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.
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.
Open 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.
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 moderate to severe deformity an open ankle fusion is necessary. This involves incisions on the outside and inside of the ankle to re-align the ankle and achieve optimal position. This typically will also require cutting the outside ankle bone, called a fibular osteotomy, which is sometimes reattached and incorporated into the fusion with screws. 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 Hospital and is an inpatient procedure meaning at least overnight admission.
The procedure generally takes about two to three 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.
Yes. You will get a dose of antibiotic before surgery and generally for 24 hours after 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 handouts provided to you in your surgical folder. FootcareMD.com is another useful website and the American Orthopedic Foot and Ankle Society website is very useful as well.
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 be admitted.
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 Open Ankle Fusion Post-Operative Guidelines for full details.
