Ankle osteoarthritis (OA), while less prevalent than hip or knee OA, presents a significant health concern, impacting patient quality of life considerably. Approximately 80% of ankle OA cases stem from post-traumatic events, frequently following malleolar fractures or chronic instability. Affecting individuals around 50 years old on average, ankle OA strikes an active, working-age demographic seeking to maintain mobility and an active lifestyle. This article delves into the critical aspects of Ankle Osteoarthritis Diagnosis, essential for automotive experts who require a comprehensive understanding of conditions that may affect vehicle operation and driver well-being.
Understanding Ankle Osteoarthritis
Ankle osteoarthritis is a chronic condition affecting roughly 1% of the global population, with an estimated incidence of 30 cases per 100,000 individuals, representing 2–4% of all OA patients [1, 2]. Compared to knee and hip OA, ankle OA is significantly less common [1, 2, 3]. Symptomatic knee OA is 8 to 9 times more prevalent, and approximately 24 times more total knee replacements are performed than ankle arthrodesis and arthroplasty combined [3, 4]. Despite being historically underestimated, advanced ankle OA can be profoundly debilitating, with quality of life repercussions comparable to severe hip OA, advanced kidney failure, and congestive heart failure [4, 5].
Unlike hip and knee OA, primary ankle OA is not the most frequent cause [1, 6, 7, 8]. Idiopathic OA accounts for only 7–9% of cases, and 13% are secondary to conditions like rheumatoid arthritis, hemochromatosis, hemophilia, or osteonecrosis. The primary etiology, in 75–80% of cases, is trauma (post-traumatic ankle OA). Fractures in the ankle region (malleolus, distal tibia, talus, etc.) (Fig. 1) are responsible for 62% of these cases, and chronic ligament instability, especially lateral collateral ankle ligament injuries, contributes to another 16% (ligamentous ankle OA) (Fig. 2) [8, 9]. Ankle instability elevates peak joint contact stresses, leading to cartilage deterioration and ultimately OA [9].
Figure 1.
Post-traumatic ankle osteoarthritis twelve years after bimalleolar fracture.
Figure 2.
Varus ankle osteoarthritis resulting from chronic lateral instability of ankle ligaments.
The relationship between osteochondral lesions of the talus and ankle OA development is debated. A 14-year follow-up study by Weigelt et al. [10] suggested that successfully nonoperatively treated osteochondral lesions of the talus have minimal long-term symptoms and low OA progression. Conversely, Stufkens et al. [5] indicated that anterolateral talar, posteromedial tibial, and medial malleolar osteochondral lesions increase the likelihood of ankle OA.
Due to its post-traumatic nature, ankle OA patients are typically younger (18–44 years) than those with other lower limb degenerative joint diseases [2]. They may experience a quicker functional decline, with progression to advanced stages within 10–20 years of onset. Degenerative changes after an ankle fracture can appear within 12–18 months post-injury [7, 11].
Pathophysiology and Cartilage Peculiarities
While the ankle joint is frequently injured, clinically significant ankle OA is less common than in other weight-bearing joints. This may be attributed to unique anatomical, biochemical, and biomolecular characteristics of ankle cartilage [12]. Ankle cartilage endures the highest force per unit area of all human hyaline cartilage (500 N/350 mm2 compared to 500 N per 1100 mm2 or 1120 mm2 in the hip or knee). Load distribution in the ankle also differs, distributing compressive forces over a smaller area. Ankle cartilage (1–1.62 mm) is thinner than knee cartilage (1.69–2.55 mm) [12, 13, 14]. Biologically, ankle cartilage is believed to possess greater self-repair capabilities than knee cartilage [14]. It exhibits higher stiffness and lower permeability due to increased water and proteoglycan content [11]. The denser extracellular matrix enhances load-bearing capacity and reduces susceptibility to mechanical damage [12]. Ankle chondrocytes are also metabolically more active and respond more robustly to anabolic factors like osteogenic protein-1 and C-propeptide of type II collagen, promoting cartilage synthesis. Furthermore, ankle cartilage is less sensitive to catabolic mediators such as fibronectin and interleukin-1 beta, which inhibit collagen synthesis [12, 15]. Synovial fluid in arthritic ankles has demonstrated biochemical alterations, particularly in matrix metalloproteinase concentrations [15], and key markers like aggrecan and BMP-7 increase with OA progression. Conversely, high BMP-2 levels correlate with good clinical function and fewer radiographic OA signs [16].
Despite these protective features, ankle joint cartilage is vulnerable to degeneration when stress and force distribution become asymmetric, such as with joint fractures, impact injuries, or weight-bearing axis malalignment [11, 16]. These factors help explain the strong link between ankle OA and traumatic event history [17].
