 Aki Breakey Joint Webinar on Foot and Angle Arthritis with Dr. Natalie Dana. She is an Assistant Professor of Orthopedic Surgery at the University of Maryland School of Medicine and an Orthopedic Foot and Angle Surgeon with the University of Maryland Orthopedics. We will invite you to leave your questions for Dr. Dana in the chat section or in the Q&A section and we'll get to those at the end of the presentation. So Dr. Dana, go ahead and take it away. Thanks Meredith and thank you all for joining me today. We're going to talk about arthritis of the foot and ankle. As Meredith mentioned, I'm Dr. Natalie Dana. A little bit about me to get started. I am an orthopedic surgeon at the University of Maryland Medical Center. As an orthopedic surgeon, I specialize in bones, joints, cartilage, tendon and ligaments. I trained in the whole body in orthopedic surgery initially and then I subspecialized in foot and ankle surgery. So some of the problems that orthopedic foot and ankle surgeons treat are listed here. These include arthritis of the foot and ankle, which will be the topic of our discussion today, tendon and ligament injuries, painful flat feet, other deformities, ankle instability, traumatic injuries, broken bones, fractures, bunions, also includes hammer toes and Charcot orthopathy, which is a problem faced by some people who have diabetes. These are some of the procedures that I perform to treat those problems. This includes ankle replacement, which we'll discuss today. Subtailor and sub-tailor joint fusion also we'll discuss that procedure. Tendon and ligament repair and reconstruction, fracture care, external fixator application, which is sometimes used for people with very bad injuries, deformity correction, bunion and hammer toe correction, minimally invasive surgery and joint preservation surgery, which we'll also touch on today. So mainly the topic of our discussion here is going to be arthritis of the foot and ankle. So let's start with the basics. What is arthritis? In arthritis, the cartilage layer that exists between the bones wears out and this leads to bone on bone contact. The function of the cartilage layer is to provide smooth motion for our joints. When that cartilage layer wears out and the bones are in contact with one another, there can be painful inflammation in the joint that results. Some of the causes of arthritis in the foot and ankle are listed here on this slide. Genetics is one possible cause. So you may have a family history of several members of your family who have had bad arthritis in their foot or in their ankle. There may have been an injury in the past. This could be anything from an old sports injury to a car accident to a bad sprain. There may be a deformity. This could be something that was present at birth with clubfoot or something that develops over time like a severe flat foot. Some medications can lead to arthritis in the foot and ankle. An infection in the bone or in the joint can also lead to arthritis. So how would you know if you had arthritis in your foot or in your ankle? Pain is one of the primary symptoms. And that's usually what patients present to my office with would be pain in the ankle or in the foot. Patients can also have stiffness and that could be anything ranging from just somewhat of a loss of their normal range of motion to a joint that doesn't move at all. Everything might be present. Some patients complain of a limp or not walking like they used to. And other patients don't notice pain or stiffness, but they do notice that they have much more difficulty walking than they used to. It takes more work, more energy, and they move a lot more slowly. So if you think you have arthritis and you make an appointment with your orthopedic surgeon to have this evaluated, what will they do to diagnose the problem? In my office, we always start by talking about what problem is you're experiencing and how that problem evolved or changed over time. So some patients can pinpoint the cause to a particular incident or injury. And other times it starts insidiously without a definite cause or time point. We will do a physical exam. I'll have you remove both socks and shoes and usually roll up your pants, legs so I can see the whole ankle and foot. It's important to have the patient stand in my office. I have you do the example sitting and standing. I like to have a sense of your alignment and also if any part of the exam changes when standing because many patients have more pain and more symptoms when standing or walking than they do when sitting or lying down. I will also almost always perform x-rays, including some specialized x-rays that are done usually, as I mentioned before, with weight bearing, with standing and pressure on the joint while performing the x-rays. And this can give me a lot more information than x-rays that are performed lying down alone. So once you know you have arthritis, how do we treat this? What are the options? There is an array of options for treating ankle arthritis and foot arthritis. And in the office, once we have a diagnosis of arthritis, we'll start talking about the options. I'll explain the details of each one. And you can decide sort of where you are on the spectrum of treatments and what you would find most helpful. So typically I like to start with anti-inflammatory medications. Now if you remember back to the discussion on the slide detailing what arthritis actually is, that bone-on-bone contact can lead to painful inflammation in the joint. So the goal of the anti-inflammatory medications is to actually take that inflammation in the joint down. So I don't think of this as a pain medication or a coverup of the symptoms. I think of the anti-inflammatory medications as actually getting at the cause of the problem. A nice secondary effect of taking the inflammation down in the joint is some relief of pain and of symptoms. But that's not the primary aim. I like to also try ankle bracing with patients with arthritis. And if the arthritis is in the foot, it would be a brace more