Ankle osteoarthritis: comprehensive review and treatment algorithm proposal

Overview

This review summarises current knowledge on ankle osteoarthritis and proposes an overall treatment algorithm. Ankle osteoarthritis is much less common than hip or knee arthritis but can be just as disabling. Most cases are post-traumatic, following ankle fractures or chronic ligament instability, so patients are often of working age and want to stay active. The ankle's cartilage resists wear but is vulnerable to uneven loading after fractures or malalignment.

Assessment

Diagnosis rests on mechanical joint pain, stiffness, swelling or deformity, and weight-bearing radiographs, including a hindfoot alignment view. MRI, SPECT-CT and weight-bearing CT help detect early disease and associated deformities. Radiological classification systems help with staging but are not reliable enough to guide decisions on their own.

Conservative treatment

Conservative care should be tried first at every stage, although the evidence is weak. It includes patient education, weight loss, avoiding high-impact activities, diet, muscle strengthening, rocker-sole shoes and ankle–foot orthoses. Pain medication follows recommendations for knee osteoarthritis. Of the injection therapies reviewed, only lubricating injections show some benefit over placebo. Steroid injections give only short-term relief, and biological options such as platelet-rich plasma and stem cells remain under study.

Surgery

Joint-preserving surgery is considered when conservative care fails. Realignment osteotomies around the ankle are the only universally accepted option. They shift load away from the damaged part of the joint in malaligned, asymmetric arthritis where enough healthy cartilage remains. Arthroscopic debridement has a limited role in early disease, and the benefit of joint distraction fades over time. For end-stage disease, ankle fusion and total ankle replacement give similar mid-term pain relief and function. Replacement preserves motion and gait but has more reoperations. Fusion remains the most common operation worldwide but can overload neighbouring joints. Arthroscopic fusion is preferred when the soft tissues are poor, and fusion extending into the hindfoot is used for salvage.

Treatment algorithm

The authors combine these steps into an algorithm based on disease stage, alignment and patient factors, to support individual decisions.