Caring Medical - Where the world comes for ProlotherapyWhy you should consider alternatives to ankle replacement surgery and ankle fusion

Alternatives to ankle replacement surgery and ankle fusion

Ross Hauser, MD

In this article Ross Hauser, MD explains why many patients have continued pain following ankle replacement surgery and ankle fusion surgery.

Before the ankle replacement surgery and ankle fusion surgery

You are likely in your situation because 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 you continue 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.

It is at a future point in the progression of the ankle degenerative disease that the patient will be recommended to more complicated medical repair including ankle fusion and ankle replacement surgeries. It is at the point of surgical recommendation that we receive our inquiries into non-surgical treatment of ankle osteoarthritis including the use of comprehensive Prolotherapy, Platelet Rich Plasma, and stem cell therapy.

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

Research in the Journal of Foot and Ankle Surgery looked at the reasons behind why a patient will still have chronic ankle pain following ankle replacement:

In this research, the doctors suggest that total ankle replacement studies, looking for sources of pain following the procedure, tend to focus on 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, what is puzzling to the researchers is that even when all these problems are eliminated, patients can still experience unresolved pain.

To find an answer, the researchers then initiated a cadaver study to examine the risk of injury to the anatomic structures in the back of the ankle that the ankle replacement procedure itself may cause. Replicating standard surgical procedures the doctors found that high rates of posterior structural injury were being caused by the surgery.

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)

More problems after major ankle surgery

Medical research is often indicative of where the future of medicine is going. When you search biomedicine or 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 doctors writing in the medical journal Foot and Ankle International put it: “total ankle prostheses design changes intended to address weaknesses in first-generation implants.”(2)

A 2017 study in the Journal of orthopaedic surgery and research cited this research in trying to identify predisposing factors related to replacement component malalignment after total ankle arthroplasty surgery.(3)

In the World journal of orthopedics, doctors wrote of defining patients who may be at high risk  for delayed and nonunion failed surgeries and recommending surgeons to be aware of these risk factors.

  • High risk patients in this study include:
    • Older or advanced age patients, smoking, alcohol abuse, worker’s compensation cases, noncompliance, obesity and systemic conditions (i.e., atherosclerosis, immune suppression, diabetes mellitus and connective tissue diseases).
    • This research team from Lenox Hill Hospital in New York stressed that while there is little evidence supporting obesity as a direct risk factor for nonunion, observation has shown that obesity interferes with the healing process for bony union. Obese patients are faced with several challenges, including adequate cast or brace fitting as well as maintaining non-weight bearing status post-operatively. These circumstances have the potential to compromise the fixation and place increased mechanical load on the implant’s fusion site, leading to unwanted motion at the prosthetic device.(4)

In the medical journal Acta orthopaedica, doctors reported on the post surgical development of tarsal tunnel syndrome, i.e. posterior tibial nerve strain due to anatomical change after total ankle replacement surgery.(5)

As reported in the Journal of foot and ankle surgery, 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.(6)

Total ankle replacement that need to be replaced

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

In recent research from Duke University medical center, 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 Belgium, doctors writing in the orthopedic journal, Acta orthopaedica Belgica, 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 technique) 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.

  • All patients driving a car prior to surgery were able to do so afterwards.
  • Forty percent walked unaided and without problems (60% did not walk unaided or without problems)
  • Fifty-one percent were able to move and be mobile, but their walking distance was limited and a stick (cane) was required
  • Nine percent were unable to leave their homes.However it was generalized osteoarthritis which limited their mobility.(Then why did they fix the ankle if everything else was a problem that ankle fusion was no help to getting the patient mobile)?
  • Forty-five percent were involved in sports.

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 as attested to by research in the American journal of orthopedics:

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)

Ankle fusion vs Total Ankle Replacement

Here is the opinion from researchers at Northwestern University published in the Journal of orthopaedic surgery and research, May 2017. Parenthesis added for clarification for the reader.

  • Total ankle arthroplasty (replacement) and ankle arthrodesis (fusion) are two surgical treatment options for end-stage tibiotalar (ankle joint) arthritis supported in the literature. Currently, there is a lack of high-quality randomized controlled trials comparing these treatments in their modern form, utilizing current techniques and implant designs.
  • The cohort studies and case series identified by this review were difficult to interpret as a whole due to heterogeneous (mixed patient bases) populations and inconsistent reporting of complications and outcomes.
  • However, pooled analysis of the data suggests that although ankle fusion may have a higher total complication rate, total ankle replacement may have a higher revision rate.
  • Therefore, until a greater degree of current data is available demonstrating a significant advantage between the two treatment options, the decision to proceed with total ankle replacement or ankle fusion should be made on a case-by-case basis, accounting for appropriate patient selection, discussions regarding pros and cons of each treatment choice, and knowledge of perioperative complication profiles with each procedure. Individual patient goals, expectations, and understanding of the differences between the respective treatment options are vital to guide the decision between treatment with total ankle replacement or ankle fusion.

If given the choice, researchers say total replacement better than fusion

Duke University researchers published a December 2017 paper with the title: The Value of Motion: Patient-Reported Outcome Measures Are Correlated With Range of Motion in Total Ankle Replacement. In this paper, the researchers suggested ankle replacement would be better than fusion because of quality of life issues regarding the value of motion.(10)

It is common for Prolotherapy doctors to see people with continued pain complaints after ankle fusion and replacement surgeries. Besides the failure of the operation to achieve the patient’s goals of greater mobility and less or no pain, often overlooked causes of this post-surgery pain are that the surgery itself may have caused injury to previously undisturbed or uninjured tissue, such as the ligaments. When performing surgery, the ligaments are stretched and pulled in order to gain access to the joint. This is typical in ankle procedures.

This article asks the reader to consider certain research before undergoing ankle fusion or replacement surgery. But what if you had surgery already or wanted to know of alternatives?

To continue your research please see our articles:


1. Reb CW, McAlister JE, Hyer CF, Berlet GC. Posterior Ankle Structure Injury During Total Ankle Replacement. J Foot Ankle Surg. 2016 Jun 9. [Google Scholar]
. 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. [Google Scholar]
3. Lee KJ, Wang SH, Lee GW, Lee KB. Accuracy assessment of measuring component position after total ankle arthroplasty using a conventional method. Journal of orthopaedic surgery and research. 2017 Dec;12(1):115. [Google Scholar]
4. 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. [Google Scholar]
5 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. [Google Scholar]
6. 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. [Google Scholar]
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.  [Google Scholar]
8. Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9.  [Google Scholar]
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. [Google Scholar]
10. Dekker TJ, Hamid KS, Federer AE, Steele JR, Easley ME, Nunley JA, Adams Jr SB. The Value of Motion: Patient-Reported Outcome Measures Are Correlated With Range of Motion in Total Ankle Replacement. Foot & ankle specialist. 2017 Dec 1:1938640017750258. [Google Scholar]



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