Ankle and subtalar arthritis
Information for patients from the Trauma and Orthopaedics (T&O) Department
What is ankle and subtalar arthritis?
Arthritis of the ankle is not as common as arthritis of the hip and knee. It happens most often after an injury.
Arthritis happens when cartilage covering the joint becomes damaged. The ankle joint is between the tibia bone and talus bone. The subtalar joint is between the talus bone and the heel bone.
What are the symptoms?
Pain, swelling, and stiffness are common symptoms, particularly when walking for long distances or on uneven ground.
As your arthritis progresses you may notice significant deformity in your ankle and / or foot. This can be uncomfortable and make finding appropriate footwear a challenge.
What are the treatments for ankle and subtalar arthritis?
In the early stages of your condition, painkillers, non-steroidal anti-inflammatory medication (for example, ibuprofen or Naproxen), and support with an ankle brace maybe of help. As your condition progresses, an injection into the joint with a steroid can be used as temporary pain relief. These treatments will be discussed with you by your doctor in the clinic you attend.
Surgery is also a possibility, but should only be considered after the treatments listed above have been tried and shown not to work for you.
What surgical options are available?
If you have reduced ankle movements but your joint does not look too arthritic, keyhole (arthroscopic) or open surgery can be done to clean up your ankle joint.
With advanced arthritis, your surgical options are either an ankle fusion (when the bones of your ankle are joined together) or an ankle replacement.
Ankle fusion
Ankle fusion is recommended for younger and more active patients, as the results are more predictable. Fusion can be performed either with keyhole or open surgery and involves the removal of any remaining cartilage and unhealthy bone from the joint surfaces. The incision(cut) for an open ankle fusion is on the front of your ankle. Once the bone surfaces are prepared, the surfaces are brought together and held in place with screws or a plate. In some cases, the joint below your ankle (subtalar joint) may also be arthritic and we may need to fuse the bones here as well. The incision for this procedure is often on the side of your ankle. We then pass a nail from the bottom of your heel across both joints into your shin bone(tibia) or a plate is applied across both joints.Ankle replacement
Unlike with ankle fusion, ankle replacement allows you to keep some movement in your ankle joint. Encouraging this movement means that you are not putting more stress on your other joints.
The decision about which surgery you will have will be made by you and your doctor together.
How long will I have to stay in hospital?
If you have keyhole surgery you normally go home the same day as your surgery. With fusion and replacement surgery you normally stay in hospital for at least one night.
Will the surgery hurt?
The surgery is normally done under general anaesthetic (you are asleep for the procedure). Sometimes a painkilling local anaesthetic is given as well to help with any pain. In addition, after surgery your doctors will give you some painkillers to help with any further pain.
Will I need further surgery?
Sometimes extra parts to the surgery may be needed but this depends on individual cases. Everyone's feet are different, so we need to treat them differently.
Also, your ankle replacement can unfortunately wear if it is used too much, and may need to be reviewed in the future. This can be a complicated procedure and your surgeon will discuss this with you before your surgery.
How will my ankle feel after surgery?
Your joint will feel stiffer but there will be no pain, and any limp you develop should be hardly noticeable. With an ankle replacement you should still have some ankle movement, which will not be the case with an ankle fusion procedure.
What happens after my surgery if I have had a bone spur removal?
If you have had a procedure to clean up the joint, your foot and ankle will be covered in a bandage and you will be given a surgical boot so you can walk. You will be given crutches for support - a member of staff will show you how to use these.
How do I look after my injury at home?
Keeping your ankle elevated (raised) as much as possible is important in the first few weeks after surgery.
Your bandages will be removed after two weeks and your dressings changed. You will be referred for physiotherapy once your wounds are fully healed. You can also go back to wearing comfortable shoes and consider returning to work once your wound is fully healed. Please discuss this with your surgeon at your follow-up appointment.
What happens after my surgery if I have had ankle fusion?
If you have had a fusion procedure your leg will be placed in a below-knee cast for two weeks. At two weeks your wound will be checked and a complete below-knee cast fitted for another four weeks.
