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Treatment Alternative to Surgery for Ankle Arthritis

What do you do if you have severe pain from an arthritic ankle and you aren't a good candidate for surgery? You need relief from the pain and some way to improve function in that ankle. You are overweight and haven't been able to lose it. Or you've tried antiinflammatories but couldn't tolerate the side effects and exercise helped but not enough. On the other hand, what if you are accepted for surgery but you don't want surgery? What are your options?

In this study, physicians from Taiwan investigate the use of hyaluronate injections into the ankle to treat ankle osteoarthritis. The procedure is referred to as viscosupplementation. The injection helps restore the normal flow of fluid inside the joint. It is a joint lubricant. The natural result is to reduce pain and improve motion and function.

Viscosupplementation of this type with hyaluronate has been done successfully with the knee. After three to five (once a week) injections, patients report considerable relief from pain. And with pain relief and improved ability for the joint to slide and glide comes a return in the ease of motion. These researchers wondered how well does this technique work for the ankle?

They gave each of 50 patients with ankle arthritis in one ankle one injection every week for three weeks. Then they measured results one to six months after the last injection. Standardized tests of pain, motion, and balance were completed. Patients were asked to rate their level of satisfaction. Complications and use of pain relievers were also recorded.

The results were very encouraging. Patients improved in all areas, used less pain medication, and rated their satisfaction high. There were no serious side effects either! In particular, the improvement in balance was consistent when measured with four different tests. The possibility of fewer falls and reduced risk of additional injuries are added benefits of viscosupplementation. There is also a cost savings in not having the expense of surgery.

All positive changes occurred within the first month following the injections. And the benefits remained when patients were checked at the end of six months. Younger patients (55 years old and younger) seemed to improve more than older adults.

The authors concluded that the use of hyaluronate injections for ankle osteoarthritis is safe and effective. Further studies are needed to determine the optimum number of injections needed for the best results. It's possible that some patients would do better with five injections instead of three (and vice versa).

Longer follow-up is also needed to see if the benefits last more than six months. With larger study groups, it might be possible to determine which patients with ankle arthritis are the best candidates for this type of treatment.

It would be helpful to know the best timing of treatment. Earlier use of hyaluronate to lubricate the affected ankle might help patients maintain balance, strength, and proprioception (fine tuning that signals even the smallest change in joint position).

And finally, hyaluronate injections must be compared to other conservative (nonoperative) treatment methods (e.g., physical therapy, antiinflammatories, weight loss, orthotics, activity modification). The result of different treatments combined together versus just viscosupplementation will be necessary. Perhaps comparing surgical results to hyaluronate injections would yield some additional helpful information for patients looking for an alternative approach to surgery.

Shu-Fen Sun, MD, et al. The Effect of Three Weekly Intra-Articular Injections of Hyaluronate on Pain, Function, and Balance in Patients with Unilateral Ankle Arthritis. In The Journal of Bone and Joint Surgery. September 21, 2011. Vol. 93-A. No. 19. Pp. 1720-1726.

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