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Total Ankle Replacement

Introduction

Total ankle replacement (TAR) is a surgical procedure designed to alleviate ankle pain, restore joint function and maintain its motion by replacing the damaged and painful joint surfaces with metal lining and polyethene insert. Indications, contraindications, surgical procedure, implant choice and postoperative course vary between patients due to individual circumstances.   

Indications and Contraindications

Total Ankle Replacement Indications

  • Osteoarthritis: Degenerative joint disease due to age-related wear and tear. 
  • Rheumatoid Arthritis: An autoimmune condition that causes inflammation and accelerated degeneration of the joint surfaces and ligamentous restraint of the joint.  
  • Post-Traumatic Arthritis: Arthritis resulting from a previous ankle injury such as fracture of the joint surface or form of chronic joint instability after repetitive sprains or severe ligamentous injury. 
  • Ankle degeneration occurring in low-demand patients: patients who would not exercise excessive force on the ankle replacement due to physical job requirements or involvement in high-impact sports.  
  • Minimal degeneration in adjacent foot joints: patients in whom application of total ankle replacement may help preserve the longevity of adjacent foot and ankle joint function.  

 

Total Ankle Replacement Contraindications

  • Severe Osteoporosis and Poor bone stock: Fragile or deficient bones may not support an artificial implant. 
  • Avascular Necrosis: Loss of blood supply leading to necrosis of an ankle bone – most often talus. 
  • Active Infections (locally or generally): Infections complicate the surgical site and recovery, a chronic infection that develops around total ankle replacement can even lead to ankle amputation.  
  • Poor Vascular Supply: Inadequate blood flow to the foot compromises wound healing and can even lead to ankle amputation.  
  • Neuropathy: Nerve damage affects sensation and healing potential. 
  • Significant Ankle Deformity: Anatomical abnormalities that could compromise implant placement should be addressed before ankle replacement surgery to ensure normal joint alignment and avoid excessive forces through the implant. 
  • Young patients: There is a high risk of revision procedure in lifetime observed among young and active patients after total ankle replacement. For these patients, an ankle fusion, or ankle transplant can be considered.  
  • Heavy labourers: There is a high rate of failures of total ankle replacement in the course of heavy load and stress across the artificial implant. For these patients, an ankle fusion can be considered.

Benefits and Risks

As with any surgical procedure, there are both benefits and risks associated with total ankle replacement:

Benefits of Total Ankle Replacement

  • Pain Relief: One of the primary goals of total ankle replacement is to alleviate chronic and severe ankle pain. By replacing the damaged joint with an artificial implant, many patients experience significant pain relief and an improved quality of life.

  • Improved Function: Total ankle replacement can restore ankle joint function, allowing for improved mobility and movement. This is particularly beneficial for individuals with arthritis or other degenerative conditions that have limited their ability to walk and perform daily activities.

  • Preservation of Range of Motion: Total ankle replacement aims to preserve the natural range of motion in the ankle joint, which is essential for walking and maintaining mobility.

  • Reduced Stiffness: By addressing issues such as arthritis and joint degeneration, total ankle replacement can reduce joint stiffness and improve flexibility.

  • Enhanced Quality of Life: Many patients who undergo successful total ankle replacement surgery report a significantly enhanced quality of life, including the ability to engage in physical activities they were unable to do before the procedure.

 

Risks of Total Ankle Replacement

  • Infection: Infection is a potential risk with any surgical procedure, including total ankle replacement. Patients are typically given antibiotics to reduce the risk, and surgical techniques are employed to minimise the chance of infection.

  • Implant Wear and Failure: Over time, artificial ankle joints may wear out or fail. The longevity of the implant can vary from patient to patient, and additional surgeries may be required to replace or revise the implant if it becomes problematic.

  • Nerve or Blood Vessel Damage: There is a risk of damaging nearby nerves or blood vessels during the surgical procedure, which can lead to sensory or motor deficits.

  • Blood Clots: Total ankle replacement surgery carries a risk of deep vein thrombosis (DVT), a blood clot in the deep veins of the leg, or its catastrophic consequences. Preventative measures, such as blood-thinning medications and compression stockings, are often employed to mitigate this risk.

