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Do you need an ankle fusion surgery? Ankle fusion has become a common surgical solution for ankle arthritis, but it’s obviously a big surgery with lots of things to consider before pulling the trigger. Let’s dig in.

What Does Fusing the Ankle Mean?

First, ankle fusions are typically performed for patients who have moderate to severe ankle arthritis (1). A fusion of a joint means to have the joint surfaces grow together so that the joint is fixed and doesn’t move any longer. In ankle fusion, given that there may be several joints involved including the tibio-talar, sub-talar, and talo-navicular joints, many different screws going many different directions are commonly placed. Another name for the procedure is an ankle arthrodesis. This basically means that the main ankle joints will no longer move.

Is Ankle Fusion a Major Surgery?

Given that the procedure involves placing multiple screws in different directions, the short answer is yes. Whether surgery is a big or small procedure is often defined by how commonly patients experience complications. For example, in one early study, the complication rate was a staggering 48%! (3) Another later study demonstrated an infection rate of 6%, a 10% rate of the patient requiring a second surgery to fix the first procedure, and a failure of the bones to grow together 14% of the time (4).  Hence, given that these complication rates are many times higher than other routine orthopedic surgeries like knee arthroscopy where the complication rate is about 1%, ankle fusion is major surgery (2).

How Long Does It Take to Recover from an Ankle Fusion? Does It Work?

Most patients will be on crutches for 2-3 months while the ankle fusion sites heal. That’s followed by 1-3 months in a walking boot. In younger patients, 62% of the patients operated in one review could return to work by 2 years (although many weren’t working before the surgery) (7).

At an average of 8 years after an ankle fusion, here’s what patients reported they could do (6):

• 73% could hike for an average of 40 minutes
• Only 40% of patients could kneel
• 25% could jump down from steps
• Only 17% of the patients could run a short distance (less than 100 yards)

Is Ankle Fusion Surgery Painful?

Yes, narcotic pain medications are generally prescribed to help with post-surgical pain. On average patients take narcotic pain medications for a few weeks (6). After that, usually, Tylenol is recommended. You should avoid NSAID drugs like Ibuprofen, Motrin, Aleve, Celebrex, and others as these have been shown to reduce bone healing (10).

Can You Drive a Car with a Fused Ankle?

The short answer is yes. However, realize that research shows that your braking reaction time will be slower than normal (9). However, it’s still within safe norms as defined by the US Highway Administration.

Should You Get an Ankle Fusion vs. Replacement?

As of a recent study comparing ankle fusion to ankle joint replacement, the conclusion was that due to complication rates, the routine use of ankle fusion can’t yet be recommended to treat arthritis (4). Surprisingly, the same researchers found that ankle replacement complications were more than double those experienced by patients who had ankle fusion surgery! Hence, it’s hard to recommend either surgery given that information. Other experts published on ankle replacement having a 15% complication rate, which is still very high compared to knee replacement where the complication rate is 8% (11,12).

Are There Newer and Less Invasive Options?

Percutaneous ankle arthroplasty (PAA) is a new procedure where the doctor uses x-ray guidance to inject your stem cells into the damaged joint and into weak areas of the bone. Loose ankle ligaments are also usually a problem as well, so they are often treated. The goal is to reduce pain and increase function without fusion surgery or ankle replacement. The procedure is minimally invasive and has a recovery time a fraction of what an ankle fusion would require. However, this is a procedure that is only performed by physician subspecialists using x-ray and ultrasound guidance using your own cells derived from bone marrow and is not the same as an umbilical cord injection performed blind.

Below is a video of the Percutaneous Ankle Ligamentoplasty part of the procedure (treating the loose ligaments that caused the ankle to get arthritis) to give you some sense of what this procedure looks like:

Hal’s Story

Hal was an accountant with ankle arthritis who had a local surgeon attempt a triple arthrodesis (an ankle fusion of three main ankle/foot joints). One of the screws inadvertently destroyed an artery that was keeping his talus bone alive, so the bone died off and began to collapse, causing severe ankle arthritis and disability. Hal had a PAA procedure at our Colorado office and went from having trouble walking 100 yards back to walking 18 holes at the golf course, all without additional surgery.

The upshot? An ankle fusion is a big surgery with quite a few complications and long recovery time. Few patients return to normal activities after these procedures. There may be newer treatment options for your ankle that don’t involve surgery.

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References:

(1) Yasui Y, Hannon CP, Seow D, Kennedy JG. Ankle arthrodesis: A systematic approach and review of the literature. World J Orthop. 2016;7(11):700–708. Published 2016 Nov 18. doi: 10.5312/wjo.v7.i11.700

(2) Friberger Pajalic K, Turkiewicz A, Englund M. Update on the risks of complications after knee arthroscopy. BMC Musculoskelet Disord. 2018;19(1):179. Published 2018 Jun 1. doi: 10.1186/s12891-018-2102-y

(3) Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am. 1980 Jul;62(5):777-84. https://www.ncbi.nlm.nih.gov/pubmed/7391101

(4) Maffulli N1, Longo UG, Locher J, Romeo G, Salvatore G, Denaro V. Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status. Br Med Bull. 2017 Dec 1;124(1):91-112. doi: 10.1093/bmb/ldx042.

(5) Kerkhoff YRA, Keijsers NLW, Louwerens JWK. Sports Participation, Functional Outcome, and Complications After Ankle Arthrodesis: Midterm Follow-up. Foot Ankle Int. 2017 Oct;38(10):1085-1091. doi: 10.1177/1071100717717221.

(6) Merrill HM, Dean DM, Mottla JL, Neufeld SK, Cuttica DJ, Buchanan MM. Opioid Consumption Following Foot and Ankle Surgery. Foot Ankle Int. 2018 Jun;39(6):649-656. doi: 10.1177/1071100718757527.

(7) Gagné OJ, Veljkovic A, Glazebrook M, Daniels TR, Penner MJ, Wing KJ, Younger ASE. Prospective Cohort Study on the Employment Status of Working Age Patients After Recovery From Ankle Arthritis Surgery. Foot Ankle Int. 2018 Jun;39(6):657-663. doi: 10.1177/1071100718757722.

(9) Jeng CL, Lin JS, Amoyal K, Campbell J, Myerson MS. Driving brake reaction time following right ankle arthrodesis. Foot Ankle Int. 2011 Sep;32(9):896-9. https://www.ncbi.nlm.nih.gov/pubmed/22097166

(10) Harder AT, An YH. The mechanisms of the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone healing: a concise review. J Clin Pharmacol. 2003 Aug;43(8):807-15. https://www.ncbi.nlm.nih.gov/pubmed/12953337

(11) Borenstein TR, Anand K, Li Q, Charlton TP, Thordarson DB. A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty. Foot Ankle Int. 2018 Feb;39(2):143-148. doi: 10.1177/1071100717738748

(12) Mulcahy H, Chew F. Current Concepts in Knee Replacement: Complications.  American Journal of Roentgenology 2014 202:1, W76-W86. https://www.ajronline.org/doi/10.2214/AJR.13.11308

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile