An Overview of Ankle Arthroplasty
Your capacity to walk, run, and engage in other activities depends heavily on the ankle joint, a complicated mechanism connecting the lower leg bones to the foot. However, it can sustain damage over time from severe injuries and degenerative diseases, just like other joints in the body.
For those with debilitating illnesses like osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis, ankle replacement has emerged as a cutting-edge treatment option.
This surgery offers a way to relieve arthritis pain and maintain joint mobility, enabling patients to engage in physical activities with ease. Moreover, with improved implant designs, surgical techniques, and postoperative care strategies, this procedure safeguards the surrounding foot joints, reducing the risk of arthritis development in those areas.
Understanding Ankle Replacement Surgery
Ankle arthroplasty involves the replacement of a deteriorated ankle joint with an artificial implant. The ankle joint, known as the tibiotalar joint, is where the shinbone (tibia) rests upon the talus bone in the foot.
Unfortunately, this joint, like others in the foot, is susceptible to arthritis, leading to the gradual erosion of the smooth cartilage that covers the bone surfaces. People may, therefore, feel discomfort, oedema, and inflammation in the damaged joint.
Total ankle replacement surgery aims to address these symptoms by replacing the damaged joint entirely. Generally performed under general anaesthesia, the procedure begins with an incision made in the ankle to access the compromised joint.
The surgeon then removes the deteriorated portions of the tibia and talus bones before affixing artificial metal joints to the remaining bone surfaces. These joints are separated by a plastic component, completing the restoration of the ankle joint.
Indications for Total Ankle Arthroplasty
For individuals with mild to moderate arthritis, healthcare providers often explore nonsurgical treatments like pain medications, specialised shoe inserts, physical therapy, or corticosteroid injections. However, if these measures fail to alleviate severe symptoms that hinder daily activities, ankle replacement surgery or other surgical interventions may be recommended.
Following are some typical causes of ankle replacement surgery:
Ankle Arthritis: Advanced arthritis in the ankle joint is the most frequent reason for undergoing this procedure. A few causes of arthritis include osteoarthritis, rheumatoid arthritis, post-traumatic arthritis (which develops after an injury), and avascular necrosis (the loss of blood flow to the bone). The effects of severe arthritis include pain, stiffness, swelling, and reduced movement.
Failed Conservative Treatment: When nonsurgical treatments like pain medications, activity modifications, physical therapy, and assistive devices no longer provide adequate pain relief or help improve ankle function, this procedure may be considered.
Functional Restrictions: Ankle arthritis can severely restrict a person’s capacity for activities, including walking, climbing stairs, and engaging in sports and leisure pursuits. Total ankle replacement may be a suitable alternative if the patient’s quality of life and everyday activities are affected by discomfort and functional restrictions.
Joint Instability: Ankle arthritis can cause joint instability, leading to recurrent ankle sprains or giving-way episodes. Severe instability that does not respond to conservative management may be an indication to consider this procedure.
Bone Fractures: Some types of ankle fractures, especially those that affect the joint surface (intra-articular fractures), can impair the ankle joint’s normal morphology and functionality. In cases where the fracture has led to significant arthritis or malunion (improper healing), ankle replacement surgery may be considered.
Diagnosis for the Ankle Arthroplasty
Ankle joint replacement is often recommended only when nonsurgical options have been exhausted and have proven ineffective. These treatments may include anti-inflammatory medication, bracing, physical therapy, activity modification, and injections.
Ankle arthroplasty may be suggested as a therapeutic option by the patient’s foot and ankle orthopaedic surgeon if the patient still experiences ankle pain and impaired function, specifically as a result of arthritis.
Speak with an orthopaedic surgeon who specialises in foot and ankle conditions to determine if total ankle arthroplasty is the most effective treatment option for your specific problem. Before proposing an ankle replacement operation as a therapeutic option, the surgeon will assess your symptoms, carry out a comprehensive physical examination, review imaging results (such as X-rays or MRI), and take your general health state into account.
Preparing for Ankle Replacement Surgery
There are numerous preparatory steps you should take to achieve a successful and pain-free ankle replacement operation.
- You must, initially, be truthful and open with your orthopaedic surgeon. Talk about your medical history, including any underlying illnesses or prescription drugs you are taking right now.
