treatment options for end stage ankle pain. anatomy of the ankle hinge joint hinge joint made up of...

Treatment Options for Treatment Options for End Stage Ankle PainEnd Stage Ankle Pain

Anatomy of the AnkleAnatomy of the Ankle

Hinge JointHinge Joint Made up of 3 Made up of 3

bonesbones Lower end of the Lower end of the

tibia (shinbone), tibia (shinbone), Fibula (the small Fibula (the small

bone of the lower bone of the lower leg)leg)

Talus, the bone Talus, the bone that fits into the that fits into the socket formed by socket formed by the tibia and the the tibia and the fibulafibula

Source: www.AllAboutArthritis.com, 2003 v203

Ankle JointAnkle Joint

Healthy ankle Healthy ankle jointjoint

Arthritic ankle Arthritic ankle jointjoint

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Causes of Ankle PainCauses of Ankle Pain

Osteoarthritis (wear and Osteoarthritis (wear and tear)tear)

Common joint injuriesCommon joint injuries Fractures and sprains Fractures and sprains

Excessive stress causing Excessive stress causing damage to the cartilage.damage to the cartilage.


Symptoms of Ankle PainSymptoms of Ankle Pain

Pain Pain During activityDuring activity At rest or sleepingAt rest or sleeping

Swelling and TightnessSwelling and Tightness Squeaking or grinding sound when Squeaking or grinding sound when

ankle is moved.ankle is moved. Stiffness and decreased movementStiffness and decreased movement


Preparing for ExaminationPreparing for Examination

Have the following information ready Have the following information ready for your exam:for your exam: Chief complaint (Where it is hurting Chief complaint (Where it is hurting

the most?)the most?) Chronology of illnessChronology of illness What effect does the pain have on What effect does the pain have on

your life?your life? Family historyFamily history

Source: www.arthritis.org, 2003

Diagnosing Ankle PainDiagnosing Ankle Pain

Physical ExaminationPhysical Examination Range of Motion TestRange of Motion Test

Medical History ReviewMedical History Review X-raysX-rays


How Can My Life ChangeHow Can My Life Change with Treatment? with Treatment?

A return to A return to mobility mobility

Regaining a sense Regaining a sense of your former of your former lifestyle.lifestyle.

A change in pain A change in pain symptoms symptoms

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Non-Surgical Treatment Options for Non-Surgical Treatment Options for Ankle Pain: Over-the-Counter Ankle Pain: Over-the-Counter

MedicationsMedications Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)

Usually first drug used to treat arthritisUsually first drug used to treat arthritis Can reduce pain, swelling and rednessCan reduce pain, swelling and redness Relief can take several monthsRelief can take several months Examples:Examples:

ibuprofen (ibuprofen (Advil®, Motrin®)Advil®, Motrin®) naproxen (naproxen (Aleve®)Aleve®)

AspirinAspirin Reduce joint pain and inflammationReduce joint pain and inflammation Form of NSAIDs.Form of NSAIDs.

Source: www.AllAboutArthritis.com , 2003 v209

Non-Surgical Treatment Options for Non-Surgical Treatment Options for Ankle Pain: Over-the-Counter Ankle Pain: Over-the-Counter

MedicationsMedications

AcetaminophenAcetaminophen Reduces painReduces pain Lowers feverLowers fever Does not reduce inflammation of Does not reduce inflammation of

arthritisarthritis Examples:Examples:

Tylenol®Tylenol® Datril® Extra StrengthDatril® Extra Strength Tempra®Tempra®

Source: www.AllAboutArthritis.com , 2003 v210

Non-Surgical Treatment Options for Non-Surgical Treatment Options for Ankle Pain: Prescription MedicationsAnkle Pain: Prescription Medications

NSAIDS NSAIDS Most popular type for osteoarthritis treatmentMost popular type for osteoarthritis treatment Includes ibuprofen (Includes ibuprofen (MotrinMotrin®®), ), naproxen sodium naproxen sodium

((AnaproxAnaprox®®)), oxaprozin , oxaprozin (Daypro(Daypro®®)), sulindac , sulindac (Clinoril(Clinoril®®) ) , etc. , etc.

AnalgesicsAnalgesics Provide pain relief, but do not reduce Provide pain relief, but do not reduce

inflammationinflammation Includes Acetaminophen with codeine (TylenolIncludes Acetaminophen with codeine (Tylenol®®

with Codeine), Oxycodone (OxyContinwith Codeine), Oxycodone (OxyContin®®, , RoxicodoneRoxicodone®®), Hydrocodone with acetaminophen ), Hydrocodone with acetaminophen (Vicodin(Vicodin®®, Dolacet, Dolacet®®), etc.), etc.

