Ankle > Arthritis > Treatments

   Total Ankle Replacement

Treatment Introduction

During an ankle replacement, the top of your anklebone (talus) and the bottom of your shinbone (tibia) are replaced by metal and polyethylene components. You typically gain some range of motion in your ankle as compared to an arthritic ankle. However, you may not have the complete range of motion of a healthy ankle. The prosthetic joint can move up, down, and side-to-side well enough for you to perform normal daily activities again. You may be a candidate for a total ankle replacement if you have severe debilitating arthritis and you are what physicians call a "low demand" patient. Low demand patients typically are in their 50's or 60's, are not overweight, and are not highly active people. Unlike knee replacements, patients need to be very cautious using their prosthetic ankles, and candidates for replacement usually are not allowed to put a lot of strain on their ankle. The new designs for ankle replacements have been developed recently and long-term studies have not proven how long your prosthetic ankle can last. But short-term studies have been very encouraging for the new prosthetic ankles. If you are suffering from severe pain and cannot walk more than a few blocks, an ankle replacement can be a good way to relieve discomfort and restore motion in your ankle.

The decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.

   Prior to your return home from the hospital, make sure that you have received any equipment you will need when you get home. This may include crutches or household items to make movement around the house easier. You should receive prescriptions for any of these from your doctor before you go home from the hospital.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any new medications you are taking.

   Learn the potential risks and benefits of the surgery by asking your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   If possible, discontinue the use of any anti-inflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the procedure.

   To reduce the risk of infection, improve healing, and decrease complications, try to quit smoking or decrease the amount you smoke. In general, smokers have a higher infection and complication rate overall.

   If possible, practice walking with your crutches so you are ready to use them after surgery. Performing some basic arm strengthening exercises in the weeks prior to surgery can make crutch use easier.

   Getting a second opinion from another qualified surgeon is often advisable, particularly in rare or unique cases.

   To check if the orthopedist performing the surgery is board-certified or eligible, call the American Board of Orthopaedic Surgery at 919-929-7103.

At most medical centers, you will go to "patient admissions" to check in for your operation. There may be separate check-in areas for ambulatory outpatient (patients go home the same day after surgery) and for overnight inpatient surgery, so be sure to ask your doctor or an assistant about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed, and your ankle may be shaved, though this is not always necessary. You will be asked to change into a hospital gown and, if applicable, remove your watch, glasses, dentures, and jewelry. You will have the opportunity to speak with your orthopedic surgeon or an assistant and meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). An IV (intravenous) line may be inserted into your arm at this time. You will then walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under anesthesia.

   Arrange for someone to drive you home when you are released.

   Wear a loose pair of shorts, sweatpants, or other clothing that will fit comfortably over your short leg cast or splint when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

During total ankle replacement surgery, your orthopedic surgeon will replace the damaged parts of your ankle joint with artificial materials. The artificial components and materials used in a total ankle replacement may enable your ankle to move comfortably, although with a slightly restricted range of motion. The metals vary and can include alloys of cobalt, chrome, titanium, or stainless steel. The plastic material is ultra high–weight molecular polyethylene (UHWMPE), a material that is extremely durable and wear resistant. "Cementless" joint replacements have been developed. Cementless joint replacements depend on a tight, intimate fit directly between the prosthesis and bone. Bone grows into crevices within the surface of the prosthesis. This process takes time, and your orthopedic surgeon typically limits the amount of weight that you can place on your ankle while this occurs. Total ankle replacements normally take about three hours to perform. Spinal anesthesia is given to numb you from the waist down, and you usually are sedated so you sleep through the procedure.

   After anesthesia is administered, the surgical team will position you on the operating room table and cleanse your skin with antiseptic solutions.

   Depending on your size and the surgeon's preferred surgical approach, a skin incision about 12 centimeters long is made over the front of your ankle.

   The joint capsule and underlying soft–tissues, such as ligaments, muscles, and tendons, are divided and, if necessary, cut away so that your surgeon can access your ankle joint.

   Your surgeon uses devices called retractors to hold the sides of the wound open.

