Ankle Fusion Surgery: Everything You Need to Know

Ankle fusion, also called ankle arthrosis, is a surgical procedure used to treat intolerable, motion-limiting ankle pain that's due to severe degenerative ankle arthritis. This surgery involves removing the inflamed cartilage and surgically joining two or more ankle bones together.

Ankle fusion is done to decrease pain, but it's important to know that this intervention also permanently limits ankle mobility.

Man on crutches in hospital
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What Is Ankle Fusion Surgery?

Ankle fusion surgery clears away swollen and degenerating cartilage in the ankle joint that's causing pain.

Once the inflamed structures are removed, the ankle bones are positioned so they can fuse together to form an immobile unit that doesn't depend on cartilage for stability.

Ankle fusion surgery can be performed with an ankle arthroscopy, which uses a small incision and the aid of a camera for visualization, or it can be an open procedure. The surgery is done with local or spinal anesthesia.

The decision regarding whether you will have a minimally invasive arthroscopic surgery or an open procedure depends on the structures in your ankle and the surgical accessibility with either approach.

Contraindications

Ankle fusion surgery is an option for people of all ages, but there are some contraindications.

If you have an infection of the joint or if you're a smoker, you have a high risk of developing complications from surgery.

You might not be able to have this procedure if you are at risk of bleeding or blood clots due to a blood clotting disorder. And if you are at risk of impaired healing due to disrupted blood flow, you might not be a candidate for ankle fusion surgery.

Potential Risks

Ankle fusion surgery comes with several risks you should consider. Short-terms risks include:

One of the long-term risks of ankle fusion surgery is problems with bone healing, which can lead to foot instability or altered ankle bone structure and interfere with your ability to walk painlessly after recovery.

Purpose of Ankle Fusion Surgery

Pain relief is the goal of ankle fusion surgery. Arthritis is a chronic inflammatory disease of the joints, and associated inflammation and cartilage degeneration can lead to severe pain and joint swelling.

Ankle fusion surgery may be able to diminish pain to the point that you are able to decrease your use of pain medications and get more physically active.

Other Treatment Options

Other options can help achieve the goals of ankle fusion. They're worth discussing with your doctor so, among other things, you can feel confident about your choice to proceed with surgery.

Many people who have mild or moderate arthritis of the ankle can find relief with non-surgical options. Anti-inflammatories, a hot or cold pack, an ankle wrap, or an ankle support can all potentially reduce painful swelling and inflammation.

Because ankle fusion reduces the range of ankle motion, these more conservative treatments should be tried (and proven to provide inadequate symptom relief) before surgery is considered.

Ankle replacement surgery is an option that's often weighed against ankle fusion surgery.

In general, ankle fusion surgery is preferred if you don't want the risk of potentially having another surgery to replace a worn-out ankle replacement (they have limited lifespans).

On the other hand, ankle replacement surgery is often recommended if you want to maintain joint flexibility.

How to Prepare

Since ankle arthritis is relatively uncommon in comparison to hip arthritis and knee arthritis, your doctor will want to confirm the cause of your pain. Often, trauma to the ankle joint, such as an ankle fracture, might precede very painful ankle arthritis.

You will have some diagnostic tests such as an ankle X-ray or magnetic resonance imaging (MRI) as part of this work-up.

Location

You will have your procedure in a surgical suite or operating room. You will have to stay in the hospital for a day or so immediately after your surgery.

What to Wear

You should wear comfortable clothes that you can easily change out of. Since you will have a cast on your affected ankle after your surgery, it's a good idea to have a comfortable shoe to wear on the other foot.

Food, Drink, and Medications

You should not eat or drink after midnight the night before your test.

Your doctor might tell you to adjust your medications for a few days before your surgery. For example, you might need to stop taking certain blood thinners or anti-inflammatories. However, don't adjust your medications without talking to your doctor first.

What to Bring

Be sure to bring your health insurance information and a form of identification. Don't bring valuables or wear jewelry.

It is important that you bring a change of clothes that you can easily put on over your cast when you are ready to leave the hospital after surgery, such as a skirt or wide-legged pants or shorts.

What to Expect on the Day of Surgery

When you go in for your surgery, your surgeon will examine your foot to make sure that there are no major changes since it was last evaluated. You might have another imaging test on the day of your procedure to help guide your surgery.

You may also have blood tests, such as a complete blood count (CBC) and a test of your electrolytes, to ensure that you don't have an acute medical problem that might contraindicate your surgery, like high blood sugar or evidence of an infection.

Before the Surgery

Before your surgery starts, you will have your vital signs checked, including your respiratory rate, heart rate, and temperature.

You will have anesthesia, which might be local anesthesia with a nerve block or spinal anesthesia. This will involve injection of medication that prevents you from feeling pain in your ankle.

Your ankle will be cleansed with a sterile solution and a drape will be placed around the area to prevent contamination of the surgical site.

During the Surgery

If you're having an arthroscopic joint procedure, your surgeon will make a small incision and insert a thin tube equipped with a camera into your ankle.

If you will have an open procedure, your surgeon will make a larger incision and can look directly at the structures in your ankle.

Regardless of the surgical approach used, your surgeon will then perform a debridement, which is the removal of cartilage and debris from your ankle.

Once your ankle is cleared of degenerative material, your surgeon will create a level bone surface on the top and bottom of the ankle joint to prepare for the optimal alignment of the bones. Then the bones will be placed in the proper position for the fusion.

