Ankle replacement
Ankle replacement
Ankle replacement
Ankle replacement
Why might I need ankle joint replacement surgery?
Are you suffering severe ankle arthritis pain that’s impacting your ability to walk or lead a comfortable life? Maybe you’ve been told you might need a replacement, or an ankle fusion and you’re unsure which is best for you? I’m a foot and ankle orthopaedic surgeon in Birmingham, and I specialise in ankle replacement surgery.
Most patients who undergo total ankle replacement have ankle arthritis, and the most common form of ankle arthritis is osteoarthritis.
Ankle arthritis
What is ankle arthritis?
Ankle arthritis is advanced wear and tear of the ankle joint – the joint between the end of the shin bone (tibia) and talus bone. It’s also called the talocrural joint. Ankle arthritis is a process of the degeneration of the shiny, articular cartilage that lines the joint, which exposes the bone underneath. This creates a big increase in frictional forces, and leads to an escalating deterioration of the joint, until it’s bone on bone.
Why does ankle arthritis happen?
Most ankle arthritis occurs because of trauma to the joint, such as a fracture. It may also occur if the ankle is persistently unstable (because of ligament tearing after a sprain), or if the person has rheumatoid arthritis which attacks the lining of the joint.
How is ankle arthritis diagnosed?
When you come to clinic, I’ll want to learn about your symptoms, how they are affecting you, and how long you’ve had them, but as importantly, a bit about you, your day-to-day life, what’s important to you in terms of activity, and how you are hoping I can help you.
I’ll also want to find out about your past medical history, the medications you may be taking, your lifestyle, and who you have around to support you in this process.
I’ll then carry out a careful examination, looking at how you walk, and stand, and of course, closely examining your ankle for signs of swelling, tenderness, and loss of movement. For an ankle replacement to function well, it needs to sit on a stable platform; I pay close attention to foot alignment, in case additional surgery may be needed (to first correct the foot alignment, and then replace the ankle).
You’ll then undergo some weight-bearing x-rays of your feet and ankles, and a C.T. scan, which is used to plan your surgery.
What are the treatment options for ankle arthritis?
Fundamentally, ankle arthritis is a quality of life and pain issue. Some patients will do their best to ‘get by’ by limiting their activity and taking pain medications. In the early stages of ankle arthritis, injection treatments and physiotherapy may give some relief. Wearing a supportive ankle brace may also be helpful if you’re going on a long walk.
Sometimes, however, the burden of the pain may lead a person to seek surgical options.
Ankle fusion versus ankle replacement surgery
Ankle fusion surgery (aka ankle arthrodesis) involves removing damaged joint surface cartilage from within the joint, and then placing screws across the joint, so that it no longer moves (or hurts). In other words, the ankle goes from being stiff and painful, to stiff and pain free.
Ankle replacement surgery aims to give you a pain free ankle and restore a more natural gait. It’s also designed to protect the other foot joints (especially if they show early signs of arthritis). Ankle fusion, however, tends to increase the load on the other foot joints, which have to work harder to compensate for lack of ankle joint movement.
If you’re a young and active person, an ankle fusion will likely be a more suitable option for you than an ankle replacement, which may not endure high loads placed upon it.
Who is suitable for an ankle replacement?
Ankle replacement surgery is best suited for an older person (over the age of 50) who has lower physical demands, isn’t significantly overweight, and is in good health (i.e., a non-smoker and have no circulation issues, neuromuscular disease or poorly controlled diabetes).
If you also have a foot deformity or ligamentous instability, you may require an additional surgery to recorrect the problem. This can usually be done at the same time but may need to take place as a staged procedure.
What is ankle joint replacement surgery?
Ankle replacement surgery is a relatively new joint replacement procedure in comparison to hip and knee replacements, and the technology is rapidly advancing. We’re now in the era of fourth generation implants.
There’s a lot of careful preparation that goes into ankle replacement surgery.
Firstly, I ask all my patients to think very carefully about making a decision to undergo ankle replacement, to read the material I send them, and we never move forward on a decision at our first time of meeting. The goal of an ankle replacement is to reduce pain, and restore a more natural range of movement, but it can never be as good as your own, healthy, original ankle.
