Ankle surgery

Anatomy of the Ankle Joint

Strictly speaking, the ankle joint is divided into an upper ankle joint and a lower ankle joint. In everyday language, however, the ankle joint usually means the upper ankle joint. This is because it is responsible for the main movement of the foot and is significantly more susceptible to injury.

The upper ankle joint forms the transition from the lower leg to the foot and consists of three bones. The tibia and fibula come together from the lower leg and form the mortice, with the palpable malleoli being the outside. The talus (ankle bone) is located in the middle of the mortice coming from above. The talus can be thought of a bit, like a pulley, so that the foot can move up (extension) and down (flexion) thanks to this joint.

Various ligament structures additionally stabilize the joint. For example, the tibia and fibula's mortice are held together by two ligaments (syndesmosis). And three external ligaments and four internal ligaments connect the lower leg to the foot.

What Conditions Cause Pain in the Ankle Joint?

The most common injury to the ankle joint is a torn lateral collateral ligament. This injury is often caused by "twisting outward." This injury is painful but usually uncomplicated to treat by stabilizing the joint from the outside with an orthosis.

In sports or traffic accidents, however, more complicated injuries can occur (various fractures and combinations with torn ligaments). An example is the so-called Weber fractures, where a fracture of the fibula/external malleolus occurs (often in addition to a tear of the syndesmosis) and, therefore, instability of the mortice.

In this case, it is of decisive importance for the therapy that successful reconstruction of the joint is achieved (surgical treatment), since otherwise, a permanent incorrect load on the joint can occur and cause ankle joint osteoarthritis ("joint wear"). Such arthrosis is accompanied by pain and severely reduced load-bearing capacity and may require further surgery.

Ankle Joint Surgery: An Overview of the Most Important Ankle Joint Surgeries

The upper and lower ankle joints are exposed to a particularly severe load since they must bear the entire body weight. In addition, it must also offer good mobility to adapt to the ground when walking and allow rolling across the feet from heel to toe.

In most cases, injuries to the ankle joint with its capsule, cartilage, and ligaments result from an accident. The consequence is various surgical methods, depending on the findings:

Ankle Joint Arthroscopy

Arthroscopy of the ankle joint is a minimally invasive surgical technique (keyhole technique) to perform joint surgery with the least possible soft tissue damage and risk of infection. In this procedure, a camera system and surgical instruments are inserted into the joint through small incisions in the skin. This allows the surgeon, in addition to determining the diagnosis, to perform minor procedures directly. For example, joint mouse, inflamed parts of the joint capsule, or connective tissue debris are typically removed. However, arthrosis and cartilage damage can also be treated.

Ankle Osteotomy

If the load axis of the joint is not centered but strongly shifted to one side, excessive wear of the joint occurs on one side. Over time, this can manifest in ankle joint arthrosis, with typical joint pain and restricted mobility. On the one hand, these deviations can originate in the foot (talipes valgus, flat foot, pes transversus). Still, most frequently, they are a consequence of accidents (bone fractures, cartilage damage) or the classic twisting of the ankle joint. During ankle osteotomy (ankle joint realignment), the doctor precisely analyzes the statics of the foot and corrects the load axis accordingly. By using screws to correct and realign the articulating joint partners, the doctor aims to prevent unilateral wear of the joint cartilage.

Ankle Impingement

Impingement of the ankle joint causes patients, besides frequent cracking noises, pain during specific movements that limit their mobility. If posterior impingement exists, plantar flexion (pointed foot position) is limited when walking downhill. A bony structure of the ankle bone is often responsible for this. In anterior impingement, on the other hand, the elevation of the foot is painfully restricted and functionally uphill. Both skeletal and connective tissue structures cause anterior impingement, usually due to accidents such as frequent ankle twisting. Scar tissue that forms disrupts joint mechanics and causes symptoms.

In the surgical removal of disturbing bony and connective tissue structures by arthroscopy, the surgeon can obtain a precise picture of the joint status via the camera system on the monitor.

