Before Surgery

How Your Primary Care Physician and Foot and Ankle Surgeon Work Together

Your foot and ankle surgeon will work closely with your regular medical doctor before and after your joint replacement surgery. An orthopedic surgeon is an expert on the conditions that affect the bones, joints and muscles of your body. Your medical doctor is an expert on medical conditions, and knows a great deal about your individual medical needs during the preparation, hospitalization and postoperative recovery. Together, these two doctors will work as a team to decide if you need special preparation for surgery and whether you need to see additional specialists during this period. Before surgery, it is important that you arrange an appointment with your regular medical doctor as you are planning surgery so that he or she may alert your orthopedic surgeon to any special needs that you may have.

If you have not had a complete physical examination recently, your medical doctor may suggest that you do so to ensure that you have no new medical problems that have not been identified in the past. This may reduce or eliminate some of the risks associated with the operation. Following surgery, you may be asked to make appointments to see both your medical doctor and foot and ankle surgeon to make sure that you receive the best care for your orthopedic and medical problems.

Preparing for Ankle Replacement Surgery

The decision to proceed with ankle replacement surgery should be made by you and your doctor only after you feel that you understand as much about the procedure as possible.

Once the decision to proceed with surgery is made, there are several things that may need to be done. Your foot and ankle surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with the physical therapist that will be managing your rehabilitation after the surgery.

On occasion a therapist will begin the teaching process before the surgery to ensure that you are ready for the rehabilitation afterwards. This includes measurements of your current pain levels, functional abilities, and the available movement and strength of each ankle. A second purpose of the preoperative visit is to prepare you for your upcoming surgery. You? ll begin to practice using crutches since you will need to use these for several weeks after surgery.

Finally, an assessment will be made of any needs you? ll have at home once you?re released from the hospital. On the day of your surgery, you will probably be admitted to the hospital early in the morning. You will be instructed not to eat or drink anything after midnight the night before surgery.

You should plan on being in the hospital for one to two nights following surgery. How long depends on your progress with physical therapy, how much discomfort you are in, your ability to get out of bed, and success using crutches or a walker. To perform an artificial ankle replacement, you may be placed under general anesthesia, regional anesthesia, or you may have a spinal type anesthetic.

During Surgery

Ankle Replacement Surgery

The Incisions

The Operation begins by making an incision through the skin into the front of the ankle. This is called an interior approach to the ankle.

Cutting the Bones

The next step in replacing the ankle joint is to cut the bones that make up the socket of the ankle joint–the tibia and the fibula–so that the metal socket will fit in place.

Next, the top of the talus is cut so the metal talar component can be inserted.

Inserting the Implant

All of the tibial implant and the talar implant portions of the artificial ankle joint are then inserted.

Inserting the Screws

Then the ankle is tested to make sure the pieces fit properly. To make sure that the ankle socket or the mortise component fits tightly, two screws are placed between the fibula and the tibia just above the artificial ankle joint.

Bone Grafting

Bone graft is then placed between fibula and the tibia to create a fusion between the two bones. This stops the motion between the two bones that could loosen the artificial joint. The bone graft is taken from the bone that has been removed from the ankle earlier.

When the surgeon is satisfied that everything is satisfactory, the ankle joint capsule is sutured back together and the skin is sutured together. A large bandage and splint are placed on the lower leg to protect the new ankle joint as your leg heals.

Closing the Incision

There are several ways that orthopedic surgeons can close the incision after performing an artificial joint replacement. Stainless steel staples are popular with many orthopedic surgeons because they are easy to put in and easy to take out. This can reduce time in the operating room. The stainless steel staples are one of the most inert types of sutures, meaning they have a very low risk of allergic reaction by the patient.

Some surgeons prefer using sutures that dissolve on their own after several weeks. These stitches are normally put in just under the skin. The advantage of this type of closure is that you don’t have to have your stitches taken out. Usually there are special tape closures (sometimes called “butterfly” tapes or “steri- strips”) that are used to hold the edges of the skin closed for the first few days. If you see strips of tape across the incision, this is probably the type of closure that was done. This type of incision closure takes a bit more time in the operating room.

Finally, many surgeons still use the old “tried and true” nylon stitches one at a time. Nylon has withstood the test of time and is nearly as inert as stainless steel. It is strong and holds well until it is removed (somewhere between 2 to 4 weeks after surgery).

