Ankle Arthritis

Ankle Arthritis – Everything You Need To Know – Dr. Nabil Ebraheim

The patient will have longstanding global pain that is inside the ankle.  The patient will have antalgic gait with swelling of the ankle and decreased ankle motion.  You want to check the sensation.  Lack of sensation with Simmons–Weinstein 5.07 monofilament testing is important because insensate patients are poor candidates for ankle joint replacement.  The patient will usually have a trial of nonsurgical treatment first.

  •          Anti-inflammatory medication
  •         Activity modification
  •         Ankle orthosis/bracing
  •          Injections

Treatment Orthosis

·       Single rocker sole shoe modification and custom Arizona brace.  You may give the patient a cane.

With failed conservative treatment, the patient may need arthrodesis of the ankle, which is fusion of the ankle, or an ankle replacement.  If you are going to do arthrodesis of the ankle, it will be arthrodesis of the tibiotalar joint.  In ankle arthrodesis, the fixation can be done by multiple techniques.  The whole idea is to obtain rigid fixation.  You can use plates, screws, or combination of both.

How to you position arthrodesis?

·         Neutral flexion

·         The gastroc recession or TAL may be needed if we cannot achieve neutral dorsiflexion.  From 0–5 hindfoot valgus when 5–10 external rotation of the foot.


·         80% will have difficulty on even ground.

·         75% will have difficulty with stairs.

If you find a person with an ankle fusion that when they walk, they have knee hyperextension when the heel comes off the ground during the stance phase, then that person’s ankle is fused and some plantar flexion.  The plantar flexion position will create forced recurvatum of the knee.  The ankle should be fused in neutral flexion.  If the person has arthritis of the ankle joint and the subtalar joint, then you will do tibiocalcaneal arthrodesis.  Some people elect to go for total ankle replacement.

What are the contraindications for total ankle replacement?

  •  Severe deformity
  • Charcot joint
  • Avascular necrosis of the talus
  • Soft tissue compromise
  • Active ankle infection

What is the relative contraindication for ankle joint replacement?

  • Ligament instability
  • Diabetes
  •  Smoking
  •  Osteoporosis
  • Morbid obesity

When do you do distraction arthroplasty?

            You do this in younger patients with some motion and less severe joint destruction.

Arthritis of the ankle can be osteoarthritis, posttraumatic arthritis, or inflammatory arthritis as rheumatoid arthritis or gout.  Posttraumatic arthritis accounts for 80% of all ankle arthritis.  The primary osteoarthritis is about 10% only.  Pain with weightbearing, swelling, decreased range of motion compared to the other side, and you will be able to see the arthritis on the x-ray.  Ankle arthrodesis will be done in younger patients with a high demand, or if the patient has comorbidities such as diabetes and obesity.  10 years after ankle arthrodesis, 50% of the patients will have subtalar arthritis.  Some of the patients may get nonunion. Revision of the nonunion can lead to fusion in about 85%.  A young, active worker is a contraindication to total ankle arthroplasty.  You will do the arthrodesis and end-stage ankle arthritis and the union rate is about 90%.  The arthrodesis gives us a reliable pain control but will also give us adjacent joint arthritis.  The entire foot and the patient’s comorbidities must be evaluated to choose the proper surgical technique.  Total ankle arthroplasty has superior gait mechanics compared to ankle arthrodesis.  Ankle arthrodesis is done 6 times more than a total ankle replacement.  If you have an elderly patient with no comorbidities and you want to do a motion preserving procedure, then this would be total ankle arthroplasty.  Revision of total ankle occurs due to loosening of the implant or subsidence, especially in patients less than 55 years old.  In a patient with rheumatoid arthritis with end-stage arthritis, total ankle may be a reasonable option.  In older patients with low demand, you will give total ankle arthroplasty.  In younger, active patients he will do a fusion.  The total ankle arthroplasty is gaining a lot of popularity.  For patients with nonunion, you need to evaluate for infection and metabolic bone disease.  You may also need a CT scan.  Preservation of the fibula can help the potential conversion to a total ankle at a later date.  When you compare patient with an ankle prosthesis to a patient with thin ankle fusion, there is more complication rate and revision rate for a patient with total ankle and more increased wound complications for people with rheumatoid arthritis.  If you are in doubt, use ankle arthrodesis.

u Need To Know — Dr. Nabil Ebraheim

Knee Pain- Common Knee Problems

Knee Pain

Common Knee Problems

A common knee problem could be patellar chondromalacia. This chronic pain is due to softening of the cartilage beneath the knee cap. Pain is from mild to complete erosion of the cartilage in the back of the knee cap. It causes pain in the front of the knee. It occurs more in young people. It becomes worse from climbing up and down stairs. Treatment for patellar chondromalacia usually includes therapy and NSAIDS. Another common knee problem could be Patellar Bursitis.knee This is characterized by pain and inflammation over the front of the kneecap. This occurs when the bursa becomes inflamed and fills with fluid at the top of the knee. It causes pain, swelling, tenderness, and a lump in the area on top of the kneecap. Lateral Collateral Ligament Rupture usually occurs as a result of sports activities. Medial Collateral Ligament Rupture is an injury to the ligament on the inner part of the knee. It is the most commonly injured knee ligament. Anterior Cruciate Ligament Tear involves valgus stress to the knee. Usually the patient will have swelling and hematoma. It can be diagnosed by MRI or a positive Lachman’s test. Patellar Tendonitis is characterized by inflammation and pain located inferior to the knee cap area. The meniscus is a cusion that protects the cartilage of the knee. A meniscal injury will cause pain of the medial or lateral side of the knee. The outer 30% of the meniscus has blood supply. Meniscal tears can be diagnosed by MRI or a positive McMurrays test. kneeePatient with meniscal tears typically have a history of locking, swelling, and instability of the knee. Arthritis of the Knee Joint is characterized by progressive wearing away of the cartilage of the joint. The knee is a common part of the body that is most affected by arthritis. Knee arthritis causes decreased joint space. A Baker’s Cyst causes swelling in the back of the knee filled with synovial fluid. The cyst is between the semimembranous and medial gastrochnemius muscles. Gout is a type of arthritis or joint inflammation caused by an excessive level of uric acid in the blood. It can affect any joint especially the big toe. The gout crystals look like needles and have a negative birefringence.

