Total ankle replacement (also called ankle arthroplasty) is a surgical option for patients with arthritis of the ankle. This operation can relieve pain and maintain motion in the arthritic ankle joint and is an alternative to arthrodesis (ankle fusion) which can relieve pain but eliminates motion in the joint. Although it does not have the same long-term track record of hip or knee replacement, shorter-term studies on ankle replacement look very promising.
Characteristics of arthritis of the ankle
The ankle joint is made up of the two bones of the lower leg and the first bone in the foot called the talus. It is often called the tibiotalar joint.
This joint can lose its cartilage covering either through injury, infection or wear and tear. X-rays will show a narrowed joint with other changes the physician will evaluate.
Types of surgery recommended
Often treatment of ankle arthritis only requires restricting the patient's activities to things that are not painful and making certain that the shoe is comfortable. In general, a shoe that laces up above the ankle and has a cushioned heel will be more protective than other types of shoes.
Bracing of the ankle is another option. This can be provided by a device known as an ankle lacer. It fits inside the shoe and laces up like an old-fashioned boot. A third option for more significant pain is an AFO which stands for Ankle Foot Orthosis. This is a plastic brace that goes along the back of the leg and the underside of the foot and also fits inside the shoe. This requires a slightly larger than normal shoe size.
Who should consider total ankle / ankle replacement surgery?
The decision to have surgery is primarily based on pain that interferes with activities one usually performs in the course of a day. When this pain cannot be controlled by bracing or over-the-counter medication, it is appropriate to consider surgery.
Surgical options include arthrodesis and ankle replacement (or total ankle arthroplasty).
Arthrodesis is the connection between the tibia fibula and talus. This operation is excellent for pain relief but sacrifices the up-and-down motion of the foot that normally occurs through the ankle. The talus is permanently fixed to the end of the leg bone.
Ankle replacement is a procedure that has been available for approximately 25 years. However, it has not been as successful as hip and knee replacement surgery. Because the ankle is not as often involved in arthritis there has been less study devoted to this area. Over the last 10 years, ankle arthroplasty has been growing in popularity as the implants available for replacement have improved. Current studies indicate about a 90 percent patient satisfaction rate in the first four years after surgery. One anticipated problem in the future may be loosening of this artificial ankle. An orthopedic surgeon should help you make the decision if you might be a candidate.
The vast majority of these surgical procedures move forward without risk.
However risks include but are not limited to:
- injury to nerve or blood vessels
- fracture of the bone
- failure of the bone to heal to the ankle replacement
- failure of the bones to heal together
- wound problems
- blood clots
There are also rare cases of pain syndromes reported from any foot ankle hand or arm surgery. There are also risks of anesthesia which you should discuss with the anesthesia team.
Before any surgery is planned, medical conditions involving the heart, lung or kidney need to be evaluated by a primary care physician.
Any infections that might be present anywhere in the body need to be treated and smoking should be discontinued. The surgeon should be made aware of any allergies or medications that you might be taking.
Plan home and work activities to include six weeks of time after surgery when you won’t be able to participate in your normal activities.
The skin incision will be primarily in the front of the ankle with smaller incisions on the outside.
The foot bone is replaced with a smooth metal surface and a high-density polyethylene (plastic).
You will wake up from surgery in a dressing that is hard in the back and soft in the front which will protect your foot and ankle and allow swelling.
Length of total ankle / ankle replacement surgery
The surgery itself takes approximately two and a half hours.
Pain and pain management
Patients are given a combination of intravenous and oral narcotics to control the pain postoperatively. If a patient has the surgery under a block, the leg may remain numb for six to 18 hours after surgery.
You will be admitted to the hospital the morning of surgery and stay in the hospital for approximately two to three days until you have adequate control of your pain and can walk safely on crutches or a walker.
Patients are discharged home from the hospital when they can walk safely using crutches and when their pain is controlled without intravenous medication.
You will return to the clinic in two weeks for suture removal but continue to have the leg protected and maintain crutch usage. At six weeks after surgery, X-rays will be performed and a decision will be made whether to advance weight bearing or continue the crutch usage. You will put about 50 percent of your weight on the operated leg for about four weeks.
The rapidity of the progress in weight bearing will depend on what other procedures need to be done to correct your individual deformity.
When to see a doctor
Please call a physician if the patient has:
- New onset of swelling, tingling pain or numbness in your toes that is not relieved by elevating your foot above your heart for one hour.
- Drainage that is foul smelling, green or yellow or drainage where there was none before.
- You have chills or a temperature above 38.5° C (101.3° F).