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Medical Edge Newspaper Column from Mayo Clinic

RELIEVING POST-TRAUMATIC ANKLE PAIN

DEAR MAYO CLINIC: My right ankle was severely smashed in a traffic accident three years ago,. The damage was repaired as completely as possible at that time, and I’ve been able to function fairly well since then. But recently the pain has gotten much worse. The orthopedic surgeon says that the gap between the ankle and leg is gone, and I have bone on bone. He wants to fuse the bones together because replacement is supposedly not an option, given my size: I am a 44-year-old man, 5 feet, 10 inches tall, who weighs about 380 pounds. Is ankle replacement really out of the question? Is fusion my only option? — Green Bay, Wis.

ANSWER: If you do in fact need surgery, ankle fusion and ankle replacement are the two main options at present. And in your case, ankle fusion may well be the preferred course.

It is important, however, that a thorough physical examination first determine whether your ankle is actually the problem. While it has clearly been affected by post-traumatic arthritis — your severe injuries have caused cartilage, which normally cushions the interfaces between connecting bones, to die off — the pain you are experiencing may largely be coming from other, nearby joints that have been similarly damaged. If that is so, neither ankle fusion nor replacement would do you much good.

Even if it turns out that the arthritic ankle is indeed the major source of your pain, a simpler, nonsurgical approach — wearing a brace that immobilizes the ankle and retaining a reasonable range of motion by wearing a rocker-bottom shoe — may be tried first. This arrangement, coupled with cortisone injections two or three times a year, can reduce pain considerably in many patients.

Your surgeon is correct that ankle replacement may not be a viable option for a patient of your size. Nor is it necessarily the best option for lots of other patients, whatever their size. While knee and hip replacements have been virtual godsends for many people, these successes do not automatically apply to the ankle. The much smaller area of interface between bone and implant results in much higher pressures there — and, all too often, less-than-satisfying outcomes.

But as long as your X-rays do not reveal avascular necrosis (a loss of nourishing blood supply to the bone), an ankle fusion can significantly reduce your pain. The fusion procedure first removes whatever cartilage remains at the ankle joint, together with the dense layer of bone that immediately abuts it. The soft, spongy and blood-supply-rich bone surfaces at the ankle and leg are then compressed with “hardware,” such as metal plates and screws, so that bone fusion can occur. The fusion may be promoted by the prior insertion of bone-graft material, often obtained from elsewhere in the body, at the interface.

The result is predictable pain relief, delivered through the most durable surgical option. Moreover, to many people’s pleasant surprise, patients often walk so well after completion of healing that even an expert may not readily discern which foot has had the ankle fusion. The reason is that the region’s several other joints, if healthy, can almost fully provide the ankle’s up-and-down range of motion needed for a normal gait. Although a criticism of ankle fusion is that the greater load on these other local joints may eventually (over 15 to 20 years or so) lead to their own arthritis, the fact is that such arthritis is rarely symptomatic — in other words, it doesn’t hurt.

I don’t mean to suggest that ankle replacement has no role, especially as additional research shows its long-term success rate. Also, “distraction arthroplasty,” a relatively new option pioneered in the Netherlands, has begun getting some attention in the United States. This technique features an external frame with pins that enter the leg above the ankle and the foot below. The device, which is worn for about three months, cyclically loads and unloads the joint — a process that stimulates the growth of some secondary cartilage.

However, this is just a temporary solution aimed at postponing fusion or replacement, and its efficacy is still being evaluated. For you, at this time, fusion is the best choice if you need ankle surgery.

— Todd Kile, M.D., Orthopedic Surgery, Mayo Clinic, Scottsdale, Ariz.

Additional Resources:
Ankle Reconstruction
Appointment Information
Information on Chronic Pain
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Medical Edge from Mayo Clinic is an educational resource and doesn’t replace regular medical care. To e-mail a question, go to www.mayoclinic.org, or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207. For health information, visit www.mayoclinic.com.