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Ankle joint replacement is a newer operation than the well-established replacement operations for hip and knee joints.
Whereas the hip is a ball in socket joint and the knee is fundamentally a hinge joint, the ability of the ankle and forefoot to flex, extend, invert and evert makes is a complex joint. These actions are necessary to be able to walk over uneven ground.
Indications and other options
Total ankle arthroplasty is indicated for patients with end-stage ankle arthritis who have sufficient bone stock available in the tibia and talus to support a prosthesis. Patients with associated arthritic changes in adjacent joints of the hindfoot and midfoot are ideal candidates.
Other treatments for ankle arthritis
Conservative treatments may be tried first:
- Non-surgical, including:
- Orthotics, such as a splint and/or a shoe with a 'rocker sole'.
- Arthroscopic debridement.
- Ilizarov joint distraction - an external frame fixed around the joint.
- It has a much lower rate of failure or complications and does not 'wear out'. It is equally effective for pain relief.
- The ankle joint will be rigid, although there can be some compensation from increased mobility at nearby joints.
- There is concern that it may lead to increased strain and therefore arthritis of nearby joints, particularly the subtalar joint. In practice, there seem to be radiological changes of the subtalar joint but few symptoms.
Replacement or fusion?
Factors to consider:
- Function of the whole limb and mobility of surrounding joints.
- Suitable patients for joint replacement tend to be in the older age group (over 50) and prepared to accept a rather higher risk of failure than with hip or knee arthroplasty.
- Younger patients are approached with more caution, as they have longer expected life, and tend to be more active and so put prosthetic joints under more stress.
- Occupation and its likely stress on the joint must be considered.
- With bilateral ankle arthritis - a bilateral fusion can be disabling for certain tasks - eg, getting up from a chair; in this situation, it may be preferable to replace one or both joints.
Contra-indications for total ankle replacement
Absolute contraindications to total ankle replacement include: active infection, peripheral vascular disease, inadequate soft-tissue envelope and Charcot neuroarthropathy.
Relative contraindications include: young, active patients, previous infection, severe lower extremity malalignment, marked ankle instability, marked osteoporosis, and osteonecrosis of the talus.
Types of prosthesis
In the UK, most ankle replacements have a mobile component between the talar and tibial components, which moves forwards and backwards slightly during ankle motion. In some ankle replacements the plastic is fixed to the tibial component, and this is known as a two-component or fixed-bearing ankle replacement.
Primary ankle joint replacements in the UK currently include Zenith®, Box®, Salto®, Hinergra®, Star® and Rebalance®.
Pre-operative and postoperative practical considerations
- Deep vein thrombosis (DVT) prophylaxis may be needed (as with any leg operation).
- Practical points after ankle replacement surgery (details will vary according to surgical practice and patient need):
- A splint or plaster cast will be fitted, and the patient may be non-weight bearing for up to six weeks.
- Physiotherapy may be advised.
- Driving may be possible after three months.
There is no strong evidence on outcomes following total ankle replacement but available evidence indicates that total ankle replacement has a positive impact on patients’ lives, with benefits lasting ten years, as judged by improvement in pain and function, improved gait and increased range of movement.
Function after ankle replacement
- Gait can be normal or near-normal (assuming the rest of the limb is unimpaired).
- Running is unlikely.
- Cycling and swimming are possible.
The following complications may occur:
- Deep infection of the joint.
- Wound infection.
- Delayed wound healing or breakdown.
- DVT or pulmonary embolism.
- Pain and stiffness despite replacement.
- Malleolar fracture.
- Failure of implant.
- Further surgery needed.
Ankle arthrodesis may be an option for failed total ankle replacement.
Both implant design and surgical technique are improving, leading to better patient outcomes.
Further reading and references
Demetracopoulos CA, Halloran JP, Maloof P, et al; Total ankle arthroplasty in end-stage ankle arthritis. Curr Rev Musculoskelet Med. 2013 Dec6(4):279-84. doi: 10.1007/s12178-013-9179-6.
Jordan RW, Chahal GS, Chapman A; Is end-stage ankle arthrosis best managed with total ankle replacement or arthrodesis? A systematic review. Adv Orthop. 20142014:986285. doi: 10.1155/2014/986285. Epub 2014 Aug 21.
van Heiningen J, Vliet Vlieland TP, van der Heide HJ; The mid-term outcome of total ankle arthroplasty and ankle fusion in rheumatoid arthritis: a systematic review. BMC Musculoskelet Disord. 2013 Oct 2614:306. doi: 10.1186/1471-2474-14-306.
Gougoulias N, Khanna A, Maffulli N; How successful are current ankle replacements?: a systematic review of the literature. Clin Orthop Relat Res. 2010 Jan468(1):199-208. doi: 10.1007/s11999-009-0987-3. Epub 2009 Jul 18.
Park JS, Mroczek KJ; Total ankle arthroplasty. Bull NYU Hosp Jt Dis. 201169(1):27-35.
Trichard T, Remy F, Girard J, et al; Long-term behavior of ankle fusion: assessment of the same series at 7 and 23 year (19-36 years) follow-up. Rev Chir Orthop Reparatrice Appar Mot. 2006 Nov92(7):701-7.
Bonasia DE, Dettoni F, Femino JE, et al; Total ankle replacement: why, when and how? Iowa Orthop J. 201030:119-30.
Ankle Arthritis; Royal National Orthopaedic Hospital NHS Trust
Annual Reports 2013/14; National Joint Registry.
Zaidi R et al; The outcome of total ankle replacement: A systematic review and meta-analysis, The Bone and Joint Journal, July 2013
Stengel D, Bauwens K, Ekkernkamp A, et al; Efficacy of total ankle replacement with meniscal-bearing devices: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2005 Mar
Gross C, Erickson BJ, Adams SB, et al; Ankle Arthrodesis After Failed Total Ankle Replacement: A Systematic Review of the Literature. Foot Ankle Spec. 2015 Jan 5. pii: 1938640014565046.
DiDomenico LA, Anania MC; Total ankle replacements: an overview. Clin Podiatr Med Surg. 2011 Aug28(4):727-44. doi: 10.1016/j.cpm.2011.08.002.
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