Q: After a very severe ankle injury, I found out I have a hole in the ankle bone that goes clear down to through the cartilage to the bone. The surgeon is recommending something called an OAT procedure. At age 55 (and being a post-menopausal woman), will this work for me? I don’t heal as well as I used to.

A: Holes referred to as “defects” in cartilage that go clear down to the bone can be treated with the technique you mentioned: osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (usually from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same person’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In a recent study from Korea, surgeons used a second arthroscopic examination a year later to evaluate the results of this procedure used on the talus (ankle bone). It is rare that a second-look arthroscopic exam is possible so the results of this study are important. Quality of bone and cartilage graft were evaluated using the second arthroscopy instead of MRI in order to get a better look at the results.

Using an analysis of many patient variables, the researchers were able to determine the most important factors affecting the final results. They investigated the role of age, gender, body mass index (BMI), duration of symptoms, severity (depth and size) and location of lesion, and presence of bone cysts as predictive factors of outcomes. They also looked at results based on patient satisfaction, pain, function, and activity level.

Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. Age was not a statistically significant factor. The most important variable in the result of the OAT procedure was actually a surgical effect. The surgeon must restore the joint surface smoothly, evenly, and anatomically accurately.

Impingement (pinching) of the surrounding soft tissues must be avoided. The graft shape and size must match the defect as closely as possible. And the graft must be covered over carefully with a patch to prevent “uncovered” areas. It seems that any gaps or uncovered spots quickly fill in with fibrous cartilage. The result is an unstable defect area.

The authors of this particular study suggest longer-term studies (beyond the one-year mark) in order to evaluate changes and look for influencing factors that might not show up in the first 12-months. They also commented that their study was fairly small in terms of number of patients (52 ankles). Therefore the study should be repeated with a larger number of subjects before accepting these results as the final word on the subject.

But it does offer some evidence that your age and potentially your postmenopausal status may not make a difference. These are good questions to ask your surgeon before having this procedure. Reparative surgery is important in this condition to avoid premature arthritic changes that can cause a chronically painful and unstable ankle.

Reference: Yong Sang Kim, MD, et al. Factors Associated with the Clinical Outcomes of the Osteochondral Autograft Transfer System in Osteochondral Lesions of the Talus. Second-Look Arthroscopic Evaluation. In The American Journal of Sports Medicine. December 2012. Vol. 40. No. 12. Pp. 2709-2719.

Q: I just noticed yesterday when I was playing Simon Says with my five-year-old that I can no longer stand on my left leg without falling over. I did have surgery on that side two years ago for a badly sprained ankle. But I went through Physical Therapy and everything seemed fine back then. Is this normal? Should I be worried?

A: What you are describing might be something referred to as functional instability. More formal testing would be needed to know for sure — and to advise you what to do. Functional instability just means the ankle holds up for you during daily activities. It doesn’t give out when standing, walking, or otherwise challenged (e.g., on hills or uneven surfaces). But when you try to balance on it, there are some obvious deficits that show up.

One of the problems may be a lack of normal proprioception. This refers to the joint’s sense of its own position. Receptors in the joint that signal the brain where the joint is and when a shift in position occurs aren’t firing properly. The signals may be absent, delayed, or too weak to allow the joint to stay stable under stress or challenge.

One thing you can try is to stand on the other (uninjred) leg and see if this is a general balance problem or just specific to the post-surgical side. In either case, some remedial work is advised to prevent future injuries or reinjuries.

Your Physical Therapist is the best one to re-evaluate you and set up a plan for functional rehabilitation. The therapist has the advantage of reviewing your discharge notes to see what the status of your balance was at that time and compare it to now. This may help you understand what happened, what is going on now, and what to do about it. You are fortunate that a simple children’s game brought this to your attention now. Simon says: you can do something about it!

