w w w . r b o . o r g . b r
Review
Article
Cartilage
lesions
and
ankle
osteoarthrosis:
review
of
the
literature
and
treatment
algorithm
夽
,
夽夽
Alexandre
Leme
Godoy
Santos
a,∗,
Marco
Kawamura
Demange
a,
Marcelo
Pires
Prado
b,
Tulio
Diniz
Fernandes
a,
Pedro
Nogueira
Giglio
a,
Beat
Hintermann
caInstituteofOrthopedicsandTraumatology,SchoolofMedicine,UniversityofSãoPaulo(USP),SãoPaulo,SP,Brazil
bOrthopedicsandRehabilitationCenter,HospitaldoCorac¸ão,SãoPaulo,SP,Brazil
cDepartmentofOrthopedics,Kantonsspital,Liestal,Switzerland
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received21October2013
Accepted21October2013
Availableonline11November2014
Keywords:
Osteoarthritis Ankle Osteotomy Arthroplasty Arthrodesis
a
b
s
t
r
a
c
t
Themainetiologyofankleosteoarthrosisispost-traumaticanditsprevalenceishighest
amongyoungindividuals.Thus,thisdiseasehasagreatsocioeconomicimpactandgivesrise
tosignificantlossesofpatients’qualityoflife.Theobjectiveofitstreatmentistoeliminate
painandkeeppatientsactive.Therefore,thetreatmentshouldbestagedaccordingtothe
degreeofdegenerativeevolution,etiology,jointlocation,systemiccondition,bonequality,
lower-limbalignment,ligamentstabilityandage.Thetreatmentalgorithmisdividedinto
non-surgicaltherapeuticmethodsandoptionsforsurgicaltreatment.Jointpreservation,
jointreplacementandarthrodesissurgicalprocedureshavepreciseindications.Thisarticle
presentsareviewonthistopicandaproposalforatreatmentalgorithmforthisdisease.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.Allrightsreserved.
Lesão
de
cartilagem
e
osteoartrose
do
tornozelo:
revisão
da
literatura
e
algoritmo
de
tratamento
Palavras-chave:
Osteoartrite Tornozelo Osteotomia Artroplastia Artrodese
r
e
s
u
m
o
A principal etiologia da osteoartrose (OA) do tornozelo é pós-traumática e sua maior
prevalência estáentreindivíduosjovens;assim,essadoenc¸aapresentagrandeimpacto
socioeconômicoesignificativoprejuízonaqualidadedevidadospacientes.Oobjetivodo
tratamentoéeliminaradoremanterospacientesativos.Dessaforma,otratamentodeve
serestagiadodeacordocomograudeevoluc¸ãodadegenerac¸ão,aetiologia,alocalizac¸ão
articular,acondic¸ãosistêmica,aqualidadeóssea,oalinhamentodomembroinferior,a
estabilidadeligamentareaidade.Oalgoritmodetratamentoédivididonasmodalidades
夽
Pleasecitethisarticleas:Santos ALG,Demange MK,Prado MP,Fernandes TD,GiglioPN,HintermannB.Lesão decartilageme
osteoartrosedotornozelo:revisãodaliteraturaealgoritmodetratamento.RevBrasOrtop.2014;49:565–572.
夽夽
WorkdevelopedattheInstituteofOrthopedicsandTraumatology,SchoolofMedicine,UniversityofSãoPaulo(USP),SãoPaulo,Brazil.
∗ Correspondingauthor.
E-mail:alexandrelemegodoy@gmail.com.br(A.L.G.Santos).
http://dx.doi.org/10.1016/j.rboe.2014.11.003
deterapianãocirúrgicasenasopc¸õesdetratamentocirúrgico.Ascirurgiasdepreservac¸ão
articular,ascirurgiasdesubstituic¸ãoarticulareasartrodesesapresentamindicac¸ões
pre-cisas.Opresenteartigoapresentaumarevisãosobreotemaeumapropostadealgoritmo
detratamentoparaessadoenc¸a.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Todososdireitosreservados.
