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Ankle fusion

MagazineApril 2009 (Vol. 20 Issue 1)Ankle fusion

Q) I have suffered from arthritis of the ankles for many years

Q) I have suffered from arthritis of the ankles for many years. I take meloxicam and have been provided with ankle splints for support, but the ankles continue to deteriorate. I have been referred to a consultant who suggests fusing the ankles, but what are the risks involved in this operation and are there any alternatives?-Anonymous, via e-mail

A) The operation your consultant has recommended is medically known as 'ankle arthrodesis', in which the bones of the ankle joint are fused together, fixing the ankle completely in one position. Arthrodesis is currently considered the gold-standard surgical treatment for managing patients with advanced ankle arthritis; its main objective is to relieve pain and improve overall function (Instr Course Lect, 2008; 57: 383-413). However, the procedure is technically complicated, often involving metal plates and screws to keep the bones in place, and the results vary widely (Foot Ankle Int, 2000; 21: 182-94). There is also a high incidence of complications, so you're right to think twice before going under the knife.

One of the most common adverse consequences of ankle arthrodesis is non-union, when the bones fail to fuse. The reported rates are as high as 40 per cent. Bone necrosis and smoking are known risk factors (J Am Acad Orthop Surg, 2000; 8: 200-9). However, one review claims that these rates are steadily declining with the development of more advanced techniques (J Bone Joint Surg Am, 2003; 85: 923-36).

Nevertheless, if arthrodesis fails, a further operation is usually required and may, in some cases, lead to amputation (Acta Orthop Scand, 1981; 52: 103-5).

Another problem with arthrodesis is that, to compensate for the lack of ankle movement, the other joints have to move much more, creating excess strain on those joints and, in the long run, pain and disability. Indeed, one arthrodesis follow-up survey concluded that, "Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction" (J Bone Joint Surg Am, 2001; 83-A: 219-28).

Other studies report that ankle fusion patients tend to develop pain and moderate-to-severe arthritis in the joints of the foot (J Bone Joint Surg Am, 2006; 88: 526-35;

Acta Orthop Scand, 1981; 52: 103-5). This suggests that arthrodesis merely shifts the problem from one set of joints to another.

If this isn't enough to put you off, there are a number of other risks to consider, including deep infection, malunion (the bones fuse in an imperfect position), delayed wound-healing, stress fracture, neurovascular injury and deep vein thrombosis (J Bone Joint Surg Am, 2003; 85: 923-36; J Bone Joint Surg Br, 2005; 87-B: 343-7). You should also bear in mind that your gait will be permanently altered, and it's likely that you'll have to wear special footwear afterwards (Foot Ankle Int, 2008; 29: 3-9; Acta Orthop Scand, 1981; 52: 103-5). In fact, even the most satisfied patients report major physical limitations compared with healthy controls (J Bone Joint Surg Am, 2003; 85: 923-36).

So, what are your other options?

- Low tibial osteotomy is an operation that maintains ankle movement and provides good long-term results (J Bone Joint Surg Br, 2006; 88-B: 909-13; Arch Orthop Trauma Surg, 2001; 121: 355-8). However, as the procedure only works in certain conditions, consult your surgeon to see if your case would qualify.

- Prolotherapy for osteoarthritis involves injecting a cocktail of agents-herbs, vitamins and, sometimes, conventional drugs such as painkillers-into the joint to cause localized inflammation, leading to wound healing and the production of collagen. There is evidence to support the use of 10-per-cent dextrose prolotherapy (Am J Phys Med Rehabil, 2004; 83: 379-89).

- Viscosupplementation involves injections of hyal-uronic acid into the joint to act as a lubricant. Recent studies have shown that this is effective for osteoarthritis of the knee and ankle, with patients reporting significant improvements in both pain and joint function (Cochrane Database Syst Rev, 2006; 2: CD005321; Osteoarthritis Cartilage, 2006; 14: 867-74).

- Bee venom acupuncture, which delivers compounds isolated from bee venom (BV) directly into an acupoint, can reduce the pain and swelling associated with arthritis (Evid Based Complement Alternat Med, 2005;

2: 79-84). In patients with osteoarthritis of the knee, four weeks of BV acupuncture was more effective at relieving pain than traditional needle acupuncture (Am J Chin Med, 2001; 29: 187-99).

- Nutritional supplementation such as with glucos-amine and chondroitin can reduce joint pain and stiffness, and even slow the progression of arthritis (Lancet, 2001; 357: 251-6; Osteoarthritis Cartilage, 1998; 6 Suppl A: 39-46). One study found that glucosamine avoided the need for knee replacement surgery in about half the number of cases (Osteoarthritis Cartilage, 2008; 16: 254-60). Other supplements that may help are cetylated fatty acids (J Rheumatol, 2002; 29: 1708-12) and S-adenosylmethionine (SAMe) (Am J Med, 1987; 83: 60-5).

- Herbal remedies that have shown promise in treating osteoarthritis include devil's claw, willow bark, Phytodolor (a fixed formulation containing alcoholic extracts of Populus tremula, Fraxinus excelsior and Solidago virgaurea), capsaicin, avocado/soybean extracts or unsaponifiables (AFUs) and rosehip powder (Rheumatology, 2001; 40: 779-93; MMW Fortschr Med, 2007; 149: 51-6).

For further information on treating arthritis naturally, see WDDTY's The Arthritis Manual, available from www.wddty.com .


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