Ankle replacement surgery for arthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

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 as a result of arthritis. X-rays will show a narrowed joint with other changes the physician will evaluate.

The ankle supports a force about five times body weight when a patient walks. Normally, the cartilage in the ankle joint cushions the bones, so walking is painless.

But when this cartilage is destroyed or seriously damaged due to arthritis, the pain can be debilitating. When this pain can no longer be managed with conservative measures such as medication or braces, a doctor may recommend one of two types of surgery: ankle replacement or ankle fusion. Careful evaluation of the particular ankle problem, lifestyle and expectations will help determine which type of surgery is best. 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.

To receive a total ankle replacement, a patient must have debilitating, end-stage arthritis. End-stage arthritis can be extremely painful and leaves patients incapacitated.

They find it difficult to stand and have a hard time maintaining employment. Furthermore, some ankle arthritic conditions are so severe that patients are unable to continue walking, even with the aid of a brace or cane. Most have been treated with anti-inflammatory medicine for many years without substantial relief. For these patients, surgery becomes the only option.

Ankle replacement surgery is a good option if a patient does not participate in high impact activities. It's better suited for people with little bone deformity, no history of infection in the ankle joint or dead bone (avascular necrosis). Most people who have ankle replacement surgery suffer from osteoarthritis, rheumatoid arthritis or arthritis caused by prior trauma such as a broken ankle. Ankle replacement leaves a patient with up and down movement in the foot and a near normal gait. After surgery, a patient may walk and play golf, for example, but should not do exercises like step-aerobics, incline treadmill or stair-step.

Ankle fusion is often the recommended surgical option for people with severe ankle joint deformity, a history of infection or dead bone or an inability to move the foot due to a neurologic lesion. Ankle fusion is more suitable for people who are younger than 30 and want to participate in high impact physical activities. Ankle fusion allows a patient to walk without a limp and without pain.

Replacement surgery or ankle fusion typically requires only a one-night hospital stay. The procedures themselves take about an hour and a half. Recovery time generally takes two to three months. The ankle will be in a cast, and a patient will have to use crutches. Unlike rehabilitation following total hip and knee replacements, little physical therapy is needed after ankle fusion or replacement. Patients do their own therapy by gradually increasing the weight load they put on the repaired ankle.

The short term complications associated with total ankle surgery are rare, but can be devastating. A deep infection can lead to removal of the implant and an extensive reconstructive surgery of the foot and ankle.

Long term problems include implants loosening and plastic irritation to the bone liner from deformation or wear. Sometimes the bone crumbles underneath the metal implant in a process known as subsidence.

This type of situation will require revision surgery to strengthen the bone and reattach the implant. If the plastic liner frays, the small particles released can induce damage to the surrounding bone, accelerating the process of subsidence. This type of situation will require revision surgery to strengthen the bone and reattach or replace the implant.

Since the implant is made of mechanical parts and all mechanical parts degrade over time, patients with long term use will sometimes require maintenance. Ideal candidates are elderly, inactive people with end stage arthritis simply because they are low demand and usually realistic about the capabilities of their implant.

It is a viable option to treat people with debilitating end-stage ankle arthritis.” Possible complications include:

infection
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.

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