What is an Ankle Arthrodesis?
An arthrodesis is a form of surgery used when joints become so painful or unstable other methods of treatment are ineffective.
Arthrodesis involves shaving away the joint space and nailing the remaining bones together so that they fuse, forming effectively a single unit of bone. This means that while the fused joint is very stable and generally painless there is no movement at the former joints.
The bones that are often involved in arthrodesis include the calcaneus (heel bone), the talus, other small bones in the foot (cuboid, navicular), and the tibia (shin bone). These bones and the joints between them create a smooth rolling motion as your heel then toe hits the ground during walking. Together, they distribute the weight of the body across the structures in the foot and minimise the energy used up with every step. Losing the mobility in these joints in arthrodesis consequently results in an abnormal walking pattern, with increased risk of arthritis developing in other joints in the foot, as well as the knee, hip and lower back.
The decision to eliminate these joints by fusing bones together is a serious one. Arthrodesis is generally only recommended when other forms of treatment have failed, or are expected to fail, and the ankle remains so painful, deformed or unstable that walking is impossible.
There are a variety of different operations available, including key-hole (arthroscopy) or open surgery. It can take many weeks or months for the bones to fuse and so needs to be protected in a plaster cast and boot. It is important that you pre-plan and pre-arrange any help you will need with everyday tasks. This will make your discharge much easier. Your physiotherapist will assess you for an appropriate mobility aid (e.g. crutches or zimmer frame) and teach your how to walk and do the stairs without putting your operated leg to the floor.
Many people are happy with the results of arthrodesis because it allows them to get back to activities their arthritis had prohibited.
Who is this operation for?
There are generally three reasons why this operation is performed:
- Pain – from osteoarthritis, rheumatoid arthritis or other causes
- Deformity – disturbance in the shape of the foot causing significant difficulty or pain walking or working.
- Following severe fractures for which other methods of treatment are not appropriate.
Arthrodesis will only be successful when the bones are sufficiently strong. When the bones in the ankle are severely osteoporotic (see osteoporosis), the screws used to fuse the bones will not hold, so other ways of treating your ankle may need to be considered.
What are the benefits of the operation?
Arthrodesis is frequently very effective in relieving pain. With physiotherapy as part of a rehabilitation program, many people are able to rapidly get back to many activities they had previously been unable to perform.
When is this surgery not appropriate?
If you have an infection in or around your ankle or leg, or a serious infection elsewhere in your body you cannot have this operation until you are healthy.
Some people, especially diabetics and smokers, have poor blood vessels in their leg. If this is severe you may not be able to have the operation.
Complications
The risks and complications of a Ankle Arthrodesis include:
- Non-union and mal-union.
- Failure of the bones to knit together is an inevitable risk of fusion surgery. It is not always clear why some people’s bones fail to heal together, however some risk factors include smoking, diabetes, poor blood vessels in the leg, severe fractures, infection and advanced age.
- Mal-union occurs when the bones fuse but in the incorrect position. This is much rarer than nonunion.
- Infection.
- Need for revision surgery due to:
- Irritation / prominence of the hardware.
- Infection of the hardware.
- Nonuniion of the bones.
General complications of any surgery include:
- Bleeding from the incisions & delayed incision healing.
- Infection
- Pain, stiffness and swelling. Swelling can persist for up to a year after surgery.
- Injury to nerves – Numbness or tingling can occur at the wound or in the foot. This is usually temporary but in some it may be permanent.
- Blood clots- Deep vein thrombosis (DVT) or pulmonary embolism (PE) is rare. If you or your family have a history please let us know.
Before the operation
Before you go into the operating theatre, your surgeon will need to take a number of tests on your ankle. This may include:
- X-Rays. As bones and joints change over time you may need an X-Ray just before your surgery is performed to check for any new changes. Your surgeon may also need special views of your ankle that show the position and strength of the other bones in your foot.
- injections. In some cases, your surgeon may need to isolate the joints that are causing you pain. For example, an injection of anaesthetic into the ankle joint should relieve nearly all your pain. If you still have some pain in your foot it may mean other joints have arthritis, and a different type of operation is required.
- Bone scan. This is a specialised test that is not usually required before arthrodesis. It may be used to check for infection in the bones if your surgeon is concerned about this.
