What are the treatments for ankle osteoarthritis?
- Non-Surgical: Conservative treatments can include: patient education, weight management, physical therapy,
and the use of assistive devices such as orthotics and ankle braces to
reduce pain and improve function [Tejero et al, 2021; Grunfeld et al, 2014; Paterson & Gates, 2019].
- Medication Management:
Topical NSAIDs or capsaicin can be used initially. If these are
insufficient, oral NSAIDs or cyclo-oxygenase-2 inhibitors may be
considered, with careful monitoring for adverse effects, especially in
older patients. Intra-articular corticosteroid injections can provide
temporary pain relief [Tejero et al, 2021; Paterson & Gates, 2019].
- Joint Injections:
- Corticosteroid Injection: The
evidence for the effectiveness of corticosteroid injections in the
treatment of ankle osteoarthritis (OA) indicates that they can provide
short-term symptomatic relief, but have limited long-term benefits.
- In a prospective study by Ward et al., intra-articular
corticosteroid injections significantly improved symptom in
patients with foot and ankle arthritis up to 6 months post-injection,
with a sustained positive response at 2 months predicting sustained benefits up to 1
year [Ward et al, 2008]. However, the duration of the response varied among patients.
- In a
systematic review by Vannabouathong et al., corticosteroid
injections provided favorable short-term symptomatic relief for ankle
OA, but the effects were generally short-lived and typically lasting around
3 months [Vannabouathong et al, 2018].
- This review highlighted the need for further high-quality comparative
trials to establish the long-term efficacy of corticosteroid injections. Grice
et al. reported that 86% of patients experienced significant symptom
improvement following corticosteroid injections, with 66% achieving
complete pain resolution. However, the median time to recurrence of pain was 3 months, indicating limited long-term efficacy [Grice et al, 2017].
- A
more recent systematic review by Paget et al. concluded that there were
no clinically relevant differences in outcomes between corticosteroid
injections and other treatments such as hyaluronic acid or platelet-rich
plasma at 3, 6, or 12 months.
This review emphasized the lack of observed long-term efficacy and
recommended against the routine use of corticosteroid injections for
ankle OA until further high-quality studies are available [Paget et al, 2023].
- Viscosupplementation Injections: Hyaluronic acid injections may offer short-term pain relief, although evidence is limited [Tejero et al, 2021; Paterson & Gates, 2019].
- A systematic review and meta-analysis by Chang et al. found that intra-articular hyaluronic acid (HA) injections can significantly reduce pain in ankle OA compared to baseline, but the placebo effect accounted for a substantial portion of the observed efficacy [Chang et al, 2013].
- Another systematic review by Vannabouathong et al. reported that HA injections significantly improved Ankle Osteoarthritis Scale scores
compared to saline at 6 months [Vannabouathong et al, 2018]. - Several prospective studies have shown promising results. Younger et al. reported that a single injection of hyaluronic acid led to significant pain and disability reduction over 26 weeks [Younger et al, 2019].
- Murphy et al. found that a 3-injection protocol of sodium hyaluronate significantly improved Foot and Ankle Outcomes Scores at 6 months [Murphy et al, 2017].
- Lee et al. demonstrated significant improvements in pain and function with 3 weekly injections of sodium hyaluronate [Lee et al, 2022].
- DeGroot et al. in a randomized, double-blind, placebo-controlled study by found no significant difference between a single injection of low-molecular-weight HA and saline in improving clinical outcomes at 12 weeks [DeGroot et al, 2012].
- Biologic Therapies:
Platelet-rich plasma (PRP) and mesenchymal stem cell injections are
emerging treatments, but further research is needed to establish their
efficacy [Paterson & Gates, 2019].
- Platelet-rich plasma (PRP): The
evidence for platelet-rich plasma (PRP) injections in the treatment of
ankle osteoarthritis (OA) is mixed, with some studies showing short-term
benefits while others do not support its use.
- A
systematic review and meta-analysis by Ding et al. found that PRP
injections significantly improved the American Orthopaedic Foot and
Ankle Society (AOFAS) scores and reduced Visual Analog Scale (VAS) pain
scores at both short-term and ≥6 months follow-up, with improvements
reaching the minimal clinically important difference (MCID) at ≥6
months [Ding et al, 2023].