Introduction
Osteoarthrosis(OA) isasyndrome characterizedby
degen-eration of the joint cartilage, alterations to subchondral
bone,intra-articularinflammatoryalterationsand
periartic-ularbonegrowth,andit causespainandfunctionallossin
theaffectedlimb.1–3Thereisstillnoeffectivecureforthis
syn-drometoday,throughanymethodsforprevention,diminution
ofitsprogressionortreatmentofsymptomsthathavebeen
proposed.1,2,4,5
OAaffects15%oftheworldwideadultpopulation,which
makesit a disease ofhigh socioeconomicimpact both for
individualsandforallofsociety.6Forexample,intheUnited
States,thisrepresentsannualcostsof60billiondollarsforthe
directtreatment.1,6,7
Themostimportantuniversalriskfactorsareage,
exces-sive joint loading, joint injuries, fractures and ligament
injuries.1,6
OAofthetibiotarsaljointispresentin4.4%ofthepatients
whoseekorthopedicattendancebecauseofOAofthelower
limbs.
Differentlyfromhipjointdegeneration(58%)andkneejoint
degeneration(67%),OAoftheankleisofprimaryorigininonly
9%ofthecases.Thesecondarycauses(rheumatoidarthritis,
hemochromatosis,hemophiliaorosteonecrosis)arepresent
in13%ofthecases.Themainetiologyispost-traumaticand
thisisthereasonfortibiotarsaljointdegenerationin78%of
thecases,whilefracturesaroundtheanklearethecausein
62%andligamentinjuriesarethecausein16%.7–9
Individualswithanklearthrosistendtobeyoungerthan
otherpatientswithjointdegenerationinthelowerlimbsand
presentfasterfunctional loss,withprogressiontothefinal
stagesofthediseasebetween10and20yearsafterthestart
ofthelesion.9
Physiopathogenesis
Avarietyofanatomicalandbiomolecularcharacteristics of
theanklearedeterminantsforunderstandingthe
susceptibil-ityofthecartilageofthisjointtodegeneration.
Thetotalareaofthetibiotarsaljointis350mm2anditis
subjectedtoaforceof500N,whilethehipandknee,withjoint
areasofrespectively1100mm2and1120mm2,aresubjected
tothesameforce.10–12Thus,thepressureonthejointcartilage
oftheanklemaybeuptothreetimesgreaterthanthepressure
ontheotherjointsofthelowerlimbs.Ontheotherhand,the
loaddistributiononthecongruentjoints,i.e.theankleand
hip,differsfromtheloaddistributionontheknee,suchthat
thecompressiveforcesaredistributedoveralargerarea.This
possiblyallowstheanklecartilagetobethinnerthanthatof
theknee.Thethicknessoftheanklejointcartilagerangesfrom
1to1.62mmandisthinnerthanthatofthehip(1.35–2mm)
andknee(1.69–2.55mm).13
Comparativebiomolecularstudiesonhumanshaveshown
thatthe anklecartilagehashigherdensity of
glycosamino-glycan sulfate and lower modulusofequilibrium, dynamic
rigidity, water componentand hydraulicpermeability than
thoseofthekneecartilage.Thepropertiesinfluencethe
capac-ity todeformundercompressionduringtheloadcycle.14,15
The way in which the collagen of the ankle cartilage is
organizedresemblesthatoftheknee,butthechondrocyte
dis-tributiondiffers.Intheankle,inthesuperficiallayerofthe
cartilage,thechondrocytesarepresentedingroups.16
Along with these characteristics, the cartilage tissueof
anklesthataresubjectedtoinjurypresentsincreased
colla-gensynthesis.Thechondrocytesoftheanklearemetabolically
more active than those of the knee and present greater
aggrecanturnoverandgreatersensitivitytoanabolicstimuli,
followedbyremovalofinterleukin-1,andgreaterresponseof
thechondrocytestoinflammatorystimuli.17–20
Thefollowingarealsodeterminantsforthe
physiopatho-genesis:poorstructuraloracquiredalignmentsofthelower
limb,muscleimbalanceandweaknessaroundthetibiotarsal
joint,age,gender,ethnicityandgeneticpredisposition.2,6
Diagnosis
and
classification
system
The clinical presentation consists ofpain in the region of
thejointinterline,withorwithoutanassociatedincreasein
volume(jointeffusion)andlimitationsontherangeofjoint
motion,functioning,workandrecreationalactivities.These
