When should you consider alternatives to ankle replacement surgery and ankle fusion
Ross Hauser, MD
Danielle R. Steilen-Matias, MMS, PA-C
When should you consider alternatives to ankle replacement surgery and ankle fusion?
This article is part of a series of articles we have prepared for our patients on the various stages of ankle instability and ankle osteoarthritis. This article is for the patient with significant ankle degeneration or post-traumatic injury damage who has been recommended to ankle replacement and ankle fusion surgery.
There are many people who benefit from ankle replacement and ankle fusion surgery. These are typically not the people we see in our clinics. We see the people post-surgery who continue to have pain and instability. Sometimes we can help people with their ankle instability by treating and strengthening the ligaments that hold the ankle, heel, foot complex together. Stronger ligaments mean more natural stability. This can also help with excessive cramping in the calf area following surgery. However, failures of shifting hardware, bone breakage from the prosthetic device, and other complications post-surgery would present significant challenges.
If you are like the many patients we see, you are considering this surgery because:
- You have a lot of pain.
- Over the years as you continued seeing doctors and specialists for your ankle problems you may have been recommended to treatments such as REST, walking boots, physical therapy, among other conservative care treatments. As the years went on, your pain got worse, the doses and prescriptions may have gotten a little bit stronger and a little more frequent. Each time, the prescription got stronger there was a hope that this next dose will get rid of your swelling and “knock out that inflammation once and for all.” You maybe here because that next dose was never strong enough. Lesser results from pain medications and anti-inflammatories is not your preferred path of treatment for the rest of your life.
- You have to teach yourself to walk with your toes pointed to the side or inwards to avoid the bone-on-bone ankle pain.
- You had cortisone injections that have worked less and less.
- You are still of working age or are retired and you would like to play a round of golf a few times a week.
So why did you NOT go for surgery?
- You have been told by your surgeons that the complication rate is high. (We will examine this below)
- A very successful ankle replacement or fusion can take 12 – 16 weeks to recover from. A less than successful surgery can go on for years
Is there options, how do you know what they are?
- For some people, ankle replacement and ankle fusion may be the only solution These are people who were involved in an accident or suffered a significant ankle injury that has deformed the structure of your ankle. These are injuries where the bones of the heel and ankle complex can no longer support the weight of the person.
- Ankle fusion or replacement may be the only solution for people whose degenerative ankle condition has caused the formation of bone spurs that have limited your ankle’s ability to rotate and bend.
- When ankle fusion or ankle replacement is considered “elective surgery,” meaning that the surgery is optional and is performed of your own choosing, we believe, that in our more than 27 years of experience seeing patients who were given the “surgery is the only option,” recommendation, elective surgery could be avoided in many cases.
We will try to offer you good and realistic information about ankle surgery in this article.
Before the ankle replacement surgery and ankle fusion surgery recommendation.
Ankle swelling and inflammation that would not go away
You are likely in your situation because the damage to your ankle ligaments, including the talofibular ligament, has brought about an advanced degree of ankle instability that causes the ankle bones to abnormally rub together and have a degenerative effect on the joint. This unrelenting joint degeneration has resulted in your chronic pain and instability, often demonstrated by ankle popping and frequent subluxations and dislocations.
If you are contemplating ankle replacement surgery read this amazing piece of research on ankle replacement failure
Researchers at Dartmouth College and Duke University published a February 2019 (1) study in which they wanted to examine why ankle replacement hardware fails. Why patients need to have a second surgery to replace this failure and what can possibly be done to prevent this failure. The research was published in the journal Foot & Ankle International.
Here are their learning points:
- The researchers noted that: “Although advances in joint-replacement technology have made total ankle replacement a viable treatment for end-stage arthritis, revision rates for ankle replacements are higher than in hip or knee replacements.” Next, they examined the hardware parts from failed replacement surgeries removed from the patients to see why. Look at what they found: The ankle implants failed most commonly for loosening and polyethylene fracture.
This is what we found so amazing: metal on metal problems replaced bone on bone problems in ankle replacement patients
- You had an ankle replacement surgery because ankle instability caused cartilage breakdown and advanced ankle degenerative disease. You had, in essence, become bone on bone.
- The ankle replacement failed because the polyethylene component, that part of the hardware that was to act as cartilage, fractured and wore away, you became metal on metal and the component could no longer properly support your weight
Loosening and polyethylene fracture in the ankle following replacement surgery can mimic ankle instability and cartilage breakdown.
What does this mean?
It is all about ankle instability, the hardware failed because it was too loose. The loose component then rubbed unnaturally against the polyethylene causing the “polyethylene” cartilage to fail. When this happens doctors have to go in, tighten the component, and replace the damaged parts.
