Total Ankle Replacement FAQ’s

Arthritis is a term that refers to inflammation of the joints. There are many types of arthritis, but the most common ones are osteoarthritis and rheumatoid arthritis.

1. Osteoarthritis (OA): This is the most prevalent form of arthritis and occurs when the protective cartilage that cushions the ends of bones wears down over time. It commonly affects joints in the hands, knees, hips, and spine, leading to pain, stiffness, and reduced joint flexibility.
2. Rheumatoid Arthritis (RA): RA is an autoimmune disease where the immune system mistakenly attacks the synovium, the lining of the membranes that surround the joints. This can lead to inflammation, joint damage, and pain. RA often affects multiple joints and can also have systemic effects on other organs.

Arthritis can cause a range of symptoms, including joint pain, swelling, stiffness, and a decreased range of motion. It can be a chronic condition and may impact a person’s quality of life. Treatment options vary depending on the type of arthritis and may include medication, physical therapy, lifestyle changes, or in some cases, surgery.

It’s essential for individuals experiencing joint symptoms to consult with a healthcare professional for an accurate diagnosis and appropriate management plan.

Ankle arthritis involves inflammation and deterioration of the ankle joint cartilage. Ankle arthritis can cause a range of symptoms, including joint pain, swelling, stiffness, and a decreased range of motion. It can be a chronic condition and may impact a person’s quality of life.

In vast majority of patients (60-80%) ankle arthritis occurs secondary to injury. This can be a fracture of the ankle or an impact injury without fracture. The initial insult to ankle cartilage results in a slow deterioration of the joint. Over time this progressively results in worsening progressive arthritis. To a lesser extent, ankle arthritis can also be due to a patient’s natural history, infection, gout, or underlying medical conditions such as rheumatoid arthritis / hemophilia.

In many of these cases, an initial fracture/impaction injury results in uneven force dissipation across the ankle joint. This causes the ankle to be overloaded in certain area. After years of walking on this unevenly distributed joint, the cartilage starts to wear thin, and inflammation ensures.

Ankle arthritis is less common that larger weight bearing joints such as the knee or hip. The incidence of ankle arthritis is approximately 30 per 100,000 people. Global approximation is roughly 1% of the population. 

Often patients will experience pain around ankle joint. This is most commonly with weight bearing, walking, or exercises. Swelling at the joint line is very common. Over time the joint will become stiff, and range of motion will be lost. If this goes on long enough, the alignment of the joint will change, and a progressive deformity will ensue. The natural history of all arthritis is to slowly and chronically progress, with worsening pain exacerbation episodes. 

A surgeon will obtain a thorough history and perform a physical examination. If there is a convincing clinical presentation, we will confirm our suspicion with X-rays and advanced imaging. Additional testing may be required. 

Yes. Most of the time we are able to detect arthritis on X-rays. In the cases of very focal disease, or early arthritis, additional advanced imaging may be required (MRI / CT scans).

Ankle arthritis will show up as narrowing of the joint space at the ankle joint line. There may also be formation of new bony spurs. In severe cases the ankle will start to drift medially or laterally, resulting in deformity. 

Once all non-operative options have been exhausted, and you are no longer able to cope with ankle arthritis, surgical options are indicated. Continue reading for further information on how surgery can be helpful for treating ankle arthritis. 

There are many surgical approaches to treating ankle arthritis. This depends on several factors. This can be patient factors such as underlying medical conditions, level of activity, goals of treatment, and expectations. Joint related factors also come into play. This includes how severe the arthritis is, whether there localized or global disease, severity of arthritis, presence of deformity, and involvement of surrounding soft tissue structures. Furthermore, concomitant foot deformity must also be considered. 

Early ankle arthritis, that is well localized, in young active healthy patients, is amenable to debridement with ankle arthroscopy. This is a minimally invasive procedure where a camera is inserted into the joint, and areas of arthritis are debrided away. This can provide pain relief, more range of motion, and long-term symptom control for patients with early ankle arthritis. See the ankle arthroscopy section for more information regarding these options. Speak to one of our experts if you think you may be a candidate. 