Preadmission Clinic | Preparing for Surgery
Before your operation, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.
During the visit, you will be seen by a
- doctor
- nurse
- anaesthetist (if necessary)
Tests
If your surgeon is concerned about the blood vessels in your leg, you may need a number of X-Rays for blood vessels. These are called angiograms, and can tell your surgeon about the size of your arteries, and whether there are any areas of narrowing or blockage.
Tests that may be to check your general health include:
- blood tests
- Xray of your Chest
- Urine Test
- ECG
Preparing Your Skin
Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.
Tip
Carry a list of your medications with you including the name, dosage and how often you take it.
Medications
Our doctors will advise you which medications you should stop or can continue taking before surgery.
Get some help from your friends and family
Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry. If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended-care facility during your recovery after surgery also may be arranged.
What is an Ankle Arthrodesis?
An arthrodesis is a form of surgery used when joints become so painful or unstable other methods of treatment are ineffective.
Arthrodesis involves shaving away the joint space and nailing the remaining bones together so that they fuse, forming effectively a single unit of bone. This means that while the fused joint is very stable and generally painless there is no movement at the former joints.
The bones that are often involved in arthrodesis include the calcaneus (heel bone), the talus, other small bones in the foot (cuboid, navicular), and the tibia (shin bone). These bones and the joints between them create a smooth rolling motion as your heel then toe hits the ground during walking. Together, they distribute the weight of the body across the structures in the foot and minimise the energy used up with every step. Losing the mobility in these joints in arthrodesis consequently results in an abnormal walking pattern, with increased risk of arthritis developing in other joints in the foot, as well as the knee, hip and lower back.
The decision to eliminate these joints by fusing bones together is a serious one. Arthrodesis is generally only recommended when other forms of treatment have failed, or are expected to fail, and the ankle remains so painful, deformed or unstable that walking is impossible.
There are a variety of different operations available, including key-hole (arthroscopy) or open surgery. It can take many weeks or months for the bones to fuse and so needs to be protected in a plaster cast and boot. It is important that you pre-plan and pre-arrange any help you will need with everyday tasks. This will make your discharge much easier. Your physiotherapist will assess you for an appropriate mobility aid (e.g. crutches or zimmer frame) and teach your how to walk and do the stairs without putting your operated leg to the floor.
Many people are happy with the results of arthrodesis because it allows them to get back to activities their arthritis had prohibited.
Who is this operation for?
There are generally three reasons why this operation is performed:
- Pain – from osteoarthritis, rheumatoid arthritis or other causes
- Deformity – disturbance in the shape of the foot causing significant difficulty or pain walking or working.
- Following severe fractures for which other methods of treatment are not appropriate.
Arthrodesis will only be successful when the bones are sufficiently strong. When the bones in the ankle are severely osteoporotic (see osteoporosis), the screws used to fuse the bones will not hold, so other ways of treating your ankle may need to be considered.
What are the benefits of the operation?
Arthrodesis is frequently very effective in relieving pain. With physiotherapy as part of a rehabilitation program, many people are able to rapidly get back to many activities they had previously been unable to perform.
When is this surgery not appropriate?
If you have an infection in or around your ankle or leg, or a serious infection elsewhere in your body you cannot have this operation until you are healthy.
Some people, especially diabetics and smokers, have poor blood vessels in their leg. If this is severe you may not be able to have the operation.
Complications
The risks and complications of a Ankle Arthrodesis include:
- Non-union and mal-union.
- Failure of the bones to knit together is an inevitable risk of fusion surgery. It is not always clear why some people’s bones fail to heal together, however some risk factors include smoking, diabetes, poor blood vessels in the leg, severe fractures, infection and advanced age.
- Mal-union occurs when the bones fuse but in the incorrect position. This is much rarer than nonunion.
- Infection.
- Need for revision surgery due to:
- Irritation / prominence of the hardware.
- Infection of the hardware.
- Nonuniion of the bones.
General complications of any surgery include:
- Bleeding from the incisions & delayed incision healing.
- Infection
- Pain, stiffness and swelling. Swelling can persist for up to a year after surgery.
- Injury to nerves – Numbness or tingling can occur at the wound or in the foot. This is usually temporary but in some it may be permanent.
