Ankle Replacement

What Is Total Ankle Replacement (TAR)?

Total Ankle Replacement (Total Ankle Arthroplasty) is a surgery that works on a principle similar to hip and knee replacements. In this operation, the damaged and worn cartilage—along with a small amount of bone tissue—is removed from the lower surface of the shin bone (tibia) and the upper surface of the ankle bone (talus), the bones that form the ankle joint (tibiotalar joint). In place of the removed surfaces, tibial and talar components, usually made of metal alloys, are inserted along with an insert made of high-density polyethylene (durable plastic) that provides smooth motion between the two metal pieces.

Main Purpose and Difference: The main purpose of ankle replacement is to eliminate the severe pain caused by osteoarthritis while preserving the ankle’s natural up-and-down (dorsiflexion-plantarflexion) motion. This is what distinguishes it from ankle arthrodesis (fusion surgery), which eliminates joint motion entirely.

Who Is a Suitable Candidate for Ankle Replacement? (Patient Selection)

Total ankle replacement is not suitable for every patient with ankle osteoarthritis. Patient selection is very important for a successful outcome, and the criteria are generally stricter than for ankle fusion surgery:

• Severe End-Stage Ankle Arthritis: Osteoarthritis that does not respond to conservative treatments and causes severe pain and loss of function (especially post-traumatic arthritis, rheumatoid arthritis, or other inflammatory arthritides).
• Lower Physical Activity Expectations / Age: Traditionally, due to concerns about implant lifespan and durability, older patients (generally over 55-60 years of age) with lower physical activity expectations have been preferred. However, these indications are expanding with advances in implant technology. The risk of prosthesis wear is higher in young and highly active patients.
• Adequate Bone Stock: Sufficient quantity and quality of bone tissue must be present to support the prosthesis components. Severe bone loss or osteoporosis may make a patient unsuitable.
• Minimal Deformity and Instability: There should be no severe deformity (varus/valgus) in the ankle or significant ligament laxity (instability). Mild-to-moderate deformities can sometimes be corrected with additional procedures.
• Healthy Soft Tissue: Good condition of the skin and circulation around the ankle is important for wound healing.
• Intact Ligaments: Intact ankle collateral ligaments are generally preferred.

Who Is Not a Suitable Candidate (Contraindications): Conditions such as active infection, severe peripheral vascular disease, uncontrolled diabetes, severe nerve damage (neuropathy), advanced bone loss, uncorrectable severe deformity or instability, severe avascular necrosis of the talus (with collapse and bone loss), expectations of high-impact sports or heavy labor, obesity, and smoking generally make a patient unsuitable for ankle replacement or increase the risks.

Symptoms Targeted by Ankle Replacement

The main symptoms targeted by TAR surgery are as follows:

• Severe, persistent ankle pain that increases with weight-bearing.
• Difficulty walking and limping due to pain.
• Painful restriction in ankle movements.
• Marked decline in quality of life.

The surgery aims to improve the patient’s function by relieving pain and preserving motion.

Diagnosis and Preoperative Planning

A detailed evaluation and planning process is carried out before deciding on ankle replacement:

• Detailed History: The severity and duration of pain, the patient’s activity level, expectations (especially regarding motion), previous treatments, and comorbidities are reviewed.
• Physical Examination: Ankle range of motion (active and passive), presence and degree of deformity, ligament stability, skin condition, pulses, and nerve function are carefully evaluated. The condition of the adjacent joints (subtalar, talonavicular) is also important.
• Imaging Methods:
  
  • Weight-Bearing X-Rays: Essential. AP, lateral, and mortise views are used to assess the severity of osteoarthritis (joint space narrowing, osteophytes, cysts), bone quality, alignment, and degree of deformity. The condition of adjacent joints is also examined.
  • Computed Tomography (CT): Often requested to better assess bone stock, cysts, and deformity in three dimensions, and to plan implant size and positioning before surgery. It is sometimes used for patient-specific cutting guides (PSI) or robotic surgery planning.
  • Magnetic Resonance Imaging (MRI): Not usually required routinely for prosthesis planning, but may be requested to assess soft tissue condition, ligaments, or blood supply to the talus (avascular necrosis).
• Preoperative Planning: Based on the data obtained, the implant type, size, and positioning best suited to the patient’s anatomy are planned.

How Is Total Ankle Replacement Surgery Performed?

TAR surgery is generally performed as open surgery and requires technical precision:

1. Anesthesia: General or spinal anesthesia is administered. A tourniquet is generally used to reduce bleeding.
2. Surgical Incision: The joint is typically accessed through an incision on the front of the ankle. Nerves, blood vessels, and tendons are carefully protected.
3. Bone Cuts: With the help of special cutting guides (jigs) or, sometimes, robotic systems, the surgeon precisely cuts away the damaged cartilage and a thin layer of bone from the lower end of the shin bone (tibia) and the upper surface of the ankle bone (talus). It is very important that the cuts are made at the correct angle and plane.
4. Placement of Prosthesis Components: Metal tibial and talar prosthesis components of appropriate size are placed on the prepared bone surfaces. These components can be fixed to the bone with cement or without cement (press-fit). A mobile polyethylene insert is placed between the metal components.
5. Inspection and Closure: The stability of the prosthesis and the range of motion and alignment of the ankle are checked. Additional procedures (ligament balancing, Achilles tendon release) may be performed if necessary. The wound layers are then carefully closed.