More extensive arthritis is typically treated with two main options: fusion (arthrodesis) or replacement (arthroplasty). Both options have their benefits and pitfalls. It is critical to have a discussion with your surgeon to determine which option is right for you. 

Ankle fusion (arthrodesis) is considered the gold standard for cases of severe ankle arthritis. It has been the go-to procedure for decades. Here we expose the joint, remove any residual cartilage, and oppose the talus bone to the end of the tibia bone. These two bones heal to one another, forming one bony structure. Functionally the joint is eliminated. There is no motion across the joint anymore. However, there is also no pain. 

Ankle replacement (arthroplasty) is a newer procedure that has been advancing quickly over the last 2 decades. Replacement surgery is much more involved than ankle fusion. It provides pain relief similar to fusion surgery. However, it allows us to maintain motion at the ankle joint. This is thought to prevent neighboring foot joints from deteriorating. The recovering and healing form this is more difficult. 

Ask one of our experts if you are a candidate for one of these procedures. 

In order to perform an ankle replacement, we often will utilize advanced imaging and patient specific instruments. This requires a CT scan before the procedure. Custom cutting jigs will be 3D printed. These improve the location of bony cuts and reduce operative time. 

We make an incision in the front of your ankle, avoiding nerves and vessels. We dissect down to the joint, preserving soft tissues. We apply and secure 3D printed custom cutting jigs. These are secured. We then cut the tibia and talus to accommodate metal implants. Once cuts are made, we remove excess bone and debris. We apply trial implants to ensure sizing and tension. Once we have determined the correct size implants, we place metal components in the tibia and talus. We then place a high-density polyethylene component. 

At this stage we stress test the ligament structures. If there is ligament deficiency, we may perform a reconstruction acutely, or stage this to a later time. Similarly, if there is a foot deformity this may be addressed at the time of surgery or staged to a later time. 

All incisions are closed, and a cast is applied. This can be present for 2-4 weeks. After this point, rehab is initiated. 

Once the surgery is complete, you are placed into a cast. The cast is required for minimum of 2-4 weeks. We will remove the sutures 2-3 weeks post op. You will have to remain non-weight bearing for minimum of 2-4 weeks. Once the cast is removed, we can start weight bearing and rehab. Often, we will transition you to a rigid removable boot, to start weight bearing. This will be weaned as you progress in physical therapy. 

It will likely take 3-4 months before you feel that you can walk on the ankle comfortably. The ankle replacement will continue to heal and remodel for over a year. Swelling will be present for at least 6 months. In some cases, swelling is present for over 18 months. It goes away eventually as you rehab. 

Ankle arthroplasty, or ankle replacement, is typically considered when conservative treatments have failed, and the patient experiences persistent pain, instability, or deformity in the ankle joint. Common indications for ankle replacement (arthroplasty) include:

1. Severe Osteoarthritis: When conservative measures such as medications, physical therapy, and joint injections are no longer effective in managing pain and functional limitations caused by advanced osteoarthritis.
2. Rheumatoid Arthritis: In cases of rheumatoid arthritis where the immune system attacks the synovium, leading to joint inflammation, pain, and deformity.
3. Post-Traumatic Arthritis: Following a severe ankle injury, such as fractures or dislocations, that results in long-term joint damage and arthritis.
4. Failed Ankle Joint Replacement: In situations where a previous ankle joint replacement has not been successful, ankle revision replacement may be considered vs fusion salvage procedure.
5. Ankle Instability: For cases of chronic ankle instability, where the ligaments supporting the joint are significantly damaged, and conservative measures are inadequate.
6. Deformities: Ankle replacement may be recommended for individuals with deformities affecting the ankle joint, such as severe misalignment or joint malformation.

The decision to undergo ankle replacement is based on a thorough evaluation by an orthopedic surgeon, considering the individual’s specific condition, symptoms, and the likelihood of success with the procedure. It’s important for patients to discuss their symptoms and treatment options with their healthcare provider to determine the most appropriate course of action.

What are the complications associated with ankle replacement (arthroplasty)?

