Who Is Ankle Replacement Surgery For?

Ankle replacement surgery, also known as total ankle replacement or total ankle arthroplasty, is a surgical treatment for carefully selected patients with painful, advanced ankle arthritis. Unlike ankle fusion, which removes movement from the ankle joint, an ankle replacement is designed to preserve movement while relieving pain.

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Whether an ankle replacement is appropriate depends on much more than the presence of arthritis on an X-ray. A detailed assessment is needed to understand the severity and pattern of arthritis, the alignment of the ankle and hindfoot, the condition of the surrounding ligaments and tendons, bone quality, previous surgery and the patient's symptoms, activity levels and expectations.

Mr Shelain Patel is a Consultant Orthopaedic Foot & Ankle Surgeon specialising in the assessment and treatment of ankle arthritis and complex foot and ankle conditions. He provides individualised advice about ankle replacement, ankle fusion and non-operative treatment according to the circumstances of each patient.

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What is ankle replacement surgery?

An ankle replacement involves removing the damaged surfaces of the ankle joint and replacing them with prosthetic components. The aim is to reduce pain while retaining useful movement at the ankle.

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An ankle replacement usually consists of components that replace the damaged surfaces of the tibia and talus, together with a bearing component between them. Modern ankle replacement systems have evolved considerably from earlier designs, with improvements in implant design, surgical techniques and understanding of ankle biomechanics.

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The objective is not simply to replace an arthritic joint. Successful ankle replacement requires careful assessment of the entire foot and ankle, including alignment, stability and the joints surrounding the ankle.

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Who may benefit from an ankle replacement?

Ankle replacement may be considered for patients with significant symptomatic ankle arthritis when non-operative measures are no longer providing satisfactory relief.

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Symptoms can include:

• Persistent ankle pain

• Pain when walking or standing

• Reduced walking distance

• Difficulty with stairs or uneven ground

• Ankle stiffness

• Swelling

• Loss of recreational or sporting activities

• Increasing dependence on pain medication

 

The severity of symptoms is particularly important. Some patients have significant arthritis on X-rays but relatively little pain and may not require surgery. Conversely, a patient with severe symptoms may warrant a specialist assessment even if the diagnosis is not immediately clear.

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What causes ankle arthritis?

Ankle arthritis can develop for several reasons.

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Post-traumatic arthritis

Previous ankle fractures, ligament injuries or other significant trauma can damage the joint and eventually lead to arthritis. Post-traumatic arthritis is one of the common reasons for severe ankle arthritis requiring specialist treatment.

Primary osteoarthritis

Some patients develop arthritis without a clearly identifiable previous injury. This is sometimes referred to as primary osteoarthritis.

Inflammatory arthritis

Conditions such as rheumatoid arthritis and other inflammatory disorders can affect the ankle joint and cause progressive cartilage damage.

Other causes

Ankle arthritis can also occur following previous surgery, infection, instability, deformity or other conditions affecting the joint.

 

Is age important?

Age is one consideration when assessing suitability for ankle replacement, but it is not the only factor and there is no single age at which an ankle replacement is automatically appropriate or inappropriate.

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The decision takes into account:

• Symptoms

• Activity levels

• Bone quality

• Alignment

• Deformity

• Previous surgery

• Ligament stability

• Other joint problems

• General health

• Expectations and lifestyle

 

The important question is whether an ankle replacement is an appropriate treatment for the individual rather than whether the patient falls within an arbitrary age range.

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What if I am very active?

Activity level is an important part of the consultation. Ankle replacement is designed to allow patients to walk and participate in many everyday and recreational activities. However, high-impact activities place greater demands on an ankle replacement than lower-impact activities.

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Patients who wish to return to activities such as cycling, swimming, walking and golf may have different considerations from patients who participate in regular high-impact running or jumping sports. The aim is to provide realistic advice based on the individual patient, their ankle condition and the implant being considered.

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What if I have a deformed ankle?

Ankle arthritis is sometimes accompanied by significant deformity. This may involve the ankle itself, the hindfoot or both. Deformity does not automatically mean that ankle replacement is impossible. In selected patients, alignment can be corrected as part of the overall reconstruction.