Reference: John G. Kennedy, MD, MCh, MMSc, FRCS (Orth), et al. Anatomic Lateral Ligament Reconstruction in the Ankle. In The American Journal of Sports Medicine. October 2012. Vol. 40. No. 10. Pp. 2309-2317.

A: Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. So say researchers at the VA Medical Center in Seattle Washington. Researchers from the Mechanical Engineering and Orthopaedics and Sports Medicine centers at the University of Washington also assisted in bringing this information to us in a recent study.

They studied 37 patients (men and women) who were expected to have ankle surgery for severe arthritis classified as end-stage arthritis. All patients in the study had failed to achieve pain control or improved function with conservative (nonoperative) care. Surgery to either fuse the ankle or replace it was scheduled.

The purpose of the study was to measure the impact of this type of ankle arthritis on function referred to as impairment of function. They used several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements were compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems.

The question they asked was: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions were answered by this study. But the researchers at least got a start on evaluating which tests and measures provide the most information about function and activity limitations. And they began to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients (just like you have experienced).

Analysis of the data showed that everyone had decreased ankle motion and power compared to the unaffected side. Average walking speed, number of steps taken each day, and length of steps were less than those of normal (control) adults. These measures were also correlated with physical function. Just moving around a room took more energy, more steps, and more time compared with normal, healthy adults. Those patients who had better physical function also had less pain and a better mental attitude.

It’s likely you will see yourself in some of these results: loss of function, increased pain, and decreased motion do tend to reduce quality of life and affect mental (and physical) health. There may still be some help that could improve your situation.

If you haven’t already tried Physical Therapy that is usually the first-line of treatment. Surgeons recommend giving this type of conservative care a good three to six months’ trial before throwing in the towel. Surgery is an option and some patients are better candidates than others. Your surgeon will be able to evaluate you and guide you through this process.

Reference: Ava D. Segal, MS, et al. Functional Limitations Associated with End-Stage Ankle Arthritis. In The Journal of Bone and Joint Surgery. May 2, 2012. Vol. 94. No. 9. Pp. 777-783.

A: Holes referred to as “defects” in cartilage that go clear down to the bone can be treated with the technique you mentioned: osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (usually from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same person’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In a recent study from Korea, surgeons used a second arthroscopic examination a year later to evaluate the results of this procedure used on the talus (ankle bone). It is rare that a second-look arthroscopic exam is possible so the results of this study are important. Quality of bone and cartilage graft were evaluated using the second arthroscopy instead of MRI in order to get a better look at the results.

Using an analysis of many patient variables, the researchers were able to determine the most important factors affecting the final results. They investigated the role of age, gender, body mass index (BMI), duration of symptoms, severity (depth and size) and location of lesion, and presence of bone cysts as predictive factors of outcomes. They also looked at results based on patient satisfaction, pain, function, and activity level.

Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. Age was not a statistically significant factor. The most important variable in the result of the OAT procedure was actually a surgical effect. The surgeon must restore the joint surface smoothly, evenly, and anatomically accurately.

Impingement (pinching) of the surrounding soft tissues must be avoided. The graft shape and size must match the defect as closely as possible. And the graft must be covered over carefully with a patch to prevent “uncovered” areas. It seems that any gaps or uncovered spots quickly fill in with fibrous cartilage. The result is an unstable defect area.

The authors of this particular study suggest longer-term studies (beyond the one-year mark) in order to evaluate changes and look for influencing factors that might not show up in the first 12-months. They also commented that their study was fairly small in terms of number of patients (52 ankles). Therefore the study should be repeated with a larger number of subjects before accepting these results as the final word on the subject.

But it does offer some evidence that your age and potentially your postmenopausal status may not make a difference. These are good questions to ask your surgeon before having this procedure. Reparative surgery is important in this condition to avoid premature arthritic changes that can cause a chronically painful and unstable ankle.