conditionsmaydiminishthequalityoflifeofindividualswith
diseaseslikehipOA,dialytickidneyfailure,congestiveheart
failureorradiculopathy.21Otherassociatedclinicalalterations
includelegmuscleatrophyandalterationstogaitpatterns,
particularlychangestokinematicsandkinetics.22–25
Theinitialinvestigationbymeansofimagingisconducted
usingradiographswithweight-bearing.Thesemayshow
dif-ferentdegreesifdiminutionofthejointspaceandformation
ofosteophytes,sclerosisandsubchondralcysts.TheMorrey
andWiedemanclassificationsystemisbasedonthese
radio-graphicfindings.26,27
Magneticresonance imaging(MRI) isthe mostsensitive
andspecificnoninvasiveimagingexaminationforevaluating
thejointcartilage.Bymeansofspecificprotocolsforimage
acquisition andanalysis,it alsoenablesaccesstothe
Determiningthepreciselocation,sizeoftheareaaffected
anddepthofthecartilaginouslesionisfundamentalin
select-ing the treatment. Thus, MRI protocols aimed toward the
cartilage andequipment withbigger magneticfields (three
tosevenTesla)provideabetterviewofthecartilageandthe
associatedlesions.29–32
New MRItechniques forstudying the cartilage,such as
volumetricquantitativeanalysis,dGEMRICmapping,T1-rho
mapping, T2 mapping and MRI using sodium-23, enable
accessto the microstructureand, indirectly, to
fundamen-talcharacteristics oftheankle cartilage,therebyimproving
thediagnosisandtreatmentofchondralandosteochondral
lesions.30–33
Recently,theSPECTtechniquemadeitpossibletocorrelate
themorphologicalandbiochemicalinformationin
investigat-ingankleOAandwasshowntobeusefulforlocatingtheactive
degeneration,especiallyinareasinwhichthenumberandthe
configurationofthejointarecomplex.34–36
Algorithm
for
staged
treatment
The decision on which treatment to use depends on the
intensity ofthe pain, functional limitation,degree ofjoint
degeneration, etiology, joint location, systemic condition,
bonequality,lower-limbalignment,ligamentstabilityandage,
followingthe stagesproposed through the treatment
algo-rithm(Fig.1).
StageI.Nonsurgicaltreatment
Nonsurgicaltreatmentismainlyindicatedforpatientswith
mildtomoderateOA,mildpain,slightfunctionallimitations,
anyetiology,good bonequality,adequate lower-limb
align-mentandstablejoints,ofanyagegroup.
Theobjectivesaretoimprovethesymptoms,maintainthe
remainingjointrangeofmotionandprovidetheconditions
forappropriatefuturesurgicaltreatment.
Bracesandinsoles
Bracesand insolesshould beusedtokeepthe jointinthe
neutral position during walking movements. Some braces
also limit ankle mobility in the sagittal plane and thus
reducethe joint instability and overloadingon the injured
cartilage.37
Although somestudies have shown satisfactory results
fromuse ofcorrectiveinsolesfortreatingknee OA(to
pro-ducevarusdeformity),38,39thishasnotbeenseenintreating
ankleOA.37,40
Analgesicsandanti-inflammatoryagents
Analgesics and anti-inflammatory agents present proven
effectsrelatingtopain,andthelatteralsoshowsadditional
reliefrelatingtoactiveOA.
However,becauseofthevarioussystemicsideeffectsand
alsobecauseprogressionofthedegenerationisnotavoided,
thesemedicationsarenotusedaslong-termsolutions.
Stage I
Stage II
Stage III
Stage IV
Nonsurgical treatment
Insoles
Modification of footwear characteristics Analgesics and anti-inflammatory agents condroprotetores
Corrective osteotomy: simple or combined Ligament repair and reconstruction Tenoplasty and tendon transfer
Corrective surgery on the osteochondral lesion arthrodiastasis
Joint preservation surgery
Three components Constrained or unconstrained Heterologous transplantation
Total ankle arthroplasty
Open or arthroscopic Single or combined Retrograde intramedullary rod Plate
Screws
Ankle arthrodesis
Fig.1–Stagedtreatmentalgorithm.