For the first six weeks after your operation, no weight-bearing is allowed, and crutches will be supplied for support when moving around. When sitting, it is important to elevate (raise) the leg that has been operated on above your heart level, as much as possible. After six weeks a walking boot will be applied and walking in the boot will be allowed for six weeks. You will also be referred for physiotherapy to help with your healing.
With regards to you returning to work, this depends on the amount of weightbearing needed in your job. If you sit down a lot at work and you can keep your foot elevated, then you can return after six weeks following your operation. Otherwise you should expect to return to work after 12 weeks.
What happens after my surgery if I have had an ankle replacement?
For ankle replacements your leg will be placed in a below-knee cast for two weeks and you will not be allowed to put any weight on the affected limb. When sitting it is important to elevate (raise) the leg that has been operated on above your heart level as much as possible. After two weeks your wound will be checked and if it has healed your leg will be placed in a walking boot and full walking is then allowed.
Physiotherapy will also start at this stage. The walking boot will be needed for any activity where you will have to put weight on your ankle for approximately the next four weeks. After this stage you can begin to wear supportive shoes.
With regards to you returning to work, this depends on the amount of weightbearing needed for your job. If you sit down a lot at work and you can keep your foot elevated, then you can return after six weeks following your operation. Otherwise you should expect to return to work after 12 weeks.
When can I drive again?
This is a difficult question to answer. Your healthcare professionals are not able to take responsibility for this. You will need to check with your insurance company as to when they will be willing to insure you to drive again. It is important not to be in a cast or boot when driving, and you must be able to do an emergency stop safely before driving again.
What are the possible risks to having this surgery?
As with any surgery there are risks. Your surgeon will discuss these with you in more detail before your procedure. However, common complications of this type of surgery include the following.
You can expect swelling for up to 12 months, particularly in the evenings.
The position of your ankle and foot may not be satisfactory after fusion. Although this is rare it can be significant if it does happen and you may need further surgery.
Infection rates are low, and antibiotics are given before any surgical treatment begins. However, if infection does happen this can cause significant problems. If you get a skin infection, this can be managed with antibiotics. If there is a deep infection, it may be necessary to remove all the metalwork and unhealthy bone, combined with a long course of antibiotics. In the case of ankle replacements a repeat of the procedure may be necessary to correct the problem.
Nerve injury can result in numbness or tingling across your foot area. This is usually temporary, but in a small number of cases it may become permanent.
Non-union (when the bones do not join together successfully) can sometimes happen with fusion surgery. There is increased risk of this happening in smokers and it may result in pain if the metalwork then loosens. If you smoke we recommend that you stop before surgery and do not start again until the fusion has healed or, better still, quit altogether.
Although rare, metalwork can become noticeable through your skin and cause pain from irritation. If this continues the metalwork may need to be removed.
Complex Regional Pain Syndrome (CRPS) can develop when the nerves around the operation site become overly sensitive. Swelling, skin changes, and stiffness can happen and can be debilitating. This is rare but if it does happen it is usually managed by a specialist in pain management.
Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) is rare with this surgery. However anticoagulation medication is given after surgery to try to prevent clots forming whilst you are not able to move your leg. This is a preventative measure, but a clot can still form despite this.
Fracture can happen during an ankle replacement or just after surgery. If this is noticed during your procedure it will be fixed immediately. This complication rarely effects how your ankle will work in the future, but you may need to keep your weight off your affected limb for six weeks to allow it to heal fully.
Loosening of the ankle replacement components may be from infection or non-infection related causes. If infection is the reason for loosening, then treatment is as above. For non-infection loosening the management is dependent on the amount of healthy bone that is left. If there is enough bone, then another ankle replacement procedure can be considered. However, if there is not enough healthy bone remaining, then a fusion procedure would be performed.
If you have any concerns or questions about any of these risks, please discuss them with your doctor before your surgery.
What if I have any questions or concerns once I return home?
You can contact the team secretary through the hospital switchboard if you have any questions before your surgery.
After surgery you can call the team secretary, the ward, or your GP if you have any further concerns or questions. If you are concerned and cannot get in touch with anyone go to your nearest Emergency Department.