Reference: Yong Sang Kim, MD, et al. Factors Associated with the Clinical Outcomes of the Osteochondral Autograft Transfer System in Osteochondral Lesions of the Talus. Second-Look Arthroscopic Evaluation. In The American Journal of Sports Medicine. December 2012. Vol. 40. No. 12. Pp. 2709-2719.

Q: I have what’s called end-stage arthritis in my left ankle. It really affects my walking. Even getting around the house can be a real chore some days. I try not to let this get me down but I have to admit it does put a damper on my life. Do other people feel this way too? Or am I just having a pity party for myself?

A: Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. So say researchers at the VA Medical Center in Seattle Washington. Researchers from the Mechanical Engineering and Orthopaedics and Sports Medicine centers at the University of Washington also assisted in bringing this information to us in a recent study.

They studied 37 patients (men and women) who were expected to have ankle surgery for severe arthritis classified as end-stage arthritis. All patients in the study had failed to achieve pain control or improved function with conservative (nonoperative) care. Surgery to either fuse the ankle or replace it was scheduled.

The purpose of the study was to measure the impact of this type of ankle arthritis on function referred to as impairment of function. They used several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements were compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems.

The question they asked was: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions were answered by this study. But the researchers at least got a start on evaluating which tests and measures provide the most information about function and activity limitations. And they began to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients (just like you have experienced).

Analysis of the data showed that everyone had decreased ankle motion and power compared to the unaffected side. Average walking speed, number of steps taken each day, and length of steps were less than those of normal (control) adults. These measures were also correlated with physical function. Just moving around a room took more energy, more steps, and more time compared with normal, healthy adults. Those patients who had better physical function also had less pain and a better mental attitude.

It’s likely you will see yourself in some of these results: loss of function, increased pain, and decreased motion do tend to reduce quality of life and affect mental (and physical) health. There may still be some help that could improve your situation.

If you haven’t already tried Physical Therapy that is usually the first-line of treatment. Surgeons recommend giving this type of conservative care a good three to six months’ trial before throwing in the towel. Surgery is an option and some patients are better candidates than others. Your surgeon will be able to evaluate you and guide you through this process.

Reference: Ava D. Segal, MS, et al. Functional Limitations Associated with End-Stage Ankle Arthritis. In The Journal of Bone and Joint Surgery. May 2, 2012. Vol. 94. No. 9. Pp. 777-783

A: Holes referred to as “defects” in cartilage that go clear down to the bone can be treated with the technique you mentioned: osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (usually from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same person’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In a recent study from Korea, surgeons used a second arthroscopic examination a year later to evaluate the results of this procedure used on the talus (ankle bone). It is rare that a second-look arthroscopic exam is possible so the results of this study are important. Quality of bone and cartilage graft were evaluated using the second arthroscopy instead of MRI in order to get a better look at the results.

Using an analysis of many patient variables, the researchers were able to determine the most important factors affecting the final results. They investigated the role of age, gender, body mass index (BMI), duration of symptoms, severity (depth and size) and location of lesion, and presence of bone cysts as predictive factors of outcomes. They also looked at results based on patient satisfaction, pain, function, and activity level.

Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. Age was not a statistically significant factor. The most important variable in the result of the OAT procedure was actually a surgical effect. The surgeon must restore the joint surface smoothly, evenly, and anatomically accurately.

Impingement (pinching) of the surrounding soft tissues must be avoided. The graft shape and size must match the defect as closely as possible. And the graft must be covered over carefully with a patch to prevent “uncovered” areas. It seems that any gaps or uncovered spots quickly fill in with fibrous cartilage. The result is an unstable defect area.

The authors of this particular study suggest longer-term studies (beyond the one-year mark) in order to evaluate changes and look for influencing factors that might not show up in the first 12-months. They also commented that their study was fairly small in terms of number of patients (52 ankles). Therefore the study should be repeated with a larger number of subjects before accepting these results as the final word on the subject.

