Fixing the joints

Damaged ankles can be fused or replaced, but these surgeries have drawbacks

By Nancy Rome
Special to The Washington Post
Tuesday, March 16, 2010

The best athlete I knew in college has just had both his hips replaced. Another friend recently got two new titanium knees. We're all in our 50s -- once among the fittest in our college classes and now suffering from the kind of worn-out, creaking joints that generally come at a much older age.

Even though I stopped playing lacrosse in 1978, I have spent the past three decades wearing out ankles made unstable by the frequent turns that sport demanded. All the cartilage in my right ankle has eroded, and there's not much remaining in the left. I'm now "bone-on-bone," as the specialists say. A formerly fit 53-year-old, I now have severe osteoarthritis. I can walk only about a dozen city blocks; I take wheelchairs in most airports and museums; and I often have to sit down suddenly in the grocery store or garden when the pain becomes intolerable.

Determined not to give up every sport I love, I've sought treatment and canvassed the ankle gurus in Baltimore, where I live. After a series of appointments with specialists, one cortisone shot, two courses of hyaluronic acid injections (a viscous fluid designed to temporarily replace the body's joint lubricants) and countless X-rays, the prognosis isn't great. They are not offering to give me new ankles in the same way my friends have been getting new hips and knees.

Here's why: Hips and shoulders are simple ball-in-socket joints, which give our limbs rotational movement. The much-injured knee allows only forward and backward motion. But ankles are far more complex: They are a combination of three bones, the tibia and fibula (large and small leg bones) and the talus (the ankle bone). The leg bones are shaped to allow the talus to slide back and forth and in circles, and the talus works inside a socket; this allows your foot to move in many directions, as anyone knows who has been instructed by a physical therapist to use her foot to write the alphabet in the air.

If the ankle is a triumph of evolutionary engineering, it is proving hard to replicate in the lab. Not only is this complex joint sometimes forced to bear nearly five times the body's weight, but it also resides in a thin "soft tissue envelope," which makes healing more difficult if you do have surgery.

Three inadequate options

The doctors discussed three options with me: Fuse the ankle, replace it, or -- and this was the choice they all encouraged me to make -- grin and bear the pain until ankle surgeries and technology catch up to the care available for other worn-out joints. Each of these options comes with a long list of associated problems, especially for someone my age who wants to remain active.

The first option, fusing (or arthrodesis), involves using screws to secure the tibia (and sometimes the fibula, too) to the talus bone (in most cases), which can alleviate much of the pain caused by bone-on-bone friction. Fusing eliminates up-and-down movement but preserves side-to-side movement and allows other bones in the foot to still move after surgery. The problem is that fusing adversely affects your gait and is likely to create arthritis in other parts of the foot. Fusing may also lead to back, hip and knee problems and usually leaves you with a joint not mobile enough to play tennis or golf.

Replacement (or arthroplasty) has been performed sporadically for about 30 years. Though the surgery has improved steadily in that time, it has still met with less success than other joint replacements, and many surgeons perform total ankle arthroplasty only as a last resort. About 7 to 9 percent of replacements fail, which usually leads to fusion, and in the worst cases can result in amputation of the foot. Ideal candidates for ankle replacement are in their mid-60s and inactive because even successful replacements don't seem to last as long or allow for as much physical activity as other replacement joints.

There are 36 devices on the market for ankle replacements, some available only in Europe, some only in the United States. The surgeons with whom I spoke, and those who have reported on the procedure through studies, primarily use just four of these. One doctor warned that it's important to remember that although there are studies and clinical trials for each of the prostheses, no study has compared the four with one another.

Some recent studies indicate that replacements compare favorably with fusing. But none of the surgeons across the country with whom I spoke was in a hurry to recommend them, citing erosion and the subsequent weakening of the bone around the prosthesis, and all worried about the difficulties of fixing a failed replacement.

It all sounds like a grim outlook for people like me suffering from worn-out ankles at an early age, but there are some promising developments that combine prosthetics with biotechnology: using the patients' own stem cells, harvested from their bone marrow, to encourage the bone and cartilage to grow into the replacement joint, thereby creating a more stable environment for the implant. Although this approach is still experimental and there aren't enough data yet to warrant its widespread use in ankles, the concept has shown early promise in repairing ligaments and tendons.

Surgeons are also trying prostheses made of more bone-friendly porous materials to encourage them to knit to the bones, and they're developing techniques that require less removal of the bone.

There are several ways in which doctors are trying to repair and rebuild the cartilage that those with osteoarthritis have lost. The most widely used is microfracture, in which tiny holes are drilled into the bone to release blood and bone marrow, which then begin to form new cartilage. One local specialist injects concentrated, bone-marrow-derived stem cells along with a collagen-based formula into the ankle to encourage cartilage growth. Others are experimenting with filling "potholes" in the ankle's cartilage, using a concoction of human cartilage and biological glue, but this method requires a donor for the replacement cartilage, which creates further complications.

The future

What can we expect in the next five to 10 years? Surgeons I spoke to all anticipate that the technology for ankles will have caught up to the other joints to such an extent that younger and younger patients requiring relief from injured or deteriorating joints will at last be able to opt for replacements that will last longer and that can be repaired with fewer complications if they fail. The doctors also were quick to disclose that many of them have affiliations with biotech companies and therefore might be invested in the success of one technological advance over another.

For now, I've elected the grin-and-bear-it route. After losing 10 pounds and receiving two rounds of hyaluronic acid injections, I'm ready to try almost anything. I've been to a naturopath who has given me supplements: various forms of omega-3 fatty acids, glucosamine sulfate and a systemic enzyme that has shown promise in reducing inflammation in severely arthritic joints. These supplements do seem to be helping, because I notice what happens when I forget to take them: I can't walk as far.

Although there's no evidence that the supplements are helping me regrow my own cartilage, I've made some progress in terms of physical activity. I still find myself sitting down abruptly when the pain overwhelms me, but it is happening less frequently.

The exercises and body-awareness lessons of the Alexander Technique have also been very useful because they can keep you from becoming lopsided and help alleviate pain. Forced to stop yoga because I could no longer manage the standing poses, I can still do Pilates because much of it can be done without putting undue pressure on my ankles.

Acupuncture has helped, but it offers short-lived pain relief in my case. Massage therapy has been more helpful than anything else. I found a licensed massage therapist, specializing in orthopedic massage methods that can take the swelling and pain away from my ankles in about 15 minutes, and the effects last for days. A machine used by another massage therapist (a neuromuscular therapist in this case) called a Thera-Stim also offers relief, although the tingling of electric currents transmitted through rubber pads is not exactly pleasant.

A remarkable thing I've learned is that the slow deterioration of cartilage resulting in severe osteoarthritis can have as great an impact on quality of life, according to many studies, as more-dramatic medical conditions. As I come to terms with my altered status -- and try to limit my ibuprofen intake -- the biggest challenge is to prevent further damage and to halt the domino effect that can happen after one part of us wears out.

Rome is a writer and documentary filmmaker.

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