If severe ankle pain affects your quality of life, then ankle replacement surgery may be an effective pain relief option for you.
Since the ankle is a weight-bearing joint that absorbs the body's full impact, pain from an injured or diseased ankle can be especially severe and debilitating. Learning more about ankle surgery options including ankle replacement and ankle fusion may be the first step towards reducing your pain and restoring your mobility.
If ankle arthritis is keeping you from participating in the activities you love, you may be adapting your life to cope with pain and decreased mobility.
Learn more about treatment options for severe ankle arthritis and pain.
Learn more about the technology of ankle implants.
Learn more about Ankle Sprains and Surgery.
Primary Ankle Fusion Surgery
An ankle fusion is a surgical procedure usually done when an ankle joint becomes worn out and painful, or degenerative. Ankle fusion is sometimes called ankle arthrodesis.
The most common cause of degenerative arthritis of the ankle is an ankle fracture. Many years after a serious fracture, the joint may wear out and become painful. A joint that is out of balance after it heals from a fracture can wear out faster than normal. Other types of arthritis can lead to a painful ankle joint as well. Rheumatoid arthritis can destroy the ankle leading to a painful joint.
Why Ankle Fusion Surgery
An ankle fusion removes the surfaces of the ankle joint and allows the tibia to grow together, or fuse, with the talus. Before the development of artificial joints this was the primary operation available to treat an extremely painful joint. In some cases, fusion is still the best choice.
Ankle fusion is a good alternative for treating a worn out joint. This is especially true if the patient is young and very active. An ankle fusion, if successful, is not in danger of wearing out like an artificial ankle. A fusion keeps the ankle joint from moving during walking and other activities, therefore ankle fusion adds stress to adjacent joints.
About Ankle Fusion Surgery Procedure
Several different operations have been developed to perform an ankle fusion. The basic procedure in each operation remains the same, however. The most common way that an ankle fusion is done is by making an incision through the skin to open the joint. Once the joint is opened, the articular cartilage surfaces of the joint must be removed.
Once the articular cartilage is removed on both sides of the joint, the body will try to heal the two surfaces together just as if it were fractured or broken.
Once the cuts are made the bones must be held in place while they fuse. This can be done using large metal screws and metal plates if necessary. The screws are usually under the skin and are not removed unless they begin to rub and cause pain.
In some cases, especially if the fusion is being done because of an infection or a failed initial fusion, an apparatus called an 'external fixator' is used to hold the bones together while they heal. This apparatus has metal pins that are inserted through the skin and into the bone. The metal pins are connected to metal rods and bolts outside the skin that hold the bones in position while the ankle fuses. The fixator is removed after the bones have healed, usually in twelve to fifteen weeks.
Some surgeons have performed ankle fusions with the help of the arthroscope. The arthroscope is a miniature TV camera that is inserted into the ankle joint through a small incision. Using the arthroscope to watch, other instruments are inserted into the ankle joint to remove the cartilage surface. The cartilage surface is removed using a small rotary cutting tool. Once the surfaces are prepared, screws are placed through small incisions in the skin to hold the bones together as they heal, or fuse. This procedure is not significantly different from the open procedure except that the incisions are smaller.
As with any medical treatment, individual results may vary. Only an orthopaedic surgeon can determine whether an orthopaedic implant is an appropriate course of treatment. There are potential risks, and recovery takes time. The performance of the new joint depends on weight, activity level, age and other factors. These need to be discussed with your doctor.
Ankle Replacement Surgery
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.
Cutting the Bones
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.
Next, the top of the talus is cut so the metal talar component can be inserted.
Inserting the Implant
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.
Inserting the Screws
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 Incision
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).
Other Surgical Procedures
Because ankle replacement implants must be aligned properly to function correctly, additional soft tissue surgeries may be required. These procedures can re-establish the proper ligament tension and ankle alignment required for proper range of motion and walking. Your surgeon can better explain the need for these surgeries based on your individual need.
Ankle Fusion Implant
Tibiotalocalcaneal (TTC) Fusion
Are you considering ankle fusion surgery? If so, your surgeon may suggest a procedure called tibiotalocalcaneal (TTC) fusion.
Tibiotalocalcaneal fusion differs from a traditional ankle fusion. In traditional ankle fusion surgery, the ankle joint is removed, allowing the tibia (shinbone) to grow together, or fuse, with the talus bone (the first large bone of the foot).
