Ankle Replacement: 12 Important Things to Tell the Patient

The main purpose of this article is to clarify many doubts and answer questions about ankle replacement—questions I frequently receive from my patients on Facebook and Instagram.
What makes this article unique compared to others is that, thanks to your questions, I can address uncertainties and concerns that are often taken for granted but actually deserve more careful attention and explanation.
For the sake of clarity, let me start with a premise:

the goal of an ankle replacement is to return to walking without pain.

Let’s begin with the first question.

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They recommended arthrodesis to me. Why not ankle replacement?

 In this case, I wouldn’t start from the assumption that the advice was wrong.
 I believe that arthrodesis is still a valid solution:

• in extreme cases, for example when there is insufficient bone quantity to plan an ankle replacement surgery;
• in certain cases of prosthetic revision.
  
  

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Ankle replacement surgery: how it differs from hip or knee replacements

Reflecting on the nature of the condition, we understand that we are not dealing with the same volumes as with hip or knee replacements.
As people age, it’s common to develop hip or knee osteoarthritis. With an aging Italian population, the numbers are high. Almost every hospital has surgeons who have completed their learning curve, meaning they perform a sufficient number of hip and knee replacements to be considered experts.

The situation is different when it comes to ankle replacements.

In fact, ankle osteoarthritis typically does not affect elderly patients, because the ankle is a congruent joint: without disruptions to this congruence, such as those caused by a fracture, it is almost impossible to develop ankle arthritis.
Consequently, ankle replacement cases are less frequent than hip or knee cases. This is why the concept of “reference centers” is crucial—places where surgeons can train under the guidance of expert tutors, acquiring the necessary skills to manage ankle prosthetics.
This leads us to the next question.

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Ankle replacement: after how many surgeries is a surgeon considered reliable?

In numerous articles, we have explored in depth the topic of the learning curve in surgery.
 Foot and Ankle Surgery, the prestigious European journal specializing in foot and ankle surgery, has published several of our articles analyzing the role of the learning curve in ankle replacement surgery.
Our studies indicate that the minimum number of ankle replacements a surgeon should perform annually to be considered proficient is at least 30 procedures per year, although this number may vary. However, surgeons must overcome the challenges posed by the relatively low incidence of ankle arthritis in order to effectively complete their learning curve. This underscores the importance of having specialized reference centers.

A particularly critical aspect is the deformity typically associated with ankle arthritis.
 After an ankle fracture, patients may develop not only stiffness and arthritis but also deformities. In such cases, it is not possible to proceed with ankle replacement surgery without first treating and realigning the deformity, which may involve both the foot and the ankle.

Very often, ankle replacement also means realigning the ankle and foot.

 Having a dedicated medical team becomes crucial in complex cases where minimizing the duration of surgery is essential.
Over the past ten years, my team has treated more than 1,000 patients with ankle arthritis. In the field of ankle replacement, we represent a unique point of reference for the care of ankle arthritis.

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Why was I advised against ankle replacement?

Because it is a relatively recent development.
To explain better: in reality, ankle prostheses were already implanted before the 1950s, but the results were poor. These implants were created without a true understanding of the ankle’s anatomy and biomechanics, and therefore lacked an appropriate design.
Failures occurred with both anterior and lateral approach prostheses.

Today, we benefit from 10–15 years of experience that has allowed us to improve. Moreover, we are now perfectly able to clearly distinguish the pros and cons of ankle replacement. Today, ankle replacement can be considered a reliable procedure in the hands of a team fully dedicated to this type of surgery.
It is also important to consider that, precisely because of the relatively young age of patients—typical for ankle arthritis—it is correct to anticipate the possibility of a revision surgery during their lifetime.
This possibility often scares surgeons who are not specialized in foot and ankle surgery or who have limited experience with ankle prostheses, leading them to propose procedures such as arthrodesis (ankle fusion).
I have repeatedly emphasized, supported by scientific literature and colleagues worldwide, that arthrodesis—because it leads to overload on the joints adjacent to the ankle and thus subsequent arthritis and secondary surgeries—is not to be seen as the solution over ankle replacement, but rather as an outdated predecessor.
Having said this, it is important to underline how fundamental it is, in ankle replacement, to use an implant that preserves bone stock.
For this reason, in recent years, there has been increasing attention to designing and developing prosthetic implants that minimize bone removal.
This need gave rise to the lateral approach and the concept of resurfacing prosthesis.
The lateral approach, in fact, allows reproduction of the ankle’s original anatomy while minimizing bone resection. It also enables direct control over the center of rotation.
To summarize, the main advantages of the lateral approach are:

• Anatomical advantage: it recreates the ankle’s shape (preserving the curvature of the tibia and the talar dome).
• Bone preservation: in this case, future revision surgery can be planned more easily.

In contrast, the anterior approach makes it difficult to reproduce the natural anatomical shape of the ankle because it requires straight cuts rather than curved ones. This results in less bone preservation.

