Arthritis of the ankle is most commonly a result of prior trauma (e.g., ankle fracture or persistent ankle instability with recurrent sprains). It can cause debilitating pain and limit the quality of life for individuals. Nonoperative treatment includes ankle brace, injections, and modified activities. Like most arthritic conditions, ankle arthritis tends to progress with time. End-stage ankle arthritis can be treated surgically with either an ankle fusion or ankle replacement. If you are younger than 65 years old, Dr. Kim focuses on preserving the joint and aims to get “as many years as possible” from the native joint. This can be achieved through minimally invasive procedures, such as arthroscopic debridement, marrow stimulation, Biocartilage, etc. The definitive treatment of your ankle arthritis depends on many factors, and it would be insufficient to categorize all arthritic ankle conditions under one category.
Ankle fractures can occur from low energy injuries, such as a simple trip and fall, to a high energy injury, such as a motor vehicle accident. Depending on the mechanism, ankle fractures can present as stable or unstable. Stress radiographs along with a detailed clinical exam can decipher stable versus unstable injuries. Unstable injuries typically necessitate surgical intervention, especially those who are community ambulators. Dr. Kim is facile at treating ankle fractures and typically operates on patients with ankle fractures on a weekly basis. Depending on the X-rays, it’s not uncommon to obtain a CT scan to delineate the fracture more acutely and may potentially change the operative plan. For instance, if the CT scan reveals a bone fragment in the joint, Dr. Kim then advocates for an arthroscopic procedure to remove the loose fragment. As in all patients, Dr. Kim approaches each patient and case methodically and ultimately has had excellent success in getting patients back to their pre-injury level of activity.
Ankle sprains are one of the most common sports injuries that bring patients to a doctors office. Most ankle sprains can be treated conservatively with a brace, physical therapy, and functional rehabilitation. However, a select few do not respond to conservative care. Before a surgical plan is made, a thorough evaluation and a workup are needed because ankle instability can also present with osteochondral lesions of the talus, peroneal tendon pathology, and arthritis. Given the variable presentation, Dr. Kim focuses on systematically evaluating each patient to find the source of pain and pathology of his patients since not all ankle instability presentations are identical. If an ankle ligament procedure is warranted, Dr. Kim uses the anatomic reconstruction of the ligaments and typically uses biologics (i.e., stem cells) to aid in healing and recovery. Additionally, Dr. Kim uses the Internal Brace from Arthrex to allow his patients to begin weight-bearing two weeks after surgery!
Bunion (AKA Hallux Valgus)
The etiology of bunions is multifactorial — for instance, there can be an association with shoe wear and have a hereditary component, regardless of cause, the treatment of bunions should be initiated with conservative care to include modified shoes, orthotics, bunion spacers and splints. It’s advisable to obtain X-rays annually to obtain objective evidence if the bunion is worsening.
Dr. Kim counsels his patients to seek surgical intervention once bunions become painful and his patients have failed a course of conservative treatment.
Historically, there are more than 100 procedures reported for bunions. Dr. Kim believes in identifying the source of the bunion and not focusing on just getting rid of the bump. Typical sources include hypermobility of the tarsometatarsal joint, subluxation of sesamoids, ligamentous laxity, etc. Given this approach, Dr. Kim performs three bunion procedures, including BOAT osteotomy, SCARF osteotomy, and Lapidus bunionectomy. Often, these procedures are accompanied by smaller procedures if need be, such as lateral capsular release, Akin osteotomy, BMAC, etc.
Adult acquired flatfoot deformity can be a spectrum of multifactorial causes but commonly shares a deficiency of the posterior tibial tendon and spring ligament. Conservative care includes orthotics, braces, physical therapy, and modified activities.
When conservative care fails, then surgery can encompass a wide variety of procedures, such as medial calcaneal osteotomy, the fusion of the medial ray, flexor digitorum longus transfer, repair of spring ligament, etc. To decipher the appropriate potpourri of procedures necessitates an evaluation, X-rays, MRI, and on occasion, a CT. Ultimately, flatfoot deformities progress from flexible to rigid deformities and eventually can progress to involve the ankle joint.
Forefoot pain is commonly called metatarsalgia and is thought to occur from mechanical overload (i.e., a flexible first ray), long second metatarsal, tight calf muscle (i.e., equinus contracture). Typical conservative care includes modified shoes and activities, orthotics, metatarsal padding, and physical therapy.
When conservative measures fail, surgery can include stabilizing the flexible first ray by fusing the first tarsometatarsal joint, shortening long metatarsals, or both.
Another common complaint in the forefoot is hammertoes. Hammertoes can either be rigid or flexible (i.e., you can straighten the toe with your fingers). Flexible hammertoes tend to respond to taping, padding, wide toe box shoes, and orthotics. Rigid hammertoes are challenging to treat conservatively, but still, an attempt at conservative care should be attempted. When the conservative measures fail, surgery involves fusing the hammertoe joint (i.e., proximal interphalangeal joint) and stabilizing it with a pin that is removed at around four weeks.
