Total Ankle Replacement

Most people know someone who has had their hip or knee replaced. But the idea of a total ankle replacement is more unusual and often misunderstood by people outside of the orthopedic medicine space.

Initially, ankle replacement surgery might sound drastic or intense. If a patient is considering the procedure, they may have questions like: What prompts the need for a replacement? What parts of the ankle are replaced during the surgery? What is the expected recovery time?

To answer those questions and more, host Adam Walker speaks with orthopedic physician and total ankle replacement expert Dr. Hodges Davis on the second episode of OrthoCarolina's Between the Bones Podcast.

Dr. Hodges Davis has practiced medicine in Charlotte, North Carolina for 29 years. Though he didn't set out to be a joint replacement surgeon, Dr. Davis recognized the immense potential in the field and set a career goal to continually find ways to serve his patients better.

This dedication to improvement manifested in his work of diagnosing and treating ankle arthritis with reconstructive surgeries. Now nearly 30 years into his career, Dr. Davis's sub-specialties and clinical interests include ankle arthritis and forefoot reconstruction. His expert narrative and insight inform the answers to common ankle replacement surgery questions detailed below.

First things first:

Why would someone need ankle replacement surgery?

Most often, people who decide to undergo ankle replacement surgery have ankle arthritis and have likely been experiencing pain for a long time. The pain is usually the outcome of a trauma that caused fractures in the ankle. Sometimes, the patient's previous trauma resulted in an ankle deformity.

Whether the patient is experiencing an obvious ankle deformity or simply unseen chronic pain, their ankle arthritis has impacted their quality of life. When ankle braces, pain killers, and stretching doesn't improve their circumstances, ankle replacement surgery is a viable option for lifestyle improvement.

What are the steps of a total ankle replacement?

A total ankle replacement has five distinct steps. This process has been refined over years to maximize the chances of success for the surgery and patient healing.

Step 1: Ankle replacement surgery

During the operation, surgeons replace the damaged portions of the ankle joints that are causing pain with a metal and plastic joint. The standard metal is articulated with the bone and plastic, which is called polyethylene. The plastic creates cushioning and allows the patient's joint to move more freely. The surgery is completed in outpatient clinics or during a one-night stay in a hospital.

Ankle replacements differ from ankle fusions, which involve taking out the damaged joint and gluing it together. Ankle fusions often result in a loss of functionality and can cause stress in surrounding joints.

Step 2: Ensuring complete wound healing

Post-surgery, orthopedic surgeons like Dr. Davis are first concerned with ensuring the surgical wound heals completely. The wound is often at the front of the ankle and traditionally it doesn't heal easily. Therefore, monitoring the skin condition and diligently changing bandaging is crucial before the next steps can begin.

Step 3: Re-establishing motion

When the surgical wound is deemed satisfactory, the next step is rotating and flexing the ankle to slowly introduce movement in the replaced joint. Increased flexibility is important to establish before continuing to Step 4, which adds further pressure onto the new joint.

Step 4: Introducing weight-bearing activities

When rotation and flexing become more comfortable, patients who have undergone surgery can begin to put their body weight on their newly replaced ankle. This step is aided by the protection of a boot, which is worn for a few months, and the addition of crutches as needed.

Step 5: Committing to physical therapy

Physical therapy is a critical final step for ankle replacement surgery. Following the recommended advice and exercises from PTs can optimize the chances for a successful post-surgery healing journey.

What is the typical recovery timeline for ankle replacement surgery?

People who have undergone ankle replacement surgery usually show marked improvements three months after surgery, and their healing has often plateaued by the six-month mark.

This healing typically continues years after the initial procedure. Dr. Hodges explains that "those that are doing well at two years are doing well at ten years."

What changes can patients expect after surgery?

Dr. Hodges shares that after the surgery and designated healing time, people who have undergone ankle replacement surgery can expect decreased pain and improved quality of life. Folks can expect to walk and participate in low-impact activities like yoga more comfortably than before their surgery.

However, Dr. Hodges advises that post-procedure, high-impact activities such as running, CrossFit, and singles tennis are not recommended. These high-impact sports put undue stress on the replaced ankle, can cause pain, and can reverse the positive effects of the initial procedure. 

How can patients optimize their chances of success?

Optimal recovery is determined by the patient's ability to maximize their medical wellness. Diabetics should be ensuring their diabetes is well-managed. Non-smokers often heal much better than smokers, so smokers should try to quit before surgery.

Most ankle replacement surgery candidates are older and therefore tend to be taking several medications. However, if the underlying conditions requiring those medications are controlled, there is a better chance for swift healing and improved ankle condition after the procedure.

Total ankle replacement surgery is a growing and evolving surgery that has the potential to improve the lives of people suffering from ankle arthritis.

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Between the Bones, powered by OrthoCarolina, explores adult & pediatric orthopedic conditions, life-changing research and the future of healthcare. Subscribe and listen to learn more about your skeleton and what goes into taking care of it.  

Hodges Davis, MD, is a foot & ankle orthopedic surgeon at the OrthoCarolina Foot & Ankle Institute in Charlotte, NC. He specializes in plantar fasciitis solutions, ankle arthritis, neuropathic disease, forefoot reconstruction and foot deformities.