But it does offer some evidence that your age and potentially your postmenopausal status may not make a difference. These are good questions to ask your surgeon before having this procedure. Reparative surgery is important in this condition to avoid premature arthritic changes that can cause a chronically painful and unstable ankle.

Reference: Yong Sang Kim, MD, et al. Factors Associated with the Clinical Outcomes of the Osteochondral Autograft Transfer System in Osteochondral Lesions of the Talus. Second-Look Arthroscopic Evaluation. In The American Journal of Sports Medicine. December 2012. Vol. 40. No. 12. Pp. 2709-2719.

Q: I have arthritis in one ankle from a bad break I got when I was a wild and wooley 20-something. Now I’m paying for it in my 40s. Is there any way to tell if I’m getting worse over time and when I should have surgery? I want to put it off for as long as possible.

A: Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. It is possible to take baseline measurements and to measure the impact of ankle arthritis on function. Limitations in function during daily activities is referred to as impairment of function.

There are several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements can be compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems or to your other ankle if it isn’t damaged. It might be better to use adult controls instead of your unaffected ankle because if your walking (gait) pattern is affected on one side, it’s likely there will be compensations on the other side even if it is normal and without injury.

Choosing between ankle fusion (called arthrodesis) and ankle replacement (arthroplasty) is always a challenge. Fusion limits pain because it stops ankle motion. But loss of ankle and foot motion causes changes or alterations in the walking (gait) pattern. That in itself can cause further problems later on. Ankle replacement restores ankle motion and takes the pressure and load off the other nearby joints. But long-term studies of ankle replacement are not showing outstanding results at this time.

The question then becomes: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions have been answered yet. But researchers have at least gotten a start on evaluating which tests and measures provide the most information about function and activity limitations. And they are beginning to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients.

Average walking speed, number of steps taken each day, and length of steps can be correlated with physical function. These tests can help identify problems with ankle motion and function. It is likely that these same measures could be used in future studies. They can be used to determine when treatment should begin and what type should be provided.

Right now, that information isn’t available to help you make your decision. Your surgeon will be the best one to advise you about the use of conservative (nonoperative) care. He or she will also guide you as to when to consider surgery and what type of surgery is best for you.

Reference: Ava D. Segal, MS, et al. Functional Limitations Associated with End-Stage Ankle Arthritis. In The Journal of Bone and Joint Surgery. May 2, 2012. Vol. 94. No. 9. Pp. 777-783.

A: Holes referred to as “defects” in cartilage that go clear down to the bone can be treated with the technique you mentioned: osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (usually from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same person’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In a recent study from Korea, surgeons used a second arthroscopic examination a year later to evaluate the results of this procedure used on the talus (ankle bone). It is rare that a second-look arthroscopic exam is possible so the results of this study are important. Quality of bone and cartilage graft were evaluated using the second arthroscopy instead of MRI in order to get a better look at the results.

Using an analysis of many patient variables, the researchers were able to determine the most important factors affecting the final results. They investigated the role of age, gender, body mass index (BMI), duration of symptoms, severity (depth and size) and location of lesion, and presence of bone cysts as predictive factors of outcomes. They also looked at results based on patient satisfaction, pain, function, and activity level.

Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. Age was not a statistically significant factor. The most important variable in the result of the OAT procedure was actually a surgical effect. The surgeon must restore the joint surface smoothly, evenly, and anatomically accurately.

Impingement (pinching) of the surrounding soft tissues must be avoided. The graft shape and size must match the defect as closely as possible. And the graft must be covered over carefully with a patch to prevent “uncovered” areas. It seems that any gaps or uncovered spots quickly fill in with fibrous cartilage. The result is an unstable defect area.

The authors of this particular study suggest longer-term studies (beyond the one-year mark) in order to evaluate changes and look for influencing factors that might not show up in the first 12-months. They also commented that their study was fairly small in terms of number of patients (52 ankles). Therefore the study should be repeated with a larger number of subjects before accepting these results as the final word on the subject.