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Additional procedures may sometimes be required, such as:

• Ligament reconstruction

• Tendon procedures

• Calcaneal osteotomy

• Corrective osteotomy

• Hindfoot or midfoot surgery

 

The more complex the deformity, the more important detailed pre-operative planning becomes.

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What if I have had previous ankle surgery?

Previous surgery does not necessarily prevent ankle replacement. However, previous operations can alter:

• Bone stock

• Alignment

• Scar tissue

• Soft tissues

• Ligament stability

• The anatomy of the ankle

 

Previous fractures and previous fixation can also make surgery more complex. A specialist assessment is therefore particularly important for patients who have previously undergone ankle surgery.

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What investigations are needed?

Assessment normally begins with a detailed history and examination.

Imaging commonly includes weight-bearing X-rays of the ankle and foot. These can show:

• The degree of arthritis

• Alignment

• Bone position

• Deformity

• Joint-space loss

• Associated changes in the foot

CT scanning may be recommended when more detailed information about bone anatomy, deformity or bone stock is required.

MRI is not routinely required for every patient but may be useful in selected circumstances, particularly when additional soft-tissue or bone pathology needs to be assessed.

The appropriate investigations depend on the individual patient.

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When might ankle replacement not be appropriate?

There are circumstances in which ankle replacement may not be the preferred treatment.

These may include significant bone loss, infection, severe or uncorrectable deformity, poor soft-tissue conditions, certain neurological or vascular problems or other factors that make an implant unsuitable.

These factors need to be considered individually. Some problems that initially appear to make replacement unsuitable can sometimes be addressed with additional treatment or reconstructive surgery.

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Ankle replacement or ankle fusion?

For patients with advanced ankle arthritis, the two principal surgical options are often ankle replacement and ankle fusion. Ankle replacement aims to preserve movement at the ankle. Ankle fusion removes movement from the arthritic ankle joint by joining the tibia and talus together. Neither procedure is universally appropriate for every patient. The decision depends on the patient's symptoms, anatomy, activity, previous surgery, deformity, adjacent joints and expectations.

 

Read more about the differences on the Ankle Replacement vs Ankle Fusion page.

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Is ankle replacement the only option?

No. Treatment for ankle arthritis should be individualised and does not automatically mean surgery.

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Depending on the severity of the arthritis and the patient's symptoms, treatment may include:

• Activity modification

• Physiotherapy

• Appropriate footwear

• Orthotics

• Medication

• Injections in selected circumstances

• Weight management where appropriate

• Ankle replacement

• Ankle fusion

 

Surgery is generally considered when symptoms remain troublesome despite appropriate non-operative treatment.

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What should I expect from a consultation?

A consultation should establish exactly what is causing your symptoms and whether the severity of your arthritis justifies considering surgery. The assessment will consider your symptoms, walking ability, activity levels, previous treatment, previous surgery and your expectations. Your imaging will then be reviewed alongside the clinical findings.

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If surgery is appropriate, the different options, expected recovery, potential risks and likely benefits should be discussed before you make a decision.

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Frequently Asked Questions

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Am I too young for an ankle replacement?

Age is only one factor. Suitability depends on your symptoms, activity levels, anatomy, bone quality and other individual factors.

Am I too old for an ankle replacement?

Not necessarily. General health, mobility, bone quality and individual circumstances are more important than age alone.

Can an ankle replacement be performed after an ankle fracture?

In selected patients, yes. Previous fracture and any resulting deformity or bone loss need to be carefully assessed.

Can an ankle replacement correct an ankle deformity?

Some deformities can be corrected during ankle replacement surgery, sometimes with additional procedures.

Can both ankles be replaced?

It is possible for some patients to require treatment of both ankles, although each ankle should be assessed individually and treatment planned appropriately.

Do I need an MRI?

Not necessarily. Weight-bearing X-rays are usually central to assessment, while CT or MRI is used selectively depending on the clinical question.

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Book a consultation

If you have painful ankle arthritis and would like to understand whether ankle replacement, ankle fusion or continued non-operative treatment is appropriate, a specialist assessment can help clarify your options.

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