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Ankle Fusion Surgery

What are the treatment options?

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When an ankle is well an truly worn out there are only 3 options:

  1. Try a steroid injection because for some patients a guided injection can bring 6 -12 months of pain relief

  2. Fuse the ankle joint

  3. Replace the ankle joint

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Why does fusing the ankle work?

An ankle fusion is the gold standard procedure to treat severe pain and deformity associated with advanced ankle arthritis. Ankle pain is produced by the bones grinding against each other and fusion stops this pain. Patients with severe ankle arthritis often have a stiff ankle and the nearby joints have stretched out to become more flexible. After ankle fusion the other joints will continue to move and give the appearance of a moving ‘ankle’.

 

What about ankle replacements?

Ankle replacements have a role but they do not offer the results that replacements in hips and knee offer. There is a national trial, the TARVA trial going on and if you wish to be a part of the trial I will make sure you are referred to the trial researchers. The downside to ankle replacements is that they often require additional surgeries and they wear out rather quickly. Ankle replacements are useful in patients whose stiff ankles and feet are riddled with arthritis (such as patients with rheumatoid arthritis) and they can work wonderfully for older, less active individuals.

 

What does Arthroscopic mean?

Arthroscopic means performing the ankle fusion through two ‘key holes”. A further incision is needed to insert the screws. Not every ankle can be fused through key hole surgery.

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What will I walk like after an Ankle fusion?

Patients walk normally and to the untrained eye it is impossible to tell that the joint is fused. It is harder to walk up hill. The reason the ankle still appears to move is because the joints near the ankle fusion stretch out and move more. Here is a video of a patient of mine who had bilateral ankle fusions nearly 10 years before the video is taken of him walking.

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What can I expect on the day of surgery?

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  • The surgery will normally be under a general anaesthetic.

  • Normally this is an overnight stay surgery.

  • I will numb the ankle with local anaesthetic so that you will be comfortable when you wake.

  • There will be a bulky half plaster cast on your lower leg which you will keep clean and dry.

  • You will be given crutches or a frame and told not to weight bear.

  • This is a major surgery and some patients may chose to pay to stay in a rehabilitation centre for a few days rather than going home.

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What are the risks and complications?

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The vast majority of patients do extremely well. A small group of patients need extra physio due to swelling or stiffness. Some patients require longer periods in plaster to assist healing. Complications include infection, blood clots (DVT), nerve damage, tendon injury, non-union, painful screws requiring removal, and long term there is risk of arthritis occurring in other joints.

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Non union is a serious complication which occurs in one patient in twenty. If a non union is painful the entire surgery must be repeated.

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When can I drive?

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The best guide that you are safe to return to driving is that you are able to walk well without crutches and without a plaster or a boot. The usual time scale also depends on whether you had surgery on your right or left foot and whether you drive a manual or an automatic

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  • Right side and all car types: 3 months

  • Left side and manual car: 3 months

  • Left side & automatic car: 2 weeks

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How long should I take off work?

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The time you require off from work depends on what type of job you do. The first two weeks of healing are critical and so you must have this time off work. Many people are able to work from home and so if you can avoid commuting in the first six - twelve weeks, you will find that your ankle does better. If your employer can be flexible with your activity at work you may be able to do some lighter duties or reduced hours from 3 weeks onward. If you work on your feet all day, do a manual job, or are required to wear dress shoes you may need 12 weeks before you are back at work.

Clear Advice About DVT

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A DVT is a Deep Vein Thrombosis or a blood clot in the leg. A blood clot occurs after surgery where patients are placed into plaster or a splint for about 2 in every 100 patients. You can help prevent a blood clot by keeping your knee moving. Keeping yourself hydrated is also helpful to prevent a DVT. Finally elevating your leg to the level of your heart will minimise the amount of swelling you have which will also help to prevent a DVT. You will be given blood thinners for the first two weeks when you at your least active.

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We will discuss how best to prevent a DVT and for most patients we opt to use injections of  blood thinners for the first two weeks after surgery. After two weeks the risk is not completely gone however, you will be able to be more active. Most patients would rather stop blood thinners at that stage and monitor their leg for symptoms.