However, there are cases where the anterior approach is more appropriate. These are cases that I personally select with care, considering that for a patient who is:

• young;
• has high functional demands;
• requires correction of a severe deformity,

Because I believe that awareness and information help patients in their postoperative journey and in setting realistic expectations, I want to conclude this article with one more question I am often asked.

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When is an ankle prosthesis indicated?

An ankle prosthesis is mainly indicated in the following clinical contexts:

1. Post-traumatic arthritis (80% of cases):
   Ankle replacement is frequently considered for arthritis that develops following trauma. Post-traumatic deformity in particular leads to degeneration of the cartilage and skeletal structures (subchondral bone). This results in refractory pain and a marked reduction in joint function.
2. Rheumatoid arthritis (15% of cases):
   Rheumatoid arthritis and other inflammatory diseases in general. Autoimmune diseases cause aggressive joint damage. This aggressive degeneration can be controlled with long-term biologic drug therapies, which, however, are not always tolerated by patients and do not always fully reverse the damage. These patients often present with polyarticular manifestations and frequently undergo corticosteroid treatments, including steroid injections. Pain, deformity, and poor bone quality in these cases severely limit quality of life and necessitate prosthetic solutions involving multiple joints. For the ankle, it is important to select implants with appropriate tribological properties.
3. Joint degeneration due to deformity:
    These patients may have congenital deformities (e.g., clubfoot) or progressive conditions (ankle instability, progressive collapsing foot – flatfoot). Treatment aims to restore physiological alignment as well as to replace the joint with a prosthesis.
4. Dissatisfaction with conservative treatments:
    When conservative therapies such as physiotherapy, pharmacotherapy, or joint-preserving surgeries fail to provide sufficient pain relief or functional improvement, prosthetic surgery can be considered.a.

The decision to proceed with ankle prosthesis implantation must be made after a careful patient evaluation, considering factors such as:

• Age
• Activity level
• Overall health status
• Specific therapeutic goals
  
  

This decision results from a thorough discussion between the patient and an orthopedic surgeon specialized in joint replacement surgery.

A surgeon specialized in prosthetic surgery is defined as one who performs at least 30 prosthetic surgery cases per year. This is important because ankle prosthetic surgery involves a significant learning curve, meaning that the surgeon’s skill and outcomes improve with experience and case volume.

What type of anesthesia is used?

The anesthesia performed is a peripheral anesthesia, more precisely a spinal anesthesia combined with selective nerve blocks. This type of anesthesia is essential because it allows the patient to experience no pain immediately after surgery, keeping the leg numb for several hours.
Fear and anxiety about the surgery should not interfere with choosing the correct anesthesia, which ideally should not be general anesthesia—except in particular cases selected by the anesthesiologist.
If the patient prefers not to be conscious during the procedure, or to calm anxiety, or if they believe ankle replacement surgery might be very painful, or are worried about the surgery and operating room environment, sedation can be requested.

Choosing the correct anesthesia results in:

• Reduced bleeding;
• An easier procedure for the surgeon;
• The possibility to stand up as early as the day after surgery.

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What is the recovery like after ankle replacement surgery?

Recovery after the surgery can vary from patient to patient.

The main difference depends on whether, based on physical characteristics, deformity, and bone quality, the patient can follow a “fast track” protocol—meaning immediate weight-bearing, which allows for faster recovery.

The “innovation” of the fast track protocol, which many of my patients have not experienced, was not introduced lightly or just out of enthusiasm.
On the contrary, the fast track protocol was adopted after studying and evaluating the benefits it showed in patients who had undergone knee and hip replacements.
This allowed us to adapt the fast track protocol to ankle replacement surgery, relying on the experience of our “older siblings” in hip and knee surgery!
Undoubtedly, immediate weight-bearing remains the core advantage of the fast track protocol. Allowing weight-bearing right away helps the body maintain proprioception and quickly become accustomed to proper foot placement. However, postoperative recovery cannot be the same for every patient. It must consider, as mentioned, the type of deformity, bone quality, patient weight, previous surgeries, and the condition of the soft tissues.
For patients eligible for fast track, we may decide not to use a plaster boot, thus avoiding immobilization but still allowing immediate weight-bearing.

In these cases, we can also use the “Game Ready” device—a sleeve that applies cold and compression, reducing swelling, pain, and soft tissue inflammation.
This represents the pinnacle of the Fast Track approach.
Then, there is another group of patients for whom we allow immediate weight-bearing but maintain immobilization with a cast. This is usually for cases where we fear soft tissue contractures.
Finally, for patients with significant deformities requiring longer surgeries, weight-bearing is important but not immediate. They use a plaster boot and are asked to avoid weight-bearing for a variable period (between 2 and 4 weeks).
It is the precise evolution and selection of all these components—anesthesia, Game Ready, fast track—that have transformed ankle replacement surgery.

