What is hindfoot/ankle arthritis? 

Hindfoot arthritis can be caused by degeneration (osteoarthritis) or inflammation (e.g.  rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis). In both cases the  cartilage, which is the shiny white gristle that lines and articulates the joint, becomes  damaged. This causes bone to rub on bone, which is painful. Osteoarthritis is usually  secondary to damage to the joint, for example as a result of previous fracture, repeated  sprains of the ankle, malalignment of the joint or infection. Excess body weight can  overload a joint and worsen the symptoms of arthritis. Every extra kilogram of body  weight is multiplied by 5 to 7 times when it is carried by the ankle. The alignment of the  leg is such that the weight passes from the centre of the hip, through the centre of the  knee, and into the centre of the ankle. Anything which changes this alignment will alter  the way the ankle is loaded and cause it to wear unevenly, and more quickly. 'Bow legs'  or 'knock knees' are examples of malalignment, which can affect the ankle. Similarly  ankles which point inwards are more prone to sprains, and consequently early arthritis.  In some cases realignment of the bones may be helpful in treatment. 

Who gets hindfoot arthritis? 

Anyone can get hindfoot arthritis. Osteoarthritis tends to become commoner as we get  older; nevertheless ankle fractures, repeated sprains, and inflammatory arthritis can  cause arthritis to occur at a younger age. 

What are the symptoms? 

Pain: Pain is the commonest and most troublesome symptom. This is usually made  worse by walking. It may disturb sleep. Simple ways to see if your pain is getting worse  

is to record whether your walking distance is decreasing, or whether you need more  painkillers to ease the pain. 

Stiffness: With osteoarthritis stiffness, or reduced movement, is common. With  inflammatory arthritis stiffness can often be worse first thing in the morning. 

Cracking/popping: There may be little pieces of loose cartilage or bone caught within  the joint causing this sensation. 

Giving way: This may be due to looseness of the ligaments, or secondary to pain. 

Swelling: Swelling may be as a result of extra bone, or fluid within the joint. The soft  tissues can also inflame and swell. 

How is hindfoot arthritis investigated? 

X-rays of the hindfoot/ankle are taken whilst you are standing. This simple test will give  the most information on whether the hindfoot is worn or not. Blood tests are sometimes  used to investigate inflammation, or gout. Occasionally special tests are needed to  determine the extent of the arthritis, or exactly which joint is involved. An MRI scan can  give a lot of information on the thickness of the cartilage lining the joint and whether  there are small areas of wear and loose cartilage. CT and bone scans may also be used  to investigate hindfoot arthritis. 

Treatment 

With any form of arthritis there are two forms of treatment. The first is without an operation, and the second is with surgery. Most arthritis can be treated without surgery, and only in severe arthritis will surgery be considered. 

Non operative treatments 

In the first instance simple modifications of the way you lead your life should be tried.  These include resting when the pain necessitates, slowing down and altering sporting  activities. Weight loss, insoles within shoes, supportive boots and walking sticks are also  useful. Splintage or bracing can sometimes help. The most important and effective non operative treatment if necessary is weight loss. 

For many people the arthritis can be controlled by support of the ankle. Supports take 2  forms. Ankle braces, which can be bought from many sports shops. These may be  bandages, lace up braces, or even individualised plastic braces that can be made for  your leg. These braces can be hot and cumbersome and so HIGH TOPPED, LACE UP 

boots with a cushioned sole should be tried. Elasticated boots do not give such good  support.  

Pain relief 

Pain killers such as Paracetamol can be effective. Non steroidal anti inflammatories  (NSAID), such as Brufen, Ibuprofen and Diclofenac can reduce inflammation. Patients  need to check with their general practitioner or pharmacist that NSAID's are suitable for  them, as they can have side effects, especially if you have asthma or stomach ulcers.  Physiotherapy and hydrotherapy can help with pain and stiffness. Patients with  inflammatory arthritis are usually looked after by a rheumatologist. Disease modifying  anti-rheumatoid drugs (DMARD's) are used to treat these conditions, in conjunction with  painkillers and NSAID's. 

