Imaging and Treatment of Posttraumatic Ankle and Hindfoot Osteoarthritis

Abstract

Posttraumatic osteoarthritis of the ankle and hindfoot is a common and frequently debilitating disorder. 70% to 90% of ankle osteoarthritis is related to prior trauma that encompasses a spectrum of disorders including fractures and ligamentous injuries that either disrupt the articular surface or result in instability of the joint. In addition to clinical evaluation, imaging plays a substantial role in the treatment planning of posttraumatic ankle and hindfoot osteoarthritis. Imaging evaluation must be tailored to specific clinical scenarios and includes weight bearing radiography that utilizes standard and specialty views, computed tomography which can be performed with a standard or a weight bearing technique, magnetic resonance imaging, and ultrasound evaluation. This review article aims to familiarize the reader with treatment rationale, to provide a brief review of surgical techniques and to illustrate expected imaging appearances of common operative procedures performed in the setting of posttraumatic ankle and hindfoot osteoarthritis, such as joint-preserving procedures, ankle fusion, subtalar fusion, tibiotalarcalcaneal fusion and ankle arthroplasty. Preoperative findings will be discussed along with the expected postoperative appearance of various procedures in order to improve detection of their complications on imaging and to provide optimal patient care.

Keywords: ankle and hindfoot osteoarthritis; ankle arthroplasty; subtalar fusion; tibiotalarcalcaneal fusion.

Figure 1

(a–d). A 25-year-old female with posttraumatic osteoarthritis of the right tibiotalar and subtalar joints. AP (a) and lateral (b) weight bearing radiographs and coronal (c) and sagittal (d) reformatted weight bearing CT images of the right ankle show an ununited medial malleolus fracture (arrowheads) and severe osteoarthritis of the tibiotalar (arrows) and subtalar joints (dashed arrows) with asymmetric joint space narrowing, subchondral sclerosis and small cyst-like changes. In (b) note the external fixator pin track in the calcaneal tuberosity. In (c,d) note a platform underneath of the foot (open arrowheads) with the CT images acquired in a cone-beam CT scanner dedicated to extremity imaging that allows the assessment of the alignment. Case courtesy of Imran Omar MD, Chicago, IL.

Figure 2

(a–e) A 47-year-old female with a history of remote trimalleolar right ankle fractures and posttraumatic tibiotalar joint osteoarthritis, treated with tibial wedge opening osteotomy and oblique fibular lengthening osteotomy. (a) Mortise and (b) lateral weight-bearing radiographs and (c) coronal reformatted CT image of the right ankle show a healed posttraumatic deformity of the medial malleolus with tibial valgus malunion transfixed by an interfragmentary screw (white asterisk in (c)) and healed posttraumatic deformities of the fibula (white arrow) and of the posterior malleolus (dashed white arrow). Note the asymmetric narrowing of the tibiotalar joint consistent with advanced posttraumatic osteoarthritis (black arrows). (d) Mortise and (e) lateral 3 months postoperative weight-bearing radiographs show improved alignment of the distal tibia (white arrow) and fibula (dashed white arrow) status post osteotomies with decreased tibiotalar joint space narrowing (black arrows). Osteotomy sites demonstrate partial union at 3 months, a normal finding.

Figure 3

(a–e) A 58-year-old male with tibiotalar and subtalar osteoarthritis with varus alignment treated with tibiotalocalcaneal arthrodesis with intramedullary nail and iliac crest bone marrow aspirate. (a,b) Coronal reformatted preoperative CT images of the right ankle show advanced osteoarthritis of the tibiotalar (black arrows) and posterior subtalar (white arrows) joints with associated varus deformity. (c) Six weeks postoperative lateral weight-bearing radiograph shows a retrograde tibiotalocalcaneal intramedullary nail with interlocking screws in the calcaneus and distal tibial diaphysis transfixing the subtalar (white arrows) and tibiotalar (black arrows) joints with associated bone graft material. (d) Coronal and (e) sagittal reformatted CT images obtained 2.5 months after surgery show markedly improved alignment with progressive fusion across the subtalar (white arrows) and tibiotalar (black arrows) joints.