  • Implant Loosening: Over time, the artificial ankle joint may become loose, causing pain and reduced function. Revision surgery may be necessary to address implant loosening.

  • Recovery and Rehabilitation: The recovery process following total ankle replacement can be challenging, requiring extensive rehabilitation and physical therapy. Some patients may experience prolonged discomfort and swelling during recovery.

  • Limited Range of Activities: While total ankle replacement improves mobility and function, patients may still have limitations in terms of high-impact activities or sports participation.

  • Surgical Complications: As with any surgery, complications such as wound healing problems, blood loss, or anaesthesia-related issues can occur.

The decision to undergo total ankle replacement should be made after careful consideration and a thorough evaluation of the individual’s specific condition and needs.

Surgical Approach

Total ankle replacement is a complex procedure that requires careful planning and precise execution. There are different surgical approaches, chosen based on the patient’s condition, needs of accessory reconstructions, types of implants used and the surgeon’s expertise. 

Pre-Surgery Information

The following is what can be expected before a total ankle replacement procedure

  1. Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
  2. Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
  3. Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.  
  4. Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
  5. Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
  6. Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

  • Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
  • A hospital gown will be given, and the operation site will be shaved and cleaned.
  • Betadine skin prep will be applied to the area above the operation site and wrapped.
  • All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

  • Anaesthesia: General anaesthesia or regional anaesthesia (spinal or epidural) is used to ensure a pain-free procedure. 
  • Incision: A carefully placed incision is made to access the ankle joint. 
  • Joint Preparation: Damaged cartilage and bone are removed using the 3D printed patient specific cutting jigs, to create space for the implant. 
  • Implant Placement: The artificial components (metal and plastic) are inserted into the joint to mimic its natural movement. The position of implants is confirmed with x-rays. 
  • Additional reconstructive procedures: if indicated, joint realignment or stabilisation is performed at the same time as ankle replacement. 
  • Closure: The incision is closed using sutures. Dressing and a cast are applied.  

Post-Surgery Information

  • Hospital Stay: You’ll typically stay in the hospital for a few days for monitoring and initial rehabilitation. 
  • Pain Management: Pain medications will be administered to keep you comfortable. 
  • Immobilization: After surgery, you will be put in a cast for a week, this will be changed to a moon-boot at a 1-week wound check. You will wear the boot for a total of 3 months.  
  • Weight-Bearing: You’ll be non-weight bearing for the first 6 weeks, then you will commence weight-bearing gradually, with the protection of a boot, following the surgeon’s instructions. 

 

Follow-Up

Regular follow-up appointments with the team will help monitor your progress and address any concerns: 

  •  1 week postop: for wound check, 
  • 2 weeks postop: for sutures removal, 
  • 6 weeks postop: for x-ray assessment of healing progressing,
  • 3 months postop: a CT scan and X-ray for assessment of healing and determining if the full weight-bearing can be allowed.  

 

After that, a 6-month postop, 1 year postop and further an annual follow-up with an xray will be mandatory. 

 

Physical Therapy

A tailored rehabilitation program will help regain strength, flexibility, and mobility. 

Recovery from total ankle replacement can take several months to a year, and commitment to rehabilitation as well as follow-up appointments is essential for optimal outcomes. Always consult with your healthcare provider for personalized guidance and recommendations. 

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000

Call on +61 2 8882 9011

X-ray facilities at all locations | Urgent appointments available if necessary.

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Professor Munjed Al Muderis

Professor Munjed Al Muderis is an orthopaedic surgeon and a clinical professor at Macquarie University and The Australian School Of Advanced Medicine. He specialises in hip, knee, trauma and osseointegration surgery. He is a fellow of the Royal Australasian College of Surgeons and Chairman of the Osseointegration Group of Australia.

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Disclaimer

Information provided via this website is for educational and communication purposes only. The material presented is neither intended to convey the only, nor necessarily the best, method or procedure, but rather represents techniques and procedures used by Professor Munjed Al Muderis. Professor Munjed Al Muderis disclaims any and all liability for injury and/or other damages which result from an individual using techniques presented on this website. Professor Munjed Al Muderis, to the best of his knowledge, believes the information presented is current and applicable to work being done by orthopaedic surgeons worldwide.