Physiotherapy
Incasesofmildtomoderateankle OA,physiotherapymay
helptopreservetherangeofmotionand mayincreasethe
dynamic jointstability throughmuscle strengthening.This
isusefuluntilthetimeoffuturetreatmentwithtotalankle
arthroplasty.8
Viscosupplementation
Interest inusing intra-articular viscosupplementationwith
hyaluronicacidintheankle,asatreatmentoptionforjoint
degeneration,hasbeenincreasingsignificantly.41
InpatientswithOA,chondrocytesandsynovialcells
pro-duce increased levels of inflammatory cytokines, such as
interleukin1(IL-1)andtumornecrosisfactoralpha
(TNF-␣).In turn,thesedecrease collagen synthesisand increase
thelevelsofcatabolicmediatorssuchasmetalloproteinases
(MMPs)andotherinflammatorymediatorslikeinterleukin8
(IL-8),interleukin6(IL-6),prostaglandinE2(PGE2)andnitric
oxide(NO).42,43Onekeyproteininthepathologicalprocessof
OAisCD44,whichisfoundonthesurfacesofchondrocytes,
synovioblastsand macrophages. CD44iscapable of
inhibi-tingthesynthesisofinflammatorycytokineswhenboundto
hyaluronicacid.44
Hyaluronic acid is an important modulator, especially
fibroblast-like synoviocytes.45 Therefore, inaddition to the
mechanicaleffectsofpromotingbetterdistributionofforces,
decreasingthepressureonthechondrocytes46andrecovering
therheologicalpropertiesofthesynovialfluid,47hyaluronic
acidactsbiochemicallytodiminishthegeneexpressionofthe
cytokinesandtheenzymesassociatedwithOA,the
produc-tionofprostaglandinsandthe intra-articularconcentration
ofmetalloproteinases.46,48
Mei-Danetal.49studied16patientswithsymptomaticOA
intheanklewhoreceivedintra-articularinjectionsof25mgof
sodiumhyaluronateforfiveconsecutiveweeks.Therewasa
20%improvementinrangeofmotionandasignificant
reduc-tion in pain, as assessed using a visual analog scale and
scoringsfortheankleandhindfoot.
Sunetal.50observedimprovementsinpainandankle
func-tioninginaseriesof50patientswithanklearthrosiswhowere
treatedwiththreeintra-articularinjectionsofhyaluronicacid
perweek.AnotherprospectivecaseseriesrevealedthatHylan
GF20waseffectiveforsignificantlyreducingthepain
associ-atedwithankleOA.Thiseffectseemedtolastevenbeyondsix
tosevenmonthsafterthetreatment.51
Thesafetyseemstobesimilartothatoftheapplications
thatarewidelyusedintreatingOAinseveralotherjoints,such
astheknee,hip,shoulderandhand.51–56
Findingsfrom meta-analyseshave suggestedthat
intra-articular viscosupplementation with hyaluronic acid can
significantlyreducepaininpatientswithankleOA,in
com-parison withthe statebefore the treatment, and that this
treatmentoptionissuperiortootherconservativetherapies
inpatientswithsymptoms.However,thereisnoconsensus
regardingthetotalnumberofinjectionsandthevolumeper
dose,inrelationtothetherapeuticresults.57
StageII.Jointpreservationsurgery
Jointpreservationsurgeryismainlyindicatedforpatientswith
moderateOApresentingdailypainofsignificantintensityand
mildtomoderatefunctionallimitation,ofpost-traumaticor
primaryetiology,withgoodbonequality,asymmetryof
lower-limbalignmentandjointinstability,inanon-elderlyagegroup
andwithoutsystemiccomorbidities.
Theobjectivesaretoreestablishthebiomechanics,
align-mentandjointstability,deceleratetheevolutionofthejoint
degeneration and postponeprocedures of a more invasive
nature.
Jointdebridement
There is controversy regarding the value of joint
debride-ment for treating ankle OA.58 Studies conducted among
patientswithkneearthrosishaveindicatedthatjointlavage
anddebridement intheabsence ofmechanicalcausesthat
would justify the procedure only provide short-term pain
relief.59,60 Thus,thereisgreater evidencethatdebridement
that addresses all the concomitant factors involved inthe
etiology of OA (removal of osteophytes and loose bodies,
resectionofscarandhypertrophicsynovialtissueandrepair
techniquesforfocalosteochondralcartilagedefects)presents
improvementsinpain,edemaandstiffnessovertheshortand
mediumterms.58,61,62
Arthroscopicjointdebridement
SpecificlesionsassociatedwithOA,suchasosteophytes,loose
bodies and chondral defects, can be treated by means of
arthroscopy. However, thesepresent worse resultsthan do
otherdiagnoses.60,61
Arthrodiastasis
Itisbelievedthatapplicationoftractiontoajointmayimprove
nutritionandtherepairproperties,throughwithdrawalofthe
load.Thisisdonebymeansofexternalfixators,whichenable
removaloftractiononthejointline,withmaintenanceofjoint
movement,whichhaspositiveeffectsonthejointfluid
pres-sure.Aldegherietal.62 describedthisprocedurein1979,for
treatingdegenerativelesionsofthehipinyoungpatients.
