During an ankle replacement, the top of your
anklebone (talus) and the bottom of your shinbone (tibia)
are replaced by metal and polyethylene components. You
typically gain some range of motion in your ankle as
compared to an arthritic ankle. However, you may not
have the complete range of motion of a healthy ankle.
The prosthetic joint can move up, down, and side-to-side
well enough for you to perform normal daily activities
again. You may be a candidate for a total ankle replacement
if you have severe debilitating arthritis and you are
what physicians call a "low demand" patient.
Low demand patients typically are in their 50's
or 60's, are not overweight, and are not highly
active people. Unlike knee replacements, patients need
to be very cautious using their prosthetic ankles, and
candidates for replacement usually are not allowed to
put a lot of strain on their ankle. The new designs
for ankle replacements have been developed recently
and long-term studies have not proven how long your
prosthetic ankle can last. But short-term studies have
been very encouraging for the new prosthetic ankles.
If you are suffering from severe pain and cannot walk
more than a few blocks, an ankle replacement can be
a good way to relieve discomfort and restore motion
in your ankle.
|Preparing for Surgery
The decisions you make and the
actions you take before your surgery can be every bit
as important as the procedure itself in ensuring a healthy
to your return home from the hospital, make sure that
you have received any equipment you will need when you
get home. This may include crutches or household items
to make movement around the house easier. You should
receive prescriptions for any of these from your doctor
before you go home from the hospital.
physical problems or changes in your overall health,
such as a fever or infection, should be reported to
your surgeon, and you should notify your surgeon of
any new medications you are taking.
the potential risks and benefits of the surgery by asking
your surgeon any questions that will help you better
understand the procedure. It can also help to talk to
someone else who has undergone the same surgery.
possible, discontinue the use of any anti-inflammatory
medicine, especially aspirin, a week prior to surgery,
to prevent excessive bleeding during the procedure.
reduce the risk of infection, improve healing, and decrease
complications, try to quit smoking or decrease the amount
you smoke. In general, smokers have a higher infection
and complication rate overall.
possible, practice walking with your crutches so you
are ready to use them after surgery. Performing some
basic arm strengthening exercises in the weeks prior
to surgery can make crutch use easier.
a second opinion from another qualified surgeon is often
advisable, particularly in rare or unique cases.
check if the orthopedist performing the surgery is board-certified
or eligible, call the American Board of Orthopaedic
Surgery at 919-929-7103.
At most medical centers, you will go to "patient
admissions" to check in for your operation. There
may be separate check-in areas for ambulatory outpatient
(patients go home the same day after surgery) and for
overnight inpatient surgery, so be sure to ask your
doctor or an assistant about this. After you have checked
in to the hospital, you will go to a holding area where
the final preparations are made. The mandatory paperwork
is completed, and your ankle may be shaved, though this
is not always necessary. You will be asked to change
into a hospital gown and, if applicable, remove your
watch, glasses, dentures, and jewelry. You will have
the opportunity to speak with your orthopedic surgeon
or an assistant and meet the anesthesiologist or nurse
anesthetist (a nurse who has done graduate training
to provide anesthesia under the supervision of an anesthesiologist).
An IV (intravenous) line may be inserted into your arm
at this time. You will then walk or ride on a stretcher
to the operating room. Most patients are not sedated
until they go into the operating room. Here are some
important steps to remember for the day of your surgery:
will probably be told not to eat or drink anything after
midnight on the night before your surgery. This will
reduce the risk of vomiting while you are under anesthesia.
for someone to drive you home when you are released.
a loose pair of shorts, sweatpants, or other clothing
that will fit comfortably over your short leg cast or
splint when you leave the hospital.
it easy. Keeping a good frame of mind can help ease
any nerves or anxiety about undergoing surgery. Distractions
such as reading, watching television, chatting with
visitors, or talking on the telephone can also help.
During total ankle replacement surgery, your orthopedic
surgeon will replace the damaged parts of your ankle
joint with artificial materials. The artificial components
and materials used in a total ankle replacement may
enable your ankle to move comfortably, although with
a slightly restricted range of motion. The metals vary
and can include alloys of cobalt, chrome, titanium,
or stainless steel. The plastic material is ultra high–weight
molecular polyethylene (UHWMPE), a material that is
extremely durable and wear resistant. "Cementless"
joint replacements have been developed. Cementless joint
replacements depend on a tight, intimate fit directly
between the prosthesis and bone. Bone grows into crevices
within the surface of the prosthesis. This process takes
time, and your orthopedic surgeon typically limits the
amount of weight that you can place on your ankle while
this occurs. Total ankle replacements normally take
about three hours to perform. Spinal anesthesia is given
to numb you from the waist down, and you usually are
sedated so you sleep through the procedure.
anesthesia is administered, the surgical team will position
you on the operating room table and cleanse your skin
with antiseptic solutions.
on your size and the surgeon's preferred surgical
approach, a skin incision about 12 centimeters long
is made over the front of your ankle.
joint capsule and underlying soft–tissues, such
as ligaments, muscles, and tendons, are divided and,
if necessary, cut away so that your surgeon can access
your ankle joint.
surgeon uses devices called retractors to hold the sides
of the wound open.
exposing the talus and base of your shinbone, your surgeon
typically makes flat cuts to prepare the bone surfaces
with a special oscillating bone saw.
the artificial talar and tibial components are made
of a metal backing with a plastic liner (metal–backed).
These metal–backed components are secured in place
by a "press–fit" technique. Press–fitting
prepares a space and then fills it with an object of
a slightly larger size. For example, if one places a
large peg in a small hole, the large peg will be difficult
some cases, screws provide additional stability and
fixation to the artificial components.
the parts are in place, the anklebone and shinbone are
placed back (reduced) into their normal positions. Your
ankle is then moved in different directions to assess
motion and stability relative to the other ankle.
some cases, a small drainage tube that exits your skin
may be placed into the wound to prevent fluid from collecting.
ligaments, tendons, and muscles of the ankle are repaired
layers of the wound are closed with sutures. A dressing
is placed over the wound and around the drain exit site.
Your ankle is immobilized in a post-surgery ankle splint.
You will then be transported to the recovery room.
After total ankle replacement surgery, you will be
transported to the recovery room where you will be closely
observed for one to two hours while the immediate effects
of anesthesia wear off. Your ankle will be elevated
and immobilized in a splint when you wake up. The post-surgery
ankle splints usually are made of a “U-shaped”
plaster splint on the inside and outside of your ankle
that wraps around your heel. It immobilizes your ankle,
but it can be removed more easily than a short leg cast.
You will not be able to see your incision wrapped in
the splint, and there usually is minimal bleeding after
surgery. You may have a tube exiting from underneath
your dressing, which is a drain to prevent fluid from
accumulating within your wound. This drain is usually
removed within two days after surgery. If you have difficulty
urinating after anesthesia, you may have a tube called
a urinary catheter inserted into your bladder that allows
urine to leave your system. The urinary catheter is
usually removed within one to two days after surgery.
Ankle replacement can cause a substantial amount of
pain, and adequate pain medications will be prescribed
for you. You ordinarily are hooked up to an intravenous
(IV) patient-controlled analgesia (PCA) device, which
delivers pain medications in safe amounts when you push
a button. Some patients may be prescribed oral or intramuscular
pain medications. You usually can have visitors no sooner
than 30 minutes after surgery if your physician feels
you are in a stable condition. Your temperature, blood
pressure, and heartbeat will be monitored by a nurse
who, with the help of the physician, will determine
when you are ready to leave the recovery room and be
transported to the hospital ward for further post-operative
care. In some cases, you may be transported to a ward
for intensive care or heart monitoring if you have special
post-operative medical needs. Most patients spend two
to three days in the hospital before going home.
|Post-op in Hospital
After ankle replacement surgery, most healthy patients
remain in the hospital from two to three days. However,
some patients may require a longer stay in the hospital
due to pre-existing medical problems or medical issues
that may arise after surgery. There are small risks
of infection after major ankle surgery. Though it happens
in less than five percent of patients, your ankle’s
blood supply may not be as good as other body parts
and you may be prone to infection. Because you cannot
see your incision inside the cast, it is important to
notify your physician if you feel discomfort. Patients
are not sent home until they demonstrate that they are
safe to go home. Each patient is different and may have
different criteria for being able to go home. In general,
the length of your hospital stay is based on the amount
of pain management you need. You will receive fluids
and medications, through an intravenous (IV) line until
you can drink an adequate amount of fluids without nausea
or vomiting. Most patients can drink something the night
after surgery and eat something more substantial the
following morning. Be sure to ask for pain medications
as soon as you feel pain coming on, because medications
are most effective on pain that is building rather than
on pain that is already present. Your nurses will not
give you more than your doctor has prescribed and what
is considered to be safe. Physicians prescribe crutches
to help you move around without putting weight on your
ankle. The day after surgery, you typically meet a physical
therapist who teaches you about using crutches and helps
you walk around the hospital. You will likely be unable
to bear weight on your ankle for about six weeks after
surgery. Your physician may obtain X-rays of your heel
and ankle before you leave the hospital. You should
arrange for someone to drive you home when you are discharged.