- Blood clots- Deep vein thrombosis (DVT) or pulmonary embolism (PE) is rare. If you or your family have a history please let us know.
Before the operation
Before you go into the operating theatre, your surgeon will need to take a number of tests on your ankle. This may include:
- X-Rays. As bones and joints change over time you may need an X-Ray just before your surgery is performed to check for any new changes. Your surgeon may also need special views of your ankle that show the position and strength of the other bones in your foot.
- injections. In some cases, your surgeon may need to isolate the joints that are causing you pain. For example, an injection of anaesthetic into the ankle joint should relieve nearly all your pain. If you still have some pain in your foot it may mean other joints have arthritis, and a different type of operation is required.
- Bone scan. This is a specialised test that is not usually required before arthrodesis. It may be used to check for infection in the bones if your surgeon is concerned about this.
Preadmission Clinic | Preparing for Surgery
Before your operation, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.
During the visit, you will be seen by a
- doctor
- nurse
- anaesthetist (if necessary)
Tests
If your surgeon is concerned about the blood vessels in your leg, you may need a number of X-Rays for blood vessels. These are called angiograms, and can tell your surgeon about the size of your arteries, and whether there are any areas of narrowing or blockage.
Tests that may be to check your general health include:
- blood tests
- Xray of your Chest
- Urine Test
- ECG
Preparing Your Skin
Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.
Tip
Carry a list of your medications with you including the name, dosage and how often you take it.
Medications
Our doctors will advise you which medications you should stop or can continue taking before surgery.
Get some help from your friends and family
Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry. If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended-care facility during your recovery after surgery also may be arranged.
About the Operation
Arthrodesis around the ankle is a large operation taking 1-2 hours.
There are a variety of types of arthrodesis surgery. You and your surgeon will decide what is best for you depending on the state of your ankle.
Surgery can be performed through key holes or through incisions that open the ankle joint. In any form of arthrodesis, the cartilage and ends of the bone that form your joint are shaved away so that fresh bone underneath is exposed. Screws, plates or other hardware can then be positioned so that the fresh bone is compressed together, growing to form one stable unit of bone.
The screws are usually left in place forever but are occasionally removed if they are prominent and cause pain.
Arthroscopic Arthrodesis
Arthroscopy is a form of key-hole surgery.
Small cuts are made on either side of the ankle and a thin camera is inserted to look inside your ankle. From here, your surgeon can trim away any damaged cartilage or joint tissues before working on the bone.
As your surgeon is working through a small hole, less bone is shaved away. Instead, the surfaces of the bone drilled slightly before being compressed by screws.
While arthroscopy is a very popular form of surgery, it is only recommended when the ankle has not become severely deformed. You must always keep in mind that if a complication develops during the surgery, your surgeon may need to make larger cuts to open your joint properly (see Open Arthrodesis below).
External Fixation Arthrodesis
In this method, your surgeon puts pins through bones above and below your ankle, then places tension across the two pins to compress the bones against one another.
The external brace will need to be worn for several weeks at least following surgery. Your surgeon will need to get X-Rays to make sure your bones are fusing together before removing the brace.
Open Arthrodesis
In this method, your surgeon will make larger cuts on either side of your ankle to open up the joint completely. Once inside the joint, your surgeon will release the tissues holding the ankle in place and trim or remove any damaged cartilage or soft tissue.
Once this is done, your surgeon can carefully shave away the ends of the bone to expose the fresh bone underneath. Your surgeon will make sure your ankle is correctly aligned before positioning screws and/or plates across the joint the compress the bones.
Many surgeons will harvest a sample of bone from the fibula (a small bone in your lower leg) to use as a graft in the arthrodesis.
Open arthrodesis is used when the ankle is significantly deformed and the surgeon needs to correct the position of the bones. Your surgeon may also take this opportunity to repair the tendons around the ankle.
After the Operation
Once the surgery is finished, you will return to the ward. At this point, your leg will be elevated to reduce swelling and may still be numb from the local anaesthetic used in the hospital. This should wear off over the following 24 hours and nurses will help you control pain with tablets.
You will stay in hospital until you are safe on crutches and the surgical team are happy with your progress. You will be in half plaster (back slab) for 2 weeks whilst the wounds heal. During this time you will need to keep the foot elevated for 50 minutes of every hour to avoid swelling and infection. You will then go into a full plaster for a further 4 weeks.