But it does offer some evidence that your age and potentially your postmenopausal status may not make a difference. These are good questions to ask your surgeon before having this procedure. Reparative surgery is important in this condition to avoid premature arthritic changes that can cause a chronically painful and unstable ankle.

Reference: Yong Sang Kim, MD, et al. Factors Associated with the Clinical Outcomes of the Osteochondral Autograft Transfer System in Osteochondral Lesions of the Talus. Second-Look Arthroscopic Evaluation. In The American Journal of Sports Medicine. December 2012. Vol. 40. No. 12. Pp. 2709-2719.

Q: I had some special injections to my knee for arthritis that helped smooth things out and improve pain and motion. It was expensive but my insurance company paid for it (well they paid the usual 80 per cent). I asked about having the same treatment for my ankle arthritis and they flat refused to pay. What’s up with that? Can I fight it?

A: It sounds like maybe you had a series of injections using hyaluronic acid. Hyaluronic acid is a substance naturally found in the body in small quantities. It seems to have a role in the multiplication of normal, healthy cartilage cells. Used as an injection into the joint, it is designed to rebuild the protective joint cartilage.

Fifteen years ago, the Food and Drug Administration (FDA) approved the use of an injection of hyaluronic acid for knee arthritis. It has been used ever since for the effective relief of arthritis pain in some carefully selected patients.

Now surgeons are turning their attention to the possible use of this same injection for ankle arthritis. Although it has not yet been approved for this type of use by the FDA, studies are starting to trickle in. From what has been reported so far, there isn’t a clear benefit to these injections for the ankle. In fact, according to one random controlled trial, hyaluronic acid didn’t work any better than a placebo injection using saline (salt) solution.

The question comes up: why do hyaluronic acid injections seem to work so well for some patients with knee osteoarthritis but patients with ankle arthritis don’t’t get the same benefit? It’s possible that because most ankle arthritis is the result of trauma (and knee arthritis is not), there is a difference in the response to hyaluronic acid. Ankle cartilage is also a lot stiffer, denser, and less elastic compared with knee cartilage. Maybe that makes a difference.

Until there is enough evidence that hyaluronic acid is an effective treatment for ankle arthritis, it is unlikely that insurance companies will reimburse for its use. With the high cost of this product, further study is needed to find new types of nonsurgical treatment for ankle osteoarthritis that are cost effective and economical.

Reference: Henry DeGroot III, MD, et al. Intra-Articular Injection of Hyaluronic Acid is Not Superior to Saline Solution Injection for Ankle Arthritis. In The Journal of Bone and Joint Surgery. January 2012. Vol. 94A. No. 1. Pp. 2-8.

A: Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. It is possible to take baseline measurements and to measure the impact of ankle arthritis on function. Limitations in function during daily activities is referred to as impairment of function.

There are several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements can be compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems or to your other ankle if it isn’t damaged. It might be better to use adult controls instead of your unaffected ankle because if your walking (gait) pattern is affected on one side, it’s likely there will be compensations on the other side even if it is normal and without injury.

Choosing between ankle fusion (called arthrodesis) and ankle replacement (arthroplasty) is always a challenge. Fusion limits pain because it stops ankle motion. But loss of ankle and foot motion causes changes or alterations in the walking (gait) pattern. That in itself can cause further problems later on. Ankle replacement restores ankle motion and takes the pressure and load off the other nearby joints. But long-term studies of ankle replacement are not showing outstanding results at this time.

The question then becomes: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions have been answered yet. But researchers have at least gotten a start on evaluating which tests and measures provide the most information about function and activity limitations. And they are beginning to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients.

Average walking speed, number of steps taken each day, and length of steps can be correlated with physical function. These tests can help identify problems with ankle motion and function. It is likely that these same measures could be used in future studies. They can be used to determine when treatment should begin and what type should be provided.

