Ankle surgery: Treatment for advanced arthritis

Overview

Ankle surgery is a procedure to treat arthritis when pain and mobility are no longer helped by other treatments. These nonsurgical treatments may include physical therapy, medicines, and supportive shoes or braces.

The type of ankle surgery needed depends on the kind of arthritis, the condition of the joint and the impact of arthritis on daily activities. The most common surgeries for ankle arthritis either fuse bones in the ankle together or replace the ankle joint.

Why it's done

Ankle surgery is done when other treatments for arthritis don't improve pain and mobility in the ankle joint.

The ankle joint is the site where three bones meet:

• The shinbone, called the tibia.
• The smaller outer bone of the lower leg, called the fibula.
• A bone, called the talus, that sits at the top of the foot and connects to the leg bones.

The ends of the bones are covered in cartilage. This slippery tissue allows the bones to move smoothly in the joint. The joint is covered in a thin tissue called the synovium. It produces a fluid that lessens friction in the joint.

The most common types of arthritis in the ankle are:

• Post-traumatic arthritis. This is the breakdown of cartilage following an injury, such as a sprained ankle or a broken bone in the lower leg, ankle or foot.
• Rheumatoid arthritis. This is swelling and pain in a joint caused by the immune system attacking the synovium, usually in several joints of the body. Over time the condition damages and changes the shape of bones in a joint.

Treatment goals

Ankle fusion. The goal of ankle fusion, also called arthrodesis, is to relieve pain by getting rid of movement in the joint. Fusion causes one or more bones to grow together as a single bone. The talus may be fused to one or both of the leg bones.

Ankle replacement. The goal of ankle replacement, also called arthroplasty, is to relieve pain and allow for a better range of motion with an artificial joint.

Risks

For surgeries in the ankle, complications may include:

• Changes to ligaments that can cause the foot and ankle to be stiff after recovery. Or the foot and ankle may not be stable.
• Nerve damage that results in numbness, weakness or pain.
• Infections in the ankle joint or wound.
• Blood clots that can increase the risk of blocked blood vessels.

Other complications are more specific to the type of surgery.

Fusion. Complications may include:

• Failure of bones to join together completely.
• Irregular alignment of fused bones that affects how a person walks or moves.
• Increased risk of arthritis in the foot.
• Broken screws in the bone.

Joint replacement. Complications may include:

• Delayed wound healing or infection.
• Loosening of the connection between bone and the artificial joint.
• Continued pain.

You may not be able to have either surgery if you have factors that increase the risk of poor outcomes. These include:

• Weakened ankle ligaments.
• Significantly misaligned ankle bones.
• Poorly managed diabetes or high blood pressure.
• Nerve damage from diabetes or other conditions.
• Bone disease, called osteoporosis, that weakens bones.
• Obesity.
• Smoking.

How you prepare

Food and medicines

Your healthcare team might advise you to stop taking certain medicines and dietary supplements before your surgery. You are instructed not to eat anything after midnight the day before your surgery.

Prepare for your recovery

For several weeks after the procedure, you need to use crutches or a walker. Arrange for them before your surgery. Make sure you have a ride home from the hospital and help with everyday tasks, such as cooking, bathing and doing laundry.

To make your home safer and make it easier for you to move around, consider the following:

• Create a living space on one floor to avoid climbing stairs.
• Get a stable chair with a firm seat cushion and back.
• Get a footstool to raise up your leg while sitting and several pillows to raise your leg while lying down.
• Arrange for a toilet seat riser with arms.
• Install safety bars or a secure handrail in your shower or bath.
• Get a stable bench or chair for your shower.
• Remove loose rugs and cords.

What you can expect

Before surgery, you put on a hospital gown. You are given a general anesthetic to put you into a sleeplike state.

During

Ankle fusion. The surgeon removes the cartilage and synovium from the joint and roughens the surfaces of the bones where they meet. The surgeon uses screws, plates, rods or pins to join the bones. This allows the bones to grow together over time to make one solid bone rather than a movable joint.

Ankle replacement. The surgeon removes the cartilage and synovium from the joint. The surgeon then removes a portion of bone from the bottom of the tibia and top of the talus. An artificial joint is screwed into each of the bones.

After

During your recovery time in the hospital, your healthcare team focuses on the following:

• Pain management. You are asked about your level of pain. You receive medicine and use ice packs to manage pain.
• Physical therapy. Your team helps you get up and learn to walk with crutches or a walker to keep weight off your ankle.
• Occupational therapy. Your team helps you practice daily tasks, such as dressing, that may be more difficult during recovery.
• Raising your ankle. When you are resting, your ankle is raised above your heart to prevent swelling.
• Maintaining blood circulation. Your health care team helps you get up and move to help maintain blood circulation. A support stocking worn on the foot not operated on promotes circulation.
• Breathing exercises. Your team asks you to cough and breathe deeply every hour to help clear your lungs.

Your care team gives you written instructions about how to continue this care after you leave the hospital. During the recovery period, you wear a cast, brace or boot — or some combination of these.

During follow-up appointments, your surgeon tells you when you can put weight on your ankle and when you can return to typical activities. You may have physical therapy to strengthen muscles and to improve balance and stability while walking.

A full recovery may take 4 to 12 months.

Results

Both ankle fusion and ankle replacement are generally effective in relieving pain and improving mobility. With ankle fusion there is limited range of motion in the ankle. There is greater range of motion with ankle replacement.

You can participate in sports and recreational activities after recovery, but it will likely not be at the same level before having arthritis. Exercise may be limited to activities such as walking, cycling, swimming, hiking and weight training. You'll likely be advised not to do high-impact sports that involve running or jumping.

Research has not shown a significant benefit of one procedure over the other. Both have similar patient-reported outcomes. They have similar rates of complications. But research does guide surgeons on whether ankle fusion or ankle replacement might be a better option for a person's particular needs.