About Total Ankle Replacement
Most people have heard of hip and knee replacements, but you may not be aware that an ankle may be replaced with a prosthetic device, too. Total ankle replacement is also known as ankle arthroplasty. Doctors began performing ankle arthroplasty many years ago, but prosthetic devices were not living up to expectations and most physicians stopped doing the procedure two decades ago.
Today, there is a new generation of replacement devices approved by the Food and Drug Administration devices that have a better anatomical design than previous implants and improved longevity. These advanced prosthetics also allow better movement. There is finally an excellent treatment option for patients who need surgery.
Patients considering ankle joint replacement have usually lived with chronic ankle arthritis that is extremely painful. Commonly, they have tried treatments such as physical therapy, rest, bracing, injections and/or medications. Sometimes, they have undergone other unsuccessful surgeries. (Click on "Are you a candidate?" for more information.)
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About Our Ankle Specialists
Doctors Hospital is home to the Center for Orthopedics and Sports Medicine. The team includes board-certified, fellowship-trained orthopedic surgeons who care for patients with a variety of orthopedic problems from shoulder and elbow injuries to knee and ankle problems. They are the sports medicine providers for the Florida Panthers, Tampa Bay Buccaneers, Miami City Ballet, Florida International University, and Miami-Dade public high school athletes. Our nurses, physical therapists and other staff members have special training in orthopedics and provide the highest quality care to all patients. The hospital's physical therapy gym is recognized for its state-of-the-art equipment as well as its outstanding and knowledgeable staff who develop a personalized training plan to get you back on your feet.
Leading the ankle replacement team is Thomas San Giovanni, M.D. Dr. San Giovanni received his medical degree from George Washington University. His postgraduate training includes a fellowship in pediatric orthopedics through Harvard Medical School at Boston Children's Hospital and an orthopedic surgery fellowship in foot and ankle surgery through Harvard at Brigham and Women's Hospital in Boston. His residency in orthopedic surgery was completed at University of Miami/Jackson Memorial Hospital. He is considered a leading expert in the field of total ankle replacement, but also is well respected for his versatility within all fields of orthopedics. Dr. San Giovanni is one of only a few orthopedic surgeons who is fellowship-trained in foot and ankle surgery in South Florida. He has lectured and trained other physicians in a variety of orthopedic techniques and procedures and has published numerous journal articles on advances in orthopedic surgical treatment.
The ankle joint is quite sophisticated. It absorbs more than four times your body weight. Think about how you move. You walk, jump, go up on tip-toe, move side-to-side. The joint allows the foot to extend and flex. Along with cartilage, ligaments and tendons, the ankle joint is the connection between the tibia (shinbone), the fibula (the smaller bone in the lower leg) and the talus (the bone that sits on the top of the heel and fits into the socket formed by the tibia and the fibula). Ankle cartilage is a quarter-inch shock-absorber between the bones that allows the joint to move smoothly. Aging and injuries can damage and wear away the cartilage, resulting in severe pain and lifestyle limitations. Rheumatoid arthritis, osteoarthritis and arthritis caused by fractures or repeated sprains are the most common reasons people seek help.
Are You a Candidate for Total Ankle Replacement?
Not everyone with an ankle problem needs or would benefit by having a total ankle replacement. If you suffer from debilitating pain and your activities are extremely limited because of severe rheumatoid arthritis or degenerative arthritis, you may be a candidate for total ankle replacement. Others who undergo the procedure do so because they have had previous ankle surgeries that have failed or they experienced a traumatic injury to the ankle (such as a displaced fracture) that later resulted in arthritis. Patients who are significantly overweight are discouraged from having the surgery because the ankle joint is smaller than most other joints and receives considerable force. Although the replacement is best for someone who is active, in most cases younger people who want to continue participating in extreme sports or regular high-impact exercise should explore other options with their physician.
What to Expect If You Undergo Total Ankle Replacement
Like any other surgical procedure, a total ankle replacement has risks that you should discuss with your doctor. If, together, you decide that it is the best choice for you, it's necessary to undergo some pre-surgery testing to determine that you are healthy enough to proceed with surgery. Once you are cleared for surgery, you will be given a date for your procedure and instructions on any preparations necessary before you come to the hospital.
On the day of surgery, you will be taken to pre-op, where you will change into a surgical gown. The staff, including doctors and nurses, will review your information with you. In addition to general anesthesia, you will receive an ankle block, which numbs you from the ankle down and helps reduce the pain in the 16 to 18 hours that follow surgery. The procedure involves making a vertical incision at the front of the ankle and making precise cuts within the bones so the prosthesis will fit properly. Generally, the surgery is complete in two to two-and-a-half hours.
After surgery, you will most likely stay in the hospital for two to three days. Your leg will be in a splint similar to a half-cast and your stitched incision will be covered in a dressing. You will be encouraged to get up and move around as soon as you feel able, although you will not be allowed to put any weight on your healing foot for approximately six weeks. Depending on how you feel, you will use crutches or a walker device, although some patients may require a wheelchair, particularly if they have other health problems or are overweight. When you leave the hospital, you will be given a prescription for pain medication. Some people make the move to milder over-the-counter painkillers quickly, others need more time.