Figure 4

(a–c). A 58-year-old male with a complex medical history including diabetes mellitus, infected right Charcot midfoot and hindfoot as well as advanced secondary osteoarthritis, treated with staged fusion: first external fixation with antibiotic spacer and intravenous antibiotics followed by tibiotalocalcaneal fusion with a structural femoral head allograft. (a) Fluoroscopic lateral intraoperative image of the right ankle shows a retrograde tibiotalocalcaneal intramedullary nail with two distal screws in the calcaneus and across the posterior calcaneal facet, and a structural femoral head allograft placed at the talar dome bone void and resection site (white arrows). (b) Sagittal reformatted CT image obtained 3.5 months after surgery shows the structural femoral head allograft (dashed white arrows) replacing the talar dome, between the calcaneus (white arrows), talar head and tibial plafond (black arrows). Partially visualized is tibiotalocalcaneal fixation hardware. (c) Seven months postoperative lateral weight-bearing radiograph status post hardware removal shows complete solid bony fusion across the subtalar and tibiotalar joints with complete incorporation of the structural femoral head allograft.

Figure 5

(a–c) A 67-year-old female with a history of remote comminuted right calcaneus fracture treated with plate and screws fixation with subsequent hardware fracture and subtalar osteoarthritis with subfibular impingement treated with calcaneal hardware removal, calcaneal exosteoectomy and subtalar arthrodesis with cellular allograft. (a) Lateral weight-bearing radiograph of the right foot shows a healed calcaneus fracture status post plate and screws fixation. Note marked asymmetric narrowing of the subtalar joint consistent with advanced posttraumatic osteoarthritis (white arrows). (b) On the axial Harris weight-bearing radiograph note fracture of multiple fixation screws (dashed white arrows). (c) Sagittal reformatted CT image shows advanced posttraumatic osteoarthritis of the subtalar joint with asymmetric joint space narrowing, scattered subchondral sclerosis and cyst-like changes. (d) Broden and (e) lateral radiographs obtained 2.5 months after subtalar arthrodesis show interval removal of the calcaneal plate and multiple screws with three broken screw fragments remaining (white dashed arrows). Note two retrograde partially threaded cannulated screws transfixing the subtalar joint (white arrows) with early fusion about the fixation screws.

Figure 6

(a,b) A 72-year-old male with pes planus and severe talonavicular greater than subtalar osteoarthritis was treated with double hindfoot arthrodesis. (a) Preoperative weight-bearing lateral radiograph of the right foot shows severe osteoarthritis of the talonavicular (dashed white arrow) greater than subtalar joints (white arrows) and mild osteoarthritis of the tibiotalar joint (black arrow). (b) Weight-bearing lateral radiograph obtained 3 weeks after surgery shows three smaller partially threaded cannulated screws transfixing the talonavicular joint (dashed white arrow) and two larger, partially threaded cannulated screws transfixing the posterior subtalar joint (white arrow). Note the significant improvement of hindfoot alignment.

Figure 7

(a,b) A 64-year-old female with a history of traumatic right talonavicular dislocation several months prior presented with continued pain, pes planus with plantar valgus and equinus contracture and posttraumatic osteoarthritis, subsequently treated with triple arthrodesis. (a) Lateral weight-bearing radiograph of the right foot shows per planus with dorsal subluxation of the talonavicular joint and superimposed advanced osteoarthritis (dashed white arrow). Note the associated mild asymmetric narrowing of the subtalar (white arrows) and calcaneocuboid joints (black arrow). (b) Postoperative weight-bearing lateral radiograph shows interval triple arthrodesis with two Herbert screws transfixing the posterior subtalar joint (white arrow), three partially threaded cannulated screws transfixing the talonavicular joint (dashed white arrow) and a short plate with two screws transfixing the calcaneocuboid joint (black arrow) with solid bony bridging across the arthrodesis sites.

