What Is Ankle Replacement Surgery?

Whether you’re walking, climbing stairs, or doing your household chores, your ankle plays a key role in allowing you to go about your day. This is because this important region, which is made up of two joints in the rear of the foot (the talocrural joint and the subtalar joint), is subjected to huge amounts of force anytime you are on your feet.

Over time, certain conditions can cause the smooth articular cartilage that coats the end of the bones in your talocrural joint (the tibia, fibula, and talus) to begin to thin or wear away. This articular degeneration can cause a lot of pain and can significantly limit your daily function.

Fortunately, a total ankle replacement surgery (also known as a total ankle arthroplasty) can often be performed to alleviate these ankle symptoms. This procedure involves replacing the damaged portion of the talus and tibia bones with parts made of metal, plastic, and other medical-grade compounds such as polyethylene and thermoplastic polymer.

While not appropriate for everyone, this surgery is often very effective in alleviating pain and improving the function of the ankle. This article will explain the purpose of this procedure and what to expect.  

Purpose of Surgery

A total ankle replacement is generally indicated for end stage arthritis and severe ankle pain. This is especially the case when there is significantly decreased functioning when the smooth, articular coating of the talus and tibia bones wears away.

This wearing away can be caused by several unique issues, including:

• Osteoarthritis: The most common type of arthritis, in which wear and tear cause cartilage (the flexible tissue that cushion the joints) to break down
• Inflammatory arthritis (such as rheumatoid arthritis or psoriatic arthritis): Conditions in which the body's immune system attacks its own tissue
• Post-traumatic arthritis: A condition that develops after a fracture or other injury

Surgical Technique

To perform a total ankle arthroplasty, an orthopedic surgeon (a specialist of the musculoskeletal system) and/or a podiatrist (a specialist in conditions of the feet) generally takes several steps, including:

1. An incision is made in the front part of your ankle and lower leg.
2. The muscles and soft tissue (any other tissue other than bone) in the region are moved to allow access to the ankle bones.
3. The inferior (bottom) portion of the tibia and superior (top) portion of the talus are removed and resurfaced with prosthetic metal pieces.
4. A plastic spacer is secured in between the bones to allow them to move smoothly on one another.
5. The incision in your skin is closed up using stitches or staples.

Contraindications

While a total ankle replacement is generally effective in treating debilitating arthritis in the talocrural joint, it is not always an option.

Unfortunately, in certain situations, this procedure is contraindicated (not advised) due to a lower chance of success. This is true for individuals with:

• Skeletal immaturity (such as children who are still growing)
• Active infection
• Large anatomical or bony deformities in their ankle
• Misalignment of the knee
• Neuromuscular diseases (such as multiple sclerosis and muscular dystrophy)
• Charcot foot (a rare condition in which bone weaken and reform, causing deformity)
• Obesity
• Significant neuropathy (damage to the nerves)
• Poor skin and soft tissue quality
• Poor bone density or the loss of blood flow to the ankle bones (avascular necrosis)
  

How to Prepare

Once you and your surgeon decide to proceed with a total ankle arthroplasty, there are several important steps you can take to help you prepare for your procedure. These include:

• Arrange your home to be as clutter free as possible. If your home allows it, plan to utilize a bedroom and bathroom on the first level to avoid the stairs.
• Discuss any medications you are taking with your surgeon in case some need to be discontinued before your procedure.
• Coordinate transportation to and from your surgery with a family member or friend.
• Plan for groceries and other necessities to be delivered in the first few weeks after your ankle replacement until you are cleared to drive.
• Try to stop smoking or using other forms of tobacco to maximize your body’s healing ability.
• Obtain a walker or set of crutches to help you move around after the surgery, before you are allowed to place weight on your foot.

What to Expect on the Day of Surgery

It is normal to feel some anxiety and uncertainty on the day of your surgery. Knowing what to expect can help keep you calm before your procedure.

On the day of your total ankle replacement, plan to shower and dress in loose, comfortable clothes before going to the surgical center. Avoid using any lotions over the ankle being operated on.

You'll also likely be instructed to abstain from eating and drinking at least eight hours prior to surgery. If your doctor instructed you to continue with any medications, take these as directed.

Prior to arriving, your medical team will give you specific instructions for checking in. Be sure to bring a bag of your clothes and toiletries along for your stay at the hospital.

Once your surgeon is ready, your medical team will take you to the operating area. Here they will clean and prepare your ankle for surgery and administer anesthesia.

Recovery

The recovery process after a total ankle replacement can be rather extended. The surgery is often a same-day procedure. This means you'll be sent home after you wake up from the anesthesia. Some patients may be admitted to the hospital for several days for observation.

During the first few days of recovery, you will receive pain medication. You will also be advised to elevate your ankle above your heart as much as possible. You'll also be instructed to ice behind the knee for 30 minutes on and 30 minutes off regularly to help control the postoperative inflammation and swelling.

Typically, your surgeon will not allow you to bear weight on the affected leg for two to six weeks to ensure proper healing.

Because staying non-weight-bearing can be somewhat challenging, a physical therapist will visit you in the hospital or at home to teach you to walk, negotiate stairs, and transition from your bed to standing. Once your pain is well managed and you are able to safely move around, you will be discharged home.

Long-Term Care

Starting about two weeks after your procedure, your surgeon will typically order outpatient physical therapy (PT). Following a total ankle replacement, PT has several specific objectives including:

• Pain and swelling control
• Restoration of range of motion
• Gradually reintroducing weight-bearing and working on your gait (as early as two weeks after surgery, and up to six weeks after)
• Improving your balance
• Building strength in the muscles of the foot, ankle, and lower leg

Because a total ankle replacement is a relatively involved procedure, it is not unusual for outpatient physical therapy to last for four to five months or more.

Along the same lines, if your occupation requires physical labor or a lot of walking, you may be unable to return to work for four to six months.

Potential Risks

Total ankle arthroplasty surgeries are typically very successful. Like all procedures, however, they are not without risks.

Potential side effects include infection, blood clots, sustaining damage to a neighboring nerve in the ankle, or developing osteoarthritis in a nearby joint.

In addition, the prosthetic pieces that are attached to your talus and tibia bones occasionally wear out or become loose.

Estimates suggest that this complication occurs in between 10% and 30% of people who undergo this procedure after about 10 years. Should this hardware failure occur, a revision arthroplasty or an ankle fusion surgery may need to be performed.

Summary

Conditions such as osteoarthritis can cause deterioration of the cartilage and bones that make up the ankle joint. Over time, this can cause pain and impair mobility. Ankle replacement surgery is a procedure that is done to replace the damaged parts with plastic and metal pieces. This is a serious procedure, and it can take four to six months of rehabilitation to recover. Most surgeries are successful and can significantly reduce pain and improve the mobility of patients.

A Word From Verywell

If you are suffering from the pain and disability associated with an arthritic ankle, a total ankle replacement may help you regain your independence. While the surgery is not without risk and typically involves extensive rehabilitation afterward, it can provide a welcome relief from the symptoms you are experiencing.  

Be sure to speak to your physician about whether this type of procedure is appropriate in your specific circumstance. Following a thorough examination, your doctor can outline all the specifics of the surgery and start you on the road to recovery.