Other Surgical Procedures

Because ankle replacement implants must be aligned properly to function correctly, additional soft tissue surgeries may be required. These procedures can re-establish the proper ligament tension and ankle alignment required for proper range of motion and walking. Your surgeon can better explain the need for these surgeries based on your individual need.

Note: Please understand that the information above is provided for reference purposes only. Your surgeon may change any or all aspects of your treatment as discussed in this section based on his/her experience, preferences and your particular situation.

Ankle Replacement Surgery Components

Total ankle replacement removes and then replaces both sides of the ankle joint with specially designed artificial parts, called prostheses. The tibial prosthesis consists of a polyethylene (medical grade plastic) and titanium base plate tray that is inserted into the tibia and fibula, giving the implant a wide base for support. The upper portion of the talus, the bone that moves up and down, is replaced with a component made of cobalt chromium alloy, a metal commonly used in joint replacement prostheses.

One type of ankle prosthesis is made by Salto Talaris. The Salto Talaris Total Ankle Prosthesis is modeled after the human anatomy and provides the ability to reproduce the natural movement of the ankle with a design that replicates the natural ankle.

Extensive work has been done to understand the normal anatomy of the ankle to reproduce it.

Each artificial ankle prosthesis is made up of two parts:

1) The tibial component is the metal portion of the artificial joint that replaces the socket of the ankle (the top portion).

2) The talus component replaces the top of the talus. The talus is the first bone of the foot and sits in the mortise of the ankle.

The talus component is made of metal. The tibial component is usually made up of two parts, a metal tray that is attached directly to the bone and a plastic cup that provides the bearing surface. The plastic used is very tough and very slick.

Recovery and Rehabilitation

Checking on Your Ankle Implant

Ankle replacement is used in patients with rheumatoid arthritis, osteoarthritis or after severe ankle injury. The diseased or damaged parts of the ankle joint are removed and replaced with an implant to reduce pain while allowing movement of the ankle.

Since an ankle implant procedure is a long-term treatment option for ankle joint pain, there is a possibility that the replacement ankle may eventually wear out or fail.

The life expectancy of an ankle implant is largely dependant on a patient’s activity level, weight, and the condition of the bone around the ankle. In the event complications with your ankle implant occur, a second surgery may need to be performed to replace the existing implant.

If you have had ankle replacement surgery, the following signs might indicate there are complications with your ankle implant:

• Delayed wound healing
• Increased ankle pain
• Swelling
• Drainage
• Elevated Temperature
• Reduced motion or instability of your ankle
• Pain around your ankle after a fall

If you suspect there may be problems with your ankle implant, consult your doctor immediately. Your doctor will most likely take an x-ray to determine if there are complications with your ankle implant. The most common treatment is to undergo another ankle replacement surgery.

Following Ankle Replacement Surgery

Recovery Room

When the procedure is completed, your surgeon will contact your family and friends to update them on your surgery. You will awaken after surgery in the post-anesthesia recovery room, probably feeling as though you were only away from your hospital room for a few minutes. You will remain there for an hour or so, or until you have recovered from the anesthesia, are breathing well, and your blood pressure and pulse are stable. If you have pain, the nurses will administer medication. Your ankle will be in a splint so you will not be able to move it.

Healing After Surgery

Your foot and lower leg will be elevated and immobilized in a splint, so you will not be able to move your ankle. Frequently, blood will be visible on the dressing and should not be cause for alarm. This is common and usually stops after a few hours. The first day after surgery, you will probably be allowed to get out of bed, sit in a chair and, on occasion, start physical therapy. The dressing is normally removed two days after surgery and movement of your ankle is started in physical therapy.

To prevent nausea immediately after surgery, you will only be given ice chips or sips of water and soft drinks. On the first postoperative day, you may begin drinking fluids and eating meals under the direction of your surgeon.

An I.V. will normally remain in your arm for one or two days to administer antibiotics and fluids. This helps prevent infection and gives you proper nourishment until you are eating and drinking normally. It is normal to feel pain and discomfort after surgery. Be sure to inform your nurse of your pain and medication will be ordered. You may be able to administer your own pain medication through a push button attached to your bed. This system is called the “Patient Controlled Analgesia” (PCA). The nurses will show you how to use the system, which is designed to prevent overdose of pain medication. When the I.V. is discontinued, you will begin taking oral pain medication, but frequently pain medication is not necessary after the first day since the ankle is immobilized with a splint.

