Total Ankle Replacement

Overview
Total ankle replacement (also known as “total ankle arthroplasty”) is a surgical procedure for patients with arthritis of the ankle. Arthritis causes wear and tear of the ankle joint, leading to bone-on-bone contact with limited motion and activity. TAR surgery can relieve pain while maintaining motion in the ankle joint and is a viable alternative to an ankle fusion (arthrodesis) which can relieve pain but completely eliminates motion in the joint.

Characteristics of the Ankle
The ankle joint is a hinge type joint comprising the three bones of the lower leg. The first bone in the ankle is the talus which contacts the second bone called the tibia, forming the tibiotalar joint. The third bone is the fibula and is the small bone on the outside part of the ankle. Held together with ligaments, the ankle joint contains cartilage that absorbs shock and allows the ankle to move. Pain-free motion and full function of the ankle joint require coordination of the ankle bones as well as the soft tissue surrounding the joint. The joint can lose its cartilage covering through post-traumatic damage, infection, or daily wear and tear. Radiographs (X-rays) will show a narrowed joint with other arthritic changes the surgeon will evaluate. Typically, advanced imaging will be ordered to determine specific characteristics of the arthritic ankle joint.

Alternatives to TAR Surgery
Treatment approaches for an arthritic ankle are based on how long the pathology has been present and the amount of pathology to the soft tissue as well as arthritic conditions to the joint. Conservative treatment options are explored prior to surgical intervention.

Ice

Putting an ice pack on your foot/ankle for 20 minutes several times a day helps reduce inflammation. Place a thin towel between the ice and your foot; do not apply ice directly to the skin.

Medications

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to reduce pain and inflammation.

Orthotic devices

Custom or over-the-counter orthotic devices that fit into your shoe may help improve the underlying mechanical structure of the foot/ankle.

Bracing

May reduce pain, assist with ambulation, assist with motion control of the ankle, and help prevent further deformity.

Physical therapy

Exercises to strengthen the muscles may provide greater stability and help avoid injury that could worsen the condition.

Stretching exercises

Exercises that stretch out the calf muscles.

Limit activities

Reduce extended physical activities.

Shoe modifications

Wearing supportive shoes with a rigid heel, good arch support, and a slightly raised heel reduces stress on the foot/ankle.

Which Patients Should Consider Total Ankle Replacement Surgery?
Surgery is recommended when pain/discomfort to the foot/ankle interferes with normal daily activities. When non-surgical methods have been explored and the pain still cannot be controlled, it is appropriate to consider surgery.

Which Patients Should Avoid a Total Ankle Replacement?
TAR is typically not suitable for patients with significant deformities or dead bone in the talus (avascular necrosis), prior or current infections of the ankle, significant lower extremity neuropathy, inadequate muscle function, poor blood flow of the extremity, or inadequate soft tissue envelopes. Elevated weight and BMI of patients also require caution regarding total ankle replacement surgery.

Surgical Options
Surgical options for an arthritic ankle joint include fusion (arthrodesis) and total ankle replacement (or total ankle arthroplasty). Fusion is the connection between the tibia fibula and talus. This surgery is excellent for pain relief but sacrifices the motion that normally occurs through the ankle. The talus is permanently fixed to the tibia. Total ankle replacement is a surgical procedure that has been available for more than 25 years. Although it has not been as successful as hip and knee replacement surgery, successful ankle replacement continues to demonstrate improvement due to improved implants, skill, and technique. Current literature indicates as high as 90 percent patient satisfaction rate. A highly skilled foot/ankle surgeon can help in making the decision about whether you are a candidate for total ankle replacement.

Risk

A majority of the total ankle replacement surgeries move forward without risk. However, risks include but are not limited to:

Infection
Damage to nerves, blood vessels or tendons/ligaments
Fracture of the bone (tibia, fibula, talus)
Failure of the bone to incorporate (heal) to the ankle replacement implant
Failure of the bones to incorporate (heal) together
Wound healing
Blood clots

There are also rare cases of complex regional pain syndrome reported from any foot ankle surgery.

Before Surgery

Before any surgery is planned and coordinated, medical conditions involving the heart, lung, or kidney need to be evaluated by a primary care physician and/or specialists. Infections or history of infection anywhere in the body need to be treated and/or investigated prior to surgery. Smoking should be discontinued immediately. The foot/ankle surgeon should be made aware of any allergies or medications that you might be taking.

Length of Surgery

Depending on the complexity of the surgery, the length of time can range from one to three hours.

During Surgery

The incision for the total ankle replacement will be primarily in the front of the ankle with the possibility of smaller incisions on the inside and outside of the ankle. The tibia and talus bones are replaced with a metal surface and an ultra-high molecular weight (high-density) polyethylene spacer (plastic).

After Surgery

When patients wake up from surgery, there will be dressings on the foot/ankle and a splint to protect the swelling. Occasionally, there will be a drain to assist with mild bleeding from the surgery. Activities will be limited for 6-12 weeks.

Pain

Patients are given both intravenous and oral narcotics to decrease the pain postoperatively. If an anesthesia block is given, the foot/ankle may remain numb for 24-48 hours after surgery.

Hospital Stay

Patients will be admitted to the hospital after the surgery is complete and stay in the hospital for two to three days until pain is controlled.

Hospital Discharge

Patients are discharged to home from the hospital when they have been evaluated and cleared by physical therapy to safely ambulate with crutches, walker, or knee scooter and when their pain is controlled.

Follow-up

Patients will return to the clinic one week after being discharged from the hospital for a dressing change. At two weeks, the sutures will be removed. Weight bearing on the operative ankle will be determined on a case-by-case basis, depending on the amount of correction of the deformity that was necessary as well as when the incision completely heals. Physical therapy will be recommended once the weight bearing process begins.