Right now, that information isn’t available to help you make your decision. Your surgeon will be the best one to advise you about the use of conservative (nonoperative) care. He or she will also guide you as to when to consider surgery and what type of surgery is best for you.

Reference: Ava D. Segal, MS, et al. Functional Limitations Associated with End-Stage Ankle Arthritis. In The Journal of Bone and Joint Surgery. May 2, 2012. Vol. 94. No. 9. Pp. 777-783.

A: Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. It is possible to take baseline measurements and to measure the impact of ankle arthritis on function. Limitations in function during daily activities is referred to as impairment of function.

There are several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements can be compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems or to your other ankle if it isn’t damaged. It might be better to use adult controls instead of your unaffected ankle because if your walking (gait) pattern is affected on one side, it’s likely there will be compensations on the other side even if it is normal and without injury.

Choosing between ankle fusion (called arthrodesis) and ankle replacement (arthroplasty) is always a challenge. Fusion limits pain because it stops ankle motion. But loss of ankle and foot motion causes changes or alterations in the walking (gait) pattern. That in itself can cause further problems later on. Ankle replacement restores ankle motion and takes the pressure and load off the other nearby joints. But long-term studies of ankle replacement are not showing outstanding results at this time.

The question then becomes: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions have been answered yet. But researchers have at least gotten a start on evaluating which tests and measures provide the most information about function and activity limitations. And they are beginning to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients.

Average walking speed, number of steps taken each day, and length of steps can be correlated with physical function. These tests can help identify problems with ankle motion and function. It is likely that these same measures could be used in future studies. They can be used to determine when treatment should begin and what type should be provided.

Right now, that information isn’t available to help you make your decision. Your surgeon will be the best one to advise you about the use of conservative (nonoperative) care. He or she will also guide you as to when to consider surgery and what type of surgery is best for you.

Reference: Ava D. Segal, MS, et al. Functional Limitations Associated with End-Stage Ankle Arthritis. In The Journal of Bone and Joint Surgery. May 2, 2012. Vol. 94. No. 9. Pp. 777-783.

A: Holes referred to as “defects” in cartilage that go clear down to the bone can be treated with the technique you mentioned: osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (usually from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same person’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In a recent study from Korea, surgeons used a second arthroscopic examination a year later to evaluate the results of this procedure used on the talus (ankle bone). It is rare that a second-look arthroscopic exam is possible so the results of this study are important. Quality of bone and cartilage graft were evaluated using the second arthroscopy instead of MRI in order to get a better look at the results.

Using an analysis of many patient variables, the researchers were able to determine the most important factors affecting the final results. They investigated the role of age, gender, body mass index (BMI), duration of symptoms, severity (depth and size) and location of lesion, and presence of bone cysts as predictive factors of outcomes. They also looked at results based on patient satisfaction, pain, function, and activity level.

Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. Age was not a statistically significant factor. The most important variable in the result of the OAT procedure was actually a surgical effect. The surgeon must restore the joint surface smoothly, evenly, and anatomically accurately.

Impingement (pinching) of the surrounding soft tissues must be avoided. The graft shape and size must match the defect as closely as possible. And the graft must be covered over carefully with a patch to prevent “uncovered” areas. It seems that any gaps or uncovered spots quickly fill in with fibrous cartilage. The result is an unstable defect area.

The authors of this particular study suggest longer-term studies (beyond the one-year mark) in order to evaluate changes and look for influencing factors that might not show up in the first 12-months. They also commented that their study was fairly small in terms of number of patients (52 ankles). Therefore the study should be repeated with a larger number of subjects before accepting these results as the final word on the subject.

But it does offer some evidence that your age and potentially your postmenopausal status may not make a difference. These are good questions to ask your surgeon before having this procedure. Reparative surgery is important in this condition to avoid premature arthritic changes that can cause a chronically painful and unstable ankle.

