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					Introduction to Ankle Replacement
Your surgeon will evaluate your ankle to determine whether or not an ankle replacement
is the best choice for you. Ankle replacement surgery is also called ankle arthroplasty.
First the doctor will evaluate the type of arthritis that you have. The best candidates for
this surgery are patients over 50 with traumatic arthritis, rheumatoid arthritis, or
osteoarthritis. In the process of examining you, your range of motion will be measured,
a detailed medical history will be obtained, and standing x-rays will be taken. This is all
to assess the size and condition of your ankle.

In the process of “wearing out”, the ankle joint can be changed with the foot turned in or
out. Most deformities can be corrected during the surgery. The primary purpose of ankle
replacement is pain relief. Motion can be gained following surgery, however it depends
on how stiff your joint is before surgery, and how long it was stiff before surgery. You
may have a range of motion of up to 40 degrees after surgery.

Ankle replacement surgery is a procedure that should be reserved until there are no other
options. Conservative treatment should always be tried first. Only when conservative
treatment fails to relieve pain, should an ankle fusion or replacement be considered.

Preparing for Ankle Replacement Surgery

Medical clearance

To proceed with surgery is a joint decision between you and your doctor. Once the
decision has been made, there are several things that need to be done. You will need to
have a complete physical exam by your family physician. This is to insure that you are in
the best possible condition to undergo surgery. Medical conditions such as urinary tract
infections, cardiac disease, and high blood pressure need to be evaluated, treated and
controlled prior to surgery. We request that your family physician send us a report
regarding your general medical health and copies of any tests they have performed.
Common tests include a urinalysis, a complete blood count with platelets, serum
chemistries, P.T, and P.T.T. For some patients, a chest x-ray and EKG may need to be
performed.

Anesthesia

You will need to meet with an anesthesiologist at The University of Chicago at least 1-2
weeks before your surgery. They will review your medical history and discuss the type
of anesthesia that is best for you. There are many options regarding your anesthesia.
They include general, regional, epidural or a combination.

Preoperative physical therapy

You will need to meet with a physical therapist before surgery. The therapist will begin
the teaching plans before surgery to ensure that you are ready for the rehabilitation
afterwards. One purpose of meeting the therapist before surgery is record baseline
information. This includes measuring your range of motion, current pain levels, and
functional ability. This second purpose is to prepare for your upcoming surgery.
Because you will be non-weight bearing after your surgery, you will need to use an
assistive device, like crutches, a walker or a roll about. You’ll begin practicing using
your crutches or walker.

Smoking

If you smoke it is very important that you stop at least 2 weeks before your surgery and
continue not to smoke after your surgery. Smoking can impair healing. When you
smoke, your blood vessels get smaller or vasoconstrict. This means that you have a
decreased blood flow of oxygen and nutrients essential for healing. Smoking can
seriously compromise your final result. It can cause bones not to heal, for the implant not
to heal in the bone, for the incision not to heal, or your skin to die.


Admission

You should plan to be admitted to the hospital the day of surgery and to stay for 1or 2
days afterwards. You will be given a preoperative instruction sheet to follow before
surgery. How long you stay depends a lot on how much pain you are having, how well
you are able to get out of bed, and how well you can get around using crutches or a
walker.


Medication

If you are taking any anti-inflammatory medications, you will be asked to stop taking
them at least one week prior to surgery. This is to minimize bleeding during your
surgery. Anti-inflammatory medications include any form of aspirin, including coated or
buffered aspirin, Disalcid, Indocin, Tolection, Clinoril, Naprosyn, Nalfon, Meclomen,
Motrin, Felden, Orudis, Butazolidin, and Phenylbutazones. Do not change or stop taking
any medication unless instructed to do so by your family physician, surgeon, or
anesthesiologist.

Minor surgical procedures or dental care

Do not schedule and minor procedures or dental procedures such as teeth cleaning, cavity
repairs or oral surgery within two weeks of your scheduled surgery.

Infections

If you develop a significant cold, sore throat, or the flu within one week of surgery,
please call your surgeon. If you develop a urinary tract infection within 2 weeks of
surgery, contact your family physician for treatment and contact your surgeon. These
conditions can increase the risk of a postoperative infection and your surgery may need to
be rescheduled

Pregnancy

Elective ankle surgery is not indicated during pregnancy. If you become pregnant prior
to your scheduled surgery, contact your surgeon so that you can reschedule.

Dentures/Contact Lenses/Jewelry

Dentures, contact lenses, and jewelry cannot be worn in the operating room. Plan on
leaving your jewelry at home, bring glasses instead of contacts, and bring your denture
cup with you.

Skin Cleansing

It is recommended that you wash your ankle, foot and toes carefully with an antibacterial
soap for 3-4 days before you are admitted. It is also important that you remove all nail
polish. Be very careful that you do not nick your skin in the area around your ankle. If
you have any breaks in the skin contact your surgeon before going to the hospital.

What to Bring to the Hospital

   1.   Comfortable, loose fitting clothing
   2.   A robe, slippers and toiletries
   3.   You may bring your own night clothes instead of wearing hospital gowns
   4.   Books, magazine, stationary, hand crafts, or hobbies
   5.   Medications you take on a regular basis
   6.   Containers and solutions for contact lenses, dentures


The Operation

First the doctor will make an incision through the skin in the front of the ankle.
This allows the surgeon to approach the ankle from the front. After getting through the
skin, the nerves, arteries and tendons are protected and moved to the side. The joint
capsule is exposed and an incision is made into the capsule to expose the ankle joint.
Now the surgeon can view the bones, the surfaces of the joints and prepare the joint for
the ankle replacement.

The next part of the surgery involves cutting the bone of the tibia and fibula. These
bones make up the socket of the ankle joint. This is where one part of the prosthesis will
fit. This part is called the tibial component.

The next step in the procedure is to cut the top of the talus, so that the talar component
can be placed.




Now the tibial implant and talar implant portion are ready to be put in.

Ankle Joint Replacement Components




Total ankle replacement surgery removes and then replaces both sides of the ankle joint
with specially designed artificial parts. These artificial parts are also known as
prosthesis. The ankle prosthesis is made up of two parts. The mortise component is the
metal portion of the artificial joint the replaces the socket of the ankle (the top portion).
The talar component, replaces the top of the talus.

The tibial component consists two parts. One is a base plate tray that is made of titanium,
and the other is a polyethylene (special plastic). The titanium base plate tray is inserted
into the tibia and fibula, to give the implant a wide space for support. The plastic part is a
cup that provides the bearing surface of the joint. The plastic is very tough and very
slick. The tibial component is also known as the mortise component. The mortise
component is the metal portion of the artificial joint the replaces the socket of the ankle
(the top portion).

The talar prosthesis is the part that moves up and down. It is made of cobalt chromium, a
metal commonly used in joint replacement prosthesis. ). The talar component, replaces
the top of the talus. The talus is the first bone of the foot and sits in the mortise of the
ankle.




To make sure that the ankle socket or the mortise component is well fit, two screws will
be placed between the fibula and tibia just above the artificial ankle joint. Bone graft is
then placed between the tibia and fibula to fuse the two bones. This is to stop any motion
between the bones that could make the implant loosen.
After the surgeon is satisfied that the surgery is satisfactory, the joint capsule and skin
will be sutured back together. Your foot and ankle will be put into a large splint that goes
from your toes, to just below your knee. This is to protect the new ankle joint as you
heal.



After Ankle Replacement Surgery

Recovery Room

After your surgery you will be taken to the recovery room where a nurse will frequently
assess your vital signs and surgical site. You may have only one visitor at a time in the
recovery room. If your family leaves the waiting area, pleas have them notify the desk so
they can be notified of your progress. Your surgeon will talk to your family after the
surgery is done. You will remain in the recovery room until your condition is stable and
then go to your hospital room.

After surgery you will be in large splint to protect your new ankle joint. Your foot and
lower leg will be elevated and iced. It is not uncommon for blood to be on your dressing.
You should not let this alarm you. It is normal and will stop in a few hours.

To prevent nausea immediately after surgery, you will only be given ice chips or sips of
fluid. On the first postoperative day you may begin drinking fluids and eating meals
under the direction of your surgeon.
You will have an I.V. that will stay in for 1-2 days after surgery. The purpose is to give
you proper nourishment until you are eating and drinking normally. It will be used for
administration of antibiotics to help prevent infection. It will also be used for the
administration of pain medications. When the I.V. is discontinued, you will begin taking
your medications by mouth.

It is normal to feel pain and discomfort after surgery. Be sure to inform your nurse so
he/she can give you pain medication.

Postoperative

The first day after surgery, you will probably be allowed to get out of bed, sit in a chair,
and start physical therapy. You will review your ability to walk safely with
crutches/walker without putting any weight on the ankle. You will stay in a splint or cast
until you see your doctor two weeks after surgery.

Weight bearing

You will not be able to put any weight on your ankle for at least 6 weeks after surgery,
during which time you will have to use a walker, crutches or Roll-a-bout. You will be
shown by physical therapy how to take off your splint and do your range of motion
exercises. You should do your exercises twice a day. Physical therapy for range of
motion will begin two weeks after surgery.

At Home

You will see your surgeon for the first time two weeks after surgery to take out the
stitches. Until you return, you must not get your splint wet. You must also check it daily
to make sure there is no drainage. If you do notice any drainage, or notice a foul odor,
contact your surgeon immediately. Also if you have a temperature that is 101.5 F or
above, notice excessive swelling or pain, call your surgeon.

Contact your family doctor if you develop a cold, fever, sore throat, breathing problems,
heart or circulation problem or other general physical difficulties that concern you.

You may need help with your daily activities. It is not a bad idea to have family and
friends prepared to help you. It is normal to feel frustrated, but these frustrations will
pass.

Resuming Activities
   1. You can walk as much as you like using crutches, a walker, or Roll-a-bout but
      you'll need to remain non-weight bearing on the affected side for six weeks. Your
      surgeon will provide specific instructions.
   2. When you rest, be sure to elevate your ankle, preferably above the level of your
      heart.
   3. Do the exercises prescribed by your doctor/physical therapist at least two to three
      times a day.
   4. At night, rest on your back with a pillow or two under your splinted ankle.
   5. For bathing, sit in the bathtub and wash. Be certain that you keep your splint and
      ankle dry until the sutures have been removed, then resume normal bathing. On
      occasion, you may use plastic to cover your splint so you can shower while you
      are still wearing the splint.
   6. You may return to work when authorized by your surgeon.

Pain Medication

It is normal to have some discomfort after surgery. However it is unusual to need pain
medication for more than a week after surgery. You will receive a prescription for pain
medication before you leave the hospital. You should not need a refill. If you do, you
may be too active and need to consider limiting your activity. Before taking narcotic pain
medication, first elevate and ice your extremity. If this fails to relieve your pain, then
you may take your pain medication. If a refill is needed please call your surgeon’s nurse
a few days before your prescription runs out.

Special Instructions

If you choose ankle replacement surgery, there are some special considerations. Your
ankle replacement may activate metal detectors. You will be given an ID card to carry
with you. Whenever you pass through a metal detector, you may show this card to the
attendant.

You must notify your dentist and physicians that you have had an ankle
replacement. You may need to take antibiotics before dental work,
surgery or other medical procedures.
Follow up

After your surgery, you will come back in 2 weeks to have the sutures removed. Then
you will return at 6 weeks and 3 months for x-rays and physical exam. X-rays are taken
to confirm that the artificial joint has not moved and that the fusion between the tibia and
fibula is forming. Then you may expect six-month follow ups to assess your progress.
You surgeon will continue to monitor your progress on a yearly basis.

Potential Complications Following Ankle Replacement Surgery

With any surgical procedure there are complications. The most common complications
after surgery are infection, loosening of the implant, and nerve injury. Infection can be a
very serious complication following a joint replacement surgery. The chance of infection
after an ankle replacement is 2-4%. Some infections may present early before you leave
the hospital. Others may not show up for months or years after the operation. You will
get antibiotics to reduce the risk. However, if you get an infection elsewhere in your
body, it is possible that it can spread to the artificial joint. When you are about to have
dental work or surgical procedures, contact your orthopedic surgeon so that he can decide
if you need to take antibiotics before the procedure.

The major reason that artificial joints eventually fail is loosening. The loosening usually
occurs where the bone meets the metal. There have been great advances in making
implants last longer, but most will eventually loosen. When an implant loosens, you will
require another surgery. Artificial ankles are not as successful as hip and knee
replacement, because the increased risk of loosening. Many have lasted for only 5-8
years. The risk of loosening is higher in younger, more active patients, or patients who
are overweight. A loose prosthesis becomes a problem because it causes pain. When the
pain is unbearable, you will need a revision of the implant, a new implant or a fusion.

All of the nerves and blood vessels that supply the foot travel across the ankle. Because
the surgery is performed in this area, there is a risk of damaging these important
structures. The result may be temporary, if the nerves were stretched while being
protected. It is uncommon to have permanent injury to nerves or blood vessels, but it is
possible.

Physical Therapy
You will attend physical therapy regularly after your surgery. Your therapist will give
you an indication of how many visits you need and for how long. Your first visit you
will determine with your therapist, what your goals are. Treatment will include
modalities for pain and swelling, range of motion, weight bearing progression,
strengthening, endurance, balance, exercise progression, and a home program. The
success of the surgery also depends on you. You must remain non-weight bearing for six
or seven weeks. You will attend physical therapy and perform a home exercise program.
It is very important for you to do the exercises the therapist shows you in order to get the
best possible outcome.
 Introduction to Ankle Replacement
          A Patient Guide

                      Brian C. Toolan MD
               Orthopaedic Foot and Ankle Surgery

                The University of Chicago
    Section of Orthopaedic Surgery and Rehabilitation
                        Medicine
5841 S. Maryland Ave. MC 3079  Chicago  Illinois 60637Phone 773.702.6984 Fax 773.702.0076
Before Ankle Replacement




After Ankle Replacement

				
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