Medical alternatives to total ankle arthroplasty
As always in surgery, the therapeutic path increases gradually with aggressiveness, and surgery comes last.
Painkiller and non-steroidians anti-inflammatory (NSAI) allow to live for a long time with a little or even a non-painful ankle.
The orthotic insoles also play a role as they correct at least partially an ankle’s axis deformity.
The patient can also use a walking support or crutches, that can sustainably relieve him as they limit the mechanical load applied to the point.
Steroid joint injections are very often efficient on pain and must be renewed as long as they provide the patient with a painless ankle.
Surgical alternatives to total ankle arthroplasty
We are not discussing the osteoarthritis’ cause treatment. When a total ankle arthroplasty is considered, the joint’s wear is too severe to hope restoring a functional ankle only with treating the causal.
Two types of alternative interventions are discussed : ankle arthrodesis, and supra-malleolar osteotomy.
Supra-malleolar osteotomy is a palliative surgery. It aims to modify the ankle’s mechanical axes so that the patient’s weight is loaded on a preserved part of the joint. The patient may hope a pain reduction but it is not a definitive procedure since the affected joint, even if not painful anymore, remains after surgery.
With an ankle arthrodesis the joint is removed and to achieve a fusion between the tibia and the talus. The joint is fixed in a walking position with the plantar sole at 90° angle with respect to the leg. The pain disappears but at the price of a definitive loss of the ankle’s motion. All the other foot’s joints are kept mobile. After surgery the movement that doesn’t occur in the ankle may partially be transferred to these joints. This explains why walking looks quite close to normal without limping after an ankle arthrodesis.
Nevertheless, this surgery requires an immobilization in a cast for 2 to 3 months with a forbidden weight-bearing.
These postoperative instructions are very different from those following a total ankle arthroplasty. They are often taken into account in the decision-making process.
Most of the time, simple X-rays are enough. Specific images must be requested before surgery to measure the axes of the ankle and confirm joint wear.
In specific cases, for instance when a poor bone quality is suspected, a CT-scan may be requested by the surgeon to ensure that the implant will anchor normally in the bone. An MRI is rarely necessary in this indication but is able to inform on the vitality of the talus, which is one of the possible causes of ankle prosthesis failure.
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