Reference: Yong Sang Kim, MD, et al. Factors Associated with the Clinical Outcomes of the Osteochondral Autograft Transfer System in Osteochondral Lesions of the Talus. Second-Look Arthroscopic Evaluation. In The American Journal of Sports Medicine. December 2012. Vol. 40. No. 12. Pp. 2709-2719.

Q: I have the most painful ankle in the world. In fact, I’m literally ready to have the surgeon just cut the foot off. I can’t walk much less run. Can’t ride my horse anymore. Can’t keep up with my grandkids. I asked about a joint replacement but the surgeon put me off. Said it was too ‘experimental.’ I know people are getting them. What do other patients say about their results? If it’s good, I’m going to find someone to do the surgery anyway.

A: Surgeons agree that a total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, it is a reasonable approach for some patients and is still considered an acceptable alternative to ankle fusion (or amputation).

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn’t a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) also remains a problem.

And studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It’s a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

Patients are selected carefully for this procedure. Your surgeon may have some specific reasons why he or she thinks you are not a good candidate. But it’s also possible your surgeon doesn’t do this type of surgery.

It may be a good idea to find a surgeon who does perform total ankle replacements on more than an occasional basis and get a second opinion. You may get the same answer in which case it would be good to explore your options for better pain management so that you can become more functional. It’s possible there are some conservative treatment approaches that could really help.

Reference: James A. Nunley, MD, et al. Intermediate to Long-Term Outcomes of the STAR Total Ankle Replacement: The Patient Perspective. In The Journal of Bone and Joint Surgery. January 4, 2012. Vol. 94A. No. 1. Pp. 43-48.

Q: I have the most painful ankle in the world. In fact, I’m literally ready to have the surgeon just cut the foot off. I can’t walk much less run. Can’t ride my horse anymore. Can’t keep up with my grandkids. I asked about a joint replacement but the surgeon put me off. Said it was too ‘experimental.’ I know people are getting them. What do other patients say about their results? If it’s good, I’m going to find someone to do the surgery anyway.

A: Surgeons agree that a total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, it is a reasonable approach for some patients and is still considered an acceptable alternative to ankle fusion (or amputation).

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn’t a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) also remains a problem.

And studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It’s a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

Patients are selected carefully for this procedure. Your surgeon may have some specific reasons why he or she thinks you are not a good candidate. But it’s also possible your surgeon doesn’t do this type of surgery.

It may be a good idea to find a surgeon who does perform total ankle replacements on more than an occasional basis and get a second opinion. You may get the same answer in which case it would be good to explore your options for better pain management so that you can become more functional. It’s possible there are some conservative treatment approaches that could really help.

Reference: James A. Nunley, MD, et al. Intermediate to Long-Term Outcomes of the STAR Total Ankle Replacement: The Patient Perspective. In The Journal of Bone and Joint Surgery. January 4, 2012. Vol. 94A. No. 1. Pp. 43-48.

Q: I’m trying to find some information on ankle replacement surgery. I’ve seen two surgeons who both think I’m a pretty good candidate for this type of surgery. I’ve talked with two other patients who seem very happy with their results. What’s the general word on the street about doing this? I know it’s a fairly new-ish procedure and that it hasn’t been perfected yet. What do you think I should know?

A: There is one recent study from Duke Medical Center that may have the answers you are looking for. In this study, one surgeon from Duke University Medical Center shares the results of 82 patients who received the STAR total ankle replacement.

This surgeon performed all of the procedures himself using the Scandinavian Total Ankle Replacement (STAR) over a 10-year-period of time. The STAR prosthesis has been in use since the early 1980s with good results. It remains one of the most widely used ankle implants.

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn’t a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) can also develop causing some difficulties.

Studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It’s a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

The surgeon who conducted this study was particularly interested in knowing how the patients viewed the results. Measurements were taken before surgery and compared to the same measurements after surgery. Pain, ankle motion, and function were the main areas assessed. Patients’ satisfaction with the results and self-reported quality of life were important means of determining patient reaction to the outcomes.