Two weeks after your surgery, you will return to the doctor. Your stitches will be removed and X-rays will be taken to ensure that healing is taking place and that the prosthesis is still properly aligned. If everything is proceeding normally, the splint is removed and replaced by a cast that will stay on from four to six weeks. During those four to six weeks, you are still unable to put any weight on your foot. You will return to the doctor again after this time, and the cast will be replaced by a removable boot, sometimes referred to as an aircast or pneumatic boot. Your doctor will discuss physical therapy with you. In order to regain strength and range of motion, most people come to physical therapy three times a week for about an hour per session. Some patients require a month of therapy while others continue for several months. Age, the extent of your surgery, your general health and the amount of inflammation you have after surgery all play a role in the length of time it requires you to recover.
Throughout the process, we are with you every step of the way. We are always available to answer your questions and address any concerns. It's our desire to see you back on your feet and leading a normal, pain-free life as soon as possible.
When will I be able to walk again?
Most patients come to us with many questions about total ankle replacement. Some of the most common questions we get are:
Initially, you are not to put any weight on your foot. Most people are able to begin physical therapy and walking about six weeks after surgery. You will begin slowly, building strength in your calf muscles and your ankle. Gradually, you will put more weight on your foot. It is a gradual process and varies with each individual.
Can I go back to work right after surgery?
Your return to work really depends upon the type of work you do. If most of your day is spent sitting, you can go back as soon as you feel better and the doctor agrees. If, however, your job requires a lot of standing or walking, it will most likely be three or more months before you can return to work.
How soon after surgery can I take a shower or bathe?
As soon as you feel well enough. However, you must take measures to cover the splint as it cannot get wet.
How soon can I drive?
If your surgery was performed on your right ankle, it will be two to two-and-a-half months before you may drive. If it was done on your left ankle, you may drive when you are no longer taking prescription pain medications. Discuss your driving questions with your doctor.
Can I exercise after a total ankle replacement?
Yes. Not right away, of course. But after physical therapy and the healing process is complete, you may resume your normal routine and exercise practices, assuming that you aren't a marathoner or into other extreme sports. You can walk, golf, play tennis and enjoy other activities, but you should not participate in exercise that requires repeated high-impact movements.
Will my prosthetic ankle function well enough for regular daily activities?
A successful ankle replacement will eliminate the bone-on-bone pain associated with arthritis and preserve motion of the joint. Patients function very well with their routine daily activities. Remember, though, that it is made of metal and special plastics. That is why high-impact activities are discouraged.
What are the risks involved with total ankle replacement surgery?
The same risks that are present with any surgical procedure exist with total ankle replacement. You will undergo general anesthesia. Early complications could include infection, delayed wound healing, and other problems. Late complications that occur in few patients are the loosening of the prosthesis and deterioration of the plastic over the years. It is difficult to predict if or when problems will occur. If your health is good, in general, the likelihood of complications is low. If you have vascular disease, poor circulation, or smoke, your healing could take longer and you are at higher risk for complications. Smokers are encouraged to quit smoking before surgery and to refrain from smoking for several months after the procedure. Smoking can affect your body's ability to form new bone that attaches to and stabilizes the prosthesis. Discuss these issues with your doctor.
Are there any long term problems associated with the surgery?
Generally, no. It's common to experience inflammation of the ankle for six months to a year after surgery, depending on your activity level. The doctor will talk to you about the proper use of anti-inflammatory medicines if necessary.
What are the surgical alternatives for advanced stage ankle arthritis?
What about an ankle fusion? Prior to the development of the improved replacement designs, ankle fusion (fusing the ankle bones together to eliminate the pain) was the standard procedure to address end-stage ankle arthritis. For certain patients, ankle fusion may still be the best option. If you have rather severe angular deformities, significant bone loss from trauma or infection or you are fairly young and have high-impact demands, you may be better served with a fusion procedure for long-term maintenance. The decision is made on a case-by-case basis, weighing the risks and matching them with your expectations.
Is the procedure covered by insurance?
Yes, total ankle replacement is covered by most insurance, including Medicare, but you'll want to check with your insurance carrier to be certain there are no problems. Our office will help you if there are any issues that need to be discussed.
One Patient's Story
Click here to read our Resource magazine story about 80-year-old John Pantesco, who had total ankle replacement surgery at Doctors Hospital.
About the Salto Talaris Prosthesis
The ankle prosthesis Dr. San Giovanni has chosen to use in most primary total ankle replacement patients is the Salto Talaris made by Tornier. The device received FDA approval for use in the United States in December 2006. Three months later, in March 2007, Dr. San Giovanni implanted the new device in a patient at Doctors Hospital the first ever implanted in Florida. The prosthetic joint is superior to older versions and other models for a number of reasons, according to Dr. San Giovanni. To implant, it requires less removal of existing bone and its special coating allows the bone to grow into it so that cement is not necessary. Dr. San Giovanni also admires its natural movement. It has been used in Europe with great success for a number of years. Doctors Hospital serves as one of the leading centers in the U.S. for this design. With his expertise in total ankle replacement systems, Dr. San Giovanni has been chosen and has served as a surgical instructor for the training of other U.S. surgeons in the proper technique.
Other Total Ankle Systems Used
Dr. San Giovanni has extensive knowledge in the field of ankle replacement and has worked with other systems in addition to the Salto Talaris. In 2006, he published the leading articles regarding the Buechel-Pappas total ankle replacement systems used in the U.S. For ankle replacement revisions and other deformities, he may use a different prosthesis called the Inbone Total Ankle by Wright Medical Technology, also FDA-approved.
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