- Preoperative examinations, including blood testing and imaging scans, will probably be requested by your surgeon to evaluate both your general health and the state of your ankle joint. They may also provide specific instructions regarding medications to stop or adjust prior to the surgery.
- To reduce the chance of difficulties during the treatment, it’s also crucial to abide by any preoperative fasting instructions given by your surgeon.
- It is imperative to find out if you need to stop taking any drugs, particularly blood thinners, before the surgery. Make sure to tell your doctor about all of your prescriptions and if you are on some kind of medication such as aspirin.
- It is also important to update them about any recent changes in your overall health, such as a recent fever.
- If you smoke, it is advised that you stop before the treatment because smoking can slow down your recovery.
- Last but not least, make transportation arrangements on the day of surgery since you won’t be able to drive yourself home.
With careful preparation and by following your surgeon’s instructions, you can help ensure a smooth and successful surgery.
Procedure of Ankle Replacement Surgery
Understanding what occurs during total ankle arthroplasty can provide valuable insight into the procedure. Although every surgery is different, the following is a basic description of what to anticipate:
Anaesthesia: You will typically receive general anaesthesia, ensuring that you are asleep throughout the surgery. This ensures you experience no pain or discomfort.
Vital Sign Monitoring: To ensure your safety and well-being, a group of medical professionals will carefully monitor your vital indicators, such as heart rate and blood pressure, throughout the procedure.
Incision and Access: After preparing the surgical site, your orthopaedic surgeon will make an incision through the skin and muscle around the ankle, potentially requiring an additional incision on the foot.
Removal of Damaged Bone: Your surgeon will carefully remove the damaged sections of the shinbone and talus, preparing the area for the placement of the new components.
Placement of Metal Joint Surfaces: The surgeon will affix the new metal joint surfaces onto the remaining bone segments. In some cases, a special cement may be used to secure the components in place.
Insertion of Plastic Spacer: A piece of plastic, acting as a spacer, may be inserted between the metal joint surfaces. This allows for smooth gliding and reduces friction between the different surfaces.
Additional Repairs: Depending on your specific condition, your healthcare provider may address any other necessary repairs or modifications during the surgery.
Closure of Incisions: Once the surgical steps are completed, your surgeon will meticulously close the layers of skin and muscle around the ankle and foot.
It is important to consult with your healthcare provider for detailed information regarding your particular ankle arthroplasty, as every procedure may have specific variations and considerations.
Postoperative Phase of Total Ankle Replacement Surgery
Total ankle replacement offers superior pain relief and functional improvement, with a success rate exceeding 90% in terms of short-term patient satisfaction. However, similar to other joint replacements, it is susceptible to wear and potential failure over time.
After your ankle replacement operation, you can expect several key aspects during the recovery period:
Monitoring and Care: Your healthcare team will closely monitor your condition and provide necessary care as you recover. This includes monitoring vital signs, managing pain, and assessing the healing process.
Immobilisation and Elevation: After waking up from the surgery, your leg will likely be immobilised and elevated. This positioning helps reduce swelling and promotes proper healing.
Resuming Normal Diet: Once you are awake and stable, you can resume a normal diet as tolerated, following any specific instructions from your healthcare provider.
Follow-up X-rays: Follow-up X-rays may be scheduled to evaluate the success of the surgery, monitor the positioning of the artificial joint, and ensure proper healing.
Hospital Stay: Typically, total ankle replacement surgery requires a hospital stay for a few days to ensure proper postoperative care and recovery.
Pain Management: You will experience significant pain immediately after the surgery. However, pain medications will be prescribed to help manage and alleviate discomfort. Over time, the pain should gradually decrease, resulting in less pain than before the surgery.
Splint and Crutches: Initially, you may need to wear a splint to provide support and protection to the surgical site. Additionally, you may be required to use crutches to assist with mobility while allowing the ankle to heal properly.
Foot Movement and Rest: Your doctor will provide specific instructions on how to move your foot and ankle during the recovery period. It is important to follow these guidelines to prevent complications and promote healing. Resting and elevating your leg for the first week or so after surgery can be beneficial in reducing swelling.
