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Treatment of Ankle Joint

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Throughout a person's life their ankle joint constantly experience tremendous load of the entire body weight. No wonder it is very susceptible to injuries, strains, displacements, and bruises, and this is only a small fraction of all problems that can happen to one of the most mobile joints throughout a human life.

Generally, any trauma leaves a trace. At a certain point an inflammatory process develops in the ankle, which can later lead to patient's disablement. Arthroses and arthritides are the most common diseases affecting this area. This is the reason why the treatment of the ankle joint requires immediate intensive care.

The treatment of ankle joint should be particularly intensive if arthritis has been diagnosed. Arthritis is an inflammatory disease that provokes the degeneration of bone and cartilage tissue. As the disease progresses, the bone tissue grows increasingly, creating outgrowths, the opening of the joint channel where the nerves are located decreases, and the nerves are pinched.

As a result, the patient is suffering from severe, lingering or stabbing pain, that does not subside even in a resting state. Arthritis has periods of remission, but a number of factors can trigger an aggravation of the disease.

The treatment of the acute arthritis of the ankle joint primarily involves the admission of analgesics, after that one should directly contact a medical specialist and take a course of physiotherapy, massage and do special exercises.

Episodes of aggravation can be relieved, the disease again becomes chronic or even goes to remission.

Arthritis or osteoarthritis of the upper ankle is caused by a disease process which was developing for many years. A damage to the joint cartilage (osteochondrosis) always triggers the arthritis. After the joint is initially damaged, its stress capacity starts to decrease.

It has a much rougher surface than a healthy cartilage which leads to an increased cartilage abrasion in the joint. The color of the joint cartilage changes from white to yellow.

At the initial stage of osteoarthritis of the upper ankle, the reduced resilience is noticeable only under heavy stress (contact sports, football, tennis). The joint remains painful even after normal loads until it recovers.

However, as the disease progresses the normal daily loads can also cause pain.

The friction of smooth cartilage surfaces in a healthy joint is much smaller than the friction between two ice cubes sliding together.

If the cartilage surface becomes rougher or completely breaks up, the friction strongly increased. In the course of time, the shock-absorbing function of the ankle joint cartilage is lost just as the sliding function.

The rubbed off particles of the cartilage continue to further abrade the joint, as the injured cartilage is damaged even more by the ongoing inflammatory process in the joint.

This increases the load on the adjoining bone, as the shock absorption is decreased because there is increasingly less elastic cartilage. In this way, bone attachments (osteophytes) are formed on the ankle joint, which increasingly restrict the joint's ability to move.

The destruction of cartilage in the upper ankle is called cartilage damage. In contrast to the hip joint or knee joint, the damage to the upper ankle cartilage is often caused by an injury. The cartilage damage itself is not referred to as osteoarthritis, but osteoarthritis of the ankle joint can occur in the result of a cartilage damage. The damage to the cartilage requires a causal therapy. For example, the cartilage condition may continue to deteriorate due to incorrect loading, increased joint movability (instability). Only when these causes are identified can a therapy strategy be developed.

How can upper ankle cartilage damage occur?

  • Cartilage damage after an accident with a so-called osteochondral fracture
  • Bone spurs on the front edge of the tibia

If the ankle gets twisted to the outside, a so-called supination trauma can cause cartilage damage. In case of such ankle joint injury, massive shear force (forces transverse to the cartilage surface) occur on the outer ankle bone cartilage. The cartilage inside the ankle is heavily squeezed (compression forces). Such pressure on the cartilage damages the bone below the cartilage on the spot where the force was applied. This leads to tiny bone fractures below the cartilage (subchondral microfractures). These injuries may result in a so-called osteochondral lesion if the damage caused an increased mobility of the upper or lower ankle (instability of the ankle). In this case, the injured bone under the cartilage does not heal, but a scar is formed between the bone and the movable cartilage and bone fragment.

The working mechanism of this damage is similar to a fallen apple. After the fall the tougher skin of the apple remains intact, though the underlying supporting apple flesh breaks. Depending on the energy of the impact, the skin can also tear. This damage is like the damage of the ankle joint cartilage caused by a trauma. Another mechanism is responsible for cartilage damage in the talus caused by bone formations (osteophytes) at the front edge of the tibia (anterior spur syndrome, impingement of the upper ankle joint).

It mostly occurs in football players and extreme athletes, because the bone spur has a high friction which grinds and damages the cartilage.

Cartilage damage not caused by an accident occurs rarely.

