Total Ankle Replacement
with Dr. Eric Malicky, M.D.
"I operated on one patient in his 50s, a retired police officer. He had tried many cortisone injections, a brace and arthroscopic cleaning of the ankle joint, but continued to have pain. He had an ankle replacement and was very pleased with the result."
An overview of ankle joint replacement
The vast majority of people who have hip and knee replacement have it done when they are in their 60s or older, replacing a joint damaged by osteoarthritis. Ankle arthritis, however, is usually trauma induced, caused by ankle sprains and breaks from sports activities and accidents. Because of the weight and wear an ankle takes, the pain can be debilitating.
Today, as in the past, one surgical option for injury-related ankle arthritis is fusion. Fusion involves attaching the tibia and talus (ankle bone) together. When the joint can't move, joint pain goes away. But for some patients, fusion is not an option. For them, there is the little-known procedure called ankle joint replacement.
Ankle replacement is similar to knee replacement, but can be done on patients as young as 50. Rehabilitation following surgery does take longer than with knees and hips. Like other joint replacement, pain relief is nearly immediate, but it may take 3 to 6 months before a patient is walking without assistance.
The history of ankle replacements
Ankle joint replacements began in the 70s, but the replacement joint did not initially appear to work as well as fusion. Then, in the early 80s, a new type of artificial ankle was developed. However, because ankle arthritis is rare, ankle joint replacement is rare as well, though the number of patients suffering from it is growing as the active baby boomer generation ages.
"From 1983 to 1987, the inventor of one of the modern artificial ankle replacements did only 27 surgeries," said Dr. Eric Malicky, an orthopedic surgeon and ankle replacement specialist with Advanced Healthcare. Dr. Malicky, one of the few experts in this area, participated in over 40 replacements during his fellowship in Seattle, and has performed 23 ankle replacements in the last three years, since coming to Milwaukee in 1998.
Who is at risk for ankle arthritis?
Anyone who has suffered severe trauma to the ankle or frequent ankle sprains is at risk for ankle arthritis. The only way to avoid the arthritis is to avoid the injuries. "I see patients who come in and cavalierly say they sprain their ankle two or three times a year as if it's nothing to worry about. These people need to go through a very thorough rehabilitation program after an ankle sprain and learn to minimize sprains," Dr. Malicky said.
Those who break an ankle need to see a specialist who can work to realign the joint and assure that it is moving properly. However, the doctor stressed that even with the best post-trauma treatment, sometimes it is impossible to determine who will later suffer from ankle arthritis.
"The die is often cast with the initial injury," he said.
Dr. Eric Malicky, M.D., Orthopaedics, Foot and Ankle Surgeon
Advanced Healthcare
"I operated on one patient in his 50s, a retired police officer. He had tried many cortisone injections, a brace and arthroscopic cleaning of the ankle joint, but continued to have pain. He had an ankle replacement and was very pleased with the result."
|
In addition to ankle arthritis, rheumatoid arthritis may also affect the ankle joints, as may primary osteoarthritis, (though this is rare because ankle joint cartilage seems less sensitive to the effects of the disease).
Avoiding surgery
Non-surgical treatments for ankle arthritis include non-narcotic pain medications, alteration of lifestyle (such as replacing soccer with swimming), cortisone injections and physical therapy. Shoe soles can also be modified by creating a rocker curve on the sole that makes an easier transition from one part of the foot to the next as someone walks. "Weight loss is also good, but it's hard when you can't exercise due to pain," Dr. Malicky said.
Replacement vs. fusion
Ankle fusion, which immobilizes the ankle joint, can be done on a patient of any age. In time, other joints in the foot increase their range of motion, providing some compensation for the stiff ankle. However, this puts added stress on other joints in the foot, a problem for those suffering from osteoarthritis. In addition, if the other joints in the foot have been fused following a trauma, a patient will not get good range of motion. For these patients, ankle replacement may be a better surgical choice.
However, ankle replacement cannot be done on people who have had an infection of the ankle, have impaired circulation in the foot, who have a great deal of soft tissue scarring around the ankle due to injuries or who don't have normal feeling in their foot. In addition, those who suffer from a lack of coordination in the foot or have significant bone loss in the ankle may not get as good an outcome from replacement surgery.
An overview of ankle replacement
Ankle replacement is done in much the same way as knee replacement. The surgeon opens up the ankle and removes a segment of bone from both the tibia and talus (ankle joint) then replaces the ends with metal, with a plastic cushion between them. The replacement joint is a press fit design, rather than cemented.
It is inpatient surgery, usually done with a general or regional anesthetic. Patients will be in the hospital for 1 to 3 nights. Their ankle will be in a cast for about 6 weeks to allow the bone to grow into the metal. The patient will then be fitted with a walking boot and begin physical therapy to increase activity and strength. The average range of recovery is 3 to 6 months, though there may be swelling that can linger up to a year.
"Many patients find this long recovery time odd because they had neighbors who had knee or hip replacements who were up and walking right away but the ankle is a different joint. The motion and stress of early weight bearing following ankle replacement surgery can adversely affect the proper healing of the bone into the artificial ankle joint. That's why it takes longer for full recovery," Dr. Malicky said.
The doctor added that his patients are pleased with both the pain relief and the function of the new ankle joint. "My first patient here had broken her ankle at a young age and had developed ankle arthritis over a thirty-year period. Now, three years out from her ankle replacement surgery, she is still very pleased with the range of motion, pain relief and function. I saw her just three months ago and she was glowing. At times, I have people contemplating surgery talk to her," Dr. Malicky said and added that her story is common among his patients.
