Surgery Often Best Option for Ankle Pain in the Elderly

From the American Academy of Orthopaedic Surgeons

CHICAGO—Ankle pain from arthritis or fracture is a common problem in adults, accounting for >2 million office visits annually, according to 2003 data from the National Center for Health Statistics. When patients do not respond to standard treatment with pain medicine, primary care physicians need to know that other options are available. At the American Academy of Orthopaedic Surgeons annual meeting, 2 orthopedists discussed new approaches to the treatment of ankle fractures and ankle arthritis that can help physicians make better treatment decisions.

Until recently, older patients with ankle fractures were usually treated with a cast. Now research suggests that it is surgery rather than nonsurgical treatment that provides better outcomes in older patients with ankle fractures, said Kenneth A. Egol, MD, chief of orthopedic trauma service, New York University-Hospital for Joint Diseases in New York City.

In a study of 369 consecutive patients (313 who were aged <60 years and 56 aged ≥60 years) who underwent surgery for unstable fractures, ankle function improved steadily over 12 months&#8217; follow-up in all participants, although to a lesser degree in the older age-group. &#8220;The older patient just takes a little longer to recover,&#8221; he noted. &#8220;Some of these patients may benefit from targeted rehabilitation to speed up that recovery.&#8221;

Noting that ankle fractures have become more common in the elderly over the last 30 years, Dr Egol explained that the best treatment is the one that will help restore an older individual to the level of ambulation he or she enjoyed before the fracture, which can allow the patient to continue living independently.

Many different treatments are being evaluated for adults with disabling ankle arthritis who do not respond to pain medications. Although the standard surgical treatment is fusion, Charles Saltzman, MD, chairman of orthopedics at the University of Utah in Salt Lake City, said this procedure is not always adequate for pain relief.?

Dr Saltzman reported on several alternative treatments that may provide better pain relief, including ankle allografts from cadaveric donors, which are now being used to successfully treat some cases of ankle arthritis. In this relatively new procedure, a fresh osteochondral allograft from an anatomically matched donor is surgically transplanted into a patient with severe ankle osteoarthritis. Although the donors and recipients are anatomically matched&#8212;meaning that the allograft must resemble the diseased ankle cartilage that is being extracted during the procedure&#8212;the allografts are not human leukocyte antigen matched.?In addition, unlike recipients of major organs, ankle allograft recipients do not need to take antirejection drugs, eliminating the risk of immunosuppression with lifelong antirejection drug use.?Dr Saltzman cited a study of 11 patients who received fresh osteochondral allografts that showed a 59% rate of sustained cartilage viability.

Another investigational procedure involves distraction. The patient wears a supportive frame for 3 months that separates 2 parts of the bone.?According to Dr Saltzman, &#8220;70% of patients report less pain 3 months after the frame is removed.&#8221;

In addition to allografts and distraction techniques for ankle arthritis, orthopedists are showing a resurgent interest in total ankle replacement.?In a study of 126 elderly patients who were followed for 9 years, >90% of the 93 patients who were alive at the end of the study reported that they were satisfied with their surgical outcome.

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Ankle fractures and arthritis may continue to vex both primary care doctors and their patients, but orthopedists are working hard to come up with better treatments