SmartHallux® Method
Smarthallux explains to you
All you need to know
on ankle osteoarthritis
What is meant by ankle osteoarthritis?
Ankle osteoarthritis, or more precisely tibiotalar or tibiotarsal osteoarthritis, is a degeneration of the articular cartilage and, in more advanced stages, of the soft tissues around the joint and of the bone beneath the articular cartilage.
In the hip and knee, osteoarthritis is a common progression of the joint, a sort of aging process, often without any apparent cause (primary osteoarthritis). Primary osteoarthritis of the foot and ankle, however, is very rare.
It's a condition that usually occurs after severe trauma (malleolar, talar, or tibial pilon fractures) or following repeated microtraumas. Other common causes include ankle arthritis (usually rheumatoid arthritis) and hemophilia.
In fact, the ankle, unlike the knee and the hip, is a congruent joint, in which each joint surface corresponds exactly to the other, just like in a puzzle.
This explains the very low incidence of primary (age-related) arthritis and the high incidence of post-traumatic arthritis, as a few millimetres of incorrect alignment following trauma can produce serious imbalances within the joint which can undergo degeneration.
Being a fundamentally post-traumatic pathology, it usually involves individuals in the young stages of their age, typically between 30 and 50 years old.
Ankle Osteoarthritis: Symptoms
Patients with ankle osteoarthritis complain of stiffness, swelling, difficulty walking for long periods, difficulty getting up from a sitting position, or difficulty moving around first thing in the morning. They may also experience difficulty walking on steps, ramps, or uneven surfaces.
In some cases, ankle arthritis can be so severe that it makes walking difficult.
If you suffer from ankle arthritis and nonsurgical treatments have not relieved your symptoms, surgery may be an option to consider.
Ankle osteoarthritis: what is the cure?
In years past, the most reliable treatment was arthrodesis, which involves fusing the tibia and talus in the correct position to eliminate pain. However, this type of solution is not free from complications and can limit walking, particularly in young people.
With the evolution of materials and especially of prosthetic designs and knowledge of foot and ankle biomechanics, the clinical results of ankle prostheses have improved significantly.
Currently, there are basically 4 solutions for ankle osteoarthritis.
The first involves articular cartilage reconstruction techniques. In cases of osteochondral damage to the talus or tibia, the joint defect can be reconstructed using a special membrane using arthroscopic techniques.
In the case of early osteoarthritis of the ankle joint, however, it is possible to correct the joint's axis to slow down or even reverse the degeneration process.
In fact, in the case of an ankle with significant asymmetry in a young patient (under 60 years of age), a supramalleolar or intra-articular osteotomy will restore the normal anatomy and functionality of the joint.
In advanced osteoarthritis, however, the ideal solution is ankle replacement. Ankle arthrodesis is reserved for cases where a prosthesis is contraindicated, such as certain neurological diseases, talar necrosis involving more than 50% of the talus, and very severe deformities.
The ankle prosthesis
The ankle prosthesis we use at SmartHallux is a true resurfacing. Essentially, it's an anatomical prosthesis that faithfully reproduces the original anatomy and biomechanics of the ankle joint, significantly reducing the amount of bone and cartilage removed compared to previous prostheses and ensuring a significantly higher survival rate.
As previously mentioned, patients with ankle osteoarthritis are typically young and have previously suffered severe ankle trauma or repetitive microtrauma. This does not mean that all patients who have suffered a fracture will need an ankle replacement in the future. Only if the osteoarthritis significantly limits daily activities will a surgical solution be considered.
Diagnosis of ankle osteoarthritis
The crucial step for a patient suffering from ankle osteoarthritis is a surgical consultation. Often, a foot and ankle surgeon can make a diagnosis in just a few steps.
The anamnesis, or collection of the patient's medical history, is crucial. Together, we'll discuss your general health and medical history and ask about any medications you may be taking.
I will examine your foot and ankle, identifying the location of the pain and the presence of effusion and swelling, and ask questions to learn more about your symptoms. These questions may include:
When did the pain start?
Where exactly is the pain?
Does it occur in one foot or both feet?
When does the pain occur?
Is it continuous or does it come and go?
Is the pain worse in the morning or evening?
Does it get worse when walking or running?
The patient's work history and goals are also crucial. Indeed, the goal of ankle replacement is not to give the patient a new ankle, but rather to eliminate pain and improve ankle mobility, which, however, will almost never be comparable to that of a "healthy" ankle.
To plan surgery or conservative treatment, it is essential to perform an X-ray of the foot under load.
This is an examination performed with the patient in orthostatism (i.e., standing). It is essential that the radiographic examination be performed with the patient in a weight-bearing position to assess the load axis of the joint and to standardize the examination.
Magnetic resonance imaging (MRI) and computed tomography (CT) are second-level investigations, useful in certain situations but often providing the surgeon with less information than X-rays, as they are performed in a clinostatism (lying down) position, and are requested as needed to evaluate the condition of the cartilage and soft tissues (tendons and ligaments).
Ankle Osteoarthritis: Conservative Approaches
Asymptomatic ankle osteoarthritis is generally untreatable; this principle applies to both conservative and surgical therapies.
There is no prevention for ankle osteoarthritis.
The insole helps the symptomatic patient to find compensation, but it is not able to guarantee a correction.
It basically acts as a “brace”, positioned inside the shoe to help the suffering tendons work in a more physiological way.
In patients who are not candidates for surgery, or who refuse surgery, the use of insoles, combined with physical therapies (Tecar Therapy, InterX) and anti-inflammatories, can be effective in controlling symptoms.
