Ankle replacement surgery treats arthritis in the ankle joint that is usually caused by a previous trauma.
“As a whole, my ankle replacement patients are the happiest compared to those who have had other surgeries,” says Sagar Chawla, MD, MPH, a Cleveland Clinic orthopedic surgeon.
Technological advancements such as patient-specific 3D-printed cutting guides and improvements in the ankle joint hardware have improved the procedure and outcomes from it. Consequently, ankle replacement is increasingly seen as the gold standard for ankle arthritis, often replacing ankle fusion.
What Is Ankle Replacement?
An ankle replacement, or ankle arthroplasty, is similar to hip or knee replacement surgery. The surgeon will resurface the joint by skimming away a small portion of the ankle where the lower end of the tibia (shinbone) and the top of a foot bone (talus) meet. The replacement implant is composed of metal and plastic components that allow motion.
Because the ankle joint provides movement in multiple directions, it is a more complicated joint than the hip or knee. While the hip is a ball and socket joint and the knee is a simple hinge, the ankle has three surfaces working together to allow rotation and up-and-down movements.
Unlike knee and hip replacements, which usually involve standing and using the new joints shortly after surgery, ankle replacements require four to six weeks to heal without any weight on the replaced ankle. After that, people can often walk without pain.
Who Needs Ankle Replacement?
“Most ankle arthritis—70% to 90%, depending on the study—is posttraumatic, meaning that at some point that ankle had an injury,” Dr. Chawla says. “Then after that injury over the course of five, 10, 15, 20 years, the joint degenerates.”
Ankle replacement candidates have pain and stiffness in the ankle and evidence of arthritis on x-rays. Although this population can include older adults, many people who have ankle replacements are in their late 40s or 50s, younger than those who typically have hip or knee replacement, since the cause for ankle replacement is often trauma earlier in life.
Many people with ankle arthritis benefit from a specialized brace known as an Arizona brace before surgery. An Arizona brace is custom-made from a mold of the foot and supports the joint. It is typically hard plastic on the inside and leather on the outside, with laces like a boot. Using an Arizona brace can all individuals to function better with ankle arthritis and sometimes delay ankle replacement surgery for years.
Ankle replacement isn’t right for everyone. People with a history of infection around the ankle or in the bone, or loss of control of the muscles that control the ankle, may not be good candidates. Having diabetes or a body mass index over 40 and smoking can also prevent you from undergoing ankle replacement surgery. Furthermore, people in some occupations like construction that demand pounding or jumping or otherwise putting a heavy load on the ankle may not be good candidates.
Ankle Replacement vs. Ankle Fusion
Ankle fusion used to be the gold standard for treating ankle arthritis before recent advancements in ankle replacement. In this procedure, a surgeon removes cartilage from the joint and connects the bones with steel screws or plates to hold the ankle together until it fuses into one solid piece of bone.
Once healed, an ankle fusion is more durable than an ankle replacement, but the fused joint does not allow motion. As such, it can force adjacent joints to work more, thereby raising the risk of developing arthritis in them and, in some cases, the need for subsequent fusion of those joints.
Ankle fusion can be performed on some people who cannot have ankle replacement due to soft tissue injuries or poor bone quality.
| ANKLE REPLACEMENT | Same-day surgery | ANKLE FUSION | Same-day surgery |
| Uses metal and plastic hardware components to replace the ankle joint | Uses hardware screws or plates to fuse joints together to create strong bone | ||
| Preserves motion after recovery | Eliminates motion in the joint | ||
| You should not run, jump or climb ladders after surgery | May allow for jumping and heavier use | ||
| Recovery takes 4–6 months | Recovery takes 6–12 weeks | ||
| Goal is preserving motion and pain relief | Goal is stability and pain relief |
Preparing for Ankle Replacement Surgery
Ankle replacement can require you to prepare your body and your life. Dr. Chawla recommends that people schedule the surgery when they have four months to recover without travel or big family events.
If you have a multistory home, it’s helpful to prepare it so you can live on a single level during the first four to six weeks when you won’t be walking or climbing stairs.
Dr. Chawla recommends performing “prehab” exercises, especially ones targeting the calf muscles, so you can go into surgery as strong as possible and help to optimize your recovery and outcomes afterward.
On the surgical side, he orders a special CT scan that can be used to 3D print customized cutting guides for the replacement procedure.
What Happens During the Procedure?
General anesthesia and a nerve block in the leg prevent pain during and after ankle replacement surgery. Your surgeon will make an incision in the ankle, remove damaged cartilage, shave parts of the bones and replace them with an implant. Custom cutting guides may help the surgeon make precision cuts to the bone. Modern ankle implants are made from polyethylene plastic and metal, like knee and hip replacement implants.
Any ankle deformities or old hardware will be corrected or removed before or during the procedure. “We really want to make sure that we correct the deformity as best as possible when we do these surgeries,” says Dr. Chawla. Uncorrected deformities from prior injuries can affect the outcome of the ankle replacement surgery.
Recovery and Rehabilitation
At Cleveland Clinic, most people who have ankle replacement will go home the day of surgery. It’s necessary to wear a splint and keep it dry. You will not be able to walk for four to six weeks and will need crutches, a knee scooter and a walker.
The nerve block used during surgery will help prevent pain for 24 to 48 hours. After that, you can manage pain with a combination of over-the-counter and prescription pain medications. Icing and elevating the foot above the heart will help reduce pain and swelling.
Weight bearing and walking will be prohibited for four to six weeks to allow for healing. At that point, physical therapy begins, and usually people are pain free.
Risks and Complications
The potential risks of total ankle replacement include:
- Infections. This risk is minimized with antibiotics given during surgery.
- Anesthesia-related risks. These vary from person to person; your anesthesiologist will discuss the risks with you.
- Blood clots. Chawla recommends taking two baby aspirin a day to minimize the risk of developing blood clots after surgery.
- Delayed wound healing. This complication is more common in people with diabetes.
If there is a problem with the ankle replacement prosthesis, a revision surgery to replace the implant may be needed to correct the issue.
Success Rates and Long-Term Outcomes
Total ankle replacements typically perform well for 10 or more years. Surgeons are still learning how long the newer implants will last.
“For most people, they’re returning to the activities they love doing within four to six months,” Dr. Chawla says. “They can walk unlimited amounts. If they want to play golf, they’re getting back to that. I have patients getting back to pickleball and skiing. You can even play tennis if you really want to play tennis. There’s not a big restriction on activities, but no running, jumping or climbing ladders.”