Ankle replacement surgery, also known as total ankle arthroplasty, is a procedure designed to relieve pain and restore function in the ankle joint affected by arthritis or other conditions. While it can be a successful intervention, like any surgery, ankle replacement comes with potential complications. Some of these complications include:

1. Infection: Infection is a risk with any surgical procedure. In ankle replacement, infections can occur in the joint or surrounding tissues. Antibiotics and, in severe cases, surgical intervention may be necessary to address infections.
2. Implant Wear and Loosening: Over time, the artificial components of the ankle replacement may experience wear, leading to potential loosening. This can cause pain and instability and may require revision surgery.
3. Blood Clot Formation: Deep vein thrombosis (DVT) is a risk after any surgery. Blood clots can form in the veins, potentially causing complications if they travel to the lungs (pulmonary embolism). Blood thinners and compression stockings are often used to reduce this risk.
4. Nerve Damage: Injury to nerves during surgery may result in numbness, tingling, or weakness. While nerve injuries are uncommon, they can occur and may have varying degrees of impact on sensation and function.
5. Delayed Wound Healing: Some individuals may experience delayed wound healing or wound complications, which may require additional medical attention.
6. Joint Instability or Malalignment: Ankle replacement aims to restore joint stability, but there can be instances of instability or malalignment, affecting the overall function of the replaced joint.
7. Allergic Reaction to Implants: In rare cases, patients may have an allergic reaction to the materials used in the implants.
8. Functional Limitations: While ankle replacement is designed to improve joint function, some patients may experience limitations in range of motion or functionality, especially compared to a healthy, natural ankle joint.

It’s crucial for patients considering ankle replacement surgery to discuss potential risks and complications with their orthopedic surgeon. The decision to undergo surgery should be based on a thorough understanding of the benefits and risks, considering the individual’s specific condition and overall health.

Typically, 2-4 weeks.

Most patients start walking in a pneumatic boot approximately 2-4  weeks post op. 

Your gait after an ankle replacement will be different, compared to pre op, or someone without arthritis. However, it is important to keep in mind, that most patients who undergo ankle replacement have severe ankle arthritis. They have stiffness in the ankle, and tend to walk with an alter gait / limp pre op. The goal of surgery is to try and eliminate this limp, however some patients may have a residual limp post op. Compared to an ankle fusion, ankle replacements have more normal gait, and less perceived limp.

Ankle replacements boast a patient satisfaction rate of 80-90%. This is when it is done in an appropriate patient with the correct indications. Speak to one of our experts to see if you are a good candidate for replacement surgery. 

The pain of surgery is worst in the first few days. After this pain slowly improves. Most patients have little pain by 6 weeks. Swelling is typically the biggest hurdle and may exacerbate pain as you increase your activity. However, this settles over several months. 

When we replace the ankle joint, you lose some motion at that joint. However, our goal is to preserve as much motion as possible. Typically, motion that you have pre-op is maintained. Certainly, more motion is maintained as compared to an ankle fusion procedure. 

The incision is well closed around 2-3 weeks post op. The bones/implants need approximately 6-8 weeks to in-grow. However, the bones will continue to remodel / heal for over a year. Patient factors can affect this healing time. Delays in healing time are seen in patients that have diabetes, smoke, are non-compliant with post op orders, have peripheral vascular disease, etc. 

Often when we perform an ankle replacement, we will mobilize tendons as a part of our approach. This allows us to safely move them out of the surgical field, so that they are at less risk of damage. In doing so, we also have a chance to remove adhesions within the tendon sheath, which is common in arthritis. 

Ankle replacement is a surgical procedure aimed at treated patients with ankle pathology. Typically, patients have disability pre-op due to pain/stiffness/instability/ and deformity. However, the goal is to eliminate this disability post operatively. 

Yes. Ankle replacement is a major surgery. It is associated with serious complications. The decision should not be taken lightly. Please discuss this further with our experts if you think you are a candidate for this surgery.

Some patients are able to get back to running after an ankle replacement. However, it is designed more so, for low impact activity.  As a result, some patients may no tolerate running after an ankle replacement.

No. However, in some rare instances, we can take down an ankle fusion and do an ankle replacement. 

Yes. In some rare instances, we can take down an ankle fusion and do an ankle replacement. Talk to one of our experts if you think you are a candidate for this procedure.

Yes. This is done often done when an ankle replacement wears down beyond revision replacement. 