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Is it possible to play sports with an ankle prosthesis?

An ankle prosthesis does not turn you into a superhero.

If before developing ankle arthritis you led a sedentary life, you will return to your sedentary lifestyle—just without pain.
However, if you were an athlete, someone who knew the sacrifices of training and the importance of setting goals over time, it is possible to return to a high level of activity.
We have treated ankle replacement patients who were mountaineers before falling ill — they have gone back to mountaineering.
 Skiers who have returned to skiing.
Of course, we discourage participation in sports with a high risk of trauma.

What Not to Do After Ankle Replacement Surgery

After ankle replacement surgery, there are some important precautions that can help patients achieve the most effective recovery possible:

1. Avoid twisting and rotational movements while bearing weight: These movements place abnormal stress on the syndesmosis (the joint between the tibia and fibula). Therefore, avoid twisting and rotational movements while standing for the first 6–8 weeks. However, performing ankle rotations while sitting or lying down is not discouraged starting from the fourth week.
2. Limit aggressive physical therapy focused on joint mobilization: Forceful ankle movements can cause internal medial pain known as medial impingement. Instead, it’s beneficial to work indirectly on joint recovery through calf muscle (triceps surae) stretching exercises.
3. Do not ignore episodes of fever or purulent discharge: A mild fever immediately after surgery should be monitored but may be normal due to resorption of post-operative hematoma. However, a fever that develops later after surgery—especially if accompanied by discharge—could indicate infection. If you experience acute pain, swelling, or redness around the surgical site, contact your doctor immediately, as these may be signs of complications.
4. Avoid high-impact activities: Activities that place high impact loads on the ankle, such as running, jumping, or contact sports, should be avoided or significantly limited according to your doctor’s recommendations.
5. Do not neglect rehabilitation: Follow the specific instructions for weight-bearing and exercises given by your surgeon (#loadtorecover).
6. Do not stop post-operative precautions: Strictly adhere to the post-operative instructions provided by your surgeon, including wound care, medication use, and specific physical exercises (even in the medium to long term).
7. Avoid soaking the wound: Until the surgical wound is fully healed, avoid immersing it in water such as baths, swimming pools, or similar environments to prevent infection.

Each patient may have specific guidelines based on their health condition and the surgical technique used, so it is essential to follow the personalized advice given by your medical team.

How long does ankle replacement surgery take?

The duration of the surgery is an important indicator of the surgical team’s experience in treating ankle arthritis with a prosthesis. Of course, it’s not the only factor!
Our average time for an ankle replacement is under 60 minutes.
This is thanks to a dedicated team: a group of anesthesiologists (led by Dr. Cama, chief anesthesiologist) who follow protocols for pain management and blood loss control; specialized surgical nurses (ferrists) assigned to my team and coordinated by a professional (Domenico Santoro); and a group of surgeons who know the procedure by heart and have worked closely together with the same passion for years.

How long does an ankle prosthesis last? How many years?

 An ankle prosthesis does not necessarily require revision.

Let’s talk numbers: it has been shown that the implant’s longevity depends on:
the surgical team’s experience, which impacts implant positioning, stability, and risk of complications,
the design and features of the implant,
the patient’s characteristics.
In specialized centers, team leaders with large case series have reported ankle prostheses without revision in 80% of cases beyond 10 years, and in 70% of cases beyond 15 years.
We are therefore talking about a large number of patients whose prostheses last more than 15 years.
These data were collected over 15 years ago, and today’s implants are expected to improve on these results.
Recently, we have achieved a 98% rate of patients free from revision at mid-term follow-up (one of the best results described in the literature).
It is important to consult centers and surgeons who maintain institutional Prosthetic Registries, because only through these tools can accurate and consistent data be provided.

The Role of Information, the Value of Awareness

The greater the awareness, the more realistic the expectations become.
Being informed is crucial for the healing process, as it allows the patient to set tangible and realistic goals, actively participating in their own rehabilitation program.

L’aspettativa errata è un errore comune tra i pazienti.

Misplaced expectations are a common mistake among patients.
An ankle with a prosthesis will never be the same as a healthy ankle; however, it represents a significant improvement compared to a diseased ankle. This highlights the importance of proper information and realistic expectations. The purpose of an ankle prosthesis is to provide a foot that properly supports the ground—in a plantigrade position—and allows for a smooth push-off during walking.
Your motivation makes the difference: I am aware of the sacrifices required when asking you to bear weight on the ankle immediately after surgery.
Trust is essential: in most cases, it leads to satisfactory results more quickly. During the first six months, the focus should be on functional recovery, trying not to concentrate solely on pain and swelling.
Therefore, it is essential to have a clear understanding not only of the type of surgery you are undergoing but also of the postoperative pathway, in which you, the patients, play the main role.

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This article is updated as of Wednesday, January 17, 2024 – Last update 1/17/2024