Ankle Arthrodesis

What Is Ankle Arthrodesis?

Ankle arthrodesis is the surgical procedure of permanently fusing (freezing) together the two main bones that form the ankle joint — namely, the lower end of the shinbone (tibia) and the upper surface of the talus (ankle bone).

During the surgery, the damaged and worn cartilage tissue on the joint surfaces between these two bones is completely removed. The underlying healthy bone surfaces are exposed and prepared to make full contact with each other. The ankle is positioned in the most functional alignment for walking (generally neutral or slightly plantarflexed — equinus, slightly externally rotated, and in a neutral varus/valgus position). The two bones are then firmly fixed together in this position. Fixation is typically achieved using strong metal screws and/or special plates. The goal is to ensure there is no movement between the bones until they are completely fused (fusion). Once fusion is complete, the tibia and talus become a single block of bone.

Basic Principle and Outcome: The fundamental principle of ankle arthrodesis is to eliminate pain by sacrificing painful joint motion. As a result, up-and-down (dorsiflexion/plantarflexion) movement of the ankle is permanently lost after surgery. However, thanks to pain relief and a stable weight-bearing surface, patients’ walking function and quality of life generally improve significantly.

Why Is Ankle Arthrodesis Performed? Indications

Ankle arthrodesis is a salvage surgery typically used for end-stage ankle problems where other treatment methods have failed or are not suitable. The main reasons it is performed include:

• Severe Ankle Arthritis (Osteoarthritis):
  
  • Post-Traumatic Arthritis: Advanced osteoarthritis that develops after previous ankle fractures or repeated severe sprains (the most common cause).
  • Primary Osteoarthritis: Age-related osteoarthritis (rarer than in the hip or knee).
  • Rheumatoid Arthritis or Other Inflammatory Arthritides: Joint destruction caused by rheumatic diseases.
• Failed Previous Surgeries: A previously performed but unsuccessful total ankle replacement or other joint-preserving procedures.
• Severe Ankle Deformity: Serious deformities and instability, caused by trauma or other reasons, that require correction.
• Talar Avascular Necrosis (Advanced Stage): When collapse and joint destruction develop due to impaired blood supply to the talus (if replacement is not suitable).
• Neuromuscular Diseases: Conditions such as Charcot neuroarthropathy (joint destruction related to diabetes), or severe deformity and instability due to certain nerve-muscle disorders.
• Chronic Ankle Infection: To stabilize the joint and control infection following treatment-resistant chronic infection (rarely).

The decision to perform arthrodesis is made by evaluating the severity of the patient’s pain, functional limitations, the degree of joint damage, age, activity level, and the suitability of other treatment options.

Symptoms Targeted by Arthrodesis

The primary goal of ankle arthrodesis is to eliminate severe, quality-of-life-impairing ankle pain, particularly pain triggered by weight-bearing. It also relieves joint instability and can correct existing deformity.

Diagnosis and Preoperative Planning

A detailed evaluation and planning process is carried out before arthrodesis surgery:

• Detailed History: The severity, duration, and location of pain, functional limitations, previous trauma, surgeries, and medical conditions are recorded.
• Physical Examination: Ankle range of motion (usually very limited and painful), location of tenderness, presence of deformity, skin condition, and circulation and nerve function are carefully evaluated. Very Important: Since the ankle will be fused, the condition and range of motion of the foot’s other joints (subtalar, talonavicular, calcaneocuboid) are always checked, because after surgery these joints will attempt to compensate somewhat for the ankle’s lost motion.
• Imaging Methods:
  
  • Weight-Bearing X-Rays: The primary diagnostic and planning tool. Anteroposterior, lateral, and mortise views are used to assess joint space narrowing (degree of osteoarthritis), bone spurs, cysts, deformity, and bone quality. The condition of adjacent joints is also examined.
  • Computed Tomography (CT): Frequently requested to better visualize bone stock, bone loss, cyst size, and the three-dimensional structure of the deformity, and to plan the screws or plates to be used during surgery.
  • Magnetic Resonance Imaging (MRI): Not usually needed routinely for arthrodesis planning. However, it may be requested if bone viability (suspected avascular necrosis) or infection is a concern.
• Preoperative Planning: The position in which the ankle will be fused during surgery is determined. This position is very important for the patient’s comfortable walking. The ankle is usually fused in a neutral position (90 degrees), slightly externally rotated (5-10 degrees external rotation), and in a neutral varus/valgus position (without inward or outward tilt).

Ankle Arthrodesis Surgical Techniques

Ankle arthrodesis can be performed using open or arthroscopic methods:

• Open Arthrodesis: The most commonly used method. The joint is accessed through one or more surgical incisions made from the front, side, or back of the ankle. The damaged cartilage on the joint surfaces is completely removed, and the underlying bone surfaces are prepared to bleed. The ankle is brought into the planned position, and the tibia and talus are firmly fixed together, usually using 2 or 3 large cannulated screws. Plates may sometimes be used for additional stability. Bone graft (from the patient or a cadaver) is frequently added to enhance bone healing. The open method is particularly better suited for correcting significant deformity.
• Arthroscopic Arthrodesis: A minimally invasive method. A camera and special instruments are inserted through small holes made in the ankle to clean the cartilage from the joint surfaces and prepare the bone surfaces. Screws are then typically inserted through small skin incisions to fix the bones in place. Advantages: Smaller incisions, less soft-tissue damage, potentially less pain, and lower infection risk. Disadvantages: Technically more demanding, may be insufficient for correcting significant deformities, and carries a risk that joint-surface preparation will not be as thorough as with the open method. Generally preferred in patients with minimal deformity or isolated intra-articular osteoarthritis.