Yes. Once you have recovered and rehabbed enough to safely operate the pedal, you can drive. Typically, this is 6-8 weeks after surgery. However, you should always confirm with your doctor prior to taking this risk.

In order to eliminate ankle pain, we need to replacement the ankle joint. Patients will typically notice stark improvement of pain, at the cost of flexibility. The ankle is stiff before and after surgery. This means that you can typically walk, without pain. However, your gait may be slightly different. Some patients have a limp in the post operative period, but this resolves with time. Certainly, much more motion is maintained at the ankle joint, as compared to an ankle fusion surgery. 

Typically, no. Some patients are able to do this. Most are not able to get back to wearing long heels. 

Yes

Typically, no. However, you may benefit from custom shoes if you have an underlying foot deformity. 

Modern implants are showing much longer survival compared to older implants. Most patient will get 15-20+ years out of replacement surgery. 90% of patients are happy and functional at 10 years post op. 

Approximately 3-4h. Possibly longer if we also have to repair ligaments / correct deformity. 

Most of the cost related to ankle replacement is covered by your insurance. Your out-of-pocket cost depends on your individual insurance plan. Speak to a member of our billing team to figure out details related to anticipated out-of-pocket expenses. 

This is a difficult and complex question. For many decades, there have been similar outcomes in
terms of post operative pain, function, and satisfaction when comparing ankle replacement to
ankle fusion. Both offer similar pain relief and function. However, ankle replacements preserve
motion. Additional, ankle replacements are high risk surgeries. There is higher risk of
complications such as infection, fracture, nerve / vessel injury, and requirement for further
surgery in the future.

Historically, ankle fusions were the surgery of choice for vast majority of patients. However, as
ankle replacement implants evolve, there is a paradigm shift. We are starting to see better
outcomes for replacement patients compared to fusion. Patients are happier, more functional, and
have more motion. There is also a lesser risk of neighboring joint degeneration because ankle
motion is preserved. This means that there is a lesser risk of the rest of the foot deteriorating
because of a fused ankle. Have a look at the below study which demonstrates this.

https://pubmed.ncbi.nlm.nih.gov/36375147/

Some patients can experience plantar fasciitis in the post operative period. This is usually in
patients with an element of plantar fasciitis prior to surgery. It tends to be exacerbated by casts
and pneumatic boots.

Yes

Yes

Yes

Typically, yes. There may be other foot conditions that limit your ability to perform hard manual
labor after this type of surgery. But in isolation, after rehab, you should be able to return to
construction.

This is not recommended. We will usually recommend that you have one side at a time. This will
allow you to rehab using the non-operative leg. Initially, you cannot put weight on the operative
side; thus, you need a leg to stand on. Otherwise, you will have very limited mobility for a few
months. Furthermore, bilateral surgery increases the risk of blood clots, falls, secondary trauma,
etc.

Yes. Although, many people have problems getting into skates. We recommend back or front-
loading ice skates (similar to ski boots) for skating.

Yes

Yes. In fact, it is encouraged.

Yes. We removed residual cartilage, cartilage flaps, hard subchondral bone, and loose debris.

Vast majority of the time, yes.

There is a theoretical advantage to using a bone stimulator after replacement surgery. However,
most clinical studies do not show an advantage in the real world. We typically will utilize this
modality if healing is slow or delayed.

You can get a prescription, but there are over the counter options as well.

Most patients are still able to drive. Arthritis causes less ankle flexion/extension. As a result,
most people use more of their leg muscle to accelerate and brake. However, ankle replacement
maintains ankle motion, compared to an ankle fusion. Thus, you will drive more normally with a
replacement, as opposed to a fusion surgery. Regardless, some re-training will be required.

Most patient will have improved mobility, as they no longer are limited by debilitating ankle
pain.

This is the goal. Most patients have complete resolution of pain at the ankle. However, there is a
risk of residual pain with this surgery. Majority of these patients (with residual pain), the pain
they experience is vastly better than their arthritic pain.

In some cases. Since this is a larger procedure, we will typically do it at a hospital. There is a
good chance you may go home the same day. However, it is not atypical for patients to stay one
night.