Surgical Overview
The ankle joint is made up of three bones: the lower end of the tibia (shin bone), the fibula (small bone of the lower leg), and the talus (bone that fits into the socket formed by the tibia and fibula). The ankle joint moves mainly in one direction like a hinge allowing your foot to move up and down. Inside the ankle joint the bones are covered with a thick, smooth material called articular cartilage. Articular cartilage allows the two bones to move/glide against one another and also helps distribute load across the entire joint surface, thus absorbing shock.
Osteoarthritis (OA) is a degenerative joint disease in which the articular cartilage (the tough but flexible tissue covering the ends of the bones) gradually wears away. In most cases, ankle osteoarthritis is related to a previous ankle injury and is termed, post-traumatic arthritis. X-rays help determine the severity of ankle damage. In a normal ankle, the articular cartilage creates the appearance of a symmetric joint space between the two bones making up the ankle joint (picture A). As the articular cartilage wears away the joint space decreases progressing to bone on bone contact (picture B).
The main symptom usually associated with osteoarthritis in the ankle joint is pain. In the early stages of disease, pain is present with movement or activity (walking, stairs, prolonged standing). As osteoarthritis (OA) progresses, the pain can be present even at rest. Other common symptoms of ankle OA include: joint stiffness, loss of ankle motion, ankle joint swelling, and difficulty walking (or walking with a limp).
Treatment for ankle OA is focused on controlling pain, limiting motion that causes pain, and assisting in increasing walking tolerance. Non-surgical treatment approaches are usually tried first. Non-surgical treatment options include: medications (nonsteroidal anti-inflammatory meds), custom foot orthotics, AFO (ankle-foot orthosis) or other ankle braces to decrease ankle motion, physical therapy, dietary supplements (glucosamine and chondroitin), CBD cream and steroid/PRP injections into the joint.
Once conservative treatment options have been exhausted or the degree of OA is very severe, surgical intervention is usually necessary. There are mainly three main surgical options to treat ankle OA. These are: ankle arthroscopy – usually an option for milder OA to “clean up” the joint; ankle arthrodesis (fusion) – the gold standard for pain relief due to ankle OA where the ankle is fused as one solid bone; and total ankle replacement (TAR) – where the ankle maintains some degree of its normal biomechanics and motion.
arthroscopic ankle fusion
Ankle fusion is a surgical procedure for the treatment of disabling ankle arthritis when conservative measures have failed to relieve pain. With this surgery, the ankle is permanently stiffened by removing the degenerated cartilage and welding the ankle (tibia and talus) together. It is a "gold standard" procedure, meaning its success for relieving pain and improving function has been documented over the years. The pain of arthritis can be greatly reduced with a solid ankle fusion. This can be performed in a minimally invasive/arthroscopic fashion for some patients.
Most patients will walk better, but not normal, after an ankle fusion. However, you will notice that your stride length is shorter and you may have some difficulty with rapid stair climbing and descent. After a year, most patients will have only a minimal limp if at all.
Yes, you will notice that you will retain some midfoot, forefoot and hindfoot motion (in and out / side to side motion).
Generally no, but you will be more comfortable in a shoe with a cushioned heel. A small heel lift may also be required. Also, the heel height of shoes should be less than one inch.
With a successful ankle fusion, most patients can walk for distance, ride a bike, perform light hiking activities, swim and golf. Some patients have been able to downhill ski on very easy smooth runs.
You will not be able to perform rigorous or agility sports such as singles tennis, soccer, or basketball. Most patients will not be able to run or jog for exercise
Obviously, an ankle fusion does not restore you to normal. When an ankle is fused it does put additional stress on adjacent joints, and studies have shown that these joints show signs of additional arthritis years down the line. However, and fortunately, most patients do not need additional surgery for this.
Alternatives to ankle fusion include non-surgical treatments such as brace wear, activity modification, NSAIDs (e.g. Advil, Aleve), cortisone/PRP injections, or "lubrication" injections (visco-supplementation). Other surgical alternatives that have been FDA approved include Total Ankle Replacement, but patients must meet fairly strict criteria to be considered a candidate for it.
Typically screws, but occasionally a plate or rod, are used to hold the bones in position until the fusion is solid. If there is minimal deformity, it may be possible to have the fusion performed arthroscopically with small incisions. Occasionally, bone graft is necessary if bony defects are present. Your own bone (autograft) or cadaver bone (allograft) may be used.
Your surgery generally takes place at the New England Baptist Outpatient Center and is an outpatient procedure.
The procedure generally takes about one to two hours.
Usually you will have general anesthesia, but occasionally spinal anesthesia will be recommended by the anesthesia team. Most patients will have a preoperative anesthetic popliteal block performed to the back of the knee immediately before the surgery. This will decrease your requirements for intra-operative anesthesia as well as post-operative pain medication. It is very effective in greatly reducing pain.
You will get a dose of antibiotics before surgery. Also, due to a length of time being immobilized, patients are started on one 325 mg aspirin once a day for 4 weeks.
No. Bleeding is minimal with use of a tourniquet during surgery
Read carefully the “What to expect and how to prepare for surgery” handout.
After your surgery you will be placed in a bulky cotton and plaster splint. You will recover in the Post Anesthesia Care Unit or PACU, and then go home.
For the first two weeks you must rest, get sleep, eat well, and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. Keep your surgical foot elevated at the level of your heart when you are not getting up to eat or use the bathroom. You should take the pain medication as directed as necessary. You should take the medication for reducing the chance of blood clots. Keep your splint dry.
Discuss this with your rheumatologist, but it is generally recommended that you stop immune suppressive modulators (e.g. Methotrexate, Enbrel, Humira) for two weeks before and two weeks after surgery.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
Download the Arthroscopic Ankle Fusion Post-Operative Guidelines for full details.
This is an important question because it impacts home and work situations. Typically, it takes about three months to heal the fusion. This will require a period of non-weight-bearing in a cast with crutches, walker or medical scooter for six weeks, followed by a walking boot for an additional six weeks, depending on each individual patient’s ability to heal. After the cast is removed and the walker boot applied, a compression sock obtained from your pharmacy will help with swelling. You will be able to remove the boot for sleep and showers. After three months, most patients are transitioned into supportive roomy shoes, ankle brace and undergo physical therapy for strengthening of the leg and gait training. Expect a limp and some swelling for several months. It usually takes a full year to recover.
If your LEFT ankle is fused, many patients drive by two weeks when they are off the pain medications. If your RIGHT ankle is fused, you may drive after eight weeks. You may want to apply for a handicap parking placard.
That depends on what you do. Sedentary desk workers may return as soon as two weeks. On the other end of the spectrum, construction laborers are typically out of work for six months. You will be provided out of work notes, or restricted duty notes, as necessary during your recovery. Family leave paperwork can also be submitted.
About ten to fifteen percent of patients will have a delayed union or non-union. This can be even greater in patients who have additional medical problems, have poor bone healing factors, or are smokers. To enhance your chances of healing, you should not smoke. For a delayed union you may be prescribed bone healing adjuvants, such as a bone stimulator, and prolonged immobilization. For an established non-union, you may require revision surgery and bone-grafting to try to get the fusion to heal.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, delayed union, non-union, or chronic pain and swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome.
Get ready for it! Optimize your physical and mental state, and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions. More information can be obtained from the American Orthopaedic Foot and Ankle Society website (www.aofas.org).