focused on the foot. But the idea is when patients have bone-on-bone contact from arthritis, it's the motion of the joint that causes pain. So by using a brace, we can support the joint from the outside to encourage less motion with walking. And by taking the level of motion down, we can often improve the symptoms. Physical therapy is often an important treatment for patients who have arthritis of the ankle and foot. The physical therapists can do a number of things. They'll usually begin with an evaluation of your functional level at the start of the therapy. And then they'll design a customized treatment program for you to increase that function, whether by strengthening exercises or range of motion exercises. We can often discuss shoewear changes for patients with arthritis. And the details of what those shoewear changes are is specific to exactly where the arthritis is occurring, which joint. But for instance, for patients who have arthritis at the ankle, the ankle's function is to help when walking rock from heel to toe. So we can often incorporate a rocker bottom in the shoe, as some of the examples you see here on the slide show, so that the shoe itself is helping the patient walk from heel to toe and to make that motion without having to move through the ankle itself. And as I just mentioned, motion through the joint when the cartilage has worn out was painful. So anything that we can do to reduce that motion through the joint tends to help the symptoms. An injection is also a possibility for patients with arthritis. That injection typically goes into the joint that has arthritis. And there are usually two medications present in that injection. So one medication would be a steroid medication. And the function there is to reduce the inflammation in the joint, much like the oral medications I mentioned earlier on this slide. But by putting the medication directly into the joint, we can reduce the effects on the whole body and target that medication specifically at the joint with arthritis. The second medication I would typically use for an injection for arthritis in the ankle and foot is a local anesthetic. So lidocaine, marquane, these are similar to the novacaine you might be familiar with at the dentist's office. But they're a local anesthetic. They last for just a short period of time, but they tend to provide very quick relief. So by putting both of these medications in the injection, patients will have sort of an immediate relief of pain from that short-acting medication, but that will wear off in a day or so. And then in about three days after the injection, the steroid will start to take effect. And that should last longer. Each patient is different, but I've seen patients who've gotten six to nine months of relief from that injection. None of these treatments mentioned on this slide with the exception of the anti-inflammatory medication really has long-term relief of symptoms and doesn't change the actual process of arthritis. The arthritis is still present, but they can help relieve the things that bother the patient and limit their everyday function. So they're very useful in that way. But if you've tried these treatments and you're still experiencing a lot of pain or symptoms that are limiting your everyday life and function, it might be time to think about surgery. So let's talk next about surgery for ankle arthritis, what the options are, what that looks like. And we'll start by using the ankle as the example, but many of the joints in the foot as well really follow the same pattern as the ankle. And so the surgical options are very similar. The principles of treatment are really the same and a lot of the post-surgery recovery is the same. So we'll talk more specifically about ankle arthritis right now, but just know that this applies to joints in the foot as well. So when it comes to surgery, there are two main surgical options that you may have heard of. Now, one option is ankle fusion. And that's what we'll talk about for you first. This is the classic surgery. This is the one that is the go-to when other surgeries haven't worked. The basic premise here is that that bone-on-bone grinding that we talked about earlier is painful in an arthritic joint. So to stop the pain, we make the two bones grow together as one bone. Once that has been accomplished, the bones don't hurt anymore because they don't move. So this does change their function somewhat, but more importantly, it changes the pain that the patient experiences. So whenever I talk to patients about an ankle fusion, the obvious question is, if my ankle doesn't move, how can I walk? Will I even be able to walk anymore after surgery? And the answer to that is yes, you will be able to walk after surgery. In fact, if you go to YouTube or else we're on the internet, you can find some videos of patients walking quite well after an ankle fusion. So how is this possible? We know that the ankle is very important. Its motion is very important for walking. So once it doesn't move anymore, how is walking possible? A couple of answers to that question. The first one is, when arthritis is bad in the ankle, patients sort of understand that motion makes the pain worse and already try to adjust their gait and adjust their functioning to move the ankle as little as possible. So most patients who I see with advanced arthritis are already, when they're walking, moving the ankle very, very little. When we perform this surgical fusion and it has fully healed, the ankle bones then function as one unit, they're one solid bone mass. And what happens is the nearby joints, in the case of the ankle, there's a joint right below it called the subtaler joint, the nearby joints adjust and they begin to move more than they did previously and they start to move how the ankle was moving. So they take over some of that function and let the gait proceed, but the walking cycle proceed as it should if the ankle were moving itself. Now, if this still sounds like something you're really not ready to consider, you don't