Can cartilage recover? Does cartilage regenerate?

The human organism has a limited ability to recover or regenerate cartilage tissue. This includes not only the ankle joint, but all joint cartilages of the body.

Depending on age, only about 4% of cartilage tissue cells can be renewed. A very small part of dividable cartilage cells are in the ankle joint. An important goal of any therapy is to prevent the breakdown of cartilage cells and further injury. This will help the cartilage to regenerate.

This is why cartilage damage in the ankle joint represents a serious therapeutic problem.

What are the possibilities of conservative or non-surgical therapy of cartilage damage in the upper ankle?

There are various approaches to a conservative treatment of cartilage damage in the upper ankle joint.

Physiotherapy is part of the standard set of conservative treatment of upper ankle joint cartilage damage. The use and selection of the therapy method is based on empirical observations and experience. There is no intrinsic proof its efficacy. The symptoms of pain, irritation and functional limitation of the ankle joint are given a targeted treatment.

The following measures shall be taken:

  • Pain therapy
  • Optimization of pressure and prevention of load peaks
  • Improvement of diffusion
  • Decongestion

What surgical therapeutic approaches can improve the cartilage structure?

There are surgical methods of the upper ankle treatment with a structure-based therapy approach. They allow to improve the structure of the ankle joint cartilage.

  • Debridement of cartilage (frequently used in the past)
  • Lavage of the ankle (frequently used in the past)
  • Stimulation of bone marrow by drilling, abrasion, microfracturing of the ankle joint
  • Cellular transplantation as autologous (bodily) cartilage and bone cylinders transplantation (OATS) into the ankle
  • Cellular transplantation as autologous chondrocytes transplantation (ACT) into the ankle

What is a cartilage damage in the ankle joint?

Cartilage damage in the ankle joint is usually caused by an accident (trauma). In this case the ankle is bent around or twisted (sprain injury). The following damages may occur in such an accident:

  • Injury by stretching or rupture of the outer or inner ankle ligaments which guide the joint.
  • Damage to the bones and cartilage due to a very high mechanical pressures emerging when the talus is twisted in the ankle. In extreme cases, talus or ankle joint can also break (ankle fracture).

In this article mainly describe modern possibilities of cartilage therapy of bone and cartilage damage caused by sprain of the ankle or by misalignment of the talus in the ankle.

What is a osteochondral lesion (bone and cartilage damage)

Sprain (twisting or bending) the ankle often leads to complex damage not only of the cartilage tissue, but also of the bone tissue in the upper ankle joint. These complex bone-cartilage damage are also referred to as osteochondral lesions. A long-lasting osteochondral lesion can cause osteoarthritis of the ankle joint. This is why the problem of its treatment is particularly important for young patients.

What are the possible treatment methods of ankle joint cartilage damage?

Nowadays, several methods of cartilage and bone damage treatment are available.

  • Drilling of the OD localization without penetrating the cartilage, from behind (retrograde drilling)
  • Reconstruction with bone grafting under the cartilage from behind (retrograde spongioplastic surgery)
  • Drilling of the OD localization through the cartilage (antegrade Pridie drilling)
  • Stabilization of the fragment or osteochondritis dissecans center
  • Microfracturing
  • Osteochondral transplantation into the OD center
  • Cartilage transplantation (autologous cartilage transplantation)

In an advanced stage of the osteochondritis dissecans (stages III-V with partial weakening of the bone centres up to the formation of cysts), the common methods of bone drilling and microfracturing after completion of bone growth are no longer effective.

In these cases the cartilage and bone transplantation, a so-called OATS (autologous osteochondral transplantation), is available for treatment of the ankle joint.

What is a cartilage and bone transplantation or OATS?

In contrast to the cartilage transplantation, round cylindrical osteochondral plugs are removed and transplanted from a less loaded region of a joint. (often it is a knee joint)

The osteochondral plugs consist of bone tissue and intact cartilage coating. Similar to the use of piles when building a house on a swampy terrain, the grafts are pressed into the solid bone base of the osteochondral damage. Several of these cylinders can be used if the damage is significant or just a single one may be sufficient. If several of these osteochondral cylindrical grafts are placed next to each other, it looks like a mosaic made of circular cartilage lids. This type of cartilage therapy is therefore also called "mosaicplasty".