- This suggests that PRP may provide clinically significant benefits in the longer term.However,
a randomized clinical trial by Paget et al. reported no significant
difference in AOFAS scores between PRP and placebo groups over 26 weeks,
indicating that PRP injections did not significantly improve ankle
symptoms and function compared to placebo [Paget et al, 2021].
- Additionally,
a prospective study by Sun et al. demonstrated significant improvements
in VAS pain scores and AOFAS hindfoot-ankle scores at 1, 3, and 6
months following a single PRP injection, suggesting short-term benefits [Sun et al, 2021].
- Mesenchymal stem cells (MSCs): Mesenchymal stem cells derived from adipose tissue and bone marrow concentrate have been investigated for their potential in treating ankle OA.
A study comparing MSC injections combined with marrow stimulation to
marrow stimulation alone found that the MSC group had significantly
better clinical outcomes and cartilage regeneration as assessed by
second-look arthroscopy [Kim & Koh, 2016].
Another study reported that MSCs in the form of stromal vascular
fraction (SVF) improved clinical and MRI outcomes in patients with
osteochondral lesions of the talus [Kim et al, 2014].
- Microfragmented adipose tissue (MFAT):
Evidence suggests that MFAT injections can provide significant pain
relief and functional improvement in patients with ankle osteoarthritis.
- In a prospective study by Natali et al., 31 patients with early or moderate ankle osteoarthritis were treated with intra-articular injections of autologous micro-fragmented adipose tissue. Clinical evaluations before the treatment demonstrated statistically significant improvements
in function using the AOFAS, FADI, and VAS scores at 6, 12, and 24 months post-injection, although there was some decline in benefits between 12 and 24 months. No severe complications were noted during the treatment and the follow-up period. The authors concluded that autologous micro-fragmented adipose tissue for the treatment of pain in ankle osteoarthritis seems safe and able to provide positive clinical outcomes, potentially offering a new minimally invasive therapeutic option for patients who are not eligible for more invasive approaches. [Natali et al, 2021].
- Bone marrow aspirate concentrate (BMAC): BMAC has shown promise in improving outcomes for ankle osteoarthritis.
- In this systematic review by Bachir et al., bone marrow aspirate (BMA) and/or BMAC injections in tendon and cartilage injuries of the foot and anklewere found to improve
function and reduce pain in patients with osteochondral lesions of the
talus and other cartilage injuries, with no serious adverse effects
reported. In this review, 11 studies were included with 527 patients with osteochondral lesions (OCLs) of the talus, cartilage lesions of the talus, and acute Achilles tendon rupture. The authors found evidence indicates that BMAC provides good clinical results, with improved function and reduced pain in adults with OCL and cartilage lesions of the talus and acute Achilles tendon [Bachir et al, 2023].
- In this retrospective cohort study of 94 patients by Abas et al., the authors found that BMAC combined with hyaluronan and fibrin
in patients with osteochondral defects of the ankle (OCD) significantly improved clinical outcomes and quality of life scores over
a 3-year follow-up period . The authors concluded that BMAC injections are safe for, and well tolerated by, patients with OCD of the ankle as both primary treatment and those who have failed primary treatment [Abas et al, 2022].
Surgical management: Surgery for ankle osteoarthritis (OA) is typically considered when conservative treatments fail to provide adequate relief. The primary surgical interventions include:
- Ankle Arthrodesis (Fusion):This procedure involves fusing the bones of the ankle joint to eliminate movement, thereby reducing pain. It is often favored for younger, more active patients or those with high-demand occupations. While it generally provides good pain relief, it can lead to complications such as nonunion, adjacent joint arthritis, and altered gait mechanics [Maffulli et al, 2017; Martin et al, 2007; Anastasio et al, 2024].
- Total Ankle Arthroplasty (TAA): Also known as total ankle replacement, TAA involves replacing the damaged joint surfaces with prosthetic components. This procedure aims to preserve joint motion and improve functional outcomes. Advances in prosthetic design have improved the success rates of TAA, making it a viable alternative to arthrodesis, particularly for older patients or those with lower activity levels. However, TAA carries risks such as implant loosening and the need for revision surgery [Wąsik et al, 2019; Maffulli et al, 2017; Martin et al, 2007; Anastasio et al, 2024]. Total ankle arthroplasties (TAAs) typically last about 10 years before requiring revision surgery [Daniels et al, 2015; Dagneaux et al, 2022; Richter et al, 2021].
