Foot and ankle osteoarthritis: early referral is key
Mr Mark Davies BA OXON MB BS FRCS(Orth) is an orthopaedic surgeon at Bupa Cromwell Hospital and is the founder of the London Foot and Ankle Centre.
An estimated eight million people in the UK suffer from osteoarthritis. In the foot and ankle, osteoarthritis most commonly develops in the following joints due to the impact they bear and their likelihood of being the site of an injury. These include:
the three joints of the hindfoot (talocalcaneal joint, talonavicular joint, calcaneocuboid joint)
the midfoot (metatarsounieform joint)
the big toe (hallus rigidus)
When a patient with osteoarthritis should be referred
Our main message to GPs in terms of osteoarthritis is please refer sooner rather than later. An early referral means we have a wider range of treatment options and we can reduce the risk of the arthritic joint leading to further deformity or mechanical problems in adjacent joints.
A patient should be referred to a specialist when:
- Pain cannot be addressed by conservative measures. These include orthotic supports, physiotherapy, anti-inflammatory medication, weight control, if required, and careful use of steroid injections.
- Bone spurs are having an impact on overall foot mechanics and therefore are likely to cause further deformity.
- Overall mobility is affected and the patient feels this is having an impact on their quality of life.
Treating patients with osteoarthritis
If the patient has early-stage osteoarthritis, we can carry out a cheilectomy, which is a clean-out procedure, removing bone spurs and debris within the joint and smoothing out the cartilage surfaces. This can sometimes be carried out using minimally-invasive surgery. It provides very effective symptom relief, although, of course, cannot reverse a progressive condition. Early referral is very important, particularly for active patients who want to preserve mobility and reduce the risk of impact in other parts of the foot and ankle. Once osteoarthritis progresses further, treatment options reduce, with fusion or joint replacement (for ankle osteoarthritis) being the only viable approaches.
Total ankle replacement surgery has taken much longer to become established compared with equivalent hip and knee replacements. This is because the ankle needs to both flex and rotate and consequently, under pressure, ankle replacement prosthetics had a reputation for breaking down. Now, the prosthetics have been significantly improved which means they are better integrated and more durable. Total ankle replacement surgery has become a good option for older and less active patients who will not place the prosthetic under too great a strain.
Fusion surgery remains a very effective option in terms of pain elimination and overall durability. Patients are naturally concerned about loss of flexibility following fusion, however those who undergo fusion surgery often are surprised about how much flexibility is maintained. They usually have been living with pain and poor mobility for many years and so a small loss of flexibility presents little difficulty compared with their pre-operative function. For example, I treated one 32-year-old patient with a severely degenerated subtalar joint following a rugby injury. Following the fusion surgery, this active young patient has gone on to compete in marathons.