Current Concepts in the Treatment of Osteoarthritis of the Ankle

  • Yasuhito TanakaEmail author


Osteoarthritis (OA) of the ankle has several causes, such as fractures around the ankle and chronic ligament injuries. Abnormal ankle morphology, such as varus deformity of the articular surface of the distal tibia, also causes ankle OA. Treatment must take the cause into consideration, as well as the stage of ankle OA, especially in varus-type OA. Conservative therapies consist of lifestyle guidance, pharmacotherapy, intra-articular steroid and/or hyaluronic acid injections, exercise therapy, physical therapy, orthotic therapy, and shoe inserts. Training of the peroneal muscle is particularly important in OA following injury to the lateral ligament. Standing on the toes so that the head of the first metatarsal presses against the ground can strengthen the peroneal muscle. As for surgeries, arthroscopic debridement, distraction arthroplasty, lateral ligament reconstruction, and distal tibiofibular ligament reconstruction, corrective osteotomies are selected as joint-preserving procedures. Low tibial osteotomy is indicated with stage II or IIIa OA and distal tibial oblique osteotomy is indicated in stage IIIb cases. Ankle arthrodesis or total ankle arthroplasty is indicated in stage IIIb or IV cases. Arthroscopic arthrodesis is possible if ankle varus or valgus is no greater than 15°. Nowadays, if the talus in the patients is severely destroyed, total ankle arthroplasty using a total talar prosthesis (combined TAA) can be selected.


Ankle osteoarthritis Conservative treatment Osteotomy Arthrodesis Total ankle arthroplasty 