At the upper ankle, this cartilage and bone transplantation is often possible only after a planned bone separation (osteotomy) performed during a surgery. The ankle joint is fixed when the operation is over in order for it to cure. For example, on the inner part of the ankle, the inner ankle joint is often temporarily detached to cover the damage to the talus In the upper ankle this is possible not only on the ankle bone or talus, but also on the joint-bearing part of the tibia. This method is used more and more widely to treat cartilage and bone lesions, death of bone tissue (bone necrosis) or early stages of osteoarthritis of the metatarsal head.

What goals can be achieved with the transplantation of autologous cartilage and bone tissues?

The aim of an osteochondral transplantation is to replace cartilage and bone damage with a wholesome cartilage. It should help to preserve the joint and to avoid a rapid progression of osteoarthritis. Another aim is the replacement of dead bone tissue. Restoration of painless joint functioning is the most important goal of the operation.

Who can benefit from a cartilage and bone transplantation into the ankle?

Patients who are suffering from bounded cartilage and bone damage or a cavity formation under the cartilage caused by a trauma or a circulatory disorder in bones.

What do you need to consider after the osteochondral transplantation into the ankle?

Initially, the ankle is fixed with a splint in a neutral position. This phase lasts for about 12 days until the wounds are healed. Right from the first day after the surgery physiotherapy should be started in order to maintain the mobility of the ankle and its muscles. A treatment of the joint using a motorised dynamic splint (CPM motion brace) is especially effective for cartilage restoration. A discharge of the ankle should last for at least six weeks. After an X-ray control showing that the bone is in a solid condition can the joint be increasingly loaded. A thrombosis prophylaxis is necessary until the ankle is fully loaded.

Autologous chondrocyte transplantation (cartilage grafting) of the upper ankle joint

A progressive, painful osteoarthritis of the ankle joint, as with other joints, is often caused by injuries of the articular cartilage. In contrast to other body's joints, the cartilage damage to the upper ankle is usually the result of a trauma.

When the ankle is bent to the outside, an excessive shearing force is applied to the cartilage of the outer anklebone and a massive pressure load on the inner part of the talus, bruising of the bone under the cartilage, which can cause injury of the joint.

In the early stages of cartilage damage, the cartilage transplant can help regenerate the joint surfaces and maintain the ankle joint. What are the conditions for a successful ankle cartilage transplantation?

How is ankle arthritis formed?

In most cases, osteoarthritis occurs in seniors because of the changes in their metabolic processes, overweight, misalignment of the joints, and often lack of exercise.

However, osteoarthritis of the ankle joint has mostly traumatic causes: this means an accident, a fracture, or a dislocated bone has caused a ligament injury. Because of this trauma the premature wear of the ankle occurs.

When the ankle is bent to the outside, an excessive shearing force is applied to the cartilage of the outer anklebone and a massive pressure load on the inner part of the talus, bruising of the bone under the cartilage, which can cause injury of the joint. Furthermore, abrasive bone spurs on the front tibia edge can cause damage to the ankle joint cartilage. Another cause of damage to ankle joint cartilage is the avascular necrosis: The bone dies out of an unknown cause, so that the cartilage above it breaks into the formed bone defect (osteochondritis dissecans (OD) in the ankle).

When is the autologous cartilage cell transplant has promising results?

In some cases, a promising method of autologous cartilage transplantation of the ankle joint is to transplant cartilage cells bred in a laboratory thus preventing osteoarthritis of the ankle joint. Since the implanted material has the biomechanical properties similar to the natural cartilage, the organism does not consider it a foreign body. The living chondrocytes are thus capable of reconstructing a functioning cartilage layer. As a rule, new cartilage tissue is formed only a few weeks after the procedure. In order to preserve the newly built tissue, it is also necessary to simultaneously treat accompanying injuries and incorrect load distribution due to axial malalignment.

How can the cartilage cells be transplanted into the ankle?

In recent years, we have achieved great success in the field of cartilage treatment. With the ARTHROcell 3d by Codon Ltd., the transplantation of free cartilage cells became possible within an arthroscopic intervention.

We have most experience in applying it to the treatment of the knee joint. The transfer of these sparing methods to the upper ankle was only logical. Today we transplant the extracted cartilage cells arthroscopically without the use of foreign materials: the so-called matrix components.

Indication: Who is the autologous cartilage transplantation suitable for?

The possibility of cartilage transplantation (grafting of cartilage cells) is limited. Before conducting the therapy, doctors need to make sure whether a less invasive procedure with unilateral action is possible.

In an autologous cartilage cell transplantation, cartilage cells are extracted in the first session and then re-implanted after breeding in a special laboratory 6-8 weeks later.

