Ankle Surgery

 

The ankles support our full body weight when we walk, stand or run. Because the relatively small ankle joint bears so much weight over time, it’s especially vulnerable to injury and deterioration. Ankle injuries can set the stage for osteoarthritis to develop. People affected by rheumatoid arthritis may also develop chronic pain and inflammation in one or both ankle joints.

To address ankle pain, there are two options for surgery: ankle fusion and total ankle replacement. While ankle fusion has been a common surgical treatment option in the past, total ankle replacement is increasingly being used to address chronic ankle pain. This resource primarily focuses on total ankle replacement.

Types of surgery

Ankle Fusion (arthrodesis)

Ankle fusion is a procedure where the diseased joint is removed and the surgeon permanently fuses the lower end of the shin bone (tibia) to the ankle bone (talus). This provides considerable pain relief but the person who undergoes fusion will lose the ability to move the ankle.

Total Ankle Replacement (arthroplasty)

In a total ankle replacement, the surgeon begins by removing damaged portions of the joint. Two metal pieces are then inserted into the bones that come together to form the ankle joint —one into the lower end of the shin bone (the tibia), the other into the ankle bone (the talus).  The metal pieces have a special coating that allows the ends of both bones to grow directly into the metal surface for greater stability. The third piece of the artificial joint, which is made of special plastic, is inserted between the two metal pieces, acting as a “shock absorber” that cuts down on friction inside the joint and limits wear and tear.  The plastic usually locks into the metal piece under the tibia.

When is ankle surgery performed?

Ankle surgery is usually necessary when ankle pain and loss of function become severe and other treatments no longer relieve pain. This may be because:

  • You have a history of severe ankle injuries (multiple serious sprains, fractures, ligament tears) which have made your ankle joint unstable and left you with chronic pain and swelling.
  • You’ve been diagnosed with rheumatoid arthritis which has affected one or both of your ankles and has caused chronic pain, stiffness and disability that have not responded to other kinds of non-surgical treatment (such as pain relievers, anti-inflammatory drugs, limiting activity, wearing an ankle brace, shoe modifications, applying heat and physiotherapy).
  • You have previously undergone ankle fusion which has not fully or permanently improved or relieved your symptoms, or which has caused other problems in your ability to move around.

How well it works

Ankle replacement surgery has grown in use over time and has even been used to replace previously-fused ankles with new implants.

How long an ankle implant will last depends on many factors: the person’s activity level, his/her body weight, the type of implant and surgical technique used, the skill of the surgeon, and the patient’s willingness to follow advice about recovery. Although a joint replacement is able to sustain many years of wear and tear, it may eventually fail.

Risks

The risks of ankle surgery can be divided into two groups:

  1. Risks associated with the surgery and recovery period that could include:
    • Blood clots
    • Infection
    • Bone fracture
    • Bleeding
    • Nerve damage
    • Problems with wound healing
    • Problems with anesthesia
    • Dislocation of the artificial joint
    • Allergic reaction to components of the implant (very rare)
  2. Long-term risks that can occur months to years after surgery and may include:
    • Loosening of the artificial joint over time
    • Post-surgical ankle weakness
    • Infection of the implant requiring its removal
    • Stiffness or instability of the ankle

Speak to your doctor or orthopedic surgeon if you have concerns about the possible risks of ankle surgery.

Pre-operative visit

Most hospitals will ask you to come in several weeks before your joint replacement surgery to review your status and talk about what will happen. It’s a good idea to bring a family member or friend to this visit to take notes and ask questions. You will be given lots of information, and this can be overwhelming and difficult to remember if you don’t have someone with you.

During the pre-operative visit, the team will talk about what kind of anaesthesia is best for you. This depends on many things, including your age, general health and preference. The team may suggest regional anaesthesia so you don't feel the area of the surgery - with this option you'll also have medicine that makes you feel relaxed or lightly asleep but you will breathe on your own. Alternatively, your team may suggest a general anaesthesia that puts you completely asleep during the surgery, which requires the placement of a breathing tube down your throat and the use of a breathing machine.

Preparation

Physical activity

Your surgeon may recommend that you do some regular pre-operative exercises. Some are aimed at strengthening your arms and shoulders, which will help you manage the use of crutches or a walker after surgery. Others will help maintain the strength of your leg muscles. The exercises should take about 20 minutes to complete, and if possible, you should do them twice a day.

Your home

Your house or apartment may need certain changes to meet your needs after your operation. Look around and see what can be done beforehand.