For four to five days after ankle replacement surgery,
you should keep off your feet, elevate your ankle above
the level of your heart, and move around the house as
little as possible. You should try to rest and avoid
too much movement for at least a week. Crutches usually
are prescribed for about eight weeks so you can keep
your body weight off your ankle. Resting with your ankle
elevated helps blood drain away from your ankle and
can control swelling. The more weight you put on your
ankle, the greater your chances of disrupting the healing
process in your anklebones. Household tasks that require
you to be on your feet may be difficult for the first
six weeks. It can be helpful to have someone around
the house to help with any physical chores. You will
be instructed to return to your physician’s office
for regular check-ups after surgery. The dressing covering
your wound inside your post-surgery ankle splint usually
does not need to be changed until the splint is removed
about ten to 14 days after surgery. A typical follow-up
schedule after you leave the hospital may go as follows:
to 14 days – Stitches are removed and your ankle
is put into a removable cam walker that can be worn
inside your shoes. Range of motion exercises begin after
about two weeks. Although ankle replacement is a major
surgery, it is good to move your ankle to circulate
blood. However, you need to continue using the crutches
and not bearing weight on your ankle for a total of
about six weeks after surgery.
weeks after surgery – Return for a check-up. Possibly
receive X-rays. If your physician sees signs of healing
in your ankle, you usually can start bearing some weight.
Weight bearing increases as you can tolerate the pain.
weeks after surgery – After two weeks of partial
weight bearing on your prosthetic ankle, you may be
comfortable bearing your body weight without crutches
or other support.
Stretching and strengthening exercises are begun two
weeks after surgery and gradually advance as ankle soft–tissues
heal and as you can tolerate the activities. The length
of your rehabilitation may vary according to your age,
other medical problems, general health, and healing
potential. In general, most patients can feel strong
again in their ankle after a month or two of physical
therapy. Physical therapy is beneficial after surgery
to teach you the proper way to move around as instructed
by your surgeon with the aid of a walker, crutches,
or other assistive device. Many patients prefer an easier–to–use
walker or a "quad cane," a special type of
cane attached to a broad base with four small "feet"
that is more stable than a standard cane. The key is
to work with your therapist to find an appropriate balance
between low–impact and weight–bearing activities.
Too much high–impact activity and exercise can
decrease the life expectancy of your artificial ankle,
but some weight bearing is needed to maintain bone density.
In conjunction with a healthy diet, exercise also can
help you lose weight, which reduces stress on your artificial
Your physical therapist will help you safely
regain range of motion of your new artificial ankle.
Some patients receive pain relief from daily stretching.
Physicians generally recommend at least 30
minutes of low–impact exercise a day for patients
with arthritis. Walking and swimming usually are recommended.
You should avoid activities that put stress on your
ankles, like running and strenuous weight lifting. Most
of the strength you need to feel stable on your feet
can be achieved simply by walking and weight bearing.
Try to walk a few blocks a day. Increase the length
of your walks as your ankle feels stronger.
Strength training usually focuses on moving light weights
through a complete, controlled range of motion. Your
physical therapist typically teaches you to move slowly
through the entire motion with enough resistance to
work your muscles without stressing your prosthesis.
Once your physical therapist has taught you a proper
exercise program, it is important to find time each
day to perform the prescribed exercises.
After ankle replacement,
you no longer have cartilage in your ankle so arthritis
can no longer trouble your ankle. But your new joint
is not the perfect bionic ankle. You need to take steps
to prevent damaging your prosthesis. It is always important
to avoid ankle injuries. Falls and trauma to a total
ankle replacement may damage your prosthesis and require
more surgery. Unlike the knee and hip, surgeons have
greater difficulty performing revision surgery to repair
your ankle replacement. Ankle fusion surgery is usually
the only recourse if your artificial ankle is damaged.
The most common cause of damage to your ankle replacement
is loosening of the components from your anklebone or
shinbone due to stress, overuse, or osteolysis (bone
absorption around the components). You will probably
not be able to run on your prosthetic ankle, which makes
returning to sports difficult. However, your ankle pain
should go away and you will be able to walk around town,
through the park, and in general be comfortable getting
around. You should be able to play golf and do other
light, walking activities. To help prevent damage in
your artificial ankle, physicians generally recommend
that you take the following precautions:
anything that makes pain last for more than an hour
controlled range of motion activities that do not overload
heavy impact on your ankle during everyday activities.
strengthen the muscles in your leg and foot to help
protect the bones in your ankle.