The method is best suited for:

  • Patients under 40 years of age
  • Single-sided ("focal") cartilage damage of the ankle
  • Cartilage damage size is less than 1.5 cm2

It is also important to consider the increased movability of the ankle joint (ankle instability) or axial malalignment of the leg. These must be treated simultaneously in order to be able to heal the cartilage cells. Otherwise the newly implanted cartilage cells will also be worn-out.

What are the alternatives to autologous cartilage cell transplantation?

The possibilities of treating cartilage damage with the bone marrow stimulating methods such as bone drilling or microfracturing are limited. In the upper ankle, these methods can be used if the damage is less than 1 cm2 and with a central placement of the talus. However, the fibre-cartilaginous replacement fabric has a low resistance against mechanical stress. A special instrument is used to freshen the bone under the damaged cartilage. This is done by pressing it into a certain depth. The drilling produces heat that may damage the bone and impede the formation of the replacement cartilage.

The osteoarthritis of ankle joint provokes changes in the cartilage tissues, causing it to lose its elasticity and cushioning effect. The cartilage becomes thin, which results in a patient complaining about distinctive crackling noise when moving, severe pain, reduce movability of the joint, and rapid foot fatigue.

People often look for the keywords "Osteoarthritis of Ankle Joint Treatment Forum" in search engines, but this is a serious chronic disease that can lead to the total destruction of a joint and can spread to neighboring joints. It requires a patient to directly contact a doctor.

DOA (deforming osteoarthritis) is a particularly dangerous form of arthrosis, which leads to a complete foot deformity as a result of cartilage ossification, proliferation of bone outgrowths, clamping of the joint nerves.

DOA of ankle joint is also treated using surgical intervention, which reduces the tissue ossification, removes excrescences that prevent the foot to move freely. It is also recommended to take cartilage protectors, which may partially accelerate the regeneration of cartilage tissues and their recovery. Periarteritis of ankle joint is also treated using cartilage protectors.

Bursitis is a disease that affects synovial bursa of a joint. The disease causes changes in its cells with subsequent cornification. The patient can find a small tumor, swelling or redness in the foot area, which are accompanied by pain that soothes during rest period. Over time bursitis reduces the mobility of the foot and can lead to its deformation.

In order to treat bursitis of ankle joints various kinds of therapy are used, but if they do not give visible results, the operation is assigned. The operation helps to eliminate the excrescence on the joint capsule, returning its size to normal. Rehabilitation period follows the procedure.

Tenosynovitis and synovitis often affect the foot joint. They cause an inflammation of synovial membrane which disturbs the secretion of synovial fluid. The fluid is produces in large volumes, provoking the enlargement of the foot, its swelling, and a strong temperature rise in the foot area. If patient tries to move the foot the pain increases, and pulsations occur.

Treatment of tenosynovitis of the ankle joint is based on the administration of anti-inflammatory non-steroid analgesics combined with physiotherapy (electrophoresis, magnetic therapy). It is also possible to use ointments, such as Fastumgel, Voltarengel, etc. The difficulty is that swelling also occurs in case of a gout, so it is not uncommon to delay the treatment in order to perform an accurate diagnosis.

Contracture of ankle joint, in other words, paralysis or paresis, is a phenomenon encountered in spinal patients suffering from osteochondrosis or paralysis. It can also often be provoked by past injuries of ligaments or joint muscles. The disease causes paralysis of the ankle joint, the inability to carry out axial motions (neither saggital nor flexing or extending).

These ankle joint diseases need comprehensive treatment. It consists of emergency measures that aim to remove the contractures and a long rehabilitation period, which always includes exercises.

If the contracture is of an extensor type, then the joint should first be carefully straightened, and only then bent. The treatment of the ankle joint contracture includes systematic exercises that strengthen muscles, ligaments, and normalize the blood and lymph circulation in the joint area. This allows to avoid muscle pinching and clamping.

The ganglia of ankle joint is a variety of cyst. It causes formation of a cavity without a membrane, which is filled with fluid. The ganglion cyst in a joint is formed using the tissue of the capsule membrane by the tendons of the foot joint. The main factors that may trigger the disease are: Inflammatory processes in tendons and synovial membrane, inflammation of a joint capsule. In this case, the patient can detect a significant enlargement of the foot, a swelling, soft to the touch when palpating, similar to an edema.