Operative treatments 

Steroid injection 

Steroid injection of the affected joint or joints may be an option that may provide  temporary relief from pain (depending on the joints involved). This option will require  admission to hospital usually as a day case with the injection taking place in an  operating theatre with x ray facility to identify the affected joint/s for injection. 

Hindfoot fusion 

Hindfoot fusion of one, two or three of the hindfoot joints is a surgical procedure to  relieve severe pain from arthritis or correct painful deformity. 

How does the procedure work? 

Hindfoot fusion is a surgical procedure that will remove the function of the joint/s below  the ankle leaving them stiff (fused). See fig.2  

If the fusion involves the subtalar joint only, an incision is made on the outside of the foot  just below the ankle. Double and triple fusion (involving the talonavicular and calcaneo  cuboid joints – see fig.1) requires an additional incision on the inside of the foot. 

The surgeon will remove damaged cartilage and position the joints correctly. They are  then fixed in this position using metal screws and staples. Positioned correctly, the  screws and staples are often felt by the patient but are not painful and will remain in  place indefinitely; there is normally no need to remove them. The operation allows the  bones to fuse together into a cohesive, painless structure.

The potential complications of hindfoot fusion include: 

1. Failure of the pain to resolve: This is usually because of one of the reasons outlined  below - occasionally no cause can be found. 

2. Failure of the bones to heal: This is rare in non-smokers, but does occur with a  higher incidence if the talonavicular joint only is fused only. In smokers the  complication rate is increased by a factor of five. For this reason it is advisable to  stop smoking 3 months before surgery. Nicotine is the cause of the problem, and  thus patches should also be avoided. If the bones fail to heal, this can usually be  rectified by a second operation. 

3. The bones not healing in the correct position (malunion): This can usually be  rectified by a second operation. 

4. Infection. 

5. Bleeding. 

6. Blood clots in the leg and, rarely, on the lung (deep venous thrombosis and  pulmonary embolus). 

7. Wound healing problems. 

8. Nerve and blood vessel damage leading to numbness, pain or weakness in the  foot.

9. Prominent metalware requiring the screws to be removed at a small second  operation. 

10. In some people, over the longer term (say more than 10 years), arthritis can  develop in other joints in the foot, as a result of the excess strain placed on them by  the fusion of the hindfoot joint/s. Treatment with further fusion (depending upon the  first procedure) may be possible. Obviously, further fusions can lead to an  excessively stiff foot. 

Most problems can be treated by medications, therapy and on occasions by further  surgery, but even allowing for these, sometimes a poor result ensues. 

How long will it take to recover? 

After the operation you will wake up with your foot in a plaster cast. To minimise swelling  the foot must be kept up (above heart level) most of the time. When the foot is lowered it  will throb and swell. This should be avoided. Over time you will be able to increase the  time that your foot is lowered. After two to three weeks you will be able to keep your foot  down most of the time. 

If you have a triple fusion, you are likely to spend about 2-3 days in hospital; less for a  single or double fusion.  

At two weeks you will attend clinic for removal of stitches and a change of plaster cast.  

As this is the period when your bones are in the process of fusing together you will wear  a plaster cast for the first 12 weeks following surgery. During this time you must not  weight bear on the operated foot for 6 of these weeks. You will then commence partial  weight bearing for the second six weeks. Your plaster will typically come off at about  twelve weeks. 

From three to six months post surgery, you will gradually start to build up your mobility  and strength with physiotherapy. Full recovery will take 10 months to one year,  (depending on your type of surgery). 

There will be some change to lifestyle required and some loss of mobility especially on  rough ground (depending on the joints fused). However, most patients are able to  resume their old activities, including walking, climbing, running and playing tennis.  

How will I know if I have a complication? 

You may be experiencing a complication if you bleed or experience an increase in pain  or swelling after you go home. If these symptoms continue after you have elevated the  leg and taken painkillers you should notify the hospital as this could indicate the early  onset of infection or possible deep vein thrombosis. (See contact numbers below)

Post-operative Venous Thromboembolism (VTE) prophylaxis 

Whilst your leg is being stabilised within a plaster cast (up to 12 weeks)you may be  required to take either an oral or injected blood thinning medication every day to prevent  the formation of a blood clot forming in your leg and associated complications. This  information will be provided to you during your inpatient stay.