Osteoarthritis

Osteoarthritis, also known as degenerative or "wear and tear" arthritis, is a common problem for many people after they reach middle age. Over the years, the smooth, gliding surface covering the ends of bones (cartilage) becomes worn and frayed. This results in inflammation, swelling, and pain in the joint.

Osteoarthritis progresses slowly and the pain and stiffness it causes worsens over time.

Rheumatoid Arthritis

Unlike osteoarthritis which follows a predictable pattern in certain joints, rheumatoid arthritis is a system-wide disease. It is an inflammatory disease where the patient's own immune system attacks and destroys cartilage.

Post-Traumatic Arthritis

Post-traumatic arthritis can develop after an injury to the foot or ankle. This type of arthritis is similar to osteoarthritis and may develop years after a fracture, severe sprain, or ligament injury.

Osteoarthritis

Many factors increase your risk for developing osteoarthritis. Because the ability of cartilage to heal itself decreases as we age, older people are more likely to develop the disease. Other risk factors include obesity and family history of the disease.

Rheumatoid Arthritis

The exact cause of rheumatoid arthritis is not known. Although it is not an inherited disease, researchers believe that some people have genes that make them more susceptible. There is usually a "trigger," such as an infection or environmental factor, which activates the genes. When the body is exposed to this trigger, the immune system begins to produce substances that attack the joint. This is what may lead to the development of rheumatoid arthritis.

Post-Traumatic Arthritis

Fractures - particularly those that damage the joint surface - and dislocations are the most common injuries that lead to this type of arthritis. An injured joint is about seven times more likely to become arthritic, even if the injury is properly treated. In fact, following injury, your body can secrete hormones that stimulate the death of your cartilage cells.

Medical History and Examination

A medical history is important to understand more about the problem. Your doctor will want to know when the pain started and when it occurs. Is it worse at night? Does it get worse when walking or running? Is it continuous, or does it come and go?

He or she will want to know if there was a past injury to the foot or ankle. If so, your doctor will discuss your injury, when it occurred, and how it was treated.

Your doctor will want to know if the pain is in both feet or only in one foot, and where it is located exactly. Footwear will be examined, and any medications will be noted.

Additional Tests

One of the tests performed during the physical examination is the gait analysis. This shows how the bones in the leg and foot line up with walking, measures stride, and tests the strength of the ankles and feet.

X-rays can show changes in the spacing between bones or in the shape of the bones themselves. Weight-bearing X-rays are the most valuable additional test in diagnosing the severity of arthritis.

A bone scan, computed tomographic (CT) scan, or magnetic resonance image (MRI) may also be used in the evaluation.

Nonsurgical Treatment

Nonsurgical treatment options include:

• Pain relievers and anti-inflammatory medications to reduce swelling
• Shoe inserts (orthotics), such as pads or arch supports
• Custom-made shoe, such as a stiff-soled shoe with a rocker bottom
• An ankle-foot orthosis (AFO)
• A brace or a cane
• Physical therapy and exercises
• Weight control or nutritional supplements
• Medications, such as a steroid medication injected into the joint

Surgical Treatment

If arthritis doesn't respond to nonsurgical treatment, surgical treatment might be considered. The choice of surgery will depend on the type of arthritis, the impact of the disease on the joints, and the location of the arthritis. Sometimes more than one type of surgery will be needed.

Surgery performed for arthritis of the foot and ankle include arthroscopic debridement, arthrodesis (or fusion of the joints), and arthroplasty (replacement of the affected joint).

Arthroscopic Debridement

Arthroscopic surgery may be helpful in the early stages of arthritis.

A flexible, fiberoptic pencil-sized instrument (arthroscope) is inserted into the joint through a series of small incisions through the skin.

The arthroscope is fitted with a small camera and lighting system, as well as various instruments. The camera projects images of the joint on a television monitor. This enables the surgeon to look directly inside the joint and identify the problem areas.

Small instruments at the end of the arthroscope, such as probes, forceps, knives, and shavers, are used to clean the joint area of foreign tissue, inflamed tissue that lines the joint, and bony outgrowths (spurs).

Arthrodesis or Fusion

(Reproduced with permission from Abdo RV, Iorio LJ: Rheumatoid Arthritis of the Foot and Ankle J Am Acad Orthop Surg 1994;2:326-332.)

Arthrodesis fuses the bones of the joint completely, making one continuous bone.

The surgeon uses pins, plates and screws, or rods to hold the bones in the proper position while the joint(s) fuse. If the joints do not fuse (nonunion), this hardware may break.

A bone graft is sometimes needed if there is bone loss. The surgeon may use a graft (a piece of bone, taken from one of the lower leg bones or the wing of the pelvis) to replace the missing bone.

This surgery is typically quite successful. A very small percentage of patients have problems with wound healing. These problems can be addressed by bracing or additional surgery.

The biggest long-term problem with fusion is the development of arthritis at the joints adjacent to those fused. This occurs from increased stresses applied to the adjacent joints.

Arthroplasty or Joint Replacement

In arthroplasty, the damaged ankle joint is replaced with an artificial implant (prosthesis).

Although not as common as as total hip or knee joint replacement, advances in implant design have made ankle replacement a feasible option for many people.

In addition to providing pain relief from arthritis, ankle replacements offer patients better mobility and movement compared to fusion. By allowing motion at the formerly arthritic joint, less stress is transferred to the adjacent joints. Less stress results in reduced occurance of adjacent joint arthritis.

Ankle replacement is most often recommended for patients with:

• Advanced arthritis of the ankle
• Destroyed ankle joint surfaces
• An ankle condition that interferes with daily activities

As in any joint replacement surgery, the ankle implant may loosen over the years or fail. If the implant failure is severe, revision surgery may be necessary.