  1. 1.
    Cushnaghan J, Dieppe P. Study of 500 patients with limb joint osteoarthritis. I. Analysis by age, sex, and distribution of symptomatic joint sites. Ann Rheum Dis. 1991;50:8–13.CrossRefGoogle Scholar
  2. 2.
    Saltzman CL, Zimmerman MB, O’Rourke M, Brown TD, Buckwalter JA, Johnston R. Impact of comorbidities on the measurement of health in patients with ankle osteoarthritis. J Bone Joint Surg Am. 2006;88:2366–72.CrossRefGoogle Scholar
  3. 3.
    Glazebrook M, Daniels T, Younger A, Foote CJ, Penner M, Wing K, Lau J, Leighton R, Dunbar M. Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis. J Bone Joint Surg Am. 2008;90:499–505.CrossRefGoogle Scholar
  4. 4.
    Al-Mahrouqi MM, MacDonald DA, Vicenzino B, Smith MD. Physical impairments in adults with ankle osteoarthritis: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2018;48:449–59.CrossRefGoogle Scholar
  5. 5.
    Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009;467:1800–6.CrossRefGoogle Scholar
  6. 6.
    Horisberger M, Valderrabano V, Hinterman B. Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma. 2009;23:60–7.CrossRefGoogle Scholar
  7. 7.
    Takakura Y, Tanaka Y, Kumai T, Tamai S. Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients. J Bone Joint Surg (Br). 1995;77:50–4.CrossRefGoogle Scholar
  8. 8.
    Tanaka Y, Takakura Y, Hayashi K, Taniguchi A, Kumai T, Sugimoto K. Low tibial osteotomy for varus-type osteoarthritis of the ankle. J Bone Joint Surg (Br). 2006;88:909–13.CrossRefGoogle Scholar
  9. 9.
    Aurich M, Squires GR, Reiner A, Mollenhauer JA, Kuettner KE, Poole AR, Cole AA. Differential matrix degradation and turnover in early cartilage lesions of human knee and ankle joints. Arthritis Rheum. 2005;52:112–9.CrossRefGoogle Scholar
  10. 10.
    Kuettner KE, Cole AA. Cartilage degeneration in different human joints. Osteoarthr Cartil. 2005;13:93–103.CrossRefGoogle Scholar
  11. 11.
    Salk RS, Chang TJ, Costa WF, Soomekh DJ, Grogan KA. Sodium hyaluronate in the treatment of osteoarthritis of the ankle. A controlled, randomized, double-blind pilot study. J Bone Joint Surg Am. 2006;88:295–302.PubMedGoogle Scholar
  12. 12.
    Karatosun V, Unver B, Ozden A, Ozay Z, Gunal I. Intra-articular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle. A prospective randomized trial with long-term follow-up. Clin Exp Rheumatol. 2008;26:288–94.PubMedGoogle Scholar
  13. 13.
    Sun SF, Chou YJ, Hsu CW, Hwang CW, Hsu PT, Wang JL, Hsu YW, Chou MC. Efficacy of intra-articular hyaluronic acid in patients with osteoarthritis of the ankle. A prospective study. Osteoarthr Cartil. 2006;14:867–74.CrossRefGoogle Scholar
  14. 14.
    Tochigi Y, Rudert MJ, McKinley TO, Pedersen DR, Brown TD. Correlation dynamic cartilage contact stress aberration with severity of instability in ankle incongruity. J Orthop Res. 2008;26:1186–93.CrossRefGoogle Scholar
  15. 15.
    McKinley TO, Tochigi Y, Rudert MJ, Brown TD. The effect of incongruity and instability on contact stress directional gradients in human cadaveric ankles. Osteoarthr Cartil. 2008;16:1363–9.CrossRefGoogle Scholar
  16. 16.
    Teramoto T, Tashiro K. Causes of and conservative therapy for osteoarthritis of the ankle. Shin OS NOW. 2002;15:28–33.Google Scholar
  17. 17.
    Takakura Y. In: Masuhara K, Takakura Y, Kitada C, editors. Osteoarthritis of the ankle—illustrations and clinical practice of the foot. Japan: Medical View Co; 1991. p. 92–9.Google Scholar
  18. 18.
    Hayashi K, Tanaka Y, Kumai T, Sugimoto K, Takakura Y. Correlation of compensatory alignment of the subtalar joint to the progression of primary osteoarthritis of the ankle. Foot Ankle Int. 2008;29:400–6.CrossRefGoogle Scholar
  19. 19.
    Hassouna H, Kumar S, Bendall S. Arthroscopic ankle debridement. 5-year survival analysis. Acta Orthop Belg. 2007;73:737–40.PubMedGoogle Scholar
  20. 20.
    Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP. Evidence-based indications for ankle arthroscopy. Arthroscopy. 2009;25:1478–90.CrossRefGoogle Scholar
  21. 21.
    Tellisi N, Fragomen AT, Kleinman D, O’Malley MJ, Rozbruch SR. Joint preservation of the osteoarthritic ankle using distraction arthroplasty. Foot Ankle Int. 2009;30:318–25.CrossRefGoogle Scholar