Somestudieshaveshownsatisfactoryresultswithtypeof
approachinsmallcaseseries,63–66 butthisoptionhastobe
understood asanon-definitive procedurethat hastheaim
ofpostponingarthroplastyor arthrodesisoftheankle. Itis
indicatedforyoungpatients.
Osteotomies
Inpatientswithasymmetryofalignmentofthelowerlimbs
(either varus or valgus) associated ankle OA, realignment
surgeryprovides analternativetofusionor arthroplastyin
selectedcases.
Osteotomies can be simple (tibia and fibula) or
com-bined (legand heel),withor withoutassociatedsoft-tissue
procedures.67
Theaimsaretotransfertheweightfromareaswith
dam-agedcartilagetoareaswithgood-qualitycartilage;toimprove
thejointcongruence;todeceleratetheprogressionoftheOA;
andtoreducethepain.
Pagenstertetal.67foundthattherewasanimprovementin
theAOFASscoreoverafive-yearfollow-upon35consecutive
patientswithpost-traumaticOAwhoweretreatedbymeans
ofrealignmentofthelegandhindfoot.
Preciseselectionofthepatientsandadequatecorrectionof
thejointalignmentanglearecrucialtosuccess.68,69
Treatmentofosteochondrallesions
Repairoffocalosteochondralcartilagedefects.
Microfractures
Themicrofracture procedureconsistsofmaking smalldrill
holes in the subchondral bone after regularization of the
lesion,inassociationwithremovalofthecalcifiedlayerofthe
jointcartilage.Thisprocedurefollowstheprincipleof
obtain-ingacoagulumformedbymesenchymalcellsoriginatingfrom
thebonemarrow.
Morerecently,somecentershavefollowedthesameline
concentratesofbonemarrowaspirate(whichcontain
mes-enchymalcells)butwithoutattackingthesubchondralbone.
Theseproceduresareunderdevelopmentandunder
evalua-tion.Thelogicbehindtheseproceduresisbasedonobtaininga
pluripotentcellcontentthatistheoreticallyataconcentration
greaterthanthroughmicrofracturing,butwithoutattacking
thesubchondralbone.Studiesonanimalshavedemonstrated
thatsuperior repairtissueisformed70 and have compared
use of bone marrow aspirate concentrate with
microfrac-turing. Furthermore, several clinical studies have reported
occurrences of significant alterations to subchondral bone
(suchasbonecystsandosteophytesinsidethelesions),after
microfractureprocedures.71,72
Thefactors indicatingapoorprognosisfrom this
proce-durecompriselesionsizegreaterthan1.5cm2,whichsignifies
diametergreaterthan1.2cm,73uncontainedlesionsand
pres-ence of cystic lesions associated with the osteochondral
lesion.74
Autologousosteochondraltransfer
Osteochondraltransferisbased onusing anosteochondral
cylinderobtainedfromalow-demandarea,usuallyfromthe
knee:inthe intercondylarregion,the lateralportionofthe
trochleaimmediatelyproximaltotheloadingareaofthe
lat-eralcondyleorthelateralcrestproximaltothetrochlea.
Thisprocedure isindicatedforlesions ofup toanarea
of 2cm2, in which either the cartilage alone is affected
or the cartilage together with the subchondralbone, as in
osteochondritisdissecans.Themainlimitingfactorfor
osteo-chondral transferconsists of morbidity inthe donor area,
whichrestrictsthequantityand sizeofthecylinderstobe
used.
Autologousimplantationofchondrocytes
Thisconsistsofcelltherapyfortreatingjointcartilagelesions
inwhichabiopsyisfirstperformedinordertoculture
chon-drocytes.This cell expansion isdone in the laboratory for
approximately six weeks. In a second surgical procedure,
debridementofthelesionandimplantationofchondrocytes
areperformed.Inthefirstgenerations,thisimplantationwas
doneusingaperiostealmembrane,butcollagenmembranes
arenowused(seededduringthesurgeryorusingcellsthat
hadpreviouslybeenculturedinthemembrane).
StageIII.Totalanklearthroplasty
Totalanklearthroplasty(TAA)ismainlyindicatedforpatients
withsevereOApresentingdailypainofsignificantintensity
andmajorfunctionallimitations,ofanyetiology,withgood
bonequality,adequatealignmentoronlymildasymmetryof
thelowerlimbsandstablejoints,inanon-elderlyagegroup
andwithoutanyseveresystemiccomorbidities.
