Total Contact AFO: An Alternative Treatment for Ankle Arthritis

Arthritis of the ankle, including that of the talocural and subtalar joints, can be very painful and debilitating. It can cause marked deformation of the joints and severely hinder movement. The pain associated with the destruction of the joints can greatly decrease an individual’s quality of life. The simple act of walking becomes dreaded and unbearable. Surgical options for treatment include joint fusions or total ankle replacements. Not every individual is a candidate for these surgeries due to various co-morbidities, while others are simply hesitant to proceed with an invasive procedure.

A total contact rigid AFO (Ankle-foot orthosis) may be a good alternative for these patients. This custom-made AFO, comprising of a posterior portion and an anterior shell, can mimic joint fusions as it eliminates pain by removing the movement at the effected joint(s). The posterior AFO portion is mainly responsible for controlling the medial/lateral stability of the foot and ankle and locking the ankle in a plantar grade position. The anterior shell, when strapped on tightly, partially offloads the foot and ankle complex by transferring weight to the calf. This creates a total contact design that distracts the bones of the subtalar and talocural joints and provides pain relief. The custom foot liner corrects any malalignment in the forefoot or rearfoot to further reduce excessive pressure on the joints.

This brace design additionally provides maximum medial/lateral stability and seats the talus in a more anatomical position. Excessive pronation where the talus is displaced medially can be corrected and supported. A severe rearfoot varus/valgus alignment can be supported if it is a fixed deformity or corrected if it is flexible. Where the ankle is fixed in plantarflexion and a lift is required to square off the alignment, a contra-lateral foot orthotic with a lift is strongly recommended to maintain a level pelvis alignment.

The AFO is aligned to reduce excessive forces through the foot and ankle during gait. Bony prominences can be relieved and padded, thus eliminating pressure sores that often occur with off-the-shelf ankle support products. The AFO can be fit into regular or extra-depth footwear for normal cosmetic appearance. This improves patient compliance. In some cases, a shoe with a rocker sole modification will assist in a natural heel strike and provide a smoother gait pattern.

Most patients will experience immediate pain relief with the offloading of the joints. They report increased activity and decreased use of pain medication. The brace can be fabricated with an articulating ankle joint in cases where ankle function is more intact or if medial/lateral instability is the issue. Successful bracing with a total contact bivalved AFO can be a good predictor of success with an ankle fusion. It is also be a good alternative when surgery is not an option.