Clinical Evaluation for Ankle Osteoarthritis Diagnosis
Diagnosis of ankle osteoarthritis hinges on clinical evaluation, focusing on joint pain with mechanical characteristics, potentially accompanied by joint effusion and/or deformity, and reduced mobility, especially ankle dorsiflexion [2, 11]. Scars from prior surgeries (osteosynthesis, hardware removal, cheilectomy, etc.) are common. Other clinical indicators include leg muscle atrophy and gait abnormalities [2, 3].
Imaging plays a crucial role in confirming the clinical diagnosis. Weight-bearing anteroposterior and lateral conventional radiographs (CR), along with a hindfoot alignment view like the Saltzman view, are fundamental [2]. However, CR may underestimate disease severity, particularly in early stages. Advanced three-dimensional (3D) imaging, such as CT and MRI, offers a more precise assessment of cartilage damage extent, location, and size. Newer MRI techniques, like T2 mapping, are being explored for early ankle OA diagnosis, although they are currently more valuable for evaluating repair tissue quality post-surgery [18]. Single-photon emission CT (SPECT-CT) is increasingly used, providing details on OA activity and chondral lesion status alongside anatomical information [19]. Modern SPECT-CT scans enable precise localization of degenerative lesions. SPECT-CT’s sensitivity stems from its ability to detect increased subchondral metabolic osseous activity, which can identify early degenerative changes before clinical symptoms manifest, making it especially useful in early ankle OA diagnosis. It is also valuable for defining OA in multiple joints with varying stages and for inconsistent clinical assessments of pathologies in adjacent structures like talonavicular and subtalar joints [19, 20, 21]. Weight-bearing CT scans have recently emerged, offering enhanced 3D understanding of ankle OA and related supra- and infra-malleolar deformities in a physiological, loaded condition [22, 23, 24, 25, 26, 27].
Classification Systems for Ankle Osteoarthritis
The Tanaka Classification [28] (Table 1) is a well-recognized system, categorizing ankle OA into four stages. This classification is clinically significant as it sets boundaries for joint-preserving surgery based on joint degeneration grade. However, a 2016 study by Claessen et al. [29] evaluating the Van Dijk, Kellgren–Lawrence, and Tanaka radiological classification systems concluded that none are reliably effective as decision-making tools or for prognosis in post-traumatic ankle OA.
Table 1.
Tanaka classification for ankle osteoarthritis stages based on radiographic findings.
| Stage | Radiographic Finding |
|---|---|
| 1 | No joint space narrowing, early sclerosis and osteophyte formation |
| 2 | Narrowing of the medial joint space |
| 3A | Medial joint space obliteration with subchondral bone contact (medial gutter only) |
| 3B | Obliteration extends to the talar dome roof |
| 4 | Complete joint space obliteration with full bone contact |
Ankle Osteoarthritis Treatment Algorithm
Treatment for ankle osteoarthritis is multifaceted [30] (Fig. 3), encompassing conservative, joint-preserving, and joint-sacrificing surgical procedures. Diagnosis severity dictates the progression through these treatment options.
Figure 3.
Global treatment algorithm for ankle osteoarthritis, guiding decisions from conservative care to surgical interventions.
Initial management always involves conservative treatment, irrespective of OA stage, for at least six months to evaluate effectiveness. Various combined approaches can alleviate ankle OA symptoms, though scientific evidence supporting them is limited, primarily consisting of level IV and V studies [30, 31, 32]. Conservative methods include patient education on modifiable risk factors like obesity, dietary adjustments, physical measures, footwear and orthotic modifications, and pharmacological interventions. Pharmacological treatments range from topical NSAIDs to intra-articular therapies like hyaluronic acid, corticosteroids, and platelet-rich plasma, aimed at pain management and symptom relief.
Surgical interventions are considered when conservative treatments fail. Joint-preserving procedures, such as arthroscopic debridement, joint distraction arthroplasty, and osteotomies around the ankle, are employed in earlier stages of OA. Joint-sacrificing procedures, including total ankle arthroplasty and ankle arthrodesis, are reserved for advanced, end-stage OA.
Conclusion
Accurate and timely diagnosis of ankle osteoarthritis is paramount for effective management and treatment planning. A comprehensive diagnostic approach, incorporating clinical evaluation and advanced imaging techniques like MRI and SPECT-CT, is crucial for determining the stage and severity of OA. While classification systems like Tanaka exist, their reliability for prognosis and treatment decisions is debated. Understanding the nuances of ankle OA diagnosis empowers healthcare professionals and provides a foundation for implementing appropriate conservative or surgical interventions, ultimately aiming to improve patient outcomes and maintain mobility. For automotive experts, recognizing the implications of ankle OA is important as it can directly affect driver comfort and safety.
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