Gelenk-Klinik Dr. Baum - Arthrosebehandlung

Osteoarthritis (degenerative arthritis) is a general term used to describe signs of wear and tear in any of our joints. Various factors may contribute to this wear and tear. Just as the term stomach ache reveals nothing about the specific cause of the ache, the term osteoarthritis should not be construed as a particular cause of joint degeneration about which nothing can be done. If your doctor succeeds in identifying a factor that is contributing to the progression of your osteoarthritis (e.g. axial displacement, a floating joint fragment, or a ligament injury), then it is clear that eliminating this factor will lead to a real improvement in the course of the disease.
Osteoarthritis in the ankle is a remarkably common disorder. Its economic significance is on a par with myocardial infarction (heart attack) and high blood pressure. In contrast to osteoarthritis in the larger hip and knee joints, osteoarthritis in the tibia and talus of the ankle often develops as a result of an earlier ankle injury. As is the case with other joints, wear and tear in the ankle leads to cartilage degeneration and an associated reduction in the height of the joint cavity. This reduction exposes the subchondral bone (the bone just behind the cartilage) to additional stress. As the cushioning and gliding function of the cartilage in the ankle joint begins to diminish more rapidly, inflammation, swelling and bone spurs develop. This development marks the transition to ankle osteoarthritis.
While the condition initially leads to no more than occasional ankle pain after strenuous or prolonged activities, the pain will eventually increase, appear more frequently, last longer and cause varying degrees of disability as the condition progresses. The ankle's range of motion declines as a result of recurring inflammation in the joint capsule. Limping and other means of favoring the joint become more distinct.
The aim of non-surgical forms of treatment is to slow down the progression of the disease. Depending on the cause, various surgical procedures may either help to slow down the disease's progression or eliminate the damage. Surgery involving ankle joint replacement has begun to replace joint fusion (arthrodesis) as the preferred method of treatment among orthopedic specialists, a development that has been inspired by significant improvements in artificial-joint technology.

What is ankle osteoarthritis and how does it develop?
Osteoarthritis in the tibia of the ankle often begins with an injury to the joint cartilage that leaves the cartilage less resistant to stress. This damaged cartilage has a far rougher surface than healthy cartilage. The increased surface roughness leads to increased friction and greater wear. Initially, the increased wear is associated with circumstances in which the joint is exposed to heavy stress (e.g. contact sports, tennis, etc.). Later, elevated rates of wear are associated with everyday activities.
The friction in a healthy joint is many times less than that of an ice cube gliding on top of another ice cube. The roughening or rupturing of the cartilage results in excessive friction that leads to further damage and a further loss of the cartilage's cushioning and gliding function.
The particles of cartilage that are often released in this process of destruction (wear debris) lead to even higher rates of friction and can trigger inflammation in the joint, another factor that accelerates degeneration.
With time, the load on the subchondral bone increases as the cushioning and gliding action of the cartilage drops below a critical level. This leads to the development of bone spurs in the ankle that further limit the ankle's range of motion.

What are the causes of ankle osteoarthritis?
The following distinction is made when considering the causes of ankle osteoarthritis:

• Primary ankle osteoarthritis (tibia)
• Secondary ankle osteoarthritis (tibia)

The cause of primary ankle osteoarthritis is not known. The condition appears to arise spontaneously, that is to say, without any known trigger or cause. Secondary ankle osteoarthritis may have any of various known causes, including:

• Injuries
• Rheumatic arthritis
• Ankle infections
• Lameness

What is the most common cause of ankle osteoarthritis?
The tibia is especially susceptible to the development of osteoarthritis after an injury. Such injuries include ligament damage (ankle sprain) and ankle fractures. Osteoarthritis may also arise in connection with fractures in other joints that do not heal properly and therefore lead to permanent misalignment. This exposes the cartilage in the ankle to continuous excessive loading, with initial signs of damage showing up at a later point in time.
In addition to conditions that we acquire, there are also congenital conditions, such as clubfoot, flat feet and pes cavus (high arch) that can lead to ankle osteoarthritis.

