title: Etiology and Treatment of Delayed-Onset Medial Malleolar Pain Following Total Ankle Arthroplasty.
abstract: BACKGROUND
  Total ankle arthroplasty (TAA) has become a successful treatment for end-stage ankle arthritis. Some patients may still have pain or may present with new pain. Suggested sources of medial pain include tibialis posterior tendonitis, impingement, or medial malleolar stress fracture. Etiology and treatment remain unclear. The objective of our study was to evaluate patients with delayed-onset medial malleolar pain following TAA who underwent treatment with percutaneous medial malleolar screw placement and propose an etiology.
  
  
  METHODS
  Patients who had undergone TAA at our institution were reviewed and those with medial malleolar pain were identified. Clinical and radiographic examinations were performed pre- and postoperatively. Radiographs were compared with those from a cohort of controls without a history of medial pain. All affected patients failed conservative therapy and were treated with percutaneous placement of medial malleolar screws positioned from the malleolar tip and extending proximally beyond the tibial component. Postoperatively, patients were placed in an ace wrap and allowed to be weightbearing to tolerance, except for 1 patient initially restricted to partial weightbearing. Visual analog scale (VAS) scores were recorded. Seventy-four (74) patients underwent TAA by the corresponding author. All (100%) were female with an average age of 66 (range, 57-73) years. Average follow-up since screw placement was 21.4 (range, 10-41) months.
  
  
  RESULTS
  Six (8.1%) underwent placement of 2 percutaneous medial malleolar screws. Patients presented with pain an average of 12 (range, 4-24) months postoperatively and underwent screw placement an average of 2.8 (range, 1-6) months after presentation. At the time of TAA, none had a coronal plane deformity and none underwent a deltoid ligament release as part of balancing. All (100%) patients had pain and swelling directly over the medial malleolus prior to screw placement. Postoperatively, 1 (17%) had mild pain clinically at this site and 2 (33%) had occasional pain medially with activity. Average VAS scores improved from 5.7 (range, 4-6) preoperatively to 1.3 (range, 0-3) postoperatively (P < .05). Three (50%) patients had a bone density test and all were normal. Prior to screw placement, radiographs demonstrated no signs of stress fracture or misalignment. Average minimum width of the medial malleolus at the level of the tibial component was 10.2 mm (range, 9.2-11.0), which was significantly less (P < .05) than the control group of 19 patients whose distance measured 12.2 mm (range, 8.5-14.8).
  
  
  CONCLUSIONS
  Patients who present with new-onset medial malleolar pain with normal radiographs following TAA may have medial malleolar insufficiency fracture. These patients can be treated successfully with minimal morbidity by placement of percutaneous medial malleolar screws. Etiology may be related to deltoid traction, subacute stress fracture, and/or impingement of the talus component on the medial malleolus. Medial malleolar pain may be misdiagnosed as tibialis posterior tendonitis, impingement, or implant failure. This diagnosis should be considered in patients who have pain at the medial malleolus, particularly if they are female or have medial malleolus thickness less than 11 mm at the level of the tibial implant. Placement of prophylactic medial malleolar screws may be considered at the time of TAA when these conditions exist.
  
  
  METHODS
  Level IV, case series.
authors.affiliation: Reno Orthopaedic Clinic, Reno, NV, USA renofootmd@gmail.com.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Lundeen
authors.affiliation: Reno Orthopaedic Clinic, Reno, NV, USA.
authors.forename: Linda J
authors.initials: LJ
authors.lastname: Dunaway
mesh_terms: D000368:Aged; D064386:Ankle Fractures / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D000843:Ankle Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D058737:Arthroplasty, Replacement, Ankle / Q000009:adverse effects*; D001863:Bone Screws; D003937:Diagnosis, Differential; D005260:Female; D005593:Fracture Fixation, Internal; D006801:Humans; D007595:Joint Prosthesis; D008875:Middle Aged; D010147:Pain Measurement; D010149:Postoperative Pain / Q000209:etiology*; D011859:Radiography
keywords: ankle pain; arthritis; outcome studies; total ankle arthroplasty