Health & Exercise Forum

2nd in Series of 2 Columns on Ankle Pain

Total ankle replacement (TAR) is recommended for severe ankle pain which has not responded to conservative treatment: weight loss, activity modification, physical therapy, anti-inflammatory medication and cortisone injections. Severe ankle pain can result from the following:

• Osteoarthritis (Degenerative Joint Disease): cartilage wears out, bone rubs on bone causing inflammation leading to pain, swelling, stiffness, instability and deformity; most common type; usually genetic.
• Trauma: if hip bones do not heal properly after a fracture (break) from a fall or blow, the joint slowly wears away leading to arthritis.
• Inflammatory Arthritis: enzymes which destroy cartilage are released in response to inflammation (e.g. Rheumatoid arthritis, Lupus, psoriatic arthritis)
• Avascular necrosis (osteonecrosis): part of the ankle bone loses its blood supply and dies; most common causes: steroid use and alcohol abuse; other causes: radiation therapy, fracture, vasculitis, infections and sickle cell diseases.
• Prior surgeries to repair fractures in the bones of the lower leg and ankle or deformity.

Ankle pain can manifest in the shin, ankle, and shin. It usually increases with activity and alleviates with rest. It may occur at night and prevent sleep. This pain is associated with stiffness, limping and functional limitation which significantly affects quality of life.

A TAR is the surgical implantation of an artificial ankle (prosthesis). The worn out joint surfaces of the end of the shin bone (tibia) and the top of the ankle bone (talus) are removed. Extreme care using precise instruments are used to insure a level surface for the implant. A metal and plastic implant is inserted into the prepared bone ends to create a new joint surface. Because the artificial ankle joint has smooth surfaces, like cartilage, complete, or near complete, pain relief is experienced which allows improved motion, enhanced function and less limping.

Candidates for Total Ankle Replacement

Ankle replacements have become better designed and more successful. A good candidate is older, less active with an average body weight. Therefore, a poor candidate is young (under 50 years old), active and overweight. For this group with disability and chronic pain an ankle fusion surgery may be more appropriate than a joint replacement.

Predicting the longevity of a TAR on an individual basis is impossible. According to Guido LaPorta, DPM, ankle implants of the 1970’s were not good and resulted in poor outcomes. Those of the 1990’s were good but not great. However, there is an 82 to 90% chance that new TAR’s will last 10-12 years in the appropriate patient.

• Post - Op
  •  3-5 days in the hospital is typical. The leg will be elevated and ankle immobilized in a splint. You will get out of bed and in a chair soon after surgery.
  • Limited weight bearing using walker or crutches for several weeks. (6 weeks non weight bearing is typical). However, the boot will be removed to begin early range of motion exercises in just a few days post-op.
• 6 weeks – begin more aggressive physical therapy for range of motion, strengthening and partial weight bearing.
• 3 month rehab for recovery
• Complications:
  • Infection
  • Wound healing
  • Pain
  • Alignment for normal gait
  • If complications are unresolved, surgical fusion may be an option
• Exercise:
  • Regular exercise is important.
  • Housekeeping, gardening, driving and dancing are encouraged.
  • Low impact activities (walking, swimming and biking) are recommended.
  • High impact activities (jogging) increase prosthetic wear and should be avoided.
• Maintain Ideal Weight:
  • Increased body weight increases amount of force on TAR.
  • Increased forces lead to increased prosthetic wear or loosening.
• Infection Precautions:
  • Antibiotics prior to procedures (surgical, podiatric, and dental) usually are not required after second year.
• Periodic Visits to the Surgeon:
  • Varies according to individual. First visit is usually 4 to 6 weeks after surgery.
  • Helps diagnose any potential problems.
  • Informs surgeon of any status changes.

Recovery following TAR takes 12 weeks. The ankle may be warm/swollen for 3 to 6 months (ice and elevation will help). The ankle will show improvements in function for up to a year. Overall a TAR relieves pain and stiffness, improves mobility and restores quality of life! Instead of limping in pain, you will return to walking painfree and maybe playing golf!

Contributor: Guido LaPorta, DPM, is president of LaPorta and Associates, a podiatric group with several offices in Northeast PA. He is also director of the podiatry residency program at Community Medical Center in Scranton, PA.

SOURCES: Rothman Institute, Philadelphia, PA and American Academy of Orthopaedic Surgeons

Visit your doctor regularly and listen to your body.

NEXT MONDAY – Read Dr. Paul J. Mackarey's “Health & Exercise Forum" in the Scranton Times-Tribune.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.