Prof. Dr. Murat Bozkurt performs total ankle replacement surgery in Ankara using modern implant designs and surgical techniques.

Risks, Benefits, and Recovery Process

• Benefits:
  
  • Pain Relief: Highly effective at relieving severe pain caused by osteoarthritis.
  • Preservation of Motion: By preserving the up-and-down motion of the ankle, it provides a potentially more natural gait pattern compared to fusion surgery.
  • Improved function and quality of life.
• Risks:
  
  • General surgical risks: infection (the risk may be somewhat higher than with hip/knee replacements), Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE), and anesthesia risks.
  • Wound Healing Problems: Because the skin around the ankle is thin, wound healing problems and infection risk are more pronounced.
  • Nerve Damage: The superficial or deep peroneal nerve or tibial nerve branches may be injured (numbness, burning, weakness).
  • Prosthesis-Related Complications:
    
    • Loosening: Separation of the prosthesis components from the bone (the most common reason for revision).
    • Wear: Gradual wearing of the polyethylene insert over time.
    • Osteolysis: Bone resorption caused by wear particles.
    • Subsidence: Sinking of the prosthesis into the bone.
    • Periprosthetic Fracture: Fracture of the bone around the prosthesis during or after surgery.
    • Impingement: Prosthesis components or surrounding tissues obstructing motion.
  • Need for Revision: The long-term durability of ankle replacements has not been proven to be as reliable as that of hip and knee replacements, and over time (10-20% or more within 10 years) the need for repeat surgery (revision) is higher than with fusion surgery. Revision surgery is generally more difficult.
  • Persistent Pain or Stiffness.
• Recovery Process: Requires careful, staged rehabilitation.
  
  • Immobilization and Non-Weight-Bearing: After surgery, the leg is generally kept non-weight-bearing or with only very limited weight-bearing in a cast or a special walking boot for several weeks (e.g., 4-8 weeks). This is important for soft tissue healing and for the prosthesis to integrate with the bone (if applicable).
  • Physical Therapy: Begins after immobilization and continues for months. The goal is to regain range of motion in a controlled manner, increase muscle strength, improve balance, and restore normal gait.
  • Timeline: Return to normal daily activities generally takes 3-6 months.
  • Activity Restrictions: To prolong the life of the ankle prosthesis, high-impact activities (running, jumping, contact sports) are generally not recommended. Low-impact sports (swimming, cycling, walking) are permitted.

Ankle Replacement or Arthrodesis (Fusion)?

In advanced-stage ankle osteoarthritis, deciding between these two surgeries is important:

• Replacement (TAR): Preserves motion and keeps gait closer to normal. However, it is less durable, carries a higher risk of revision, and requires activity restrictions. It is generally suitable for older, less active patients with minimal deformity.
• Arthrodesis (Fusion): Eliminates motion, alters gait, and places extra load on adjacent joints. However, it is very reliable at relieving pain, is very durable, and may require fewer activity restrictions. It is generally preferable for younger, more active patients, those doing heavy labor, or those with severe deformity/bone loss.

This decision must be made on an individualized basis, taking into account many factors such as the patient’s age, activity level, expectations, the extent of joint damage, and the surgeon’s experience.

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

Total ankle replacement is a surgery performed at centers providing advanced ankle surgery in Ankara, requiring technical precision and experience. In his approach to patients with advanced-stage ankle osteoarthritis, Prof. Dr. Murat Bozkurt:

• Comprehensive Evaluation: Evaluates the patient’s condition from every aspect (pain, function, activity, expectations, radiology).
• Discussion of Treatment Options: Discusses the advantages, disadvantages, risks, and long-term outcomes of both total ankle replacement and ankle fusion surgery in detail with the patient, and decides together on the treatment best suited to the patient’s condition and expectations.
• Correct Patient Selection: Is aware that correct patient selection is critical to the success of ankle replacement and applies indications carefully.
• Modern Surgical Techniques: Once the decision for replacement surgery is made, performs the operation meticulously using current implant designs and modern surgical techniques.
• Rehabilitation and Follow-Up: Explains the postoperative rehabilitation process and activity restrictions to the patient and provides long-term follow-up.

Total ankle replacement is a valuable surgical option that relieves severe ankle pain while preserving joint motion in properly selected patients. However, the risks of the surgery, its long-term durability, and activity restrictions must be taken into consideration. The treatment decision must always be made together with an orthopedic surgeon experienced in this field. You can consult Prof. Dr. Murat Bozkurt for information about ankle replacement and other treatment options in Ankara.

For detailed information and appointments, you can reach Prof. Dr. Murat Bozkurt at 0312 502 70 74.