Theaimsaretorestore thefunctional range ofmotion,
eliminatepainandimprovequalityoflife.
Thefirstdesignsfortotalankleprosthesesappearedinthe
1970s.Despitehighfailureratesexperienceswiththefirst
gen-erationsoftotalankleprostheses,75severalgroupscontinued
withtheresearchandtodayavarietyofimplantsthatcome
closetotheanatomicalandfunctionalrequirementsofthis
jointareavailable.
Thisevolutionhasresultedinimprovementoftheclinical
resultsandhasmadethisproceduremorepopularfortreating
ankleOA.76
Analysisoftheliteratureindicatesthatthemainadvance
has been the concept of “mobile support”, in which the
prosthetic components interrelatewith various degrees of
freedom,without any occurrenceofjoint constriction.The
third-generationprostheses,whichcomprisethreeelements
(tibial, talar and intermediate components), have been the
mostsuccessfulofthesesofar.77–79
However,TAAstillpresentshighcomplicationratesin
com-parisonwithkneeandhiparthroplasty.80Theintraoperative
complicationsareduetodifficultyinaligningthecomponents
and making the bonecuts and to fracturing ofthe
malle-oli.Duringthepostoperativeperiod,thecomplicationsrelate
todehiscenceofthesurgicalincisionandinfection.78,81Over
thelongterm,thegreatestcomplicationisasepticloosening
ofthetibialortalarcomponents,followedbystress
fractur-ing,capsuleretractionandretractionoftheperiarticularsoft
tissues.82
Thus,precisepatientselectionisfundamentaltothe
suc-cessofthisprocedure.
The contraindications include osteonecrosis, severe
peripheral vascular disease, peripheral neuropathy, recent
orpreviousjointinfection,severeligamentinstability,major
misalignmentofthelowerlimbandpoorbonequality.8
Thereisalsothepossibilityofperformingcompletejoint
replacementbymeansofafreshbipolargraftfromthe
tibio-tarsal joint.This procedure isa useful option forcarefully
selectedpatients,especiallyyoungandactiveindividuals.It
allowspainreliefandmaintenanceoffunctionaljoint
mobil-ity.However,furtherstudiesontheimmunologicalbehavior
of the transplanted cartilage in this type ofprocedure are
needed.83–85
StageIV.Arthrodesis
Arthrodesisismainlyindicatedforpatientswithsevere OA
presentingdailypainofsignificantintensityandmajor
func-tional limitation, of any etiology, with good bone quality,
adequate alignment ormildasymmetryofthe lowerlimbs
andstablejoints,intheelderlyandyoungadultagegroups
andwithabsenceofseveresystemiccomorbidities.
Theaimsaretoreestablishthealignmentofthelowerlimb
andeliminatethepain.
Tibiotarsalandtibiotalar-calcanealarthrodesis
Patients withadvancedankleOA without anindicationfor
totalankle arthroplastyandthosewho presentTAAfailure
formagroupthatmightbenefitfromsalvageprocedures
con-sistingoftibiotarsalortibiotalar-calcanealarthrodesis.Many
surgicaltechniquesandfixationmaterialshavealreadybeen
describedintheliterature.86–88
The choice between tibiotarsal or tibiotalar-calcaneal
arthrodesiswilldepend onthe conditionsofdegeneration,
Thisproceduregenerallyprovidesgoodfunctionalresults
andahighrateofsymptomrelief.Thereisnodoubtthat
cor-rectpositioningofthejointfusionduringtheoperationhas
adirectimpactontheclinicalresultsachieved.Thus,valgus
anglesof5◦, externalrotationangles of5◦-10◦ and neutral
flexion-extensionpositionsoftheankleneedtobeachieved.89
Itsdisadvantagesincludethe timetaken afterthe
oper-ationtoreachconsolidation,painfulnonunionrates,length
discrepancies between the lower limbs, chronic edema,
implantlooseningandperi-implantfracturing.88,89
Final
remarks
AnkleOAisadiseasethatdiffersfromotherformsofarthrosis
ofthelowerlimbs.Itsmainetiologicalfactorisjointtrauma,
especiallymalleolarfractures,chronicankle instabilityand
distalfractures of the tibia. It affects young individuals in
theproductiveagegroup,whichresultsinhighpersonaland
socialcostsrelatingtothedirecttreatmentofthisdisease,
whichusuallytakesalongtime.
Thetherapeuticstrategiesarebasedonastagedtreatment
algorithmanddependonabroadspectrumofrelatedfactors.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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