Caring Medical - Where the world comes for ProlotherapyAlternatives to ankle replacement surgery and ankle fusion


In this article Ross Hauser, MD explains why many patients have continued pain following ankle replacement surgery and ankle fusion surgery and how non-surgical remedies may help these patients.

Research in the Journal of Foot and Ankle Surgery looked at the reasons behind why a patient will continue to suffer from chronic ankle pain following ankle replacement:

Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence (the ankle is “caving” in), infection, bone fractures, and heterotopic ossification (bone material forms within soft tissue).

However, patients can still experience unresolved pain even when these problems have been ruled out.

The doctors then initiated a cadaver study to more clearly define the relative risk of injury to the anatomic structures in the back of the ankle during total ankle replacement.

Replicating standard surgical procedures the doctors found that high rates of posterior structural injury were found.

In particular posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. (this can be troubling because a problem has been detected in the supportive structures of the ankle following ankle replacement) and that further study of the  posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.1

Surgery damages healthy non-injured tissue and can cause pain and complication

Problems after Ankle Surgery

Medical research is often indicative of where the future of medicine is going. When you search stem cell therapy in the medical literature you can find papers being released on a near daily basis. The same can be said for ankle replacement and fusion therapies.

In this constantly updating research doctors typically explore fixing old replacements or fusions or as they put it “total ankle prostheses design changes intended to address weaknesses in first-generation implants.”2

Or – defining patients who may be at high risk  for delayed and nonunion failed surgeries and recommending surgeons to be aware of these risk factors.3

Or – the post surgical development of tarsal tunnel syndrome, i.e. posterior tibial nerve strain due to anatomical change after total ankle replacement surgery.4

Or – and this is something that patients often do not think about – the amount of radiation they are exposed to during ankle procedures. Significant radiation exposure has been linked to these procedures and doctors now recommend trying not to send the patient to revision surgery to avoid further radiation risk.5

Or – how to avoid revision surgery by getting bone marrow aspirate stem cell therapy to finish the ankle fusion in non-union fusion revisions.6

It is common for Prolotherapy doctors to see people with continued pain complaints after surgery. Often overlooked causes of this post-surgery pain are that the surgery itself may have caused ligament injury, or, the surgery may not have repaired the ligament injury. When performing surgery, the ligaments are stretched and pulled in order to gain access to the joint. This is typical in ankle procedures.

Causes of ankle arthritis – ligament damage

Damage to ankle ligaments, including the talofibular ligament, can bring about ligament laxity which causes the ankle bones to abnormally rub together and have a degenerative effect on the joint, and resulting in chronic pain and instability, often demonstrated by ankle popping and dislocations.

As a person continues to walk and bear weight on the unstable ankle joint, the bones abnormally wear and tear on the cartilage. In this situation, the body will attempt to stabilize the ankle with swelling – inflammation and eventually overgrowth of bone. This was clearly brought out by the research we cited above.

Total ankle replacements

Obviously as the number of total ankle replacements performed increases, so has the need for revision when the first surgery fails.

In new research doctors examined clinical outcomes following a salvage (revision) ankle implant from a failed total ankle replacement to identify patient- and technique-specific prognostic factors and to determine the clinical outcomes and complications following an ankle arthrodesis for a failed total ankle replacements.

The majority of patients (41%) underwent the total ankle replacements for rheumatoid arthritis. The majority of these revision surgeries were secondary to component loosening, frequently of the talar component (38%).

In the cases that were revised to an ankle arthrodesis, 81% fused after their first arthrodesis procedure. The overall complication rate was 18.2%, whereas the overall nonunion rate was 10.6%.

A salvage ankle arthrodesis for a failed total ankle replacements results in favorable clinical end points and overall satisfaction at short-term follow-up if the patients achieve fusion. (IF THEY ACHIEVE FUSION) 7

Ankle Fusions – a 50-50 chance that surgery would help

When ankle replacement is not indicated, ankle fusion may provide some temporary pain relief but problems with range of motion and non-union of bones is a considerable concern.

Doctors who recommended a surgical ankle fusion or surgical implantation of a cadaver or artificial implant may also recommend that the patient alter their lifestyles, live with the pain, because typically there was only a 50-50 chance that surgery would help.

In another recent paper doctors expressed concern about ankle fusion outcomes. They noted that by introducing artificial implants in ankle fusion surgery the aim is to give pain relief by abolishing the movement of the ankle joint.

However, few studies describe the patient’s post-surgery experience and whether it was successful or not.

This was the major concern of the authors, when they set up their retrospective study about the outcome after ankle fusion or subtalar fusion. Inclusion criteria were: pre-existing idiopathic and posttraumatic osteoarthritis (an osteoarthritis that just showed up or had unknown origin), leading to joint pain.

Also they looked for patients who were unresponsive to conservative treatment (RICE and NSAIDs), clinically and radiologically fused with an open approach between 2007 and 2011.

They excluded patients who had a preexisting joint infection, diabetes, rheumatoid arthritis, nonunion, age below 18 years, deceased, and arthroscopic fusion (This is the arthroscopic or minimally invasive techinique) the doctors here looked at the open technique.

Fifteen ankle fusions and 18 subtalar fusions fulfilled the criteria. The mean age of the patients was 77 and 69 years, respectively; the average follow-up period was 3 and 4 years.

