Edited by Robert Leland, MD
Ankle replacement is performed as a treatment for end-stage ankle arthritis (See Figure 1). It is typically indicated in older, lower demand individuals, as the lifespan of the ankle replacement is uncertain. Patients that have arthritis (or fusions) involving the joints below the ankle (subtalar, talonavicular and calcaneocuboid joints), may benefit from an ankle replacement, as it will help to preserve some hindfoot motion. Relatively young, active patients typically do not do well with ankle replacements in the long run due to an unacceptably high failure rate. These younger patients are usually best served with a well performed ankle fusion. The results of ankle replacement, unfortunately, have not matched the results we see in knee and hip replacements. While 2nd generation and newer ankle replacement designs have been in use for approximately 25 years, there have been more recent design changes that limit bone resection and have potential to improve results of total ankle replacement even more. Consideration of not only the ankle but also any deformities in the foot is imperative to achieving good outcomes in ankle replacement. This can make ankle replacement surgery a greater challenge than hip and knee replacement.
Figure 1A: Normal Ankle Joint on X-ray
Figure 1B: Ankle Arthritis on X-ray (Loss of ankle joint space)
The procedure depends on the type of prosthesis that is used. In all ankle replacements, the arthritic surface of the distal tibia is removed, as is the arthritic surface of the top surface talus. Typically only the tibial surface and some of the talar dome are removed (Figures 2 and 3). The resected areas of bone are then replaced with the prosthesis. The prosthesis typically has a metal surface on the tibia, and talar sides with a polyethylene surface attached to the tibial component.
Figure 2: Total Ankle Replacement (Cadence -Integra LifeScinces)
Figure 3: Saltos Talaris Total Ankle Replacement (Integra Life Sciences)
Previous infection: a previous deep infection around the ankle will result in a high likelihood that the ankle replacement will become infected which is a major complication.
Neuropathy: Patients that do not have normal sensation in their feet and ankles will not do well in the long run with a total ankle replacement because the long term success of a joint replacement requires intact proprioception of the joint that is being replaced. Proprioception is the brains ability to sense what is happening to the joint at any point in time and make the necessary muscle contractions to ensure the joint is not excessively stressed.
Severe deformity: For an ankle replacement to work well over a long period of time it has to be well-balanced. Essentially the ankle prosthesis must be loaded evenly. In individuals with severe deformities achieving this type of even balancing becomes difficult or impossible.
Advanced avascular necrosis (AVN): Avascular necrosis of bone means that a section of bone has lost its blood supply. Loss of blood supply to part of the talus (the lower bone of the ankle joint) can occur and may lead to significant ankle arthritis. In these patients performing a total ankle replacement is not a good idea as the ankle replacement needs to be placed onto living bone so that the bone can grow into the prosthesis and so that the bone will have a good chance of remaining strong and solid enough to support the weight going through the prosthesis in the years ahead.
These include the potential complications that can occur with any surgery such as:
There are some specific complications that can occur with total ankle replacement including:
Deep Infection of the Prosthesis.
The deep wound infection rate in patients undergoing Total Ankle Replacement is not necessarily any higher than with other major ankle surgery. However, the significance of a deep infection is profound. A deep infection often requires removal of the prosthesis in order to eradicate the infection. The deep infection rate is approximately 1-3%.
Major Wound Breakdown
Most total ankle replacements are inserted through an incision in the front of the ankle. This area of tissue has a somewhat tenuous blood supply. It is supplied by one main artery, whereas most other areas of the body are supplied by two or more major arteries. While wound healing problems are not frequent, proper surgical technique is required to minimize risks. Often, this requires immobilizing the ankle for a few weeks to improve the chances of successful wound healing. In some patients, however, an area of wound breakdown or a failure to heal the surgical incision occurs. This can be a difficult and potentially devastating complication because the failure to obtain adequate wound healing can lead to a deep infection involving the prosthesis.
Tibial Nerve Injury
There is a chance of an injury to the surrounding nerves, including the tibial nerve, when the ankle joint is prepared to receive the ankle prosthesis.
Failure of the Ankle Replacement over time
All joint replacements will eventually fail if the patient uses the joint enough, and lives long enough. There are a variety of ways that joint replacements can fail, each of which lead to pain and dysfunction. Perhaps the most common mode of failure of a joint replacement is from shifting of the prosthesis, when the supporting bone becomes weak from repetitive loading or osteolysis – breakdown of the bone under the prosthesis resulting from a reaction of the immune system to very small particles of the polyethylene section of the prosthesis.
Total ankle replacements historically have failed earlier, and at a substantially higher rate, when compared to knee and hip replacements. For example, studies have suggested that certain hip replacements have good or excellent results in over 90% of patients after 18 years. In knee replacements, the figures are close to 90% success after an average of 13 years. However, in ankle replacements, the best prospective study suggests that 85% of patients have a successful result after 5 years – not bad, but nowhere near as successful as knee and hip replacement surgery. However, newer studies suggest that if an ankle replacement is performing well 2 years after surgery, there is a very high likelihood that it will last at least 10 years.
Ankle replacements fail at a higher rate because of a variety of factors related to the ankle joint itself. These include:
- the small joint surface area (half the size of the knee joint)
- high joint reactive forces during walking (2-4 x body weight, almost twice that of the knee joint)
- Uneven distribution of force across the tibial prosthesis
- The lower bone of the ankle (Talus) is relatively small and has a poor blood supply, providing a less than ideal base of support for the prosthesis.
- There are limits to how much bone can be removed from the ankle joint, and this limits the size of polyethylene that can be used. The smaller the polyethylene, the poorer the wear characteristics
- The relatively confined nature (many important structures nearby) of the ankle joint makes placing an ankle replacement technically challenging for the surgeon.
When an ankle joint fails, a revision surgery is necessary. Often the prosthesis can be replaced. However, there may be much less bone stock available around the ankle, so revision surgery is often substantially more difficult with results that are less predictable than the original operation. If the prosthesis cannot be replaced, the ankle joint is then fused, but studies show that patients who have an ankle fusion after a failed ankle replacement may do poorer than patients who have an ankle fusion first. Newer implant designs which minimize bone resection and implants designed for revision total ankle arthroplasty will hopefully improve results of revision surgery.
Total Ankle Arthroplasty is being performed with increased frequency for end stage ankle arthritis. It’s important to consider many factors when considering this as a surgery option. While both ankle arthrodesis (fusion) and ankle replacement have similar outcomes as far as patient satisfaction, gait is more normal after ankle arthroplasty. Proper surgical indications and technique, as well as correction of any associated foot deformity, is imperative to achieving good outcomes.
Previously edited by Sam Dellenbaugh, MD
Edited July 8, 2019