Source: www.AllAboutArthritis.com , 2003

Non-Surgical Treatment Options for Non-Surgical Treatment Options for Ankle Pain: Prescription MedicationsAnkle Pain: Prescription Medications

Biological Response ModifiersBiological Response Modifiers Treat rheumatoid arthritis; may postpone injury to the jointsTreat rheumatoid arthritis; may postpone injury to the joints Includes: Infliximab (RemicadeIncludes: Infliximab (Remicade®®), Etanercept (Enbrel ), Etanercept (Enbrel ®®))

Glucocorticoids or CorticosteroidsGlucocorticoids or Corticosteroids Treat rheumatoid arthritis; fight inflammationTreat rheumatoid arthritis; fight inflammation Includes: cortisone, hydrocortisone (CortefIncludes: cortisone, hydrocortisone (Cortef®®, ,

HydrocortoneHydrocortone®®), Prednisolone (Prelone), Prednisolone (Prelone®®) ) DMARDSDMARDS

Treat rheumatoid arthritis; slow joint destructionTreat rheumatoid arthritis; slow joint destruction Includes: methotrexate, injectable gold, penicillamine Includes: methotrexate, injectable gold, penicillamine

(Depen(Depen®®), Azathioprine (Imuran), Azathioprine (Imuran®®), etc.), etc.

Source: www.AllAboutArthritis.com , 2003

Non-Surgical Treatment Options Non-Surgical Treatment Options for Ankle Painfor Ankle Pain

Physical TherapyPhysical Therapy Assistive devicesAssistive devices

Orthosis, walking aidsOrthosis, walking aids Activity ModificationActivity Modification

Avoid activities that put Avoid activities that put excessive stress on the excessive stress on the ankle joint.ankle joint.


Surgical Options for Ankle PainSurgical Options for Ankle Pain

Arthroscopic DebridementArthroscopic Debridement Appx. 11,200 debridements a year. Appx. 11,200 debridements a year.

Ankle Fusion surgeryAnkle Fusion surgery 12,000 fusions estimated for 2003.12,000 fusions estimated for 2003.

Ankle Replacement surgeryAnkle Replacement surgery Appx. 1,500 replacements a year.Appx. 1,500 replacements a year.

Copyright 2002 by Solucient LLC v215

Arthroscopic DebridementArthroscopic Debridement

Early stage of arthritis and ankle Early stage of arthritis and ankle damage.damage.

Small camera is inserted into the Small camera is inserted into the ankle through small incisions. ankle through small incisions.

Remove debrisRemove debris Cartilage surfaces smoothed.Cartilage surfaces smoothed.

Source: www.AAOS.org, 2003 v216

Ankle Fusion SurgeryAnkle Fusion Surgery

End stage of arthritis and ankle painEnd stage of arthritis and ankle pain Traditional treatment historicallyTraditional treatment historically Fuse the bones of the joint to grow Fuse the bones of the joint to grow

together.together. Results in :Results in :

Strong jointStrong joint Eliminate painEliminate pain Immobile ankle (no range of motion).Immobile ankle (no range of motion).


Ankle Fusion SurgeryAnkle Fusion Surgery Incision is made.Incision is made. Fibula and tibia are Fibula and tibia are

held together until held together until they heal and fuse they heal and fuse into one with:into one with: PinsPins PlatesPlates ScrewsScrews

A bone graft is A bone graft is sometimes needed. sometimes needed.


Ankle Fusion SurgeryAnkle Fusion SurgeryBenefits of ankle fusionsBenefits of ankle fusions

Durable and strongDurable and strong Usually walk with a near normal gaitUsually walk with a near normal gait Removes pain of arthritisRemoves pain of arthritis

Disadvantages of ankle fusionDisadvantages of ankle fusion Immobile joint; forcing remaining joints to move Immobile joint; forcing remaining joints to move

more.more. Load transfer leading to arthritisLoad transfer leading to arthritis Uneven leg lengths, may cause limpingUneven leg lengths, may cause limping

“Source: www.AllAboutArthritis.com, 2003 v219

Ankle Replacement surgeryAnkle Replacement surgery

End Stage of Arthritis and Ankle PainEnd Stage of Arthritis and Ankle Pain Replaces Diseased BoneReplaces Diseased Bone ResultsResults

Moveable Ankle JointMoveable Ankle Joint Eliminates PainEliminates Pain

Source: www.agilityankle.com , 2003 v220

When is Ankle Replacement When is Ankle Replacement Surgery Right for You?Surgery Right for You?

Significant pain, even when Significant pain, even when sleeping.sleeping.

Loss of function despite non-Loss of function despite non-surgical treatments.surgical treatments.

