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What is ankle replacement surgery?
Ankle replacement surgery is when a damaged ankle joint is substituted with an implant. This procedure assists in eliminating persistent pain and swelling, usually from an arthritic ankle joint.
Damaged bone and cartilage are removed from your ankle joint and replaced with a stronger artificial joint, allowing smooth pain-free motion. It improves your ankle stability and ability to walk and reduces the swelling at the ankle joint.
If first-line modalities have failed to reduce the pain and swelling in an injured ankle, replacing the ankle joint may be your next option.
Ankle replacement surgery is also known as total ankle arthroplasty. Ankle arthroplasty, when compared with an ankle fusion, has an added advantage of maintaining joint movement. (1)
When is an ankle replacement surgery needed?
If you have painful arthritis in your ankle and non-surgical management has not helped relieve pain, you may want to consider ankle replacement surgery.
Ankle arthritis differs from other types of degenerative arthritis in that the majority of cases has a post-traumatic origin and occur in the younger age group. (2)
If the range of motion in your ankle is well kept and you have minimal to no ankle deformity, you may be considered a good candidate for total ankle replacement.
This procedure is not recommended if you have a history of infection in the ankle joint, poor bone quality to support the implant, or neuromuscular disease.
Total ankle replacement is also not recommended to those who have a serious deformity of the ankle, Charcot neuropathy, a history of ankle fusion, or poor muscle quality.
What are the possible risks of ankle replacement surgery?
Any type of surgery has possible risks, which include infection, blood clots in the leg, nerve damage, and excessive bleeding.
Some complications that are a possibility after total ankle replacement include:
- Non-healing incision site
- Failure of the ankle implant
- Misalignment of the joint
- Loosening of the ankle joint implant
- Wearing out of the components of the ankle joint implant
The possible complications after surgery vary depending on the individual. Factors include age, medical history, and smoking. If you have diabetes and it is not controlled, you may have a higher risk of complications after surgery.
It is imperative to discuss all possible risks and complications with your surgeon before surgery. Most complications reported are preventable with good patient selection and technique or are treatable once they occur. (2)
How is an ankle replacement surgery done? What should the patient expect?
Total ankle replacement is performed under general anesthesia. You remain asleep so that you will not feel pain during the surgery. A nerve block around the knee is also performed to provide pain control after surgery.
A tourniquet is placed around the thigh. This device controls bleeding during the operation. A healthcare professional will monitor your vital signs, such as your heart rate and blood pressure, throughout the procedure.
Your ankle will be cleansed thoroughly prior to incision to prevent infection. Depending on the type of ankle joint implant used, a cut with a surgical blade is performed in either the front or side of the ankle.
All damaged bone and cartilage will be removed. Guides to assist in proper cuts and alignment are applied to the bones.
Proper positioning is confirmed with an X-ray during the surgery. When excellent alignment is confirmed, cuts in the bones are then performed to allow for the placement of the parts of the implant.
X-rays are performed throughout the surgery to confirm the proper placement of the implant. A special cement might be used to hold the implant in place.
The incisions are closed with sutures and/or staples. Your leg will then be placed in a splint or cast to control and stabilize the operated site. This procedure makes ankle replacement to be the only surgery involving endoprosthesis, wherein a cast is placed immediately post-surgery. (3)
You will be transferred to the recovery room where your vital signs will be monitored. You will be able to resume a normal diet as soon as tolerated.
You might need to stay at the hospital for a few days, depending on your surgeon’s preference. Pain is controlled with medication, rest, ice, and elevation of the leg.
You will not be able to put weight on your foot. Therefore, you will use crutches, a knee scooter, or a wheelchair. Your surgeon will give you instructions on how to move your ankle during your recovery period.
What conditions can be treated with ankle replacement surgery?
Ankle replacement surgery may be an option if you have severe arthritis in your ankle.
The main types of ankle arthritis are:
- Osteoarthritis: Osteoarthritis is overuse arthritis that usually develops in more mature adults. It is the “wear and tear” of the joints. Approximately 1% of the adult population suffers from painful ankle osteoarthritis. (4)
- Rheumatoid arthritis: Rheumatoid arthritis is a systemic autoimmune disease characterized by inflammatory arthritis. (5)
- Post-traumatic arthritis: Post-traumatic arthritis occurs after a previous injury to your ankle joint. Any event that compromises the articular surface of the ankle joint has potential to develop post-traumatic arthritis. (6)
It is important to discuss all your treatment options with your surgeon if you suffer from arthritis.
What measures should be taken after an ankle replacement surgery?
Pain after surgery will be controlled by medication, rest, ice, and elevation of your lower extremity. The pain will decrease over time.
Antibiotics may be necessary to prevent infection. After surgery, immobilization of your ankle will be needed for a couple of weeks, either with a cast or splint. Crutches, a knee scooter, or a wheelchair may be useful because you will not be able to put weight on your foot for a few weeks.
You will follow up with your surgeon about 7-10 days after your surgery. It is important to follow your appointment schedule so your surgeon can monitor your progress and make sure you are healing properly.
Your incision site will be evaluated and your bandages will be changed. Sutures and staples may be removed 2-4 weeks after surgery.
Your splint or cast will eventually be removed and then replaced with a walking boot. You might ambulate in a walking boot for many weeks.
Physical therapy will assist you in strengthening your leg and ankle and increasing the range of motion of your ankle. Physical therapy also trains you to walk properly with an ankle joint implant. Therapy will allow you to recover sooner. However, it may take many months for you to return to daily activities.
Your surgeon might recommend low-impact activities after ankle joint replacement to lengthen the life of the implant.
What treatments are usually done with ankle replacement surgery?
The Achilles tendon is the tendon running behind your leg, connecting your calf muscle to the back of your heel bone. In some patients, this tendon is tight, or they have tight calf muscles.
If tightness is present, the Achilles tendon might need to be lengthened to increase the motion at the ankle joint. This procedure is known as Achilles tendon lengthening.
This procedure may need to be performed in conjunction with total ankle replacement. Achilles tendon lengthening allows fluid motion in the ankle joint and proper function of the ankle joint implant.
A variety of ways can lengthen the Achilles tendon. The surgeon will decide which procedure is best for you as each surgery is custom to each individual.
When to see a doctor?
If you believe you have arthritis in your ankle joint and you have consistent pain and swelling, schedule an appointment with your doctor to get a full workup.
Non-surgical treatments will be recommended before surgical consideration, such as, but not limited to, bracing, orthopedic shoes, medications, injections, and rehabilitation.
If conservative treatment fails, ankle replacement or total ankle arthroplasty may be beneficial.
Expert Answers (Q&A)
Answered by Dr. Adam Bitterman, DO (Orthopedic Surgeon)
The duration of an ankle surgery varies depending on the pathology being treated. When bones are broken, the surgical treatment may be longer than 1 hour.
In the case of instability, the surgery may finish within 30 minutes. It is hard to put a definitive time frame on ankle surgery as a whole.
When bones are broken within the ankle, doctors frequently place hardware, which may include a combination of plates and screws to secure the bone fragments into anatomic alignment, thus enabling appropriate healing. (7)
Ankle fracture surgery is frequently done for displaced ankle fractures that result in instability.
No, conservative treatment may provide relief of symptoms, thus preventing surgical intervention.
Post-traumatic arthritis is a frequently encountered complication from ankle trauma. When the joint is affected, the cartilage surfaces may become disrupted, leading to the progression of degenerative arthritis.
The actual surgical procedure of placing hardware may not lead to any complications, but the post-operative risk of being non-weight bearing may lead to falls.
Furthermore, the risk of anesthesia to the unborn baby must be considered. Anesthesia has modalities available to ensure a safe outcome.
Immediately following an ankle fracture, X-rays should be taken to assess the bony alignment. If there is malalignment, the bones must be manipulated to ensure an appropriate alignment before immobilizing the leg and ankle.
About Dr. Adam D. Bitterman, DO: Dr. Bitterman is an Assistant Professor of Orthopaedic Surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Dr. Bitterman is a board-certified, fellowship-trained foot and ankle orthopedic specialist and has a focus in treating conditions of the lower leg.