Total Ankle Replacement
Total ankle replacement is an increasingly common surgical procedure used to treat severe joint conditions of the ankle, such as advanced arthritis or complex fractures. Unlike hip or knee replacement, total ankle replacement is a more recent procedure, but it offers patients a promising treatment option to relieve pain and restore ankle functionality. In this article, we will explore in detail the indications, surgical techniques, benefits and risks associated with total ankle replacement, as well as long-term outcomes for patients.
What is a total ankle replacement ?
A total ankle replacement consists of 3 components: a tibial component fixed in the tibia by cementless impaction, a talar component fixed in the talus by cementless impaction, and a polyethylene insert. The components form the metal-polyethylene "bearing couple."
The prosthetic components (generally coated with calcium hydroxyapatite crystals to promote biological fixation through bone ingrowth) are impacted into the bone: this is the primary stability of the implants. The osseointegration phase then lasts 2 months, providing the implants with their secondary stability through bone anchoring
Why a Total Ankle Replacement?
Total ankle replacement is a functional procedure, its goal is to improve your pain while preserving ankle mobility. The decision to have surgery is yours, and it depends on your level of disability. Regardless of your age, gender, or activity level, the purpose of this procedure will be to improve your quality of life.
The procedure will help relieve your joint pain, improve your functional performance, and allow you to discontinue pain medications. In some cases, it may also provide relief if you suffer from lower back pain. You will be the main actor in your recovery, and we will be by your side to guide you. Following the advice you will be given carefully will help minimize the risk of complications, which are always possible after a surgical procedure.
Your consultation with the surgeon
Following a medical interview (during which risk factors for scarring complications will be assessed: diabetes, smoking, obesity, corticosteroid use, etc.) and a clinical and radiological examination of your ankle, the surgeon will advise you, based on your level of disability, whether an ankle replacement can improve your quality of life. The consultation with the surgeon is an important moment to ensure that your expectations align with what surgery can offer you.
The alternative to total ankle replacement is ankle arthrodesis ; your surgeon will need to explain the advantages and disadvantages of these 2 techniques to you. In this booklet, the alternatives to ankle replacement and the complications of this procedure will not be covered, they will be explained to you during your consultation with your surgeon and when you sign the informed consent form.
Your Consultation with the Anesthesiologist
The consultation with the anesthesiologist will aim to review your medical history and personalize your medical and surgical care. The anesthesiologist will select the anesthesia and pain management techniques best suited for you. They will advise you on which medications to continue and which ones will need to be stopped prior to the procedure. This is the right time to ask any questions you may have about pain management. Several treatments and techniques can be combined to address the temporary discomfort associated with the surgery. An infectious disease screening will be ordered: it will involve identifying and eliminating potential sources of infection (dental, urinary, gynecological, and others) which is essential before any implant placement.
Surgical Technique Used
Placing the prosthesis requires accessing the inside of the ankle joint. The anatomical pathway used to reach it is called the surgical approach. We classically use an anterior approach passing between the tendon of the anterior tibialis muscle and the tendon of the extensor hallucis longus muscle, allowing exposure of the ankle and placement of the implants.
Total ankle replacement is a minimally invasive technique. The skin incision will measure between 10 and 12 cm depending on your build. The procedure is performed with the patient in the supine position (lying on their back). For this procedure, anesthesia may be general or locoregional. This approach causes minimal discomfort.
At the end of the procedure, you will have a cast boot, meaning a cast stopping below the knee. You will keep this cast for 21 days without being able to bear weight on it. Depending on intraoperative conditions, technical adjustments may be made. During the procedure, and with your prior consent, we may take photographs that will be used for scientific purposes (presentations, conferences).
Your Preparation Before the Surgery
To optimize the chances of success of your procedure and reduce the risk of complications, several preparatory measures are recommended:
- Weight management: If you are overweight, even losing a few pounds will significantly relieve your joints. Walking generates a load equivalent to 5 times your body weight at the ankle level. Follow-up with a dietitian or a nutrition specialist is advised.
- Smoking cessation: Smoking considerably increases the risk of infectious complications, scarring issues, vascular thrombosis (phlebitis), and can compromise the osseointegration of prostheses. Stopping 6 weeks before and 6 weeks after the procedure significantly reduces the rate of postoperative complications.
- Muscle strengthening: Regardless of your current level of physical activity, muscle preparation before surgery facilitates recovery. Preoperative physical therapy sessions will be prescribed by your surgeon (use of crutches, self-rehabilitation exercises).
- Self-rehabilitation exercises: Your surgeon will teach you specific exercises to maintain the muscles of the lower limb, to be practiced before and after the procedure.
The better prepared you are ahead of the procedure, the faster and more effective your postoperative recovery will be.
Your Stay at Clinique Saint George in Nice
You will be admitted for ankle replacement surgery. Please fast for 6 hours before the procedure (no food, no liquids, no cigarettes) and let us know if you experience significant anxiety: a treatment may be offered to you. The surgery lasts between 1 hour and 1 hour 30 minutes, followed by a stay in the recovery room until the anesthesia wears off and pain is under control.
Your first time getting up will take place as early as the evening of the surgery or the following day, with the assistance of the surgeon or the physical therapist. Move as soon as possible: prolonged immobility worsens pain, and pain management treatments are available if needed. You will be able to eat as soon as you return to your room, which promotes healing and reduces nausea. Throughout your stay, the surgeon and the physical therapist will guide you in regaining your independence as quickly as possible.
Precautions for getting around during the first 3 months
Your cast requires some important precautions to follow throughout your treatment:
- Do not get the cast wet: protect it while showering with a plastic bag or a waterproof cover available at your pharmacy. If the cast breaks: come back to see us so it can be replaced.
- If you experience itching: be patient and never insert any object inside, as your skin loses sensitivity and you could injure your wound without feeling it.
- If you experience tightness, swelling, or blue discoloration of your toes, or if you feel an uncomfortable pressure point: come back to see us so the cast can be redone. Elevate the limb during the first 10 days to limit swelling and reduce pain. For more details, refer to our complete cast care guide.
- For getting around: use crutches or a walker, a wheelchair is reserved for long distances.
- For sleeping: keep your usual position, but if the pain wakes you up, lie on your back with a pillow under your heel to help the ankle swelling go down.
By following these instructions, you will promote your comfort and proper healing throughout the time you are in a cast.
Returning Home
Returning home can happen directly after hospitalization or following a recovery period of approximately one and a half months. Once the cast is removed (generally 21 days after surgery, or 45 days in the case of additional bone, tendon, or ligament procedures) physical therapy with a licensed physical therapist will be required. For 6 weeks, an anticoagulant treatment will also be prescribed to prevent any risk of deep vein thrombosis.
Resuming Activities
Driving may be resumed from the 8th week onward, with the surgeon's approval. Regarding sports, a gradual return is possible as early as three months, with the exception of pivot, contact, or high-impact sports (basketball, soccer, volleyball, rugby, combat sports, water skiing), while swimming and cycling are particularly recommended for ankle rehabilitation.
From a functional standpoint, continuous improvement is possible for up to one to two years following the procedure, at which point the final outcome of the prosthesis is reached. Regular follow-up with the surgeon is scheduled, with appointments whose frequency will be specified during the first year, followed by annual monitoring including X-rays and CT scans.
Particular vigilance is required regarding infection risks: urinary, gynecological, dental, skin, or ENT infections must be treated promptly, and teeth should be brushed gently to avoid any gingival bleeding that could lead to bacteremia. A prosthetic passport containing all information related to the implant will be provided after the procedure. Any questions may be noted in advance to be submitted to the surgeon at the next appointment.