Synovial cyst of the ankle joint is treated using radical surgical intervention. This is useful when conservative therapy methods are ineffective. Using surgical intervention, the soft tissue is punctured removing the fluids and the cavity is filled with various medications to eliminate the risk of inflammation. Removal of the fluid in the ankle joint is an integral part of recovery. After the liquid has been removed, it is recommended to take a course of physiotherapy with warming and electrophoresis.

When a specialist diagnoses arthrosis or arthritis of the ankle joint, the treatment intensity primarily depends on how severe the disease is and how sharp the pain is. On the early stages a rheumatologist or an orthopedist offers their patients a conservative treatment:

  • Physiotherapy;
  • Exercises;
  • Medication therapy;
  • Manual therapy;
  • Diet.

The first step is to secure and immobilize the sick joint. It should be given time to rest: patient is recommended to minimize the load on the joint, lose weight, stick to a diet and to the basics of healthy eating. On the early stages of treatment it is better to refrain from long walks.

The next equally important step is to relieve pain and to neutralize the inflammation. Drugs like Paracetamol, Ibuprofen, Spazmalgon, Solpadein, Peltalgin and others are the most effective analgesics that quickly eliminate pain. The analgesics in form of ointment and cream, such as Apizatron, Remesid, Fastum Gel and others, have proved to be very effective. Drugs like Ibuprofen, Ortofen and others will not only reduce pain, but also have anti-inflammatory effect.

Glycosaminoglycans, chondroprotectors are often used to restore the cartilage tissue, when treating the ankle joint.

One should not neglect the efficiency of physiotherapy procedures in treatment of the ankle joint diseases:

  • Magnet therapy;
  • UHF;
  • Acupuncture;
  • Balneotherapy with hydrogen sulfide and radon baths;
  • Hydro massage and therapeutic muds.

Physical activity and exercises play a particular role in the treatment of the ankle joint diseases. A special set of exercises allows you to retain the mobility of the joint for a longer time. Many specialists and chiropractors have developed a series of gymnastic exercises with and without special equipment to treat osteoarthritis and arthritis of the ankle joint. As a rule, these simple monotonous exercises do not cause pain, and usually should be done for several hours a day.

Orthopedists, surgeons and reumatologists insist that a patient should restrain from certain food: in other words doctors use diet to cure joint diseases. It is required not only to ease the strain of the joint: the smaller the weight of a patient, the more seldom occurs the disease; it is also useful to normalize the patient's overall condition. As many orthopedists claim, it is precisely the bad eating habits and disturbed water-salt balance that lead to increased salt deposits in joints. In these pathologies specialists recommend the following:

  • Reduce salt consumption;
  • Eliminate tomatoes, sorrel, pepper and spicy seasonings from ration;
  • Patients are recommended eat more potassium containing food: dried apricots, bananas, jacket potatoes;
  • Abundant drinking: at least 1.5-2 liters (0.4-0.5 gallons) of pure water a day.

The diet helps to cope with the swellings of tissues and reduces the inflammatory processes in joints.

Every person who was confronted with ankle diseases should understand that only contacting the doctors on the early stage and performing all the recommendations and regularity of curing courses can possibly restore the physical health and help to avoid operation and disability.

In the event when joints are almost completely destroyed, usually it is the third stage of the disease and there is no hope of restoring the health of limbs using conservative methods, a specialist resorts to surgery.

Nowadays, there are several types of surgical interventions:

Arthroplasty is one of the most effective methods used to treat pathologies of the ankle. Partially destroyed cartilage is restored using the patient's own tissues or artificial substitutes. The joint is partially modeled or a gasket that replaces the cartilage tissue is used. Total arthroplasty is the replacement of the whole problem area by a prosthesis. It successfully replaces the natural joint and flawlessly performs its functions for several decades.

Arthrodesis is a surgical intervention that ensures a complete immobility of the joint, returning its weight-bearing capacity, removing painful feelings.

If your ankle is prone to frequent injury, you feel a periodic nagging pain in this area, see your doctor. The sooner you receive help from specialists, the more likely you will be able to keep your joint healthy with the help of conservative therapy.

GermanMedicalGroup + 49 (7221) 39-65-785 Flugstrasse 8a 76532 Baden-Baden Germany Throughout a person's’ life their ankle joint constantly experience tremendous load of the entire body weight. Throughout a person's’ life their ankle joint constantly experience tremendous load of the entire body weight. 2017-11-06 Throughout a person's’ life their ankle joint constantly experience tremendous load of the entire body weight.

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