Ankle Arthrodesis

Arthrodesis (stiffening) or ankle fusion is a standard surgery for osteoarthritis of the upper ankle joint. If the patient suffers significantly from the typical painful movement restrictions, stiffening the joint is an advisable option to achieve immediate help of the pain if all conservative and joint-preserving therapies do not improve. In this case, the involved joints, the tibia, fibula, and talus, are surgically fused with plates and screws. Patients are limited in everyday life only when walking faster and in some movements; normal walking is possible because other ankles can compensate for the movement. Ankle arthrodesis also offers the last therapeutic option in some cases, such as joint infections or ankle prostheses that cannot be revised. If the treating physician chooses arthroscopic arthrodesis (stiffening of the ankle joint with keyhole surgical arthroscopy), the option of a later ankle joint prosthesis remains open. However, this is not possible in all patients and must be decided individually.

Triple Arthrodesis

Triple arthrodesis involves the fusion of the lower ankle joint, which consists of three lower joints (triple). As in the case of fusion of the upper ankle joint, osteoarthritis is the cause of the patient's pain. Likewise, the fusion of the three joints, the calcaneus, talus, and navicular bone, is carried out with screws and plates, which results in immobility. However, unlike in the case of the upper ankle joint, it is not the bending and stretching of the foot that is restricted here, but rather twisting and turning incidents. Patients can therefore walk on even surfaces without any problems; uneven and sloping surfaces cause more difficulties after surgery. In general, however, patients can manage their daily routine with little pain and no issues.

Cartilage Transplantation in the Ankle Joint

Suppose there is considerable cartilage damage, or arthrosis, in younger patients (under 40), e.g., as a consequence of an accident or injury. In that case, the patient's cartilage can be removed and implanted into the affected area of the ankle joint cartilage after cultivation in a specialized laboratory. In this way, further, wear and tear can be stopped, and arthrosis can be counteracted at an early stage. The surgical procedure of choice would be a minimally invasive arthroscopy with minor damage to the soft tissue. However, this method is only realizable in cases of relatively small cartilage damage (< 1.5cm2). In addition, there cannot be instability of the joint or severe axis deviation, as this would not allow a sustainable and good surgical result.

Ligament Surgery on the Ankle Joint

Due to its construction from the two lower leg bones, the upper ankle joint, tibia, and fibula connect to the foot bones via the talus. For this hinge joint to be stabilized, it is surrounded laterally by internal and external ligaments in addition to a joint capsule. Due to anatomical conditions, supination trauma (twisting to the outside) and injury to the outer ligaments occur much more frequently than pronation trauma (to the inside) with an inner ligament lesion. If repeated trauma of this type occurs in the ankle joint, the capsule-ligament apparatus loosens, and the joint becomes unstable. To minimize the consequences of instability, such as cartilage damage with osteoarthritis formation, ligament surgery may follow if conservative, nonsurgical treatment is inadequate. During the arthroscopic surgery, the surgeon decides, depending on the findings, whether the existing ligament tissue can be reconstructed or an additional ligament reconstruction (tendons from the ankle area are used as stabilizing ligaments) is required.

Ankle Joint Prosthesis

If patients suffer from severe pain and restricted movement due to ankle arthrosis, an artificial ankle joint can help patients achieve a better quality of life and freedom from pain. However, it cannot be used in every case and requires comprehensive findings from a specialist. During surgery, the joint surfaces between the tibia (shin bone) and talus (ankle bone) are replaced with an implant made of titanium and resilient plastic. This eliminates pain and allows the mobility of the hinge joint compared to ankle arthrodesis (stiffening). After successful surgery, even gentle sports, such as cross-country skiing and hiking, are possible again. However, heavy loads on the ankle joint and sports such as tennis or skiing should be avoided.

Which Doctors and Clinics are Ankle Specialists?

The doctors who deal with ankle joint problems and injuries are specialists in orthopedics and trauma surgery. In addition, some clinics specialize in such issues. Therefore, it is best to ask your general practitioner or treating orthopedist to find a suitable clinic near you.

Every patient who needs a doctor wants the best medical care. Therefore, the patient is wondering where to find the best clinic. As this question cannot be answered objectively, and a reliable doctor would never claim to be the best one, we can only rely on a doctor's experience.

We will help you find an expert for your condition. All listed doctors and clinics have been reviewed by us for their outstanding specialization in ankle surgery and are awaiting your inquiry or treatment request.

Sources:

Duale Reihe Orthopädie und Unfallchirurgie; Niethard, Pfeil, Biberthaler; 7. Auflage Thieme Verlag

Prometheus Lernatlas der Anatomie; Schünke, Schulte, Schumacher; 3. Auflage Thieme Verlag