In TTC fusion, the tibia, talus and calcaneal bones are fused together using sophisticated metal implants called intramedullary nails (intradmedullary means within the bone). Using this system, surgeons can adapt the implant for the specific size and anatomy of each patient, and help achieve optimum alignment of the bones of the foot and ankle.
How Ankle Implant Works?
In TTC surgery, the surgeon inserts the ankle implant into the patient’s foot and ankle, through an incision in the bottom of the foot. The ankle implant is slightly larger than the diameter of a pencil and from 6 to 10 inches long. Special holes in the side of the implant accommodate five screws used to secure the implant in the patient’s ankle and shin bone. When inserted, the implant’s purpose is to firmly secure (or fuse) the heel and the ankle joints much like a nail secures two pieces of wood.
Who is a Candidate for TTC Fusion Ankle Implant?
TTC fusion is ideal for patients with advanced osteoarthritis or rheumatoid diseases, injuries from accidents, ankle deformity, and complications from diabetes (Charcot), as well as to treat conditions such as talar avascular necrosis.
TTC is generally used in advanced cases (called “end-stage ankle disorder”) where more conservative treatments like medication have not worked. It is also indicated for some patients who have had prior surgeries with inadequate results. Only a surgeon trained in foot and ankle can determine whether a patient is a candidate for TTC fusion.
The TTC Fusion Ankle Replacment Implant
The decision to proceed with tibiotalocalcaneal (TTC) fusion surgery should be made jointly by you and your doctor. If the decision to proceed with surgery is made, there are several things that may need to be done.
Your surgeon will reexamine your foot and ankle and your clinical test results, including X-rays.
Your surgeon may suggest a complete physical examination by your medical or family doctor.
You may also see a physical therapist.
An assessment will be made of any needs you will have at home after you are released from the hospital.
About TTC Fusion Surgery Procedure
On the day of surgery, you will probably be admitted to the hospital in the morning. For TTC ankle fusion, you will be placed under general anesthesia, or a spinal type anesthetic. The procedure begins by accessing the diseased ankle and preparing it for the implant.
Your doctor will provide detailed instructions to let you know what to expect after surgery. Typically, a short leg cast will be applied during your first return visit after surgery. You’ll be advised to keep your weight off the ankle for about six weeks. Then, X-rays may be used to examine the success of the fusion process – the degree to which the bones of the ankle joint and the implant begin to fuse together as a result of the surgery. A cast may be applied for an additional four to six weeks or until the fusion is complete. Once healed, the patient is typically instructed to wear a solid-ankle, cushioned-heel shoe with a rocker-sole attachment.
When is surgery necessary for an ankle sprain?
Surgery is only very rarely part of the acute treatment of an ankle sprain. Rather, patients who require surgery usually have recurrent ankle sprain injuries, and persistent ankle pain. These patients have ligaments that were torn and have not healed properly, leaving the ankle joint too loose.
What surgery is performed for the treatment of chronic ankle sprains?
Patients who have chronic, recurring ankle sprains usually have loose ligaments that need to be tightened. The most commonly performed surgery to repair these ligaments is called a Brostrom repair. In this surgery, the ligaments on the outside of the ankle, are tightened, and the thick tissue around these ligaments, called the retinaculum, is advanced. This procedure tightens the loose tissue, preventing the ankle from being unstable.
How do I know if my ankle is unstable?
Instability of an ankle joint can be detected both by careful physical examination as well as special x-rays tests.
On physical examination, your doctor can stress the ligaments that were injured to feel how tightly they have healed.
- By comparing to your opposite ankle, your doctor can get an idea of how loose the injured ankle is compared to the normal ankle.
- X-ray Tests
A x-ray test can also be performed to assess the stability of the ankle. By placing a stress on the ligaments, and taking an x-ray, your doctor can see if the bones are held together tightly enough.
What other problems could be causing these symptoms of chronic ankle pain?
There are a number of causes of chronic ankle pain, and it is important to ensure the cause of yours before embarking on a treatment plan. Causes of chronic pain following ankle sprains include:
- Incomplete rehabilitation
- Injury to other ligaments
- Subtalar ligament injuries
- Syndesmosis ligament injuries
- Cartilage injury (OCD)
- Nerve damage
- Reflex sympathetic dystrophy
- Peroneal tendon dysfunction
This is not a comprehensive list, just a few of the potential causes of chronic ankle pain. Therefore, if you have persistent pain after an ankle sprain, a careful examination is necessary to ensure you have the proper diagnosis. Only then can treatment focused on the problem can begin.