- Total Ankle Arthroplasty
- Orthopedic Surgery
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Ankle replacement is surgery to replace the damaged parts of the three bones that make up the ankle joint. Artificial joint parts (prosthetics) are used to replace your own bones. They come in different sizes to fit different-size people.
A total ankle replacement involves removing damaged cartilage and bone from the joint. The bones of the joint have to be reshaped to fit the artificial joint. These bones include the large bone (tibia) and small bone (fibula) of the shin and the foot bone (talus), which the tibia and fibula rest on. The artificial joint is then attached to the bones. Screws may be inserted into the tibia and fibula, or a bone graft may be done for more stability.
Ankle Replacement Candidates
One of the most common reasons for a total ankle replacement is rheumatoid arthritis. Other conditions that may call for total arthroplasty include osteoarthritis, a severe bone fracture or complications from previous ankle surgery. Symptoms of these conditions include severe pain and difficulty moving the ankle joint. Because the ankle is a weight-bearing joint, these conditions can make it difficult for a person to have a normal life.
The best candidates for total ankle replacement are those who are older than 50, not overweight and not extremely active. It's possible to hike, ride a bicycle or even ski after a total ankle replacement. But people who are runners or do heavy labor are not good candidates for ankle replacement. People who have diabetes, nerve problems in their legs or poor circulation also are not good candidates.
Ankle Replacement Alternatives
Ankle replacement options include smoothing the surfaces where the bones meet (debridement), fusing the bones of the ankle joint, removing bone and procedures aimed at restoring the bone and cartilage of the ankle.
Patients with concomitant subtalar joint arthritis (who would require a tibiotalarcalcaneal fusion) or contralateral ankle arthritis or fusion (who may end up with bilateral ankle fusions) are ideal candidates for total ankle arthroplasty, as the morbidity of the fusion alternatives is significantly higher than an isolated ankle fusion.
The best approach will depend on the patient, the patient's lifestyle and the condition of the joint.
Ankle Replacement Outcome & Benifits
A total ankle replacement will last about 10 years. While it restores some range of motion to the joint, it doesn't totally restore it. Total ankle replacements tend to be less successful than hip or knee replacements. People who have total ankle arthroplasty are more likely to develop infections from the artificial joint or to require follow-up surgery due to complications.
Prepare for Ankle Replacement
Once the decision to proceed with surgery is made, there are several things that may need to be done. Your foot and ankle surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with the physical therapist who will be managing your rehabilitation after the surgery.
On occasion a therapist will begin the teaching process before the surgery to ensure that you are ready for the rehabilitation afterwards. This includes measurements of your current pain levels, functional abilities, and the available movement and strength of each ankle. A second purpose of the preoperative visit is to prepare you for your upcoming surgery. You’ll begin to practice using crutches since you will need to use these for several weeks after surgery.
Finally, an assessment will be made of any needs you’ll have at home once you’re released from the hospital. On the day of your surgery, you will probably be admitted to the hospital early in the morning. You will be instructed not to eat or drink anything after midnight the night before surgery.
You should plan on being in the hospital for one to two nights following surgery. How long depends on your progress with physical therapy, how much discomfort you are in, your ability to get out of bed, and success using crutches or a walker. To perform an ankle replacement, you may be placed under general anesthesia, regional anesthesia, or you may have a spinal type anesthetic.
Ankle Replacement Surgery Overview
Total ankle replacement removes and then replaces both sides of the ankle joint with specially designed components, called prostheses. The tibial prosthesis consists of a polyethylene (medical grade plastic) and titanium base plate tray that is inserted into the tibia and fibula, giving the implant a wide base for support. The upper portion of the talus, the bone that moves up and down, is replaced with a component made of cobalt chromium alloy, a metal commonly used in joint replacement prostheses.
Each artificial ankle prosthesis is made up of two parts:
- The tibial component is the metal portion of the joint replacement that replaces the socket of the ankle (the top portion).
- The talus component replaces the top of the talus. The talus is the first bone of the foot and sits in the mortise of the ankle.