Osteonecrosis of the Knee

There are three different types of osteonecrosis of the knee. There is Spontaneous Osteonecrosis of the Knee, Post Arthroscopic Osteonecrosis of the knee, and Secondary Osteonecrosis of the knee. Osteonecrosis is further classified by severity using Ficat Stages of Knee Osteonecrosis. In Stage I, the x-ray appears normal. Stage II, Sclerosis of the condyle is present. In Stage III, the crescent sign is found as well as a subchondral fracture. Stage IV, there is a collapse of subchondral bone.

ficatSpontaneous Osteonecrosis of the Knee typically occurs in females older than 55. Usually one joint and one compartment is affected (medial femoral compartment). No etiology is known. Symptoms typically consist of a sudden onset of severe pain with decreased range of motion as well as swelling in the knee. X-rays will probably appear to be normal. An MRI is helpful, the provider may find a crescent shaped lesion. This conditionspontaneous can cause arthritis. If severe knee pain is present in a middle aged or elderly female patient, and the x-ray is negative, the provider should order an MRI to rule out osteonecrosis of the knee. Treatment consists of protected weightbearing as well as therapy and NSAIDs. An arthroplasty may be required when conservative treatment fails. A unicompartmental knee arthroplasty will be performed for small lesions. A total knee arthroplasty will be completed for large lesions or collapse.

Post Arthroscopy Osteonecrosis of the Knee most commonly occurs in middle aged secondarywomen after a knee arthroplasty. Secondary Osteonecrosis of the knee is common in women under 55 years of age and has associated risk factors. This condition involves more than one compartment or the metaphysis of the knee. Secondary Osteonecrosis occurs bilaterally in 80% of cases and multifocal lesions may be seen. There is a cause for Secondary Osteonecrosis of the knee, which is why it can be bilateral, multiple, and everywhere. Risk factors include:

  • Alcohol use
  • Sickle cell disease
  • Steroid usedissecans
  • Trauma
  • HIV medications
  • Gaucher Disease


These patients should be screened for other joint involvement. The lesion is a subcondylar insufficiency fracture and the patient will have severe pain with weight bearing either standing or sitting. An x-ray may show a wedge-shaped lesion and MRI is the better study. A differential diagnosis is Osteochondral Dissecans, which is located in the lateral aspect of the medial femoral condyle in younger patients. Other differentials include: Occult trauma, bone bruise and overuse, as well as transient osteoporosis which is found more in middle-aged men and usually in the hip rather than the knee. Treatment consists of NSAIDs, a decrease in activity and weightbearing, and physical therapy. A scope surgery may be necessary to remove loose fragments or core decompression for lesions not extending to the joint. An Osteocondylar allograft may be performed for large, painful lesions in younger patients. A total knee replacement may be done for larger lesions, for collapse, or if multiple compartments are involved. Conservative treatment is not as successful with secondary avascular necrosis. Without surgery, secondary AVN will advance to osteoarthritis. Bisphosphonates have no effect on knee osteonecrosis.

Dislocations of the Talus

dislocationtalusA dislocation of the talus can be a total dislocation or a subtalar dislocation. There are two different main types of dislocations, total and subtalar. Subtalar dislocations are further categorized into lateral and medial dislocations.

A total dislocation of the talus that is not accompanied by a fracture is a very rare injury. Most of the injuries are open and urgent care is necessary totalin order to avoid any soft tissue complications. There is a high risk of avascular necrosis of the talus, as well as arthritis and soft tissue infection.

Subtalar dislocations of the talus are rare injuries that result from either excessive supination or from excessive pronation. It involves a simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. A lateral subtalar dislocation is often the result of a high energy trauma. These dislocations have a worse long-term prognosis. Irreducible lateral dislocation due to interposed tibialis posterior tendon. Lateral subtalar dislocations can be unstable and may sublux. The physician may need a CT scan to check for fractures. 85% of the dislocations are medial and subtalaroften result from low energy trauma. Irreducible medial dislocations can be due to the interposed extensor digitorum brevis or extensor retinaculum. The direction of subtalar dislocation has important effects with respect to management and outcome. Complications of subtalar dislocations may include stiffness and subtalar arthritis.


Stable dislocations will be treated with a closed reduction. The patient should have 3-4 weeks of immobilization, followed by physical therapy. Unstable fractures will require a closed reduction; an internal fixation may be required. An anteromedial incision is used for medial dislocations and a lateral approach is used for lateral dislocations.