14595 Total Ankle Replacement

Overview

A total ankle replacement is an operation that swaps a worn-out ankle joint for an artificial one. The surgeon removes the damaged ends of the bones that meet at your ankle and fits smooth metal and plastic parts in their place. The new joint is designed to let your ankle bend and move, and to take away the grinding pain of arthritis. It is also called ankle arthroplasty. It is different from an ankle fusion, which joins the bones together so they stop moving.

It is much less common than hip or knee replacement, but it is a well-established operation done regularly in specialist orthopaedic (bone and joint) centres.

Most people who have it are adults with severe ankle arthritis — often caused by an old fracture, repeated sprains, rheumatoid arthritis or other inflammatory joint conditions. It is very rarely done in children or teenagers, because their bones are still growing and other treatments are usually tried first.

Symptoms

Common symptoms

• Deep pain in the ankle that is worse when you walk, stand or climb stairs
• Stiffness, especially first thing in the morning or after sitting
• Swelling around the ankle that gets worse as the day goes on
• A grinding, crunching or catching feeling inside the joint
• Limping, or walking on the outer edge of your foot to ease the pain
• Pain that wakes you at night or stops you walking as far as you used to
• Trouble standing on uneven ground, or feeling unsteady on your feet

Symptoms in children

• Ankle replacement is very rarely done in children. Children with ankle pain more often have injuries, growth-plate problems or inflammatory joint conditions, so ankle pain in a child should always be checked by a doctor.

Symptoms in older adults

• Pain and stiffness that build up slowly over years
• Swelling and a feeling of instability that make falls more likely
• Other joints, such as the knee or hip, may also be affected by arthritis
• Recovery after surgery may be slower, and bone strength and general health matter when deciding on an operation

Causes

Main causes

• Osteoarthritis of the ankle, often years after an old fracture or severe sprain
• Rheumatoid arthritis and other inflammatory joint diseases
• Damage to the joint surface from repeated injuries or heavy loading
• Death of bone tissue near the joint (avascular necrosis), or joint damage after an infection

Risk factors

• A previous ankle fracture or repeated ankle sprains
• Being very overweight, which puts extra load on the ankle
• Inflammatory arthritis or a family history of joint problems
• Jobs or sports that involve a lot of jumping, twisting or heavy lifting
• Smoking, which slows healing and raises the risk of surgery complications

When to see a doctor

See a doctor urgently if:

• You cannot put any weight on the ankle after an injury, or the ankle looks deformed
• The ankle becomes hot, red and very swollen, or you feel feverish
• You have severe pain that is not controlled by the pain relief you have been advised to use
• After surgery: a wound that is leaking, spreading redness, or a calf that becomes swollen and painful

Book a routine appointment if:

• Ankle pain or stiffness that has lasted more than a few weeks
• Pain that limits walking, work or everyday activities
• Repeated swelling, giving way, or a feeling that the ankle is not stable
• You have been offered an ankle replacement and want to talk through the options

Diagnosis

There is no single test for ankle arthritis. Your doctor will talk to you about your pain, your history of injuries and how your ankle affects your daily life. They will look at how you walk and feel your ankle for swelling, warmth and tenderness, and check how far it moves. Imaging and sometimes blood tests then help confirm the cause and how much the joint is worn.

Tests that may be done

• A physical examination of the ankle, foot and how you walk
• X-rays, usually standing up, to show the gap between the bones and any bone spurs
• A CT scan for a more detailed 3D picture of the bone, sometimes used in planning surgery
• An MRI scan if soft tissue, ligaments or infection need checking
• Blood tests if an inflammatory type of arthritis is suspected
• Sometimes a steroid or local anaesthetic injection into the joint to see whether the pain comes from the ankle itself

What to expect at your appointment

You will usually start in general practice and be referred to an orthopaedic foot and ankle specialist if surgery might be an option. The specialist will explain the likely benefits and risks of ankle replacement compared with an ankle fusion or with non-surgical treatment, so you can decide together. Bring a list of your medicines and any questions, and it can help to take someone with you.

Treatment

Treatment usually starts without surgery. The aim is to reduce pain, keep the ankle moving and help you stay active. If those measures stop working and the joint is badly worn, an ankle replacement or an ankle fusion may be considered.

