Arthrodesis

Q In 1977, my husband broke and dislocated his ankle. He was told he needed a plate and screws in the joint to prevent arthritis later. Arthritis set in anyway and is now so severe that, at 58, he has difficulty walking and has had to give up the outdoor work he has been doing for most of his life.

His consultant has recommended an operation to fuse the joint, but what are the risks involved and is there any less drastic alternative, aside from callipers? – G. Leppard, Haywards Heath

A Arthrodesis is the operation in which the bones of the ankle joint are fused together, making the ankle completely stuck in one position. Surgeons say this strengthens the ankle and eliminates pain, and point out that the patient can still flex his feet.

But, as you say, the operation is rather drastic and, like most surgery on the skeleton, irreversible. Here’s what your surgeon may not tell you:

* Like your husband’s previous surgery, arthrodesis often involves metal plates or rods to keep the bones in place, so at the end, his foot may well be a hodge-podge of ironmongery.

* It may take up to six months for the bones to fuse, and may totally fail in one in three cases. It can also trigger deep vein thrombosis in the leg.

* To compensate for fusion, the other joints have to move much more, creating excessive strain on these joints, and long-term pain and disability. In one arthrodesis follow-up survey, 67 per cent of patients had foot pain, and 75 per cent had to wear special footwear because of the operation (Acta Orthop Scand, 1981; 52: 103-5).

* Ironically, arthrodesis – the cure for arthritis – will actually cause arthritis elsewhere in the foot (J Bone Joint Surg Am, 2001; 83-A: 219-28).

So what are your other options?

Low tibial osteotomy is an operation that maintains ankle movement, and is claimed to be successful in over 80 per cent of cases of ‘moderate ankle arthritis’ (Arch Orthop Trauma Surg, 2001; 121: 355-8).

Mesotherapy (or prolotherapy) involves injecting a cocktail of agents – usually herbs or vitamins, but sometimes conventional drugs like painkillers – into the joint to cause a localised inflammation, leading to a ‘wound-healing cascade’ and the production of collagen. Developed in 1952 by Dr Michel Pistor in France, there appears to be no formal clinical evidence to support its use. Mesotherapy doctors claim a 70 per cent cure rate for arthritis.

Viscosupplementation involves injecting hyaluronic acid into the joint to act as a joint lubricant. This is now a recommended treatment for osteoarthritis in the US, although clinical trials have shown only moderate results. It also needs to be repeated every six months.

Microcurrent electrical therapy (MET) has shown some success in relieving pain, including arthritis (Br J Rheumatol, 1993; 32: 1-3). A hand-held device sends an imperceptible current through the painful area in repeated ‘doses’ of about 10 seconds each. The pain is usually gone within two minutes, and this benefit may last from eight hours to three weeks (Arch Otolaryngol, 1983; 109: 382-3).

Nutritional supplements such as chondroitin and glucosamine are antiarthritics, both well supported by clinical evidence (WDDTY vol 9 no 8). Less well-known, but nevertheless effective, for the relief of arthritic pain is S-adenosylmethionine (SAMe) (J Fam Pract, 2002; 51: 425-30).