  • Remove small mats and area rugs. Tape down the edges of larger rugs so you won’t trip over them.
  • Keep rooms and hallways well-lit so you can see obstacles.
  • Make sure all stair railings in and outside your home are secure.
  • Keep cords out of the way.
  • Getting in and out of bed can be difficult after joint replacement surgery. It’s important that your bed isn’t too low.
  • Get a rubber (non-skid) mat for your bathtub or shower stall so you don’t slip while bathing. A tub bench is also helpful. Purchase a long, handheld sponge to help you wash your feet without bending over.
  • Put all your bathroom utensils, such as toothbrush, comb, hair dryer, make-up, and razor in a single area so you can reach them without moving around.

What to expect after surgery

Right after surgery

You should expect to be in hospital for a day or two, although some patients go home the same day (possibly longer for more complicated surgery). Immediately after surgery, you will need to keep your foot elevated. You will be “non-weight bearing”—that is, you must not put weight on the new ankle joint but instead use crutches to get around—for at least four to six weeks after surgery.

Moving around

On the day of surgery or the day after, you will be encouraged to get out of bed with help. You’ll also be taught how to walk safely using crutches or a walker. You will be non-weight bearing for the first two weeks—this means you must NOT put any weight on the affected foot.

You can expect some discomfort right after surgery which should gradually improve over the coming days, weeks and months. Your physiotherapy will begin in the hospital where you’ll be encouraged to do some simple bed exercises during the first day or two.

Leaving the hospital

You may go home on the day of surgery, or within two days after surgery. You will have a cast or supportive boot on your leg when you leave the hospital. The supportive boot is removable and has foam or air cushions to support your foot. You should only remove the boot when needed, and only if your surgeon says it is safe to do so.

You’ll be sent home from the hospital when you can walk safely using crutches or a walker and your pain is under control.

Some people who need more therapy or who have other health problems which might complicate their recovery are more likely to be sent to a rehabilitation unit or hospital.

Continued recovery

Call your surgeon or family doctor if:

  • you develop a temperature higher than 38 C (101 F)
  • you notice any change in the amount, colour or odour of drainage from your incision or a sudden increase in pain around the incision
  • you notice increased pain, swelling or tenderness in the ankle area of either leg
  • you notice that either leg appears pale or bluish in colour
  • you notice that either leg feels unusually cool to the touch
  • you suddenly have trouble walking

Full recovery after ankle replacement surgery usually takes at least six months, although in more complicated cases, recovery can take a year or longer. If your ankle pain and other symptoms are due to inflammatory arthritis, your recovery may be slower than average and/or you may be left with some degree of pain and/or disability.

The skin covering your foot and ankle, including the area over your incision, will remain sensitive for a while after your surgery. This means the skin could break down easily, which can sometimes lead to an infection. Try to avoid walking in bare feet or open-toed sandals to avoid skin breakdown.

Wearing the right shoes is important, both before and after ankle replacement surgery. Wearing proper shoes after surgery helps put the foot in correct alignment, ensuring that you walk properly—meaning that you don’t over-stress the new ankle joint or put extra stress on other parts of your body (your knees, hips and lower back).

Even if you purchased and wore special shoes and orthotics (shoe inserts) before surgery, as you recover you may find that the no longer fit in the same way. Ask your surgeon for advice. You should also avoid shoes with a heel higher than 2.5 cm, since higher heels place unhealthy stress on the ankle joint.

Living with an ankle replacement

Your surgeon and physiotherapist will explain what you should and shouldn’t do so that your ankle will heal properly. While you should address your specific concerns, these general recommendations are known as “precautions" and must be followed for 6-8 weeks after surgery:

  • You can rest your foot on the ground when you are standing. Just don’t put your body weight on your operated leg when walking.
  • When you’re sitting in a chair, the foot should be elevated on a stool or other surface.
  • Avoid letting your affected leg and foot dangle (hang down) for any extended period of time.
  • When you’re lying in bed, raise the ankle on a pillow so that it’s higher than the level of your heart.

While ankle replacement surgery can help reduce pain and increase function, you shouldn’t necessarily expect your new ankle to be as strong and flexible as it was in the past—for example, when you were younger and before your ankle was affected by injury and/or disease. It’s important to follow your surgeon’s advice for optimal recovery and to protect your new ankle joint. This may mean that you’ll have to reduce or change the physical demands you place on your body after your operation.

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Contributors

This information was reviewed in September 2019 with expert advice from:

Dr. Johnny Lau
Orthopedic Surgeon, UHN – Toronto Western Hospital
Assistant Professor, University of Toronto
 
Dr. James Rofaiel
Orthopedic Surgeon

Sources

http://www.orthop.washington.edu/patient-care/articles/ankle/total-ankle-replacement-surgery-for-arthritis.html
https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?HwId=acd5781