Prof. Dr. Murat Bozkurt selects the most appropriate surgical technique (open or arthroscopic) and fixation method based on the patient’s condition, the severity of the deformity, and bone quality.

Risks, Benefits, and the Very Long Recovery Process

Ankle arthrodesis is a major surgery with potential risks as well as significant benefits.

• Benefits:
  
  • Pain Relief: The most important benefit. Because painful joint motion is eliminated, it provides excellent and lasting pain control in the vast majority of patients.
  • Stability: Creates a pain-free, stable weight-bearing surface.
  • Deformity Correction: Can correct existing deformity.
  • Durability: An extremely durable and long-lasting solution once fusion is successful.
• Risks:
  
  • General surgical risks: infection (wound-healing problems and infection risk around the ankle are somewhat higher than in other areas), bleeding, deep vein thrombosis (DVT), pulmonary embolism (PE), and anesthesia risks.
  • Nonunion: The most important specific risk (5-10%). This occurs when the tibia and talus fail to fuse together. It causes persistent pain and usually requires reoperation. Factors such as smoking, diabetes, and poor bone quality increase the risk.
  • Malunion: Fusion of the ankle in an undesired angle. Can cause gait disturbance and pain.
  • Hardware (Screw/Plate) Problems: Discomfort under the skin, loosening, or breakage (rare). Can be removed after fusion is complete if it causes discomfort.
  • Nerve Injury: Injury to the superficial or deep peroneal nerve, or branches of the tibial nerve, may occur during the surgical incision or screw placement (numbness, burning).
  • Adjacent Joint Arthritis: Because ankle motion is eliminated, adjacent joints (particularly the subtalar joint and other joints of the foot) that try to compensate for this lost motion during walking bear additional load. This increases the risk of osteoarthritis developing in these joints over the long term.
  • Joint Stiffness: Stiffness may develop in adjacent joints.
• Recovery Process: Recovery after ankle arthrodesis is a very long process requiring patience. Strict adherence to instructions by the patient is essential for success.
  
  • Immobilization in a Cast/Boot and NO WEIGHT-BEARING: Critical for achieving fusion. After surgery, the operated leg is typically kept in a cast or a special walking boot for at least 8 to 12 weeks (sometimes longer), during which absolutely no weight is placed on the leg. Crutches or a walker are used throughout this period.
  • Gradual Weight-Bearing: Once adequate fusion is confirmed on X-ray, partial weight-bearing within the boot is gradually started with the doctor’s approval, progressing over time to full weight-bearing.
  • Physical Therapy: Physical therapy becomes important once weight-bearing begins. The goals are to reduce swelling, preserve motion in adjacent joints, increase muscle strength, improve balance, and adapt to the new gait pattern. Since the ankle will no longer move, the patient’s walking pattern will change. Special shoe modifications (e.g., a rocker-bottom sole) can make walking easier.
  • Timeline: Full recovery, return to normal daily activities, and comfortable walking generally take 6 to 12 months. Swelling may persist longer. High-impact sports (running, jumping) are generally not possible or are not recommended.

Ankle Arthrodesis or Total Ankle Replacement?

For advanced-stage ankle osteoarthritis, total ankle replacement (TAR) is also an option as an alternative to arthrodesis. Briefly compared:

• Arthrodesis (Fusion): Eliminates motion but provides very reliable pain control and is highly durable. Generally more suitable for young, active patients, those with physically demanding jobs, or patients with poor bone stock and deformity.
• Total Ankle Replacement (TAR): Preserves motion and can provide a more natural gait. However, its long-term durability has not been proven to match that of arthrodesis, the risk of revision (repeat surgery) is higher, and it is used in more carefully selected patients (older age, low activity, minimal deformity).

The decision is made on an individualized basis, taking into account the patient’s age, activity level, expectations, the extent of joint damage, and the surgeon’s experience.

Ankle Arthrodesis in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Ankle arthrodesis is a last-resort surgery for serious ankle problems, but when performed correctly it significantly improves the patient’s quality of life. In Ankara, Prof. Dr. Murat Bozkurt’s approach to patients requiring this surgery includes:

• Comprehensive Evaluation: Thoroughly evaluates the patient’s complaints, functional status, radiological findings, and the condition of adjacent joints. Carefully establishes the indication for arthrodesis and discusses alternatives such as replacement with the patient.
• Precise Surgical Planning: Plans the most appropriate fusion position and fixation method based on preoperative X-rays and CT scans.
• Meticulous Surgical Technique: Whether using the open or arthroscopic method, prepares the joint surfaces optimally for fusion, corrects deformity, and applies stable fixation. Evaluates the need for bone graft.
• Reducing Nonunion Risk: Warns patients about factors that increase nonunion risk (such as smoking) and takes necessary precautions.
• Commitment to the Rehabilitation Protocol: Emphasizes to the patient the critical importance of adhering to the prolonged non-weight-bearing rule after surgery and closely monitors the rehabilitation process.