Self-care at home

• Keep active in low-impact ways, such as swimming, cycling or walking on flat ground — movement helps keep the joint supple
• Stay at a healthy weight to reduce the load on your ankle
• Wear supportive shoes with a cushioned sole, and avoid very flat or very high shoes
• Use a walking stick or pole if it helps, and pace activities with rests in between
• Try warm packs for stiffness and cold packs for swelling, always wrapped in a cloth
• Follow the exercises your physiotherapist gives you, and build up slowly

Medical treatments

Doctors can offer pain relief and anti-inflammatory medicines that are right for you, always checking them against your other health conditions. Physiotherapy helps strengthen the muscles around the ankle and improve balance. A podiatrist can advise on insoles, braces or specially made footwear. Specialists may offer injections into the joint to calm pain for a while. These approaches do not repair the worn joint, but they can delay or sometimes avoid the need for surgery.

When is surgery considered?

Surgery may be discussed when pain and stiffness seriously affect your sleep, work or walking despite other treatments, and scans show the joint is badly worn. Your surgeon will weigh up ankle replacement against ankle fusion, taking into account your age, weight, bone quality, other health problems and how active you want to be. Ankle replacement preserves movement but the artificial joint can wear out and may eventually need further surgery; fusion is very reliable for pain but leaves the ankle stiff. Both are reasonable choices for different people.

Living with this condition

After an ankle replacement you will usually stay in hospital for a short time. Your leg will be in a cast or a protective boot, and you will not be able to put weight on it for several weeks — your team will tell you exactly when to start. Crutches or a frame help you get around. Physiotherapy begins early and continues for months. Most people notice real improvement by six months, but swelling and stiffness can keep easing for up to a year. Elevating your leg and following your team's advice helps recovery go smoothly.

Lifestyle tips

• Plan your home before surgery: clear pathways, move things you use daily to waist height, and arrange help with shopping and cleaning
• Avoid high-impact activities such as running or jumping after surgery — your surgeon will advise what is safe
• Build balance and strength with the exercises you are given; this lowers your risk of falls
• Stop smoking if you can, and cut back on alcohol, as both affect healing
• Keep up with follow-up appointments and X-rays so the joint can be checked over the years

Diet and exercise

A balanced diet with enough protein, calcium and vitamin D supports bone and wound healing. Keep moving in ways that suit your stage of recovery, starting with the physiotherapy programme and gentle walking once you are allowed. Swimming and cycling are often good long-term choices because they keep you fit without jarring the ankle. Ask your team before starting any new activity.

Mental health and emotional wellbeing

It is normal to feel anxious before surgery, and to feel low or frustrated during the weeks of limited mobility afterwards. Needing help from others can be hard to accept. Tell your doctor or nurse how you are feeling — practical support and, if needed, talking therapies are available. If you ever feel hopeless or have thoughts of harming yourself, contact your local emergency number or a crisis support service straight away.

Prevention

You cannot undo arthritis that is already there, but you can lower the risk of ankle damage in the first place. Get ankle sprains and fractures treated properly, do balance and strengthening work, keep to a healthy weight, and wear footwear that supports your feet. If you have inflammatory arthritis, keeping it well controlled helps protect your joints.

Screening programmes

There is no screening programme for ankle arthritis. If you have ongoing ankle pain, stiffness or swelling, ask your doctor for an assessment rather than waiting.

Complications

If left untreated

• Pain and stiffness that slowly get worse, making walking and everyday tasks harder
• Increasing difficulty with work, driving, stairs and uneven ground
• Muscle weakness and poorer balance, which raise the risk of falls
• Other joints, such as the knee or other foot, taking extra strain
• Low mood and loss of independence if pain limits activity for a long time

Long-term outlook

Most people who have an ankle replacement get good pain relief and a more mobile ankle, though it is not quite the same as a natural joint. Some people still have stiffness or swelling, and there is a chance the joint may need further surgery many years later. Non-surgical treatment helps many people for a long time, and if surgery is needed, planning it carefully with your team gives the best chance of a good result. Your doctor and surgeon can help you choose the path that fits your life.

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