 

If you were to develop a DVT you would likely have some symptoms and so it is very helpful if know what to look for:

  • The leg (above the dressing/foot) would become hard, heavy, swollen, painful and/or red

  • If you were to have any of the above symptoms you would have to have a scan to look for a blood clot and then be treated with blood thinners

If the blood clot were to move to the lungs you would have a pulmonary embolism which is a medical emergency

  • The symptoms of a pulmonary embolism are breathless & chest pain- Call 911

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The Recovery after ankle fusion surgery

Instructions 0-2 weeks

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  1. Elevate Leg Above Heart most of the time

  2. Keep dry for two weeks

  3. Low-Molecular-Weight Heparin Injection daily for two weeks

  4. Non weight bearing in plaster back slab

  5. Move toes and knee

  6. Take Vitamin D (25ug) and ensure good sources of Calcium in Diet (yoghurt, cheese, milk, oily fish, dark green vegetables and fortified cereals) and do so for the first 3 months after surgery

  7. Use the heavy duty painkillers that contain codeine or tramadol at night but use regular paracetamol during the day

  8. Avoid taking anti-inflammatories where you can as these can stop bone healing especially if used regularly

 

2 weeks in clinic

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  • I will arrange to have your plaster & sutures removed

  • You will then be placed in a full plaster and instructed to be non weight bearing for the next four weeks

 

6 weeks in clinic

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  • I will remove your plaster and send you for a X-rays of the ankle

  • Provided the X-rays show some early healing you will be placed in a weight bearing plaster

 

6 weeks- 3 months

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  • Initially you will only place some weight through the plaster and some through crutches

  • Week on week you should find that you can put more weight through the plaster

  • Eventually you will take your weight fully through the plaster

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3 months in clinic

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  • I will remove your plaster & send you for new X-rays

  • If there is any doubt about whether there is solid bony union a CT scan will be arranged

  • You will go into an Aircast boot

  • You will then be able to wash the ankle

 

 Physiotherapy instructions once able to weightbear and remove the Aircast boot

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  • Use the Boot for comfort but start to take small steps at home without the boot

  • Gradually use the boot less and less as comfort allows

  • Use Contrast bathing with bowls of hot and cold water. Place foot for 20 sec in cold and then alternate for 30 sec in hot. Do for 5 min.

  • Your physiotherapist can use other local modalities to reduce swelling

  • You may ice the ankle if this helps

  • Use a compression stocking and elevate the ankle above the heart to help swelling

  • Start to work on strengthening

    • Theraband Resistance

    • Cycling on stationary cycle

    • Swimming and Hydrotherapy

    • Work on developing an even gait

    • Progressing to double heel rises

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THE ‘SURREY STAGES’ PHYSIOTHERAPY STRENGTHENING PROGRAM

 

BRONZE AWARD

DOUBLE HEEL RISES (DHR)

  • You can go up and down on tiptoes in sets of 3, slowly and 15 reps in each

  • You can stand on a skipping rope and adjust your foot position

  • You can hold a DHR for 15 seconds

  • It can be difficult to progress to the next award level because the ankle will take double the weight when you move to lifting the good leg to lower only on the operated leg.

  • You are better to stay at the bronze award level but to add in a back pack with increasing weight as you feel ready for more

  • When you have done this for some time you will be ready to progress to the silver award level

 

SILVER AWARD

DOUBLE HEEL RISES WITH A LIFT

  • May need to add weight in backpack on DHR to reach silver level

  • You go up on both feet but lift unoperated leg and lower slowly only on operated leg

  • 3 sets, working up to 15 reps in each

  • You can stand both feet on a wobble board

  • You can hold a solid DHR for 20 seconds

 

GOLD AWARD

SINGLE HEEL RISES

  • 3 sets, working up to 15 reps in each

  • You can stand on one foot on wobble board

  • You can hold a solid DHR for 40+ seconds

 

PLATINUM AWARD

  • Progress to hopping in all directions

  • Double Hops

  • Gentle jogging to reintroduce running

BOFAS Registry

All Ankle Fusions are entered into the UK data base held by the British Orthopaedic Foot and Ankle Society

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The consent form is below

Bilateral Ankle Fusion Surgery Case Example

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