During this total 6 week period you will need to be non-weight bearing on the leg affected – this will mean you will be hopping and using crutches or some other sort of walking aid. This will temporarily limit your mobility both indoors and outdoors and you should try to plan for this before having the operation.
After this period most patients are placed in a removable boot in which they can partially weight bear with instruction from the physiotherapy department.
What about pain?
Whilst you are in hospital you will be monitored and the medical staff will give you painkillers as required and prescribed. You will be given painkillers and instructions on management of the pain by nursing staff before you leave hospital.
What should I do when I leave hospital?
Swelling is quite common, so in order to reduce swelling, your foot should be elevated (above the level of your heart) for 50 minutes in every hour for the first two weeks. Your activities will be initially affected whilst you are in a cast particularly when you have to non-weight bear. This includes household and work activities. You will not be expected to return to a normal level of activity until you have been advised on your progress.
Recovery and Rehabilitation
Recovery from an arthrodesis takes a number of months. The first few weeks are usually the most frustrating, as you will be unable to put any weight on your ankle.
Around the 6-8 week mark your surgeon will take X-Rays to check the bones are fusing, then apply a removable boot that will allow you to put weight through your leg. If everything is going well, you should be able to put all your weight through your ankle before three months.
Over this period, your physiotherapist will give you a series of exercises to maintain the strength in your ankle and leg, as well as your general fitness.
By the end of six months you should be able to wear normal shoes and be back to your normal activities.
F.A.Q.s | Frequently Asked Questions
What are the alternative treatments to having a Ankle Arthrodesis?
An ankle replacement is sometimes considered as an alternative to arthrodesis.
When can I return to work?
Your own circumstances will determine when you feel ready to go back to work. If you have an office-type job and you can elevate your leg then you should be able to return to work within 7 days. If your job requires a lot of walking or is strenuous then you may need 2-3 weeks off work. Patients can self-certificate their sick leave for 7 days. If you require a sick certificate please ask your GP.
When can I return to driving?
You must be free of pain and able to perform an emergency stop. This will also depend on which foot was operated on (right or left). If you have had left sided surgery and drive an automatic car you may be able to drive 2-4 weeks following surgery. Your insurance company must be notified regarding the type of operation that you have undergone to ensure that cover is valid.
What should I do if I have a problem?
If you experience severe pain, excessive swelling, inflammation or discharge please report it to your GP. If you cannot contact your GP you should contact A&E.
What are the likely long-term results from ankle arthrodesis?
Despite the loss of motion in the ankle joint, most people who have an arthrodesis are happy with their newfound ability to walk and move virtually painlessly. The loss of motion in the ankle does make certain types of activity more difficult, including:
- walking quickly
- walking on uneven surfaces
- inability to wear certain shoes – any shoe that demands a non-neutral position at your ankle may be uncomfortable, for example high-heels (more than 2 inches)
Problems that do crop up years after the operation include arthritis in other joints in the foot, in particular the tarsal joints.
References
Abidi, N. A., et al., ‘Ankle Arthrodesis: Indications and Treatment’, Journal of the American Academy of Orthopaedic Surgeons, Vol. 8, No. 3, May-June 2000, pp. 200-209.
DiStefano, J. G., Pinney, S., ‘Ankle Arthritis: Etiology and Epidemiology’, Seminars in Arthroplasty, Vol. 21, Iss. 4, Dec 2010, p218-222.
Easley, M. E., et al., ‘Perspectives on Modern Orthopaedics: Total Ankle Arthroplasty’, Journal of American Academy of Orthopaedic Surgery, Vol. 10, No. 3, May/June 2002, pp. 157-167.
Espinosa, N., Klammer, G., ‘Treatment of Ankle Osteoarthritis: Arthrodesis Versus Total Ankle Replacement’, European Journal of Trauma and Emergency Surgery, Vol. 36, 2010. pp 525-535.
Thordarson, D. B., ‘Fustion in Posttraumatic Foot and Ankle Reconstruction’, Journal of American Academy of Orthopaedic Surgeons, Vol. 12, No. 5, Sept/Oct 2004, pp 322-333.