Pain is no longer manageable.Pain is no longer manageable. Mobility similar to normal ankle is Mobility similar to normal ankle is

desired.desired.

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Total Ankle Replacement Total Ankle Replacement ComponentsComponents

Tibial component Tibial component made of medical made of medical

grade plastic with a grade plastic with a metal base plate tray.metal base plate tray.

Talar ComponentTalar Component made of metalmade of metal replaces the top of the replaces the top of the

talus.talus.TalarTalar


Benefits to Patient from Benefits to Patient from SurgerySurgery

Return to MobilityReturn to Mobility Restore their lifestyleRestore their lifestyle FreedomFreedom

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Surgical ProcedureSurgical Procedure

Incision is made Incision is made All arthritic portions of the ankle All arthritic portions of the ankle

joint are removed.joint are removed. Tibia (shinbone) and fibula are Tibia (shinbone) and fibula are

shaped for the implant.shaped for the implant.

Source: www.jointreplacement.com, 2003 v224

Surgical ProcedureSurgical Procedure

After the top of the talus After the top of the talus is cut the talar is cut the talar component is inserted component is inserted and tested.and tested.

The ankle joint is closed.The ankle joint is closed. Your leg will be wrapped Your leg will be wrapped

in a bandage and placed in a bandage and placed in a splint as it heals.in a splint as it heals.


X-Rays Before-After Total X-Rays Before-After Total Ankle ReplacementAnkle Replacement

Before After v226

Preparing for Joint Preparing for Joint Replacement SurgeryReplacement Surgery

Ease anxiety by mentally preparing with:Ease anxiety by mentally preparing with: Breathing exercisesBreathing exercises MeditationMeditation Talking with family and friendsTalking with family and friends

Learn more about ankle replacement surgeryLearn more about ankle replacement surgery BrochuresBrochures HandoutsHandouts WebsitesWebsites VideosVideos


The Night Before SurgeryThe Night Before Surgery

Avoid medications, such as “blood Avoid medications, such as “blood thinners” (aspirin, ibuprofen, etc.) thinners” (aspirin, ibuprofen, etc.)

Do not consume any food or liquid Do not consume any food or liquid after midnight.after midnight.

Make sure you have everything you’ll Make sure you have everything you’ll need at the hospital.need at the hospital.

Ask any questions you may have Ask any questions you may have before surgery.before surgery.


After SurgeryAfter Surgery

Foot is elevated and immobilized in a Foot is elevated and immobilized in a splint.splint.

Basic gentle range-of-motion Basic gentle range-of-motion exercises are started. exercises are started.

The dressing is normally removed The dressing is normally removed two days after surgery.two days after surgery.

If necessary, physical therapy will be If necessary, physical therapy will be prescribed by your doctor.prescribed by your doctor.


Hospital DischargeHospital Discharge

Hospital stay Hospital stay Three to five daysThree to five days Dependent on healing.Dependent on healing.

May need some assistance for May need some assistance for several weeks after surgery.several weeks after surgery.

Post-operative care period lasts for Post-operative care period lasts for approximately six weeks.approximately six weeks.

Follow surgeon’s directions precisely.Follow surgeon’s directions precisely.


A Caregiver’s RoleA Caregiver’s Role

Provide support and show patienceProvide support and show patience Help with needs that the patient can Help with needs that the patient can

not do, like:not do, like: Meal preparationMeal preparation Grocery shoppingGrocery shopping LaundryLaundry Driving to medical appointmentsDriving to medical appointments


Recovery in the First WeekRecovery in the First Week

Use a walker or crutchesUse a walker or crutches No weight on your ankle until No weight on your ankle until

instructed by your doctor.instructed by your doctor. Range-of-motion exercises at least Range-of-motion exercises at least

two to three times a day.two to three times a day. Special precautions during bathing.Special precautions during bathing.


Recovery in the First MonthRecovery in the First Month

““Post-operative” visitPost-operative” visit X-rays X-rays ExaminationExamination

2 Weeks: Sutures Removed2 Weeks: Sutures Removed


Recovery After Six WeeksRecovery After Six Weeks

6 weeks (with Doctors Instruction)6 weeks (with Doctors Instruction) Gradually put weight on the leg Gradually put weight on the leg Use of a cane or walker.Use of a cane or walker.

Begin Driving Begin Driving 6 to 8 weeks - automatic shift 6 to 8 weeks - automatic shift 12 weeks – manual shift12 weeks – manual shift

12 weeks - low-impact activities, such as 12 weeks - low-impact activities, such as walking.walking.

Up to 1 year - may require the use of an Up to 1 year - may require the use of an ankle supportankle support


Questions?Questions?

Thank-youThank-you

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