Surgery: Ankle Osteoarthritis
Before undergoing surgery for ankle osteoarthritis, it is important to discuss with Dr. Luigi Manzi all the factors to consider, including
which:
• Your medical history
• Your general health status
• Your goals and expectations for the procedure
• The risks and benefits of the intervention
As previously explained, there are different types of intervention for ANKLE OSTEOARTHRITIS
The surgeon's task is to identify the specific treatment based on the symptoms, the presence of a deformity, the age and the patient's expectations.
In cases where joints other than the ankle have degenerated, the surgeon will plan one or more procedures (osteotomies, tendon transfers, Achilles tendon lengthening) to achieve good range of motion and proper foot support. Only in the most severe cases may it be necessary to perform arthrodesis, which involves fusing specific joints, to achieve a more aligned foot, allowing the patient to walk pain-free, with the loss of some foot motion (not the ankle).
Post-operative recovery
The post-operative period includes a plaster cast made of fiberglass, which is generally worn for 4 weeks, on which the patient does not put weight.
The patient usually remains hospitalized for one or two nights.
Approximately 30 days after surgery, the cast is removed, and the patient can return to bearing weight without a cast or aids.
It is essential to explain the possible complications to the patient.
The most common complication (approximately 0,2%) is infection, a rate that tends to increase in diabetic, obese, and smoker patients, as well as with advancing age. To reduce the risk of infection, it is crucial that the procedure lasts less than 2 hours and that the operating rooms have certain features, such as laminar flow, and a low operating room temperature.
The administration of appropriate antibiotics helps reduce the risk of infection. If infection does occur, proper wound management with advanced dressings and the use of oral antibiotics are often sufficient to eradicate the problem. Only rarely is a new surgical solution necessary, which often involves simply removing fixation devices (plates and screws, not the prosthesis), washing the surgical site, and possibly placing absorbable devices that release antibiotics locally for extended periods.
Patients often wonder how long a prosthesis lasts. To date, we don't have a definitive answer, as this type of prosthesis has been implanted in Italy for no more than seven years. However, older prosthetic designs have a ten-year survival rate of over 7%. Presumably, prostheses used in recent years should have an even longer survival rate.
The goal of SmartHallux
SmartHallux's goal is to revolutionize the treatment of ankle osteoarthritis and all the most common foot and ankle conditions. To achieve this goal, we adopt the best surgical techniques, orthopedic devices, instruments, and materials available on the market.
This is why we propose ourselves as private healthcare at an accessible and financeable cost. Unfortunately, public and subsidized healthcare have spending limits that place limits on the use of materials, instruments and structures.
With SmartHallux you will have access to the best possible treatments, in excellent facilities and without having to wait for public health authorities.
If you're in severe pain and don't want to wait any longer, we can schedule and perform your surgery within a few days, so you can begin your recovery process as soon as possible and get back to living and walking freely.
A good candidate for ankle osteoarthritis surgery is someone who has pain and limited range of motion that has not improved with nonsurgical treatments.
As with any surgery, there are some risks associated with ankle osteoarthritis surgery. These risks include infection, bleeding, and deep vein thrombosis.
Painless anesthesia
Surgical techniques have undergone an important evolution compared to the past, starting from anesthesia and post-operative pain control.
Anesthesia is spinal, unless contraindicated. It is a very safe anesthesia technique, with very rare complications.
At SmartHallux, we also usually administer anesthesia to the popliteal area, behind the knee, which allows for pain control for 12-14 hours after the procedure.
With ultrasound guidance, our anesthetists are able to identify the nerves and with a single puncture behind the knee they are able to selectively "put to sleep" the nervous structures necessary and sufficient to perform the operation without pain, leaving the mobility of the legs and bladder control to the patient.
Sedation allows the patient to avoid anxiety and often wake up immediately after surgery. This type of anesthesia also allows for anesthesia to be prolonged for up to 24-48 hours, reducing or even eliminating postoperative pain, without any risks or contraindications.
The patient is usually discharged after one or two nights, when the pain is well controlled and medications are reduced to the minimum necessary.
The return to activities
Return to daily activities depends on various factors, particularly the patient's age and the type of surgery performed. The cast is generally removed after four weeks, allowing for almost full weight bearing from the first day after surgery.
The patient can return to driving 6 weeks after surgery.
If additional procedures such as arthrodesis, tendon transfers, or Achilles tendon lengthening are performed, recovery times may be slightly longer.
For all patients, water-based gait rehabilitation, or hydrokinesitherapy, can help them regain normal gait more quickly.
Post-operative check-ups are of fundamental importance, to evaluate recovery and introduce new exercises or physical therapies to improve and speed up recovery.
As previously mentioned, despite using the best prosthesis on the market and proper surgery, it will be impossible to regain 100% function. The most recommended sports activities for patients with an ankle replacement are cycling, swimming, doubles tennis, skiing, yoga, and Pilates, although some patients return to much more demanding sports such as calisthenics.
Why choose SmartHallux for surgery?
Our doctors, led by Dr. Manzi, have extensive experience in treating ankle osteoarthritis with a very high percentage of satisfied patients.
The secrets of our success lie in the use of the best surgical and anesthesiological techniques, and the use of cutting-edge, top-quality materials.
Waiting times for ankle osteoarthritis surgery through the National Health Service (NHS) can be very long, varying from region to region and from facility to facility. In some cases, the wait can be several months or even years. SmartHallux offers the opportunity to access the procedure more quickly, avoiding long waiting lists.
SmartHallux® Certified Clinics
FAQ
The cost of ankle osteoarthritis surgery can vary depending on the type of surgery performed.
In any case, we offer significantly lower prices than other surgeons who perform this type of surgery.
We recommend contacting Dr. Luigi Manzi for a personalized quote.
There are several options for booking a visit with Dr. Manzi
Dr. Manzi visits medical practices that collaborate with SmartHallux located in Rome, Milan and Naples
It is also possible to book a telemedicine visit.