Figure 8

(a–f) A 36-year-old male with posttraumatic osteoarthritis of the left tibiotalar joint and equinus contracture resulting from open distal tibia fracture treated with open reduction internal fixation and free flap, with previous hardware removal, subsequently treated with ankle arthroplasty and gastrocnemius resection. (a) Mortise and (b) lateral weight-bearing radiographs of the left ankle show marked asymmetric narrowing of the tibiotalar joint (white arrows) with marginal osteophytes and intraarticular bodies consistent with severe osteoarthritis. Note tracts in the calcaneus and talus related to removed surgical hardware and retained laterally placed screw transfixing the distal tibiofibular syndesmosis. Numerous vascular clips overly the soft tissues of the lower leg. (c) Coronal fluid sensitive MR image shows asymmetric narrowing of the tibiotalar joint (white arrows). (d) Mortise and (e) lateral postoperative radiographs show interval placement of total ankle arthroplasty (Wright Medical Infinity with an Inbone talus). Note well seated tibial (white arrow) and talar (dashed white arrow) prosthesis components. (f) The intraoperative image shows tibial (white arrow) and talar components (dashed white arrow) in place.

Figure 8

(a–f) A 36-year-old male with posttraumatic osteoarthritis of the left tibiotalar joint and equinus contracture resulting from open distal tibia fracture treated with open reduction internal fixation and free flap, with previous hardware removal, subsequently treated with ankle arthroplasty and gastrocnemius resection. (a) Mortise and (b) lateral weight-bearing radiographs of the left ankle show marked asymmetric narrowing of the tibiotalar joint (white arrows) with marginal osteophytes and intraarticular bodies consistent with severe osteoarthritis. Note tracts in the calcaneus and talus related to removed surgical hardware and retained laterally placed screw transfixing the distal tibiofibular syndesmosis. Numerous vascular clips overly the soft tissues of the lower leg. (c) Coronal fluid sensitive MR image shows asymmetric narrowing of the tibiotalar joint (white arrows). (d) Mortise and (e) lateral postoperative radiographs show interval placement of total ankle arthroplasty (Wright Medical Infinity with an Inbone talus). Note well seated tibial (white arrow) and talar (dashed white arrow) prosthesis components. (f) The intraoperative image shows tibial (white arrow) and talar components (dashed white arrow) in place.

Figure 9

(a–e) A 57-year-old female with a history of remote open reduction and surgical fixation of the right ankle fractures, revision posterior malleolus 2 years prior and posttraumatic osteoarthritis with 2 cm devitalized bone at the central tibial plafond; patient subsequently treated with hardware removal and total ankle arthroplasty (Wright Medical with Inbone tibia and talus). (a) Mortise radiograph and (b) coronal and (c) sagittal reformatted CT images of the right ankle show asymmetric narrowing of the tibiotalar joint (black arrows) consistent with advanced osteoarthritis. In (a,b) note two retained screws in the distal tibia. In (b,c) note marked irregularity of the tibial plafond with scattered foci of sclerosis corresponding to devitalized bone (white arrow). (d) Mortise and (e) lateral postoperative weight-bearing radiographs show total ankle arthroplasty with well seated tibial (white arrow) and talar components (white arrowhead).

Figure 9

(a–e) A 57-year-old female with a history of remote open reduction and surgical fixation of the right ankle fractures, revision posterior malleolus 2 years prior and posttraumatic osteoarthritis with 2 cm devitalized bone at the central tibial plafond; patient subsequently treated with hardware removal and total ankle arthroplasty (Wright Medical with Inbone tibia and talus). (a) Mortise radiograph and (b) coronal and (c) sagittal reformatted CT images of the right ankle show asymmetric narrowing of the tibiotalar joint (black arrows) consistent with advanced osteoarthritis. In (a,b) note two retained screws in the distal tibia. In (b,c) note marked irregularity of the tibial plafond with scattered foci of sclerosis corresponding to devitalized bone (white arrow). (d) Mortise and (e) lateral postoperative weight-bearing radiographs show total ankle arthroplasty with well seated tibial (white arrow) and talar components (white arrowhead).