What are the symptoms of ankle osteoarthritis?
Various symptoms may occur depending on the extent of the damage in the ankle. Typical early symptoms of ankle osteoarthritis, as well as of osteoarthritis in other joints in the body, include occasional ankle pain, ankle fatigue and ankle pain as you take your first steps in the morning or after an extended period of rest. As the condition progresses, ankle pain begins to occur after strenuous or prolonged activities and at night.
In time, the ankle pain gradually reduces the quality of life of those affected. The range we are able to walk without experiencing discomfort grows shorter, the capacity of our ankle respond to the demands of strenuous activities declines significantly, and our daily work and recreational activities become more difficult. The reduction in the ankle's range of motion and attempts to favor the ankle lead to referred pain in the foot and calve.
A specialist can usually arrive at a reliable diagnosis of the condition by carefully interviewing the patient and conducting a physical examination.

What imaging procedures are used to diagnose ankle osteoarthritis?
Weight-bearing x-rays of the ankle are indispensable for diagnosing ankle osteoarthritis. Non-weight-bearing x-rays provide only a part of the necessary information, such as the axial placement, the pattern of the cartilage damage in the ankle and possible causes of the osteoarthritis. An x-ray of the position of the heel bone prior to surgery will help the surgeon determine the necessity of rear foot correction.
Weight-bearing x-rays of the foot are taken to determine the degree of any existing osteoarthritis in the joints near the ankle. Whole-leg x-rays are important for surgical planning. Computed tomography images offer a means of effectively visualizing any accompanying osteoarthritis. SPECT/CT images may provide important information about the spontaneous bone remodeling that takes place as a result of the changed weight distribution.

How does your doctor detect ankle osteoarthritis in an x-ray?

Early Signs of Ankle Osteoarthritis:
A narrowing of the joint cavity is a sign of cartilage damage and ankle osteoarthritis.
The subchondral bone begins to thicken and harden (subchondral sclerosis) in response the added pressure that arises as the cartilage begins to wear away and lose its cushioning and gliding function.

Signs of Advanced Ankle Osteoarthritis:
The joint cavity disappears as the cartilage continues to disintegrate. The subchondral bone shows even more thickening. The bone reacts to the increased pressure associated with the loss of cartilage by producing osteophytes (bony outgrowths or spurs). Subchondral cysts appear. Tiny cavities form in the subchondral bone as bone tissues dies. As the condition progresses even further, the bony parts of the joints begin to deform as a response to the new distribution of weight. The talar dome flattens out and the tibia begins to slide forward. These changes lead to increasing disability that will ultimately have an impact on neighboring joints.

What are the goals of treatment for ankle osteoarthritis?

• Removal of aggravating factors (floating joint fragments, inflammation in the synovial membrane)
• Reconstruction of damaged or missing cartilage surfaces
• Protection of newly formed replacement cartilage

Initial treatment is usually conservative, with the particular measures depending on the stage of the ankle osteoarthritis. The goal of treatment is to delay the progression of the osteoarthritis.
The treatment may include Diclofenac or other NSAIDS (non-steroidal anti-inflammatory drugs), physical therapy and a prescription for orthopedic shoes (e.g. for ankle fixation or to facilitate rolling).
Special injections may used in an attempt to prevent further cartilage deterioration and stimulate cartilage repair.

Conservative Measures

• Orthopedic shoes
• Chondro-protective therapy for cartilage retention
• Varus-valgus brace
• Muscle strength training
• PMT
• Acupuncture
• Physical therapy

Surgical Procedures

• 

  Arthroscopic cleaning of the ankle
• Abrasion arthroplasty
• Microfracture technique
• Autologous chondrocyte implantation
• Axial displacement correction for the lower leg or heel
• Ligament reconstruction
• Ankle joint replacement
• Arthrodesis (joint fusion)