Ankle replacement surgery may be done while you are under general anesthesia. This means you will be unconscious and unable to feel pain. Or, you may have spinal anesthesia. You will be awake but will not feel anything below your waist. If you have spinal anesthesia, you will also be given medicine to help you relax during the operation.
The operation begins by making an incision through the skin into the front of the ankle. This is called an anterior approach to the ankle. Once through the skin, the nerves and blood vessels are protected and moved to the side. The tendons are also moved to the side. The ankle joint is entered by making an incision into the joint capsule that surrounds the ankle joint. The surgeon can now look at the surfaces of the joint as he/she prepares the bone to replace the ankle joint surfaces.
The next step in replacing the ankle joint is to cut the bones that make up the socket of the ankle joint (the tibia and the fibula) so that the metal socket will fit in place. The top of the talus is cut so the metal talar component can be inserted. All of the tibial implant and the talar implant portions of the artificial ankle joint are then inserted.
Bone graft is then placed between fibula and the tibia to create a fusion between the two bones. This stops the motion between the two bones that could loosen the joint replacement. The bone graft is taken from the bone that has been removed from the ankle earlier.
Then the ankle is tested to make sure the pieces fit properly. To make sure that the ankle socket or the mortise component fits tightly, two screws are placed between the fibula and the tibia just above the ankle joint.
When the surgeon decides that everything is satisfactory, the ankle joint capsule is sutured back together and the skin is sutured together. A large bandage and splint are placed on the lower leg to protect the new ankle joint as your leg heals.
Closing the Incisions
There are several ways that orthopaedic surgeons can close the incision after performing a joint replacement. Stainless steel staples are popular with many orthopaedic surgeons because they are easy to put in and easy to take out. This can reduce time in the operating room. The stainless steel staples are one of the most inert types of sutures, meaning they have a very low risk of allergic reaction in the patient.
Some surgeons prefer using sutures that dissolve on their own after several weeks. These stitches are normally put in just under the skin. The advantage of this type of closure is that you don't have to have your stitches taken out. Usually there are special tape closures (sometimes called "butterfly" tapes or "steri- strips") that are used to hold the edges of the skin closed for the first few days. If you see strips of tape across the incision, this is probably the type of closure that was done. This type of incision closure takes a bit more time in the operating room.
Finally, many surgeons still use the old "tried and true" nylon stitches one at a time. Nylon has withstood the test of time and is nearly as inert as stainless steel. It is strong and holds well until it is removed (somewhere between 2 to 4 weeks after surgery).
Once your physical therapist has completed the examination, an intervention/treatment plan will be established. This plan will list the goals for getting you back to daily activities. It will include how much time and how many visits the therapist feels will be needed.
You should continue following the precautions taught in the hospital to protect your ankle replacement for approximately 6 weeks. The precautions may include:
- Avoid weight bearing on the foot. When standing or walking, keep the foot off the ground at all times. When sitting, elevate the foot.
- Avoid letting your leg hand down for any extended period of time elevating your leg when sitting or lying down.
- Avoid getting the ankle wet until the sutures are removed.
Your therapist may choose from one or more of the following interventions to facilitate your recuperative process:
- Decreasing Swelling
- Strengthening and Stability Exercises
- Endurance Exercises
- Weight Bearing Exercises
- Maintaining Hip and Knee Motion and Strength
- Postural Exercises
- Walking and Stair Climbing
- Functional Activities
- Heat and Cold Therapy
- Other Activities
- Home Program
The instructions you will be given following your ankle replacement surgery will depend on the type of ankle implant used. The components of the in-patient physical therapy program are detailed below.
Ankle Replacement Recovery
A successful ankle replacement will get rid of your pain and allow you to move your ankle to up and down. Usually, total ankle replacements last 10 or more years. How long yours lasts will depend on your activity level, overall health, and the amount of damage to your ankle joint before surgery.
After surgery, you will need to stay in the hospital for up to 4 days. When your surgery is complete, your leg will be elevated and your ankle immobilized in a splint.