In terms of face value, half the people were helped by an open ankle fusion. Again these were the patients examined that did not have issues of nonunion – the surgery failed – that was another group.8

Clearly the arthroscopic ankle fusion should be favored because it offers a less demanding surgery with less hospital stay and less chance for complications. However there are difficulties getting all the surgical instruments into the ankle during the arthroscopic procedure and some people’s ankles are not large enough to allow this procedure to be successful. But the problem remains:

Ankle arthritis is a painful and functionally limiting condition that can significantly worsen quality of life. Ankle implants (arthrodesis), a common surgical procedure for ankle arthritis, provides good pain relief, patient satisfaction, and clinical outcomes when fusion is achieved. Potential disadvantages include malunion and nonunion (FUSION IS NOT ACHIEVED), malalignment, limited range of motion (ROM), altered gait mechanics, and development of adjacent joint arthritis requiring reoperation.9

Before you consider the ankle fusion surgery

A better approach, in our opinion, to alleviating ankle pain is to stimulate soft tissue, ligament and cartilage repair as chronic pain is most commonly due to tendon and ligament weakness or cartilage deterioration.

In recent research, doctors from Rizzoli Orthopedic Institute, University of Bologna, Bologna, Italy examined bone marrow derived stem cells and their impact on osteochondral lesions of the talus in ankle osteoarthritis.9 Here is a summary of their research:

Ankle osteoarthritis is a challenging pathology, often requiring surgical treatments. In young patients, joint sparing, biologic procedures would be desirable.

Recently, a few reports have described the efficacy of bone marrow stem cells in osteoarthritis. Considering the good outcomes of one-step bone marrow derived cells transplantation (BMDCT) for osteochondral lesions of the talus, the doctors applied this procedure for in concomitant ankle osteoarthritis. (The surgical implantation of a “patch” scaffold from donor cartilage).

56 patients, with an average age of 35.6 years (range 16-50), who suffered from osteochondral lesions of the talus and ankle osteoarthritis, were treated using BMDCT.

The whole clinical outcome had a remarkable improvement at 12 months, a further amelioration at 24 months and a lowering trend at 36 months. Early osteoarthritis had better outcomes. 16 patients required another treatment and they were considered failures.9

Comprehensive Prolotherapy research on the ankle produced by Caring Medical

In the medical journal Practical Pain Management, we published our findings that patients with ankle instability, ankle ligament sprain, and ankle degenerative arthritis responded favorably to Prolotherapy.

Prolotherapy helped the patients in the study make significant improvement in stiffness, range of motion, exercise ability, activities of daily living and walking ability, as well as decreasing their levels of anxiety and depression. Prolotherapy helped all patients on pain medications reduce the amount of medications taken. All 19 patients have recommended prolotherapy to another person.

Direct Bone Marrow Injections for Avascular Necrosis of the Talus: A Case Report

The use of surgery and stem cell scaffold as well as direct injections of stem cells are discussed in this full free access article from the Journal of Prolotherapy Direct Bone Marrow Injections for Avascular Necrosis of the Talus).

Alternatives to ankle replacement surgery and ankle fusion


This article cites references from: The Journal of Foot and Ankle Surgery, Foot and Ankle International, The World Journal of Orthopedics,  Foot and Ankle Specialists and other publications.

1. Reb CW, McAlister JE, Hyer CF, Berlet GC. Posterior Ankle Structure Injury During Total Ankle Replacement. J Foot Ankle Surg. 2016 Jun 9.
. Haytmanek CT Jr, Gross C, Easley ME, Nunley JA. Radiographic Outcomes of a Mobile-Bearing Total Ankle Replacement. Foot Ankle Int. 2015 Apr 24. pii: 1071100715583353. [Epub ahead of print]
3. Rabinovich RV, Haleem AM, Rozbruch SR. Complex ankle arthrodesis: Review of the literature. World J Orthop. 2015 Sep 18;6(8):602-13. doi: 10.5312/wjo.v6.i8.602. eCollection 2015.
4. Primadi A, Kim B-S, Lee K-B. Tarsal tunnel syndrome after total ankle replacement—a report of 3 cases. Acta Orthopaedica. 2016;87(2):205-206. doi:10.3109/17453674.2015.1132186.
5. Roukis TS, Iceman K, Elliott AD. Intraoperative Radiation Exposure During Revision Total Ankle Replacement. J Foot Ankle Surg. 2016 Jul-Aug;55(4):732-7.
6. McAlister JE, Hyer CF, Berlet GC, Collins CL. Effect of Osteogenic Progenitor Cell Concentration on the Incidence of Foot and Ankle Fusion. J Foot Ankle Surg. 2015 May 20. pii: S1067-2516(15)00087-3. doi: 10.1053/j.jfas.2015.03.001.
7. Gross C, Erickson BJ, Adams SB, Parekh SG. Ankle Arthrodesis After Failed Total Ankle Replacement: A Systematic Review of the Literature. Foot Ankle Spec. 2015 Jan 5. pii: 1938640014565046. [Epub ahead of print]
8. Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9.
9. Hsu AR, Anderson RB, Cohen BE. 5 points on total ankle arthroplasty. Am J Orthop (Belle Mead NJ). 2014 Oct;43(10):451-7.
10. Buda R, Castagnini F, Cavallo M, Ramponi L, Vannini F, Giannini S. “One-step” bone marrow-derived cells transplantation and joint debridement for osteochondral lesions of the talus in ankle osteoarthritis: clinical and radiological outcomes at 36 months. Arch Orthop Trauma Surg. 2015 Oct 15.

4. Cho BK, Park KJ, Choi SM, Kang SW, Lee HK. Ankle Fusion Combined With Calcaneal Sliding Osteotomy for Severe Arthritic Ball and Socket Ankle Deformity. Foot Ankle Int. 2016 Dec;37(12):1310-1316. Epub 2016 Aug 16.

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