Hallux rigidus is the medical term for arthritis of the big toe joint. It typically arises from an accumulation of microtrauma and tends to worsen with time and activity. Conservative treatment includes orthotics, NSAIDs (e.g., ibuprofen), modified shoes and activities, steroid injections, and more. However, these tend not to stop the progression of arthritis.
Surgical intervention depends on the degree and level of arthritis. For bone spurs with relatively little cartilage involvement can be treated with bone spur removal (AKA cheilectomy) and also Dr. Kim tends to also concurrently perform a Moberg osteotomy, which is removing a triangular piece of bone to gain artificial dorsiflexion. Dr. Kim performed a cadaveric study that showed removing a 3-mm wedge of bone would change the contact pressure to center on non-arthritic cartilage. However, if the arthritis is severe (e.g., Grade 3), the options are fusion or Cartiva implantation. Dr. Kim is a recognized provider who performs Cartiva, and the midterm results have been promising.
Hindfoot arthritis encompasses three joints, the subtalar joint, talonavicular joint and calcaneocuboid joint. Post-traumatic arthritis is a common cause of hindfoot arthritis but can be caused by inflammatory arthritis, such as rheumatoid arthritis. The first line of treatment is conservative, to include a brace, orthotics, modified shoes and activities, and injections. However, hindfoot arthritis tends to progress with time and activity. The standard of care is typically fusion. Dr. Kim uses stem cells, titanium screws with variated pitches on the threads, compression plates, and Nitinol staples. Regardless of the fixation, Dr. Kim has a successful track record with his fusion procedures and approaches each patient with a tailored plan specific to the individual’s anatomy and pathology.
Arthritis of the midfoot is best characterized as pain in the middle of the foot between the metatarsals and Chopart’s Joint (i.e., calcaneocuboid and talonavicular joint). Etiology varies from trauma, degenerative changes from being active, ligamentous injury and other causes. Typically, it’s treated conservatively with orthotics and rocker bottom shoes. Fluoroscopic-guided injections work well but are not permanent. However, these injections can be repeated every three to six months.
Definitive treatment for midfoot arthritis is fusion. The word fusion instills a sense of fear and worry that you will have a stiff foot. However, the joints that are fused in midfoot arthritis are termed non-essential joints since there is relatively little native motion. Despite the recovery, patients do very well after the procedure with significant improvement in pain and functional outcomes.
Neuromas are a common occurrence in the foot especially given how many steps we take on an average day. Neuromas typically occur between the third and fourth toes since the medial and lateral plantar nerves contribute to form the common digital nerve (i.e., makes it thicker), but they can occur between the other toes. Some have attributed neuromas to foot type, narrow shoes, and types of activities, but regardless of the cause, by and large, the most common treatment for neuromas is conservative, to include neuroma pads, orthotics, modified shoes and activities, and ultrasound-guided steroid injections. Despite most neuromas responding to conservative care, some require surgery. The most common surgical procedure for neuromas is excision.
Osteochondral Lesions of the Talus
Osteochondral lesions of the talus (OCL) are cartilage defects that can occur from trauma but can occur with no known cause, such as osteochondritis dissecans. Dr. Kim compares OCLs to having a small pothole in the ankle. Despite this, not all OCLs need to be treated surgically. Many OCLs can be treated nonoperatively with NSAIDs (e.g., ibuprofen), physical therapy, modified activities, and protected weight bearing. Usually, surgery is reserved for the patients with OCLs who have tried conservative care for about three months.
Surgery for OCLs depend on one major criterion: its size. To gauge the size of the OCL, Dr. Kim typically recommends X-rays, MRI, and on some occasions, a CT scan. When the size is determined, treatment can range from marrow stimulation (AKA microfracture), Biocartilage (i.e., morselized cadaver cartilage) mixed with stem cells, or osteochondral plugs (AKA mosaicplasty).
The literature regarding treatment of OCLs is encouraging and changing our approach to OCLs.
Total Ankle Replacement
History has proven that joint replacements can be very successful, and despite ankle replacements not having had the long-term success of knee and hip replacements, it has shown more recently that the newer technique and refined implants now work very well. More recent studies have revealed that the current modern ankle replacements now rival the success of ankle fusion, which has for decades been the standard of care for end-stage ankle arthritis.
Dr. Kim is well trained in ankle replacements and currently uses CT formulated cutting blocks to tailor the surgery towards your anatomy. He has had many patients return to a lifestyle they once thought was lost.
If you have been diagnosed with any of the above conditions and would like to learn more, please call Dr. Paul Kim at 415-927-5300 for an appointment, and after an evaluation, an optimal treatment plan will be tailored to get you back to your active lifestyle.