Each ankle replacement procedure is individual to the patient, and I use a planning system called ‘Prophecy’ which takes a CT scan of your ankle, which is used to make an individualised surgery plan. It allows me to put the ankle replacement in exactly the right position, based on the shape and bony landmarks of your ankle. In other words, the ankle replacement kit is tailored to fit you. Ankle replacements that are accurately positioned function better, and last longer.
On the day of the surgery, you’ll come into hospital, and you’ll likely stay for a day or two.
The surgery may be carried out under a general anaesthetic, or ‘awake’ under a spinal anaesthesia, which numbs your legs during the procedure and for a few hours afterwards.
An incision is made over the front of the ankle joint, and the worn cartilage and bone surfaces are removed. A cut-out shape that will receive the new ankle joint component is accurately made with cuts placed using the individually planned template, and then then the new ankle components are inserted. One is attached to the end of the tibia (shin bone), and one covers the top of the talus (hinge bone). Peg shapes on the back of the components enables them to hold fast into the bone, and they are coated with a specialised coating that encourages the bone to grow into the replacement. A special type of plastic (polyethylene) insert sits between the two metal components to reduce friction within the joint.
How long does ankle replacement surgery take?
The surgery takes around 2 hours, and after the surgery you’ll spend a short while in the recovery area. You’ll then return to the ward, and when you’re feeling up to it, a physiotherapist will get you up and moving with the aid of crutches. Your pain will be well controlled with pain medication. After a couple of days, you’ll be ready to go home.
You’ll have a cast on the ankle to protect the wound for around 3 weeks, and during this time you need to keep your weight entirely off your ankle.
When you’re not needing to move about to (e.g. to get to the bathroom), you must keep your foot elevated above the level of your heart. This is important, and it’s to reduce swelling and to ensure good wound healing.
After three weeks, the cast comes off, and you’ll go into a boot, so you can start fully weight bearing, and commence your physio exercises. Most people will wear the boot for around 3 weeks, until they feel confident to go without it.
What to expect after an ankle replacement.
It’s going to take several months for your ankle replacement to feel natural, and you’ll need to continue your physio for a few weeks to strengthen around the ankle and restore the range of movement and your ability to balance.
When can I drive after an ankle replacement?
If all is going well after your surgery, and your ankle is moving well, you could reasonably expect to be back driving after 6 weeks.
What sports can I do after an ankle replacement?
I encourage patients to be active but kind to their replacement. Ankle replacements are designed to reduce pain, and get people back walking, but they are not engineered to withstand high impact activities, such as running. Swimming, cycling, hiking and playing golf are all very achievable with ankle replacement.
Risks of ankle replacement surgery
Ankle replacement surgery is major surgery, and whilst we do all we can to minimise problems, no surgery is without risk. Infection, pain, nerve damage, poor wound healing, residual pain, and failure of the replacement to bond fully with the bones are some of the potential complications.
Ankle replacement surgery success rates
The ankle is a complex joint and it has less soft tissue padding around it than other joints. Replacement is therefore more complicated.
Around 90 % of patients describe their ankle replacement as being very satisfactory. Around one in ten patients may have some residual pain (aka gutter pain) after replacement which very occasionally requires keyhole surgery to correct it.
How long do ankle replacements last?
All ankle replacements can never be as good as the original, ‘native’ ankle, but thankfully, the newer generation ankle replacements are lasting longer and performing better. The failure rate for a ‘third generation’ replaced ankle is around 1.5% for every year it’s in existence, which means that at least 85% are still going strong at 10 years. I use a 4th generation implant; we don’t yet have long-term data for 4th generation replacements, but early data is looking very promising.
What happens when an ankle replacement wears out?
The commonest cause of ankle replacement failure is loosening of the metal components. It is possible to have a second ankle replacement (which involves removing the old components and implanting new components), and we now have better ankle revision systems than we’ve had before. Alternatively, the components may be removed, and the ankle fused with a plate and screws and bone grafts.
If you’re struggling with ankle arthritis and you’re looking to explore your options, including ankle replacement, I’m here to help.
