Let us assume for a moment that the treatment of osteoarthritis of the knee can be translated to treatment of PTA of the knee. The American Academy of Orthopedic Surgeons (AAOS) Evidence-Based Guidelines for osteoarthritis of the knee recommended strengthening, low-impact aerobic exercise, neuromuscular education, and weight loss [12]. A systematic review of 60 randomized control trials of 8,218 patients on exercise interventions for knee osteoarthritis noted the best clinical improvements were observed with an exercise program which integrated strengthening, flexibility, and aerobic activities [13].

Many orthopedic surgeons use intra-articular corticosteroid injections. A Cochrane review performed by Bellamy et al. evaluating the efficacy of intra-articular corticosteroids identified 28 trials involving 1,973 patients ([14], Art. No. CD005328). Intra-articular corticosteroids at 1 week after injection were found to be more effective than placebo for pain reduction, but the results after 4 weeks and 24 weeks after injection were much less favorable.

Intra-articular hyaluronic acid (HA) injections (viscosupplementation) are an option when intra-articular injections of corticosteroids fail. Adverse side effects associated with HA injections include benign local skin/soft tissue reactions. A Cochrane review performed by Bellamy et al. evaluated the efficacy of viscosupplementation for knee osteoarthritis ([15], Art. No. CD005321). Seventy-six trials were analyzed supporting the use of viscosupplementation over placebo with improvements in pain from 28 to 54 % at 5–13 weeks postinjection and 9 to 32 % for function. In comparison with corticosteroids, longer-term benefits were observed with viscosupplementation ([15], Art. No. CD005321). Housman et al. investigated the efficacy of intra-articular hylastan compared to intra-articular corticosteroids via a double-blind, randomized, multicenter trial with follow-up of 6 months [16]. Both hylastan and corticosteroids significantly reduced pain scores. All secondary outcomes were similar including responder rates, global assessments, and walking pain. In addition, Cheng et al. performed a literature review which supported the use of intra-articular corticosteroids and noted significant pain relief and improved function up to 1 year postinjection [17]. Nonetheless, intra-articular HA injections may provide longer pain relief than intra-articular corticosteroid injections.

Platelet-rich plasma (PRP) is another injectable option. The clinical outcomes of PRP intra-articular knee injections with 6 months follow-up were investigated by Raeissadat et al. and demonstrated significant improvements in both physical and mental domains of the SF-36 and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires [18]. Khoshbin et al. performed a systematic review of six level I and II studies investigating PRP in knee osteoarthritis consisting of 577 patients identifying PRP as significantly better than HA or normal saline injections with pooled results using the WOMAC Index Scale [19]. No significant difference was seen for visual analog scale score or overall patient satisfaction. Of note, a higher incidence of nonspecific adverse events were witnessed with PRP over HA or placebo. This data suggests that PRP injections may be an alternative treatment; however, there is a need for more evidence to better define clinical guidelines.

Non-arthroplasty surgical interventions for PTA of the knee with good clinical outcomes include knee arthroscopy, osteochondral allograft transplantation for localized defects, and distal femoral or proximal tibia osteotomies for deformity correction or single-compartment disease. The AAOS developed appropriate use criteria (AUC) on the non-arthroplasty treatment of knee osteoarthrosis and four “appropriate” treatment recommendations: self-management, prescribed physical therapy, nonsteroidal anti-inflammatory drugs, and acetaminophen [20]. There were 3 “maybe appropriate” recommendations: arthroscopic partial meniscectomy or loose body removal, hinged knee brace and/or unloading brace, and intra-articular steroids [20]. Although osteoarthrosis is not the same entity as PTA, these recommendations are compelling.

Initial treatments of PTA of the ankle are nonsteroidal anti-inflammatory medications, physical therapy, shoe-wear modifications, orthotics, intra-articular injections of corticosteroids, and viscosupplementation. Glazebrook noted that the current literature that supports most nonsurgical treatments for ankle arthritis use lesser quality, level IV studies [26]. He stated that a systematic review was necessary in the future to determine the level of evidence available to guide the recommendations of nonsurgical options for treating ankle arthritis [26].

A series of three HA viscosupplementation injections were performed under fluoroscopic guidance and evaluated at 4 and 12 months postinjection with the American Orthopedic Foot and Ankle Society (AOFAS) score [27]. AOFAS scores were statistically significant at 4 and 12 months, with 73 % of patients reporting satisfaction at an average follow-up of close to 4 years. Five patients required surgical intervention an average of 27 months.

DeGroot et al. performed a randomized, double-blind, placebo-controlled trial of a single intra-articular HA injection versus an injection of normal saline for knee osteoarthritis [28]. Sixty-four patients were assessed at 6 weeks and 12 weeks postinjection with AOFAS scores. Changes from baseline in both groups were significant, yet the analysis between groups demonstrated no significant differences. This demonstrates the variability present in the literature concerning HA injections as treatment for arthrosis of the ankle. Currently, more clinical trials investigating both corticosteroid and viscosupplementation efficacies are necessary in order to fully support ankle injections for post-traumatic arthrosis.

Mousopoulos et al. noted that corticosteroids or HA joint injections for PTA offer “temporary pain relief with hardly any mid- or long-term benefit” [29]. Johnson et al. noted that evidence-based guidelines for the use of injectable corticosteroids were lacking [30]. These investigators noted that younger orthopedic surgeons (less than 5 years in practice) performed fewer injections than those in practice 6–10 years [30].

Wexler et al. noted that corticosteroid injections are not typically done for ankle arthritis, are generally of limited duration, but can provide excellent temporary pain relief in patients with end-stage disease [31].

Ankle arthrosis after trauma can be treated with a myriad of surgical options. These include arthroscopic debridement, allograft resurfacing, osteotomy, distraction arthroplasty, and tibiotalar arthrodesis.