A small tube that helps drain blood from the ankle joint will be left in your ankle for 1 or 2 days. To keep swelling down, you can keep your foot raised higher than your heart while you are sleeping or resting.
Your doctor may recommend physical therapy to learn exercises that will help with ankle motion.
Ankle Replacement After Care
Not all surgeons require that you see a physical therapist after your ankle replacement surgery. In fact, some surgeons may recommend special exercises you can do at home. These may include certain range-of-motion exercises or low-weight bearing activities.
If a physical therapist is recommended, they will teach you about the safest method of getting in and out of a chair and moving around. They will also determine whether it is best for you to use a walker or crutches. After your therapy session, the boot or splint will be reapplied and must be worn 24 hours a day and removed only at exercise time.
If other procedures are performed during your surgery, a plaster splint will be applied, requiring your ankle to be immobile for a longer period of time. If this is the case, your cast will not be removed for two to three weeks and no range-of-motion exercises or dressing changes will occur during this time.
Pain is a normal side effect to any surgery, but it would be unusual for you to use pain medication for more than five to seven days after surgery. However, don't hesitate to talk to your surgeon should you experience discomfort.
You will not be able to put weight on your ankle for the first six weeks after surgery, but this doesn't mean that you will be immobile as long as you learn to use crutches or a walker.
When You Return Home
After you return home, it will take time to adjust. Elevate your ankle, preferably above the level of your heart, when resting. At night, you should lie on your back with one or more pillows under your splinted ankle.
Feel free to walk as much as you like using crutches or a walker, but be sure not to put any weight on your ankle for the first six weeks after surgery or until the time specified by your surgeon.
Make certain that your ankle incision stays dry and is not draining. If you notice any drainage or foul odor from your incision, contact your surgeon right away. If your temperature reaches above 100.4 degrees or you notice any increased swelling or tenderness, call your surgeon immediately.
The range-of-motion exercises are very important to your recovery so you must do them at least two to three times a day.
Using a walker or crutches can become a little frustrating, but you will have it mastered in a few days. Take special care while becoming familiar with the device, and don't become over confident once you get the hang of it. This is when accidents can happen.
You can bathe but special precautions are necessary. Make sure that you protect the ankle from water by wrapping plastic wrap over the dressing.
Remain active after you return home, but do not over due it. Each person heals at their own rate, and it is difficult to predict when you will be able to resume your normal activities.
After about 8-12 days after surgery, you may have your first "post-operative" visit. Your surgeon will exam the ankle and may call for an x-ray evaluation to be sure the healing process is going well. Your sutures will probably be removed two weeks after surgery. You will be seen again at six weeks, and then at three months after surgery. A six-month exam is usually scheduled for new x-rays and an assessment of your progress.
For the first six weeks, use crutches and do not put any weight on the affected leg. At the six-week mark, you may begin to gradually put weight on the leg with the use of a cane or walker.
You may be able to begin driving an automatic shift car in six to eight weeks. If you have a manual transmission and your right ankle was operated on, you will not begin to drive for 12 weeks.
After 12 weeks, you can begin low impact, weight-bearing activities, such as walking, golfing, and bicycling on level surfaces. Avoid contact sports, weightlifting, and any activity that puts stress on the joint. Your surgeon may suggest that you use an ankle support for up to one year.
Do not be alarmed by the swelling, which can be expected for up to 12 months.
Ankle Replacement Possible Risks
Rheumatoid arthritis sufferers tend to have thin skin, poorer healing potential, and higher infection risk. In the early postoperative period, this has been shown to result in a 14-times-higher risk of a major wound-related complication requiring a return to the operating room for management.
If this is avoided, patients with rheumatoid arthritis may have an increased life expectancy of the component due to their lower activity demand and frequently low BMI.
Risks for ankle replacement surgery are:
- Loosening of the artificial joint over time
- Nerve damage
- Blood vessel damage
- Bone break during surgery
- Ankle weakness, stiffness, or instability
- Dislocation of the artificial joint
- Allergic reaction to the artificial joint