MAYBE, you try to do this with your own ankle with regenerative medicine injections. Naturally make the body tighten the ankle, provide stability, which allows cartilage to regenerate.
Let’s follow the path of options:
Your body is trying to fuse your ankle on its own
The degeneration process and clues how to avoid surgery
- As you continue to walk and bear weight on the unstable ankle joint, your body will attempt to stabilize the ankle with swelling and inflammation and eventually overgrowth of bone. Your body is trying to fuse your ankle on its own.
One of the challenges of treating patients with advanced ankle osteoarthritis is the formation of large bone spurs in the ankle. These patients are in our clinics because they have a recommendation for fusion surgery. They do not want the fusion because it will limit their ankle range of motion and lock their ankle in an immovable position. When the patient gives us x-rays with large bone spurs present, we explain that their own body is busy doing its own fusion. The bone overgrowth or bone spurs are already locking up the ankle to help support the weight of the body. Advanced degeneration of this nature is challenging to treat in a non-surgical manner.
In November 2018 in the journal Clinical Anatomy (2), doctors from Case Western Reserve University School of Medicine and the University Hospitals Cleveland Medical Center examined the relationship between Anterior ankle impingement and bone spur formation. Here are the learning points of their research:
- Anterior ankle impingement results from repetitive microtrauma (the ankle instability stemming from ligament wear and tear) leading to pain and decreased dorsiflexion (your ability to point your toes upward) due to spur formation and synovial hypertrophy (swelling).
- In a study on cadavers, (people who died between the ages of 20 – 40) bony impingement was observed in 21% of the ankles examined, with bilateral (both ankles) involvement in 8%
- In the ankles with Anterior ankle impingement, spurs were seen:
- on the talus only in 61%,
- on the tibia only in 14%,
- and on both the tibia and talus in 26%.
- Spurs were significantly more prevalent in males and with increasing specimen age.
What does this tell us? Ankle instability and bone spur formation happen quickly. For more on this subject, please see our article Ankle impingement non-surgical treatment.
Surgery damages healthy non-injured tissue and can cause pain and complication
Research in the Journal of Foot and Ankle Surgery (3) looked at the reasons 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 ankle pain following an ankle replacement.
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.
- The learning point here was the surgery caused damage to the soft tissue of the ankle with an “unknown frequency and undetermined significance.” No one knew how often or how bad this damage was occurring during surgery. The only reason it was found was that people were still in pain after the procedure.
More problems after major ankle surgery – things don’t line up
In the September/October 2015 issue of The Journal of Foot and Ankle Surgery,(4) doctors reported on the second generation of total ankle prostheses mechanisms and hardware. It was hoped this new generation of implants would address the weaknesses doctors and patients found in first-generation implants that led to complications and continued pain after surgery.
Here are the learning points of this research:
- Of 79 ankles studied, 25 underwent a second surgery (31.6%).
- The secondary surgery consisted of Coronal plane correction (for patients this means that the ankle has turned inwards and needs to realigned). In a subgroup of these patients, the Coronal plane deformity was so severe the metallic component failed, this occurred in 14.3% of the subgroup patients.
Overall the second, corrective surgery was deemed successful. “Statistically significant correction in coronal alignment was achieved immediately after surgery and maintained until a final mean follow-up of 8 years, even in patients with preoperative deformity greater than 10 degrees.
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.(5)
In the World Journal of Orthopedics, (6) 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 the bony union. Obese patients are faced with several challenges, including adequate cast or brace fitting as well as maintaining non-weight bearing status postoperatively. These circumstances have the potential to compromise the fixation and place an increased mechanical load on the implant’s fusion site, leading to unwanted motion at the prosthetic device.
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.(7)
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.(8)
Total ankle replacement that needs 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 ankle arthrodesis for a failed total ankle replacements.
- The majority of patients (41%) underwent 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 endpoints and overall satisfaction at short-term follow-up if the patients achieve fusion. (IF THEY ACHIEVE FUSION) (9).
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 are considerable concerns.
Doctors who recommended a surgical ankle fusion or the 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 author 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 (osteoarthritis that just showed up or had an unknown origin), leading to joint pain.
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 afterward.
- 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.(10)
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.(11)
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, a 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.(12)
The rehabilitation/complication aspect of recovery
In October of 2019, doctors at Brighton and Sussex Medical School, University of Sussex and the Royal Sussex County Hospital in the United Kingdom published research in The bone & joint journal (13) examining the considerably varying regiments of postoperative rehabilitation regimens following ankle fusion. Specifically what they were looking at was the duration of postoperative non-weight bearing.