The nurses will help you out of bed and into a chair on the day after surgery or possibly the afternoon of surgery.

Two days after surgery, the ankle splint will be changed and you will begin gentle range of motion exercises. The physical therapist will instruct you on the safest method of getting in and out of a chair and will also determine which is the safest way for you to get around, either with a walker or crutches.

Progress

You will not be able to put weight on your ankle for the first six weeks, during which time you will be using crutches or a walker. Instructions on how to take the splint off twice a day to perform range of motion exercises will be given prior to your discharge. The sutures will be removed about two weeks after surgery.

At Home

Until you see your surgeon for your first follow-up visit, make certain that your wound stays dry and is not draining. If you do notice any drainage or foul odor from your incision, please contact your surgeon. Also, if your temperature goes over 100.4 degrees or you notice any increased swelling or tenderness, call your surgeon. Take time to adjust to your home environment–it’s okay to take it easy. You may need help with your daily activities, so it is a good idea to have family and friends prepared to help you. It is normal to feel frustrated, but these frustrations will soon pass.

Resuming Activities

You can walk as much as you like using crutches or a walker, but you’ll need to remain non-weight bearing on the affected side for about six weeks. Your surgeon will provide specific instructions.

When you rest, be sure to elevate your ankle, preferably above the level of your heart.

Do the exercises prescribed by your doctor/physical therapist at least two to three times a day

At night, rest on your back with a pillow or two under your splinted ankle.

For bathing, sit in the bathtub and wash. Be certain that you keep your ankle dry until the sutures have been removed, then resume normal bathing. On occasion, you may use plastic to cover your ankle so you can shower while the sutures are still in place.

You may return to work when authorized by your surgeon.

Contact Your Family Doctor if you develop a cold, fever, sore throat, pulmonary (breathing) problems, cardiovascular (heart or circulation) problems or other general physical difficulties that cause you concern.

Contact Your Surgeon If:

You develop an increase in ankle pain, swelling, drainage, temperature or have any problems controlling the motion of your ankle.

Medication/Pain Control

It is normal for you to have some discomfort, but it would be unusual for you to use pain medication more than five to seven days after surgery. You will receive a prescription for pain medication before you leave the hospital. If a refill is needed, please call your surgeon’s nurse at least three days before you run out of pills.

Special Instructions

You will normally be seen six weeks and three months after surgery. A six-month exam is also usually scheduled for new x-rays and an assessment of your progress.

Note for the future: You should always tell your dentist or physician that you have an artificial joint. If you are having dental work performed, notify your dentist or physician so he/she can prescribe antibiotics for the day before and the day of your dental care. Antibiotics must be used before and after any medical or dental procedure. This precaution must be taken for the rest of your life.

Any infection must be promptly treated with proper antibiotics because infection can spread from one area to others through the blood stream. Every effort must be made to prevent infection in your artificial joint. Your surgeon can give you instructions on the use of special antibiotics.

Physical Therapy Evaluation Following Ankle Replacement Surgery

Inpatient Physical Therapy

Prior to your scheduled ankle replacement surgery, you may have the opportunity to visit your physical therapist for a preoperative assessment. One purpose of this visit is to get a baseline of information that includes the location and severity of your pain, your functional abilities, and your strength and available motion of each ankle. A second purpose of the preoperative visit is to prepare you for your upcoming surgery. You’ll begin to practice some of the exercises you’ll use after surgery. You’ll also be shown how to use either a walker or crutches. Whether the surgeon uses a cemented or noncemented prosthesis will make a difference in just how much weight you’ll be able to apply through your foot while walking.

You will be seen by your inpatient physical therapist one day after surgery to begin very gentle exercises. You will be helped out of bed for a short outing using your crutches or walker. Again, the amount of weight you can put on the foot depends on whether your surgery was a cemented or noncemented procedure. Inpatient treatments are usually done two times per day for up to four days after surgery. By that time, you should be safe and ready to go home. You’ll be on your way home once you can safely get in and out of bed, walk 75 feet, and go up and down stairs with your crutches or walker.