   After exposing the talus and base of your shinbone, your surgeon typically makes flat cuts to prepare the bone surfaces with a special oscillating bone saw.

   Usually, the artificial talar and tibial components are made of a metal backing with a plastic liner (metal–backed). These metal–backed components are secured in place by a "press–fit" technique. Press–fitting prepares a space and then fills it with an object of a slightly larger size. For example, if one places a large peg in a small hole, the large peg will be difficult to remove.

   In some cases, screws provide additional stability and fixation to the artificial components.

   After the parts are in place, the anklebone and shinbone are placed back (reduced) into their normal positions. Your ankle is then moved in different directions to assess motion and stability relative to the other ankle.

   In some cases, a small drainage tube that exits your skin may be placed into the wound to prevent fluid from collecting.

   The ligaments, tendons, and muscles of the ankle are repaired with sutures.

   The layers of the wound are closed with sutures. A dressing is placed over the wound and around the drain exit site. Your ankle is immobilized in a post-surgery ankle splint. You will then be transported to the recovery room.

After total ankle replacement surgery, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of anesthesia wear off. Your ankle will be elevated and immobilized in a splint when you wake up. The post-surgery ankle splints usually are made of a “U-shaped” plaster splint on the inside and outside of your ankle that wraps around your heel. It immobilizes your ankle, but it can be removed more easily than a short leg cast. You will not be able to see your incision wrapped in the splint, and there usually is minimal bleeding after surgery. You may have a tube exiting from underneath your dressing, which is a drain to prevent fluid from accumulating within your wound. This drain is usually removed within two days after surgery. If you have difficulty urinating after anesthesia, you may have a tube called a urinary catheter inserted into your bladder that allows urine to leave your system. The urinary catheter is usually removed within one to two days after surgery. Ankle replacement can cause a substantial amount of pain, and adequate pain medications will be prescribed for you. You ordinarily are hooked up to an intravenous (IV) patient-controlled analgesia (PCA) device, which delivers pain medications in safe amounts when you push a button. Some patients may be prescribed oral or intramuscular pain medications. You usually can have visitors no sooner than 30 minutes after surgery if your physician feels you are in a stable condition. Your temperature, blood pressure, and heartbeat will be monitored by a nurse who, with the help of the physician, will determine when you are ready to leave the recovery room and be transported to the hospital ward for further post-operative care. In some cases, you may be transported to a ward for intensive care or heart monitoring if you have special post-operative medical needs. Most patients spend two to three days in the hospital before going home.

After ankle replacement surgery, most healthy patients remain in the hospital from two to three days. However, some patients may require a longer stay in the hospital due to pre-existing medical problems or medical issues that may arise after surgery. There are small risks of infection after major ankle surgery. Though it happens in less than five percent of patients, your ankle’s blood supply may not be as good as other body parts and you may be prone to infection. Because you cannot see your incision inside the cast, it is important to notify your physician if you feel discomfort. Patients are not sent home until they demonstrate that they are safe to go home. Each patient is different and may have different criteria for being able to go home. In general, the length of your hospital stay is based on the amount of pain management you need. You will receive fluids and medications, through an intravenous (IV) line until you can drink an adequate amount of fluids without nausea or vomiting. Most patients can drink something the night after surgery and eat something more substantial the following morning. Be sure to ask for pain medications as soon as you feel pain coming on, because medications are most effective on pain that is building rather than on pain that is already present. Your nurses will not give you more than your doctor has prescribed and what is considered to be safe. Physicians prescribe crutches to help you move around without putting weight on your ankle. The day after surgery, you typically meet a physical therapist who teaches you about using crutches and helps you walk around the hospital. You will likely be unable to bear weight on your ankle for about six weeks after surgery. Your physician may obtain X-rays of your heel and ankle before you leave the hospital. You should arrange for someone to drive you home when you are discharged.

