Ankle replacement surgery is now a frequently performed treatment for ankle arthritis. Total ankle replacements have been shown to reduce pain, improve range of motion and enhance quality of life, but there is a lot of misinformation on the Internet. In this article we explain everything you need to know.
What Is an Ankle Replacement?
An ankle replacement is an operation to replace a worn-out ankle joint by resurfacing the ends of your tibia and talus with metal components with a plastic insert in between them to allow gliding motion. The metal components fix into bones using pegs or stems. They have a special coating to encourage the patient’s bone to grow into them. 
Which is the best ankle replacement?
Total ankle replacement (TAR) is an emerging technology. Although the first generation of total ankle replacements in the 1970’s showed poor results. Improvements in technology and research have led to the development of a third and forth generation of uncemented, two and three component implants.
The problem is that there are more than 15 different designs on the market and there are differences between the implants available in the USA and Europe and so it is no wonder that a lot of confusion runs riot.
The basic premise is that the tibia and talar bones of the ankle are resurfaced with metal components. In a two-component or fixed bearing implant, the plastic liner (made of high density polyethylene) is attached onto the tibial component so there are just two moving parts. In the USA this is the only implant allowed because the Food & Drug Administration have reservations about mobile bearing implants.
There are also three-component or mobile bearing implants where the plastic liner is not fixed but an independent third part of the ankle replacement so there are three moving parts. In order to have a market in the USA and Europe some manufacturers have launched a two and three component implant of the same type. Examples are the Vantage ankle or the Salto ankle replacement. In the USA the polyethylene is attached to the tibial component and in Europe it has a flat surface and is freely mobile.
There is no good evidence that a two or a three component implant makes a big difference to the outcome of the ankle replacement. Its a bit like the war between BetaMax and VHS video formats in the 1970’s. Both were good video formats but in the end BetaMax died and VHS was victorious.
The commonest used implant globally until 2014 was a three component mobile bearing implant. However, since that date and the growth of ankle replacements in the USA, fixed bearing implants have dominated the market and now the Infinity ankle replacement manufactured by Wright Medical (recently acquired by Stryker) has become the market leader. Although many ankle replacements have limited published outcome data, the Infinity Ankle Replacement has a 500 patient post market surveillance study on the outcome of new ankle replacement surgery, which is the largest study of its kind in the world. You can read about ankle replacement success and outcomes here.
Another important point is that all implants in the USA are meant to be cemented, where bone cement is used to join the metal components into the bone. However, it is important to bear in mind that almost all surgeons do not use bone cement, because this has been shown to have poor results and virtually all ankle replacements are designed to be used without bone cement. As a result, most ankle replacements performed in the USA are known as “off label” which is a very strange situation. To get around this, some surgeons in the USA place a tiny amount of bone cement into the bone, to remain “on label” but this is not usually material to the fixation of the metal components which rely on bone integration for fixation. In Europe, this is less of an issue, as ankle replacement implants are recognised as being uncemented meaning that the surgeon does not need to use bone cement.
Who is the best ankle surgeon?
Most surgeons do not perform ankle replacement and so determining who is the best ankle replacement surgeon to perform your surgery is not an easy task. Of surgeons that do perform ankle replacement the average number performed per year is just 4 ankle replacements per year. Some surgeons perform 20 or more per year and there is good evidence that surgeons who perform more procedures get better outcomes. It is important that you discuss your expectations with your surgeon to make sure yours and their expectations are aligned.
What is the alternative treatment?
There are many non operative treatments that can be tried before considering surgery and most patients with ankle arthritis do not require surgery. Here is a video on the ways in which you can treat ankle arthritis.
If non surgical treatments for ankle arthritis have been tried and failed then surgery may be considered. There are two recognised surgical treatments for ankle arthritis, ankle fusion and ankle replacement. Both are excellent treatments for ankle arthritis but there are pros and cons to both treatments. Here is a video on choosing between them.
What Can I Expect After Surgery?
Total ankle replacement provides excellent-pain relief and good function. It has a greater than 90% success rate, as measured by patient satisfaction in the short term. But like all joint replacements is prone to wear and failure with time. This appears more likely to occur in ankle replacement than in hip or knee replacements.
In most cases, the range of motion after a replacement is better than before, but in some patients, this is not the case, largely due to stiffness and scarring of the soft tissues. It is important that you discuss the likely range of movement you should expect with your surgeon before having your surgery, as this helps you to have realistic expectations.
You should be able to return to walking, hiking, dancing and many sports such as swimming, tennis, bowling, and golf afterwards.
What do patients think of ankle replacement surgery?
The following video shows a patient 6 months after ankle replacement surgery and provides his experience and advice for other patients.
QUESTIONS TO ASK YOUR ANKLE SURGEON.
- What are my treatment options?
- Do I need any special tests?
- What’s the best treatment plan for me?
- Are there any alternatives to what you are suggesting?
- How many of this type of surgery do you perform per year?
- Are there any complications I need to be aware of?
- Are there any similar patients to me that I could perhaps speak to?
- Do you recommend any patient information guides or websites for more information?
This is a procedure that you want to last for many years to come and so its important that you do your research and weight up the pros and cons of an ankle replacement before rushing into surgery. Whatever you choose to do, good luck and be safe.
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