Your First Visit to Outpatient Physical Therpay

On your first outpatient visit, your physical therapist will want to gather more information about the history of your condition. You may be given a questionnaire that helps you explain the day-to-day problems you are having with your ankle now that you’ve had surgery. The information you give will help measure the success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This will help your physical therapist gauge how much pain you have now and how your pain changes once you’ve had treatment. Your physical therapist will probably ask some more questions about your condition to begin zeroing in on what will be needed to best treat your condition. Here are some questions your physical therapist may ask you:

• How is your pain since having surgery?
• Where do you feel the pain now?
• What makes the pain better or worse?
• How do your symptoms affect your daily activities?
• Do you have pain above or below the new ankle joint?
• Do you have swelling?

Physical Therapy Evaluation

Once all this information has been gathered, your condition will be evaluated.

Posture: Once all this information has been gathered, your condition will be evaluated.

Observation: Your therapist will note if there is any swelling in or around the ankle joint. If so, measurements will be taken to get an idea how much swelling is present. Volumetric testing is done by placing your foot and lower leg in a container of water and measuring how much water is displaced. The results of each ankle and leg are compared. Another way to measure swelling is to use a tape measure and compare several measurements around one ankle and then the other. These measurements can be rechecked later to get an idea if the swelling is going away.

Gait Analysis: Your therapist will check to make sure you are walking safely and with the right amount of weight on your foot. If you were issued a walking aid, your therapist will check to make sure it is fit for you and that you are using it safely.

Range of Motion (ROM): Next, your physical therapist will check the ROM in your ankle. This is a measurement of how far you can move your ankle in different directions. Ankle movements include bending the ankle up and down (dorsiflexion/plantarflexion), as well as in and out (inversion/eversion). Your therapist may also want to get an idea of how other joints around the ankle are moving, including the foot, the lower leg, knee, and possibly even your hip. Your ROM is written down to compare how much improvement you are making with the treatments.

Strength: Your therapist will then test the strength of your muscles. You’ll be asked to hold against resistance as your therapist tests the muscles around the ankle. Other areas that may be checked include the muscles of the knee and hip. These measurements are compared to your other leg. Weakness in key muscles of the leg or ankle will be addressed with a strengthening program. Trained muscles can help control your new ankle, which eases pain and keeps the joint healthy for as long as possible.

Manual Examination: You may be given a manual examination of the muscles and joints of the ankle. Your physical therapist will carefully move your ankle in different positions to make sure that the new joint and surrounding joints are moving smoothly. Your physical therapist will also look at the flexibility of the muscles and tendons around your ankle. This type of exam can help guide your therapist to know which type of treatment will help you the most.

Palpation: The evaluation usually ends with palpation. Palpation is when your physical therapist feels the soft tissues around the joint. This is done to check the skin for changes in temperature, areas of soreness, and whether you have swelling. Palpation is also done to find out whether there are tender points or spasm in the muscles around the ankle. This can help your therapist get a good idea about which treatments will help you the most.

Potential Complications Following Ankle Replacement Surgery

Most surgeons will recommend that you remain on crutches or a walker for 10-12 weeks following the replacement of the ankle with an artificial ankle joint. X-rays will be taken several times after your surgery to make sure that the artificial joint has not moved and that the fusion between the fibula and the tibia is beginning to form. When the cementless type of implant is used it is important that the surgeon be able to determine whether bone is attaching to the metal implant. X-rays can help determine this.

Complications

As with all major surgical procedures, complications can occur. Some of the most common complications following artificial ankle replacement are Infection, Loosening and Nerve Injury. This is not intended to be a complete list of the possible complications, but they are the most common.

Infection

Infection can be a very serious complication following an artificial joint replacement surgery. The chance of getting an infection following artificial ankle replacement is probably somewhere around 2% to 4%. This is somewhat higher than the risk of infection after a hip or knee replacement. Some infections may show up very early, before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

Loosening

The major reason that artificial joints eventually fail continues to be a process of loosening where the metal or cement meets the bone. There have been great advances in extending how long an artificial joint will last, but most will eventually loosen and require a revision. In the past, the artificial ankle has not been considered as successful as the hip and knee replacement since there has been a much higher risk of loosening and failure of the artificial ankle replacement. Many have only lasted for 5-8 years. The risk of loosening is much higher in younger, more active patients and patients who are overweight. A loose prosthesis is a problem because it causes pain. Once the pain becomes unbearable, another operation will probably be required to either revise the ankle replacement, or perform an ankle fusion.

Nerve Injury

All of the nerves and blood vessels that go to the foot travel across the ankle joint. Due to the fact that the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerves have been stretched by retractors holding them out of the way. It is very uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.