Ankle Replacement

Ankle replacement surgery explained by Dr. Robert Anderson

Indications for a total ankle replacement (TAR) are for those individuals that suffer from severe arthritis or degeneration, or in some cases, someone who has suffered from a traumatic injury. TAR is usually considered when conservative/alternate treatments have failed. The purpose for having a TAR is to primarily reduce pain and increase range of motion. The goal of TAR is to improve ankle motion so the patient has less pain during activity. The advantage in getting a TAR versus an ankle fusion is that the patient has more range of motion.

Anatomy
The extent to the involvement of the surgery will be up to the physician in order to ensure the best result for the patient. The most common anatomy involved with TAR is osteotomies or fusion of bones of the foot including the calcaneus, metatarsals, talonavicular, and other midfoot fusions are common.

Causes
Diagnoses that commonly result in replacements include degenerative ankle/joint disease from trauma either from repetitive ankle sprains, ligamentous injury, or previous malleolar fracture, rheumatoid arthritis, and end-stage osteoporosis. People that have the best outcomes are those who are healthy, active people with no significant co-morbidities, and no neurovascular conditions.

Symptoms
Symptoms include ankle pain that increases with walking, standing, and decreased function (inability to do daily tasks such as bending your ankle going down stairs/driving), swelling, and stiffness that doesn't get better with rest and persists over time.

Diagnosis
Need for a TAR will come from an orthopedic surgeon and most commonly one who is an ankle specialist. They will take X-rays or MRIs to see the integrity of the ankle joint and decide to do surgery when other treatments have failed.

Surgery
TAR is performed either under general anesthesia or a nerve block. The ankle is approached from the front or the side depending on the type of implant being used, and then the damaged bone and cartilage is removed allowing for placement of the metal and plastic components that will make up the new ankle joint. Sometimes the patient will have a severely tight Achilles tendon which is lengthened if the patient has a tight calf. The wounds are then closed using stitches or staples, and a splint is applied. 

Recovery
Post recovery in the hospital may take 2-3 days and patients can leave once the pain is controlled and they are able to use a walker or crutches to safely perform walking and transfers in order to safely return home. The leg may be numb for up to 18 hours after surgery. The patient will wear a splint or a cast for healing of the wound until the MD deems it to be healed or "stable." Crutches or a walker will also be utilized to decrease weight through the joint in order to allow healing and reduce pain. The patient will be progressed to a walking boot (CAM boot) when necessary, or cast up to 3 months.

Treatment
Care will vary from person to person but normally they are cleared to weight bear as tolerated in the boot/cast 4-6 weeks post-surgery and progressed out of the boot to walk 8 weeks post. Physical therapy will normally begin when the person is cleared to weight bear or when the MD sees that bone healing is present, which on average is 6 weeks post-surgery. Physical Therapy may be ordered earlier if there is increased pain or swelling present and to improve range of motion. Overall rehab for return to normal activities is 16+ weeks for low impact jobs and may take up to 6-9 months dependent on the surgery and type of job requirements.

Prevention
To prevent getting a TAR, patients may undergo steroid injections to reduce pain and inflammation or anti-inflammatory medications. Braces may be utilized or a cane to take pressure off the joint with weight-bearing activities. Physical Therapy is also a good option to assess joint mobility and to decrease pain, increase range of motion, as well as, strengthening other areas of the body in order to relieve pressure of the patient's arthritic joints.