Avoiding Ankle Replacement and Fusion - Magaziner

Avoiding Ankle Replacement and Fusion

Non-surgical management of ankle osteoarthritis

In many patients that we see, a diagnosis of degenerative ankle disease is usually given three paths of treatment.

Manage the pain until the ankle is no longer functional;

Ankle Fusion; Ankle Replacement.

Are these three options the only options?

A March 2019 study  from the University of Melbourne (1) discusses the treatment options for patients with advanced ankle osteoarthritis. Since the management of ankle osteoarthritis has no real guideline recommendations on its own, researchers say most doctors use a knee or hip osteoarthritis patient criteria. Is this a good thing or a bad thing? Probably not a good thing given the amounts of knee and hip replacements being performed. Think about it. If you are a patient with ankle osteoarthritis and you were told that you were being given the same guidelines that hip and knee osteoarthritis patients get to help hold off joint replacement, how confident would you be in that treatment?

Here are the criteria. Most of you are probably already familiar with these recommendations.

Exercise or physical therapy and weight loss.

If this does not work or the patient needs more help then:

Topical non-steroidal anti-inflammatory drugs (NSAIDs) or capsaicin may be used.

If this does not work or the patient needs more help then:

Acetaminophen (paracetamol (tylenol) should be recommended; however, if there is inadequate symptomatic relief, then clinicians should try oral NSAID or a cyclo-oxygenase-2 inhibitor.

Older patients should be treated with  hyaluronic acid given that there is some evidence this treatment would work.

Do non-surgical management treatments for ankle osteoarthritis work? For some yes, for some no. This is why patient move to surgical recommendations that will hopefully preserve their ankles.

In a recent study from doctors in Italy, researchers at the University of Bologna (2) discussed the current options patients have for sparing their ankle from replacement surgery.

These options include:

Arthroscopic debridement, a surgical procedure that uses a “power wash” to spray off damaged cartilage, bone and other tissue.

Arthrodiastasis, rods are inserted into the ankle bones and suspended from a external cage, this is a picture from Podiatry Today. The idea is to provide more bone space to allow cartilage to grow and heal.

Ankle osteotomy. a surgery that shaves or remodels the bone.

As the Italian researchers point out: “(these) are the current joint sparing procedures, but, in the available studies, controversial results were achieved.” Controversial means less than hoped for success.

The same researchers looked at stem cells as a non-surgical option

This is where the university researchers decided to look at the stem cell option. In studying stem cell injections they were able to note: After interesting reports of mesenchymal stem cells seeded on scaffold (a biological patch) and applied to cartilage defects in non-degenerated joints, bone marrow derived cells transplantation appears to be a promising technique in order to control the degenerative pathway and restore the osteochondral (bone and cartilage) defects.

More research on stem cells

In the medical journal Regenerative medicine, (3) researchers also explored the use of stem cells as a means of not only preserving the ankle but as a means to rebuild and repair damage. The researchers especially focused on the use of mesenchymal stromal cells (MSCs or stem cells) because of their beneficial and dual functions of regeneration and cell modulation (the ability to communicate with other cells). The researchers believed that  the regenerative therapies compared favorably against standard surgical treatment.

A well received and heavily cited 2015 study (4) showed that stem cell treatments were able to regrow cartilage in ankles significant enough to improve function and pain levels in selected patients. Walking distances were shown to dramatically improve in the patient group.

So there is promise in the research that surgery may be avoidable. Certainly in our clinical observation in our patients we have seen surgery avoided. Can surgery be avoided in your case? If you have been given a recommendation to ankle fusion or ankle replacement surgery and would like to explore your options please contact our office.

If you would like to explore more information, please contact our office so we can start a conversation with you.

Related articles

Treating Joint Inflammation. The Problem With NSAIDs.

What are the Side Effects of Cortisone Injections?


Paterson KL, Gates L. Clinical Assessment and Management of Foot and Ankle Osteoarthritis: A Review of Current Evidence and Focus on Pharmacological Treatment. Drugs & aging. 2019 Jan 25:1-9.
2 Castagnini F, Pellegrini C, Perazzo L, Vannini F, Buda R. Joint sparing treatments in early ankle osteoarthritis: current procedures and future perspectives. Journal of Experimental Orthopaedics. 2016;3:3. doi:10.1186/s40634-016-0038-4.
3 El-Jawhari JJ, Brockett CL, Ktistakis I, Jones E, Giannoudis PV. The regenerative therapies of the ankle degeneration: a focus on multipotential mesenchymal stromal cells. Regenerative medicine. 2018 Mar 19;13(2):175-88.
4 Emadedin M, Ghorbani Liastani M, Fazeli R, et al.Long-Term Follow-up of Intra-articular Injection of Autologous Mesenchymal Stem Cells in Patients with Knee, Ankle, or Hip Osteoarthritis. Arch Iran Med. 2015 Jun;18(6):336-44. doi: 015186/AIM.003.

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