Finally, metal implants—usually large screws—are used to hold the bones in this position. This hardware is placed into the bones, typically with an accessible portion positioned to protrude from the skin so it can be removed later on.

Metal hardware (screws, pins, rods, etc.) is used to maintain surgical placement of the individual ankle bones.

After surgery, bone cells grow, fusing individual ankle bones into one structural unit. The hardware isn't needed after bone fusion is complete—a process that will take weeks or months.

Once your surgeon is finished working on your ankle joint, the arthroscope or any other surgical tools will be removed. If you have had a great deal of edema, you might have a small drain placed in your ankle to collect fluid and prevent buildup.

The area will be cleaned again and incisions closed with sutures or staples. A sterile bandage will be placed over the area, and your ankle will be wrapped with gauze and a compression bandage.

You will also have a hard cast or a splint placed to immobilize your foot so the bones won't move and to reduce swelling-induced pain.

After the Surgery

After your procedure, your foot will be elevated while you lie in a hospital bed. You will be observed in a post-operative area for signs of pain, bleeding, infection, or drainage from your wound.

If you have a drain, it will be monitored for concerning such as excess bleeding or infectious fluid.

Your medical team will ask you about your pain and might give you pain treatment while you are in the hospital.

You will likely have to remain in the hospital for a day after your procedure. During this time, your medical team will show you how to use crutches or a walker, which you will probably need once you have been discharged.

Once it's determined that you are healing well and your pain is well managed, you will be sent home with instructions and a prescription for pain medication to take if needed.

Recovery

You'll need follow-up appointments with your doctor so they can evaluate your recovery. Your medical team will evaluate your ankle to see if it is healing well and to look for any signs of complications (such as a blood clot, infection, or inadequate wound healing).

You should also describe any pain you have and make sure you tell your doctor how much pain medication you have been using. This will help them assess your healing, whether you are having more pain than expected, and possibly adjust your medication if needed.

Most of the time, all of your surgical hardware will be removed at one of your follow-up appointments, but your doctor might leave one or more pieces in place for joint stability.

For example, if your ankle joint was severely injured prior to your surgery or if your joint healing is incomplete, you may need the metal implants to remain long term or permanently.

Removal is done in the office with a very rapid pull on the hardware so that each screw, pin, or rod is pulled out in one piece. This can be uncomfortable or painful for a few seconds, but pain medication isn't typically necessary.

Over time, the bone will grow to fill the space that the hardware once occupied.

Healing

As you are recovering at home, be sure to look out for signs of infection (e.g., warmth, redness, or oozing from the foot) or wound healing problems, such as wound dehiscence (separation). Call your doctor if you have any concerns.

Get emergency medical attention you have severe swelling, pain, redness, pale or blue discoloration, or loss of sensation of your foot. These issues can signal a severe infection or a blood clot.

Coping With Recovery

In the weeks after your surgery, you might feel some discomfort. Your medical team will give you instructions regarding pain control and management of swelling. This can include the use of pain medications and/or ice packs.

You will most likely have to stay off your feet for eight to 12 weeks after your surgery. Thereafter, you will be able to walk while wearing a boot or cast to protect your ankle.

Talk to your doctor or physical therapist about a realistic target number of steps to take each day. While it's important to start being active again once you get the green light, remember to also listen to your body and avoid overdoing it.

Your medical team will let you know when you can go without your cast/boot and start to put weight on your foot again. Complete healing of an ankle fusion may take four to six months.

Long-Term Care

You will probably need modified or specially-designed shoes that have a slip-resistant sole and/or provide ankle joint support to prevent twisting. Your doctor or therapist will let you know which type of shoe you should buy or whether you need custom shoes.

Additionally, because ankle fusion limits motion, you can develop pain or arthritic changes in either foot down the road as you place uneven pressure on your feet while walking. A splint or other supportive foot device may help you avoid these issues.

Possible Future Surgeries

Some people can develop bone deformities after having ankle fusion surgery. This can cause severe pain and disability requiring surgical revision.

Similarly, if you develop a nonunion, which is impaired healing of the bone, your bones might be unstable. You might need a repeat surgery to repair your ankle joint.

Nonunion can happen to anyone, but factors that increase your risk include:

  • Older age
  • Smoking
  • Cancer
  • Malnutrition

Smokers have a much higher rate of nonunion and should carefully consider the risk of this possible complication. Smoking cessation can be helpful in lowering the chance this occurring.

And if you develop severe arthritis pain that doesn't improve with conservative management in another joint, you might need surgical treatment to manage the issues in that joint as well.

Lifestyle Adjustments

After ankle fusion surgery, the permanent limitation of foot movement could mean you can't walk as much as you used to. The lack of flexibility in your ankles will also inhibit your ability to run, bike, and participate in certain sports that require ankle flexibility.

However, you can walk as long as it doesn't cause discomfort. You can also participate in sports and physical activities like weight lifting, rowing, core training, and aerobic exercises that don't rely on running or jumping.

A Word From Verywell

You'll need to consider a number of factors as you decide whether ankle fusion surgery is right for you. Issues that should play a role in your decision include:

  • Limitations to your activity level
  • Use of pain medications
  • Readiness to go through recovery

If you decide to have ankle fusion surgery, you should know that it's generally considered a safe procedure, but you will have to adjust to the permanent limitation of your ankle motion.

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Article Sources
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