want to risk that loss of motion in your ankle and you really wanna know if there is another option, there is another option, but it's not for everyone. So we do ankle replacements in the same way that we do knee replacements or hip replacements, but the mechanics of the ankle joint is a little bit different and so the surgery is a little bit different. In an ankle replacement, the premise of the surgery is to replace the worn out cartilage with metal caps on the end of the bone and then put a plastic spacer in between those metal caps. This allows the ankle to continue to move as it did before the arthritis while still providing pain relief to the patient because we no longer have that bone-on-bone contact. As I mentioned, ankle replacement is not for everyone. Since the ankle still moves, the parts can wear out and that means that the ankle replacement might need to be revised once or twice, maybe even more times in the patient time if the parts have worn out. So if people have their ankles replaced in their 20s, 30s, or even 40s, they may have to have an additional surgery, maybe even two additional surgeries, et cetera, over the course of their lifetime and each subsequent surgery is a little bit more complicated than the previous one because the old metal caps have to come out and often they take a little bit of bone with them and then new metal caps have to go in. So for those patients who are very young, very, very active, it might be better to have a fusion and that's an individualized conversation that I have with each patient in the office and there's many factors that go into the decision of which is the best surgery for each patient. But for healthy patients who are in their 50s or older who understand the process of the ankle replacement and the recovery, if those who've never had an infection in their ankle in the past, for all these people, ankle replacement is an option that's worth discussing. So the next question you might be wondering is what is the recovery like after surgery? After surgery on the ankle or on the foot, I advise no weight on that leg for four to six weeks. How to achieve that? Crutches are an option and the best option for many patients but there's also knee scooters that are becoming more popular now and you may have seen these on the street or know someone in your family who's used a knee scooter. It's a scooter with a little pad that you rest your knee on. That way your foot doesn't touch the ground at all and some of the advantages of knee scooters over crutches are that the scooters are very stable. They usually have four wheels so it's difficult to tip them over. So unlike the crutches, balance is, you don't have to have such good balance to use the knee scooter. So there may be a safer option for a lot of patients. Patients will be in a soft cast for two weeks after the surgery. It's also called the splint. And then after two weeks, patients come back to my office. I take the stitches out at that time and then we go into a hard cast if you've had a fusion or a boot for those who have had an ankle replacement. At about week six, depending on again exactly which surgery you had and the details of each patient, we tend to start weight bearing back on the surgical leg. And usually I'll have you start to walk on your own at first and then I'll have another follow-up appointment with you a couple of weeks later to assess how you're doing walking on your own and whether there's a need for physical therapy. So now that you understand the surgery, the question would be have ankle arthritis how do you know if you're ready for surgery? At what point we start to consider the surgical options? Everyone would rather avoid surgery if possible. And I agree that we should always try the nonoperative treatment strategies first. But once you've tried those treatments, if you still haven't achieved relief, if your daily activities are limited by these symptoms, if your other medical problems are well controlled, so heart problems, lung problems, diabetes, your weight is healthy, if you've quit smoking for those who smoke, it's important not to be smoking at the time of surgery because cigarette smoke can often interfere and delay bone healing. And whether you have a fusion or replacement bone healing is an important part of the healing and recovery process. And then it's important to understand the recovery process before deciding to move forward with surgery. You wanna know what to expect, both in the first few days after surgery, but also down the road, what's the timeline to getting back to your regular shoes, the timeline to walking, the timeline to resuming all activities in sports. If you think you would like to have an evaluation for your ankle pain, if you wonder if you have ankle arthritis, if you've been diagnosed with ankle arthritis in the past and thought that there was nothing that could be done to relieve or improve your pain, it's important to have a conversation with orthopedic foot and ankle surgeon with somebody who treats ankle arthritis specifically and find out what can be done to help with your symptoms. So I encourage you to give us a call at the University of Maryland. I see patients three days a week and operate on the other days. I'm doing appointments both in person in a socially distanced way and also over telemedicine for those who would prefer not to come into the office. So it's important to at least be evaluated to know where your ankle stands and what the options are for you to relieve your pain and resume your activities as you would like to. So I'd like to invite any questions from any attendees, what I can answer, happy to spend some time just talking to you and finding out what you wanna know about ankle and foot arthritis. Thank you, Dr. Dana. As she mentioned, we invite you to leave your questions for her either in the chat box or you can submit them to us through the questions function. We've also received several questions through email. So if that's your preferred route, you can do that as well.