Ankle replacement revision surgery

Revision ankle replacement surgery is performed when a previous ankle replacement has developed a significant problem requiring further treatment.

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Revision surgery is generally more complex than primary ankle replacement because the surgeon must work around an existing implant and may need to address bone loss, scar tissue, altered anatomy, deformity, infection or instability.

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The appropriate treatment depends on why the original ankle replacement has failed and the condition of the ankle and surrounding foot.

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Mr Shelain Patel has a specialist practice in foot and ankle surgery, including the assessment of complex ankle arthritis and patients requiring specialist advice about previous surgery.

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Why might an ankle replacement require revision?

There are several possible reasons for revision surgery.

Loosening - A component can become loose from the surrounding bone.

Loosening may cause pain and may be visible on serial X-rays or other investigations.

Subsidence - Subsidence occurs when an implant component settles or sinks into the surrounding bone. The significance depends on the degree of subsidence and whether it affects alignment or function.

Wear - The bearing surfaces can wear over time. The clinical significance varies between patients and implant systems.

Instability - An ankle replacement may become unstable if the surrounding ligaments or alignment are inadequate. Treatment may involve addressing the underlying instability as well as the implant itself.

Fracture - A fracture around an ankle replacement can occur following trauma or, less commonly, around areas of altered bone. Treatment depends on fracture location, implant stability and bone quality.

Infection - An infection involving an ankle replacement can occur early or later following surgery. Establishing whether infection is present is an important part of assessing a painful ankle replacement.

Persistent pain - Not every painful ankle replacement has failed mechanically.

Pain can originate from:

• The replacement

• Adjacent joints

• Tendons

• Nerves

• Scar tissue

• Alignment problems

• Other conditions affecting the foot and ankle

 

A detailed assessment is therefore necessary before deciding that revision surgery is required.

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How is a painful ankle replacement investigated?

Assessment begins with a detailed history.

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Important questions include:

• When did the pain begin?

• Was the ankle ever pain-free after the original surgery?

• Has the pain changed recently?

• Is there swelling?

• Is there instability?

• Has there been an injury?

• Have there been previous infections or wound problems?

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Clinical examination assesses:

• Ankle movement

• Stability

• Alignment

• Hindfoot position

• Tendons

• Skin and soft tissues

• Neurovascular status

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Imaging

Weight-bearing X-rays or CT scans are usually an important part of the assessment. Comparison with previous X-rays can be particularly useful because changes over time may provide important information.

CT may be required to assess:

• Bone loss

• Implant position

• Component fixation

• Fracture

• Alignment

MRI may occasionally have a role, depending on the clinical question and implant.

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Investigating infection

Infection needs to be considered carefully in a painful joint replacement.

Assessment may include:

• Blood tests

• Imaging

• Joint aspiration

• Microbiological testing

The exact investigations depend on the clinical circumstances. It is important to establish whether infection is present because it can significantly change the surgical plan.

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What are the treatment options?

Revision does not automatically mean replacing every component.

Depending on the problem, treatment may include:

• Observation

• Activity modification

• Physiotherapy

• Injection in selected circumstances

• Revision of part of the replacement

• Complete revision ankle replacement

• Bone grafting

• Ligament reconstruction

• Corrective osteotomy

• Treatment of infection

• Conversion to ankle fusion

The treatment should address the underlying cause of failure rather than simply replacing the implant.

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Revision ankle replacement

A revision ankle replacement involves replacing some or all of the components of the existing implant. This may be possible when there is sufficient bone stock and the surrounding soft tissues and anatomy allow reconstruction. Revision planning often requires detailed imaging and consideration of available revision implants.

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Conversion to ankle fusion

In some patients, the appropriate treatment for a failed ankle replacement is conversion to ankle fusion.

This may be considered where:

• There is substantial bone loss

• The implant cannot be revised reliably

• Infection or other factors make replacement unsuitable

• The anatomy is unsuitable for another replacement

Conversion to fusion is a significant procedure and requires careful planning.

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Why is revision surgery more complex?

Primary ankle replacement is performed on an ankle that has not previously contained an implant.

Revision surgery may involve:

• Scar tissue

• Bone loss

• Previous fixation

• Altered anatomy

• Previous infection

• Reduced bone stock

• Soft-tissue problems

• Malalignment

These factors can make both planning and surgery more challenging.

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Additional procedures

Revision ankle replacement may need to be combined with other procedures.

These could include:

• Bone grafting

• Osteotomy

• Ligament reconstruction

• Tendon reconstruction

• Hindfoot correction

• Treatment of adjacent-joint pathology

The exact combination depends on the underlying problem.

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Recovery following revision ankle replacement

Recovery following revision surgery can be longer and more variable than following a primary ankle replacement.

The rehabilitation programme depends on:

• The type of revision

• Bone quality

• Additional procedures

• Weight-bearing requirements

• Soft-tissue healing

• Overall health

Patients may require a period of protected weight-bearing. A detailed rehabilitation programme is provided following surgery.

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When should I seek a specialist second opinion?

A specialist assessment can be particularly useful if:

• You have persistent pain following ankle replacement

• Your X-rays have changed

• You have been told your implant may be loose

• You have been advised that revision surgery is required

• You have been offered conversion to fusion

• You have had previous infection

• You are uncertain about your treatment options

A second opinion does not necessarily mean that further surgery is required. It can help establish the diagnosis and clarify the available options.

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What should I bring to a consultation?

If possible, bring:

• Previous X-rays

• CT or MRI scans

• Operative reports

• Details of the original implant

• Previous clinic letters

• Previous infection or microbiology results

• A list of current medication

Information about the original operation and implant can be particularly valuable when planning revision surgery.

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Frequently Asked Questions

Can a failed ankle replacement be replaced?

In selected patients, revision ankle replacement is possible. The feasibility depends on the implant, bone stock, alignment and surrounding soft tissues.

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Can an ankle replacement be converted to a fusion?

Yes. Conversion to ankle fusion is an established option for selected failed ankle replacements.

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Is revision ankle replacement more complicated than primary surgery?

It can be. Previous surgery, bone loss, scar tissue and altered anatomy can make revision technically more demanding.

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Will I need bone graft?

Bone graft may be required when there is significant bone loss, but this is determined during preoperative planning.

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How long does revision surgery take?

The duration varies substantially depending on the reason for revision and the procedures required.

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Will I be able to walk normally again?

The aim of revision surgery is to improve pain and function, but the outcome depends on the underlying problem and the condition of the ankle. Expectations should be discussed individually.

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Book a consultation

If you have a painful or problematic ankle replacement, or you have been advised that revision surgery or ankle fusion may be necessary, a specialist assessment can help establish the cause of your symptoms and explain the available treatment options.

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Book a consultation with Mr Shelain Patel, Consultant Orthopaedic Foot & Ankle Surgeon in London.