They examined the results of 60 studies and the 2426 ankles included. They divided these people and their ankles into 4 main groups:
- Group A whose patients had up to one week of non-weight bearing activity and average achieved fusion union 93.2% at 10.4 weeks and had a complication rate of 22.3%
- Group B whose patients had two to three weeks of non-weight bearing activity and average achieved fusion union 95.5% at 14.5 weeks and had a complication rate of 23.0%
- Group C whose patients had four to five weeks of non-weight bearing activity and average achieved fusion union 93.0% at 12.4 weeks and had a complication rate of 27.1%
- Group D whose patients had six weeks or more of non-weight bearing activity and average achieved fusion union 93.0% at 14.4 weeks and had a complication rate of 28.7%
Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative non-weight-bearing, although the existing literature is insufficient to make definitive conclusions.
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:
- Prolotherapy for Ankle Osteoarthritis
- Chronic ankle sprain and instability treatment
- Researchers challenge the idea of ankle impingement surgery
Ankle Instability and Prolotherapy
This section will deal with the question, How do WE treat chronic ankle sprains and instability?
In this video, Danielle R. Steilen-Matias, MMS, PA-C demonstrates treatment to the lateral ankle
The treatment begins immediately in the video
This is comprehensive Prolotherapy, meaning there are a lot of injections. The patient getting the injections in this video is comfortable and tolerates the treatment well. The patient in this video is having the lateral or outer ankle treated.
- The injections are given at the ligament attachment to the bone. This helps stimulate healing and strengthening of the ankle ligaments.
- At 0:48 the importance of treating the lateral ligaments of the ankle, the anterior talo-fibular ligament (ATFL), the calcaneo-fibular ligament (CFL) and the posterior talo-fibular ligament.
- The patient is not sedated in any way, once treatment begins patients are surprised that it is not as painful as it looks. We do offer various pre-treatment medications to help the patient including IV sedation. Especially those with a fear of needles.
- This patient came to see us for an old ankle sprain injury causing chronic ankle instability and pain with running and lower body activities.
- On his first physical exam he had some ligament laxity, a lot of tenderness and instability in his ankle. At that visit we treated the lateral side. This is a follow up treatment.
- Depending on the severity of the ankle sprain, it could take 3 to 8 treatments to affect a repair.
A demonstration of how we offer PRP and Prolotherapy.
- In this video, the treatment begins with an ultrasound examination to help guide some of the injections during the treatment.
- Before the treatment begins the patient receives some numbing solutions in the form of injections, while the ultrasound examination continues. Not all patients request the numbing solutions. It is an option that we do offer. Typically while the patients receive many injections, the treatment is tolerated quite well with or without being numbed.
- At 0:45 we see the PRP / Prolotherapy treatment begin. Our PRP treatments are more than “one shot.” In our opinion to best treat ankle pain, injections are given into the joint as well as the outer and surrounding ligaments and the muscle/tendon attachments to the bone.
- At 1:00 we see the Prolotherapy injections into the medial and lateral ankle, the inside and outside.
- In this particular patient, he had suffered an ankle fracture 30 years prior and had a repair surgery. His range of motion had decreased significantly becoming harder for him to perform his job.
- In total, this patient received 6 treatments over 6 months. The difference between surgery and our treatments was that he was able to continue to work during the treatment phase while his ankle pain and stability improved.
A demonstration of Stem Cell Therapy and Prolotherapy
In our clinics, stem cell therapy, which are cells taken from the patient, NOT donated “stem cells,” are used in only the most advanced cases. This is not our “go to,” treatment. In the same way the joint degeneration does not occur overnight, one cannot expect the repair to be achieved overnight. In more advanced cases it can take more than 1 treatment to achieve treatment goals.
The treatment begins at 1:06 of the video
- When someone has very advanced osteoarthritis of a joint, like an ankle joint, we may use platelet rich plasma combined with lipoaspirate (fat derived stem cells). Very advanced osteoarthritis have a deficiency of cells in the joint, or better understood as deficiency of building material.
- In this video, fat derived stem cells are drawn in liposuction procedure from the buttocks of this patient.
- This procedure begins at 1:42 of the video. A very dilute anesthetic is injected into the area to numb the pain. The collected fat is then combined with Platelet Rich Plasma. and injected into the ankle.
- The ankle injections begin at 2:29. This patient is having numbing solutions to make the treatment more comfortable.
- The procedure is done very quickly.
- At 3:30 the stem cell/PRP combination is injected.
- Advanced degeneration is usually seen every few weeks for up to 4 to 6 visits.
Do you have questions about Your ankle pain? You can get help and information from our Caring Medical Staff.
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