For four to five days after ankle replacement surgery, you should keep off your feet, elevate your ankle above the level of your heart, and move around the house as little as possible. You should try to rest and avoid too much movement for at least a week. Crutches usually are prescribed for about eight weeks so you can keep your body weight off your ankle. Resting with your ankle elevated helps blood drain away from your ankle and can control swelling. The more weight you put on your ankle, the greater your chances of disrupting the healing process in your anklebones. Household tasks that require you to be on your feet may be difficult for the first six weeks. It can be helpful to have someone around the house to help with any physical chores. You will be instructed to return to your physician’s office for regular check-ups after surgery. The dressing covering your wound inside your post-surgery ankle splint usually does not need to be changed until the splint is removed about ten to 14 days after surgery. A typical follow-up schedule after you leave the hospital may go as follows:

   Ten to 14 days – Stitches are removed and your ankle is put into a removable cam walker that can be worn inside your shoes. Range of motion exercises begin after about two weeks. Although ankle replacement is a major surgery, it is good to move your ankle to circulate blood. However, you need to continue using the crutches and not bearing weight on your ankle for a total of about six weeks after surgery.

   Six weeks after surgery – Return for a check-up. Possibly receive X-rays. If your physician sees signs of healing in your ankle, you usually can start bearing some weight. Weight bearing increases as you can tolerate the pain.

   Eight weeks after surgery – After two weeks of partial weight bearing on your prosthetic ankle, you may be comfortable bearing your body weight without crutches or other support.

Stretching and strengthening exercises are begun two weeks after surgery and gradually advance as ankle soft–tissues heal and as you can tolerate the activities. The length of your rehabilitation may vary according to your age, other medical problems, general health, and healing potential. In general, most patients can feel strong again in their ankle after a month or two of physical therapy. Physical therapy is beneficial after surgery to teach you the proper way to move around as instructed by your surgeon with the aid of a walker, crutches, or other assistive device. Many patients prefer an easier–to–use walker or a "quad cane," a special type of cane attached to a broad base with four small "feet" that is more stable than a standard cane. The key is to work with your therapist to find an appropriate balance between low–impact and weight–bearing activities. Too much high–impact activity and exercise can decrease the life expectancy of your artificial ankle, but some weight bearing is needed to maintain bone density. In conjunction with a healthy diet, exercise also can help you lose weight, which reduces stress on your artificial ankle.

STRETCHING

Your physical therapist will help you safely regain range of motion of your new artificial ankle. Some patients receive pain relief from daily stretching.

AEROBIC EXERCISE

Physicians generally recommend at least 30 minutes of low–impact exercise a day for patients with arthritis. Walking and swimming usually are recommended. You should avoid activities that put stress on your ankles, like running and strenuous weight lifting. Most of the strength you need to feel stable on your feet can be achieved simply by walking and weight bearing. Try to walk a few blocks a day. Increase the length of your walks as your ankle feels stronger.

STRENGTHENING

Strength training usually focuses on moving light weights through a complete, controlled range of motion. Your physical therapist typically teaches you to move slowly through the entire motion with enough resistance to work your muscles without stressing your prosthesis. Once your physical therapist has taught you a proper exercise program, it is important to find time each day to perform the prescribed exercises.

After ankle replacement, you no longer have cartilage in your ankle so arthritis can no longer trouble your ankle. But your new joint is not the perfect bionic ankle. You need to take steps to prevent damaging your prosthesis. It is always important to avoid ankle injuries. Falls and trauma to a total ankle replacement may damage your prosthesis and require more surgery. Unlike the knee and hip, surgeons have greater difficulty performing revision surgery to repair your ankle replacement. Ankle fusion surgery is usually the only recourse if your artificial ankle is damaged. The most common cause of damage to your ankle replacement is loosening of the components from your anklebone or shinbone due to stress, overuse, or osteolysis (bone absorption around the components). You will probably not be able to run on your prosthetic ankle, which makes returning to sports difficult. However, your ankle pain should go away and you will be able to walk around town, through the park, and in general be comfortable getting around. You should be able to play golf and do other light, walking activities. To help prevent damage in your artificial ankle, physicians generally recommend that you take the following precautions:

   Avoid anything that makes pain last for more than an hour or two.

   Perform controlled range of motion activities that do not overload the joint.

   Avoid heavy impact on your ankle during everyday activities.

   Gently strengthen the muscles in your leg and foot to help protect the bones in your ankle.