Ankle Arthritis With Additional Deformities

Ankle Arthritis Primary arthritis without a deformity Secondary arthritis with associated deformity, such as ankle varus, valgus, or rotational abnormalities.

Primary Ankle Arthritis

Primary ankle arthritis is a degenerative condition of the ankle joint cartilage. Patients typically present with pain that is initially activity-related but gradually becomes persistent.

Clinical features

• Pain in the ankle during walking or prolonged standing in the early stages
• Progressive swelling and stiffness
• Reduced walking tolerance
• In advanced disease, pain may occur even at rest or during the night

Surgical options

Joint fusion (arthrodesis)

This operation permanently stiffens the painful joint by removing the damaged cartilage and allowing the bones to heal together. It reliably relieves pain but sacrifices joint movement.

• Often performed as a day-case procedure
• Non-weight-bearing for approximately 6 weeks, followed by gradual rehabilitation
• Walking improves once the bones unite, although some loss of mobility is permanent
• Adjacent joints may gradually take on more stress over time

Ankle replacement (total ankle arthroplasty)

The aim of ankle replacement is to relieve pain while preserving joint movement.
I do not personally perform this procedure; therefore, patients wishing to consider this option will be referred to a specialist colleague for further discussion.

Potential disadvantages of ankle replacement

• Limited lifespan of the prosthesis — many patients may require revision surgery after around 10 years
• Reduced suitability for heavy manual work or high-impact activities
• Risk of loosening or fractures around the implant

If the implant fails or wears out, further surgery is required, which may involve either revision replacement or conversion to an ankle fusion.

Secondary Ankle Arthritis with Associated Deformity

Secondary ankle arthritis develops as a consequence of previous injury or abnormal alignment. The deformity may be varus, valgus, or rotational and leads to uneven loading of the joint, resulting in progressive cartilage wear.

This condition is commonly seen following:

• Tibial fractures
• Chronic ankle ligament instability
• Malunited ankle fractures

Symptoms

• Pain typically localised to one side of the ankle (corresponding to the overloaded joint surface)
• Swelling and stiffness
• Sensation of instability or “giving way” in some patients
• Gradual reduction in walking tolerance

Investigations

• Weight-bearing X-rays: demonstrate asymmetric cartilage loss, joint narrowing and bone loss.
• CT scan: assesses joint surface damage and the extent of deformity in detail.
• Long-leg alignment X-ray: helps identify the centre and level of deformity and guides surgical planning.

Treatment options

Early stages

• Activity modification
• Steroid with local anaesthetic or platelet-rich plasma (PRP) injection for symptom relief
• Correction of alignment using orthotics, insoles or specialised footwear

Advanced stages
Management depends on:

• Cause of arthritis
• Severity of deformity
• Patient activity level and functional demands

Surgical treatment may involve deformity correction (osteotomy), ligament reconstruction, joint fusion, or joint replacement, either alone or in combination, to restore alignment and relieve pain.

Ankle Arthritis Secondary to Instability

Chronic ankle ligament instability leads to abnormal joint loading and progressive cartilage wear, eventually resulting in arthritis. Management depends on the stage of the disease and the severity of symptoms.

Early arthritis

When cartilage damage is limited, the aim is to restore stability and unload the affected joint surface.

• Lateral ligament reconstruction
• Selective soft-tissue releases where required

These procedures may slow progression of arthritis and improve function.

Moderate arthritis

Restoring alignment and stability is the priority. Treatment is guided by symptom pattern.

Episodic or activity-related symptoms (joint preservation possible):

• Lateral ligament reconstruction
• Medial soft-tissue release if contracture is present
• Corrective osteotomy (calcaneal or distal tibial) to redistribute load

The goal is to rebalance the ankle and delay joint-sacrificing surgery.

Severe arthritis

Patients typically have constant pain, limited walking tolerance and disturbed sleep.

At this stage, joint preservation procedures are unlikely to be beneficial.

Surgical options

• Ankle fusion (arthrodesis), with or without deformity correction

This reliably relieves pain by eliminating movement at the arthritic joint while restoring a plantigrade, stable foot.