After analyzing all the data, he found there were improvements in all areas measured but especially in patient quality of life and satisfaction. Everyone was followed for at least two years and some patients were in the study for almost 10 years. This is probably one of the most comprehensive, long-term studies of patient perceived outcomes currently available.

The surgeon reminds the reader that these are self-reported results for a particular ankle implant (the STAR prosthesis). The more objective measures (number of patients requiring further surgery, number of failed implants, and implant survival rate) were also favorable. There was a revision rate of four per cent early on that increased over time. The survival rate was 88.5 per cent after 10 years.

It should help you to know that surgeons agree total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, as this study showed, it is a reasonable approach for some patients. And is still considered an acceptable alternative to ankle fusion (or amputation). As the patients in this study report, function and quality of life are improved. Patient satisfaction is ranked high enough to make this a procedure worth considering.

Reference: James A. Nunley, MD, et al. Intermediate to Long-Term Outcomes of the STAR Total Ankle Replacement: The Patient Perspective. In The Journal of Bone and Joint Surgery. January 4, 2012. Vol. 94A. No. 1. Pp. 43-48.

Q: O geez. I sprained the outside edge of my left ankle two months ago and it never healed right. Clicking, popping, pain, etc. Finally saw an orthopedist. Said I need surgery because the tendon is popping in and out of the groove. Yikes. Is there anything else that can be done?

A: You may have an unusual lateral ankle sprain with a condition called peroneal tendon instability. A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.

When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation such as you mentioned.

Conservative (nonoperative) care is only possible when the unstable tendons can reposition inside the retromalleolar groove. A cast or boot placed on the lower leg will give the tendon a chance to heal. If conservative care is unable to achieve a stable gliding tendon or if the tendon displacement is unstable from the start, then surgery is necessary.

There are several different surgical options to consider. The fibrous protective sheath (retinaculum) can be reinforced or reconstructed. The groove can be reshaped (deepened) and rebuilt. The surgeon will probably suggest some additional imaging studies to determine the extent of the damage and the best way to surgically treat it. If you are still uncertain about the need for surgery, you always have the option of seeking a second opinion. There is nothing wrong with asking questions and seeking further advice.

Reference: Markus Walther, MD, PhD, et al. Peroneal Tendon Instability: Diagnosis and Authors’ Recommended Treatment. In Current Orthopaedic Practice. March/April 2012. Vol. 23. No. 2. Pp. 80-85.

Q: I sprained my ankle doing a stupid move on my motorcycle. It never seemed to heal so I finally went in for help. They discovered the tendons along the outside of my leg aren’t staying in the groove where they are supposed to be. The doc said it was unusual but I didn’t catch what was unusual and why mine aren’t staying where they are supposed to. Can you help explain this to me?

A:  Ankle sprain is a common injury in athletes as well as the active adult. Most of the time, the ankle heals with a little care (rest, taping, ice). But one rare complication of lateral ankle sprains is a condition called peroneal tendon instability. It sounds like this may be what you are experiencing.

A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.

When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. Traumatic displacement of the peroneal tendons is a rare but painful complication of some lateral ankle sprains. Some people have a naturally shallow groove, which contributes to the likelihood of tendon displacement after ankle sprain.

The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation. Swelling may mask the symptoms of tendon displacement at first. It’s only weeks to months later when the painful symptoms don’t go away that the additional tendon damage is recognized. Early MRIs may not show peroneal tendon instability, especially if the tendon pops in and out of the groove spontaneously. Dynamic ultrasound tests are the best diagnostic tests because they will reveal the movement of the unstable tendon.

Reference: Markus Walther, MD, PhD, et al. Peroneal Tendon Instability: Diagnosis and Authors’ Recommended Treatment. In Current Orthopaedic Practice. March/April 2012. Vol. 23. No. 2. Pp. 80-85