  22. 22.
    Harrington KD. Degenerative arthritis of the ankle secondary to longstanding lateral ligament instability. J Bone Joint Surg Am. 1979;61:354–61.CrossRefGoogle Scholar
  23. 23.
    Noguchi K. Biomechanical analysis for osteoarthritis of the ankle. J Jpn Orthop Assoc. 1985;59:213–20.Google Scholar
  24. 24.
    Tanaka Y. Mid-, long-term natural course of varus-type osteoarthritis of the ankle. J Joint Surg. 2003;22:65–70.Google Scholar
  25. 25.
    Takao M, Komatsu F, Naito K, Uchio Y, Ochi M. Reconstruction of lateral ligament with arthroscopic drilling for treatment of early-stage osteoarthritis in unstable ankles. Arthroscopy. 2006;22:1119–25.CrossRefGoogle Scholar
  26. 26.
    Löfvenberg R, Kärrholm J, Lund B. The outcome of nonoperated patients with chronic lateral instability of the ankle: a 20-year follow-up study. Foot Ankle Int. 1994;15:165–9.CrossRefGoogle Scholar
  27. 27.
    Lee HS, Wapner KL, Park SS, Kim JS, Lee DH, Sohn DW. Ligament reconstruction and calcaneal osteotomy for osteoarthritis of the ankle. Foot Ankle Int. 2009;30:475–80.CrossRefGoogle Scholar
  28. 28.
    Yablon IG, Heller FG, Shouse L. The key role of the lateral malleolus in displaced fractures of the ankle. J Bone Joint Surg Am. 1977;59:169–73.CrossRefGoogle Scholar
  29. 29.
    Weber BG, Simpson LA. Corrective lengthening osteotomy of the fibula. Clin Orthop. 1985;199:81–7.Google Scholar
  30. 30.
    Tanaka Y, Takakura Y. Indications and limitations of distal tibial osteotomy for osteoarthritis of the ankle. Orthop Surg Supp. 1994;25:138–41.Google Scholar
  31. 31.
    Takakura Y, Takaoka T, Tanaka Y, Yajima H, Tamai S. Results of open-wedge osteotomy for the treatment of a post-traumatic varus deformity of the ankle. J Bone Joint Surg Am. 1998;80:213–8.CrossRefGoogle Scholar
  32. 32.
    Katsui T, Takakura Y, Kitada C, Masuhara K. Radiographic investigation of osteoarthritis of the ankle. J Jpn Soc Surg Foot. 1980;1:52–7.Google Scholar
  33. 33.
    Moji J. Radiographic investigation of osteoarthritis of the ankle and the morphology of the ankle. J Jpn Orthop Ass. 1980;54:791–802.Google Scholar
  34. 34.
    Teramoto T, Otsuka K, Makino Y, Tashiro K, Sugitani Y. Kinetic evaluation of distal tibial oblique osteotomy (DTOO) for osteoarthritis of the ankle. J Jpn Ass Ext Fix Limb Leng. 2006;17:27–31.Google Scholar
  35. 35.
    Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle. A study of adjacent joints. J Bone Joint Surg (Br). 2003;85:994–8.CrossRefGoogle Scholar
  36. 36.
    Takakura Y, Tanaka Y, Sugimoto K, Akiyama K, Tamai S. Long-term results of arthrodesis for osteoarthritis of the ankle. Clin Orthop Relat Res. 1999;361:178–85.CrossRefGoogle Scholar
  37. 37.
    Gougoulias N, Khanna A, Maffulli N. How successful are current ankle replacements? A systematic review of the literature. Clin Orthop Relat Res. 2010;468:199–208.CrossRefGoogle Scholar
  38. 38.
    Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009;30:579–96.CrossRefGoogle Scholar
  39. 39.
    Kofoed H. Scandinavian total ankle replacement (STAR). Clin Orthop. 2004;424:73–9.CrossRefGoogle Scholar
  40. 40.
    Anderson T, Montgomery F, Carlsson A. Uncemented STAR total ankle prostheses. Three to eight year follow-up of fifty-one consecutive ankles. J Bone Joint Surg Am. 2003;85:1321–9.CrossRefGoogle Scholar
  41. 41.
    Takakura Y, Tanaka Y, Kumai T, Sugimoto K, Ohgushi H. Ankle arthroplasty using three generations of metal and ceramic prostheses. Clin Orthop Relat Res. 2004;424:130–6.CrossRefGoogle Scholar
  42. 42.
    Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007;89:1899–905.PubMedGoogle Scholar
  43. 43.
    Taniguchi A, Takakura Y, Tanaka Y, Kurokawa H, Tomiwa K, Matsuda T, Kumai T, Sugimoto K. An alumina ceramic total talar prosthesis for osteonecrosis of the talus. J Bone Joint Surg Am. 2015;97:1348–53.CrossRefGoogle Scholar

Copyright information

© ISAKOS 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryNara Medical UniversityKashiharaJapan

Personalised recommendations