER: The X-ray you have been shown belongs to a 42year-old manual worker who had an ankle fracture 7 years ago which was managed non-operatively. Describe your management strategy for this patient.
CANDIDATE: I would first want to perform a full history and examination, and obtain a lateral radiograph.
EXAMINER: Absolutely. Tell me about the management options available for ankle arthritis.
CANDIDATE: I would start with conservative measures and optimize the patient’s analgesia adding in NSAIDs, and suggest activity modification. He could try footwear modification with a cushioned sole and rocker-bottom shoe which may improve his symptoms as may use of an ankle brace or AFO. Similarly an injection of intra-articular steroid or viscosupplementation may be of symptomatic benefit. Physiotherapy could be an adjunctive treatment in patients with symptoms of instability or weakness but may aggravate symptoms.
EXAMINER: What surgical options are available?
CANDIDATE: There are two types of surgical option available, those aimed to ‘buy time’ or provide temporary relief and definitive treatments. The temporizing measures are debridement of the joint which can be performed arthroscopically or open depending on the extent of disease and should be aimed at treating identifiable causes of symptoms such as removing loose bodies, trimming anterior osteophytes which may give impingement symptoms, or debriding loose areas of articular cartilage and areas of synovitis. The other option is distraction arthroplasty.2 The definitive surgical options are ankle fusion or ankle replacement.
EXAMINER: Isn’t fusion an outdated treatment now that ankle replacements are available?
CANDIDATE: No, total ankle replacements are not suitable for every patient and ankle fusion is still considered the ‘gold standard’.
EXAMINER: So which patients should be considered for ankle replacement surgery?
CANDIDATE: Ankle replacement surgery could be considered in low-demand patients over the age of 60 years who have inflammatory arthritis or osteoarthritis. Bilateral disease or arthritis affecting adjacent joints is a relative indication. Contraindications would include younger, more active patients, significant ankle instability, particularly deltoid ligament insufficiency, significant deformity, especially varus or valgus of more than 10, peripheral vascular disease, a poor soft tissue envelope, marked osteoporosis or avascular necrosis of the tibial plafond or talar dome.
EXAMINER: Do you know anything about the types of ankle replacement available?
CANDIDATE: The earlier designs involved a two-component design such as the Agility total ankle replacement, which required fusion of the distal tibiofibular joint. Most modern designs are three-component uncemented mobile bearing prostheses.
EXAMINER: A patient wants to know how long an ankle replacement will last. What will you tell them?
CANDIDATE: The 10-year survival is approaching 85% but there are fewer data available than for knee and hip replacements. Many series are small.2–5
EXAMINER: The 42-year-old patient we began by discussing wants an ankle replacement. What would you tell him?
CANDIDATE: He is a young patient, in a manual job. He wouldn’t be a candidate for total ankle replacement and I would explain to him that if his symptoms have failed to be controlled by non-operative measures and he requires definitive surgical treatment then an ankle fusion would be a better option for him.
EXAMINER: He still wants a replacement, as he is keen to get back to hill walking and sports and doesn’t want a stiff ankle. What will you tell him now?
CANDIDATE: He would be at risk of early failure with an ankle replacement due to his young age and level of activity. A fusion would provide a stable pain-free ankle that would allow him to return to the majority of activities that he wishes to do. I would explain that many patients return to sports after ankle fusion. I would also explain that an ankle fusion would only sacrifice the residual movement that he has at his ankle joint and that his subtalar, midfoot and forefoot movements would still be present.
EXAMINER: What position should his ankle be fused in?
CANDIDATE: The foot should be plantigrade with a physiological 5 of hindfoot valgus and 5 of external rotation.
EXAMINER: What complications will you warn him about?
CANDIDATE: Non-union, malunion, delayed union, infection, wound-healing problems, nerve or vessel damage, DVT/PE, risk of exacerbating or developing arthritis in other joints.
EXAMINER: Thank you.
-
Kellgren JH, Lawrence JS. Radiological assessment of osteoarthrosis. Ann Rheum Dis 1957;16:494–501.
-
van Valberg AA, van Roermund PM, Marijnissen AC et al. Joint distraction in treatment of osteoarthritis: a two-year follow-up of the ankle. Osteoarthritis Cartilage 1999;7:474–479.
-
Wood PLR, Prem H, Sutton C. Total ankle replacement: medium term results in 200 Scandinavian total ankle replacements. J Bone Joint Surg Br 2008;90-B:605–609.
-
Bonnin M, Gaudot F, Laurent JR et al. The Salto total ankle arthroplasty: survivorship and analysis of failures at 7 to 11 years. Clin Orthop Relat Res 2011;469:225–236.
-
Mann JA, Mann RA, Horton E. STAR ankle: long-term results. Foot Ankle Int 2011;32(5):473–484.
-
Labek G, Klaus H, Schlichtherle R et al. Revision rates after total ankle arthroplasty in sample-based clinical studies and national registries. Foot Ankle Int 2011;32 (8):740–745.