Weight-Bearing Restrictions: For several months, you will not be able to put your full weight on your foot. Your healthcare provider will advise you on when and how much weight you can gradually bear on the ankle as part of the rehabilitation process.
Incision Care: While the incision may not be visible initially, it is crucial to promptly notify your healthcare provider if you experience increased pain, redness, swelling, drainage, or any signs of infection.
Follow-up Appointments: It is important to attend all scheduled follow-up appointments with your healthcare provider. These visits allow them to monitor your progress, assess the healing process, and make any necessary adjustments to your treatment plan.
Rehabilitation, physical therapy, and a gradual return to activities will be a part of your recovery journey. Your healthcare provider will provide specific instructions according to your condition and progress. By following their guidance and adhering to proper wound care, medication management, and rehabilitation protocols, you can increase the chances of a successful recovery and improved function of your ankle joint.
Potential Risks and Complications
It is important to discuss these potential risks and complications with your healthcare provider before undergoing ankle replacement surgery. They will provide you with personalised information based on your medical history, overall health, and specific circumstances.
Like any other surgery, an ankle replacement operation also has some associated risks, which are discussed further.
Anaesthesia-related Risks: Anaesthesia carries certain inherent risks, like adverse reactions, respiratory complications, or medication-related side effects. Your anesthesiologist will carefully monitor you during the surgery to minimise these risks.
Infection: Despite strict precautions, there is a risk of infection following total ankle arthroplasty. It may include redness around the wound (superficial wound infections), occurring in up to 5% of cases. Deep infections involving the metalwork or bone are much rarer, affecting less than 1% of patients.
Infections can be superficial or deep and may require additional treatment, such as antibiotics or surgical intervention.
Nerve and Blood Vessel Damage: The surgical procedure involves delicate structures, and there is a possibility of damage to nerves or blood vessels near the surgical site. As a consequence, numbness, tingling, or a reduction in blood flow to the foot may occur.
Blood clots and Bleeding: During surgical operations, blood clots or bleeding may occur. If blood clots spread to other bodily areas, such as the lungs (pulmonary embolism), they risk being seriously harmful. Measures are taken to minimise these risks, including using blood thinners and compression stockings.
Fracture or Breakage of Implant: The most common complication following total ankle replacement surgery is a fracture or breakage of the bone adjacent to the implant. This can occur due to excessive stress on the bone or other factors. Additional surgery may be required to address this complication.
Persistent Pain: Approximately 10% of ankle replacement operation patients may experience unexplained residual pain despite normal X-ray findings.(2) While these symptoms typically resolve within 12–18 months, a small percentage may require reoperation or revision surgery to address persistent pain.
Injury to Tendons, Nerves, or Blood Vessels: There is a slight possibility that the surgery could cause injury to tendons, nerves, or blood vessels. To restore normal function after such injuries, additional medical attention or surgery may be necessary.
Wound Healing Issues: Proper wound healing is essential for a successful recovery. Complications, such as superficial or deep infections, can occur if the wound does not heal properly. Patients who smoke, have diabetes, or have rheumatoid arthritis may be more susceptible to having trouble with wound healing.
Implant Failure or Complications: Ankle implants, like knee and hip replacements, can develop issues over time. Studies show that around 8%–90% of ankle replacements remain intact after 10 years, but some may require early surgery due to loosening within 1 or 2 years.
These may cause infection, loosening, or wear of the artificial components. Such complications may require additional surgery or revision of the implant.
A favourable outcome can be increased by taking precautions to limit hazards, such as adhering to postoperative instructions, caring for wounds properly, and attending planned follow-up appointments.
Factors to Consider – Ankle Replacement for End-Stage Ankle Arthritis
The decision regarding ankle replacement surgery should be made in consultation with your foot and ankle orthopaedic surgeon, taking into account various factors specific to your case.
In general, preserving ankle motion through replacement surgery can help protect the surrounding joints from increased wear. It is particularly crucial when arthritis affects neighbouring joints. The number of ankle replacements performed is rising significantly, accompanied by a wealth of published research and ongoing studies in this field.
Constant advancements in implant designs and surgical techniques aim to provide ankle replacement patients with outcomes comparable to those of hip and knee replacements.
