Ankle Replacement
Let’s discuss ankle replacement surgery
Relieving ankle pain while preserving movement
Severe symptomatic ankle arthritis can gradually turn ordinary things such as walking the dog, playing golf, travelling, working or simply getting through the shops into a painful exercise.
When non-operative treatments are no longer giving enough relief, there are two main surgical options for advanced ankle arthritis: ankle fusion and total ankle replacement.
An ankle replacement aims to do something a fusion cannot: relieve the pain of an arthritic ankle while preserving movement through the joint.
Modern ankle replacements have changed considerably from the implants used several decades ago. Better implant design, improved imaging and instrumentation, and a better understanding of ankle alignment have made ankle replacement an increasingly important option for appropriately selected patients. I use a a system that enables minimal bone removal and also get my patients to have a CT scan protocol to help with accurate calculations even before the operation so that we can get 3D printing of patient-specific instrumentation to make placement of these ankle replacements extremely accurate.
What is an ankle replacement?
A total ankle replacement, also known as total ankle arthroplasty, replaces the worn surfaces of the ankle joint with artificial components.
The arthritic surfaces at the bottom of the tibia and the top of the talus are carefully removed. Metal components are positioned on each side of the joint, with a highly engineered polyethylene bearing between them.
The objective is not to create a completely normal ankle. Rather, it is to create a comfortable, stable and functional ankle that retains useful movement.
This is different from an ankle fusion, where the tibia and talus are permanently joined together and movement through the ankle joint is eliminated.
Who may benefit from an ankle replacement?
An ankle replacement is principally considered for people with advanced or end-stage ankle arthritis whose symptoms are significantly affecting their quality of life.
Common symptoms include:
pain with standing and walking
stiffness and loss of ankle movement
swelling around the ankle
difficulty walking on uneven ground
reduced walking distance
pain that increasingly limits work, travel, recreation or exercise
pain despite appropriate footwear, braces, medication, injections or other non-operative treatment.
Unlike hip and knee arthritis, ankle arthritis is very often the result of a previous injury (almost 70%). A significant ankle fracture, recurrent instability or an injury many years earlier may eventually lead to post-traumatic ankle arthritis.
Other causes include primary osteoarthritis, inflammatory arthritis (such as rheumatoid arthritis, psoriatic arthritis, -many more) and, less commonly, other disorders affecting the ankle joint.
Who is a good candidate?
There is no single age at which somebody becomes suitable for an ankle replacement.
The decision is based on the whole ankle and the whole patient, rather than age alone.
Factors I consider include:
the severity and location of the arthritis
how much pain and disability the ankle is causing
remaining ankle movement
alignment of the ankle, hindfoot and leg
ligament stability
bone quality
previous operations or fractures
the condition of the skin and soft tissues
circulation and nerve function
arthritis in the neighbouring joints
activity expectations
general health.
Historically, ankle replacement was mainly offered to older, relatively low-demand patients. -This has changed in my practice over the years. -That distinction is becoming less rigid. -Now we even have scientific evidence to back this up. A 2024 systematic review comparing younger and older patients did not find a statistically significant difference in implant survival -in terms of moderate term results, complications or reoperation according to age, although the authors emphasised that the available evidence remains limited. Moreover, my philosophy has changed over the years, thanks to the modern implants and techniques.
The important question is therefore usually not simply “Am I too young?” but “Is an ankle replacement the right operation for this particular ankle and person?”
When might ankle replacement not be appropriate?
There are circumstances where an ankle fusion or another procedure may be more appropriate.
Significant concerns include:
active or recent infection
severely impaired circulation
significant peripheral neuropathy or loss of protective sensation
very poor bone quality
major bone loss
severe instability that cannot be reconstructed
some forms of severe deformity
inadequate muscle control around the ankle.
Smoking, diabetes, obesity, previous surgery and significant deformity do not automatically exclude ankle replacement, but they can alter the risks and need to be considered individually.
Sometimes additional procedures may be required to correct alignment or balance the foot at the same time as the ankle replacement.
Ankle replacement or ankle fusion?
This is one of the most important discussions in ankle arthritis surgery.
Ankle fusion
Fusion is a well-established operation that can provide excellent pain relief. Once the joint has united, however, movement through the ankle joint itself is permanently lost. I still do many ankle fusions. Sometimes, in the future these ankle fusions can be taken down and converted to ankle replacements in people who fit the right circumstances.
Ankle replacement
Replacement also aims to relieve pain, but preserves movement at the ankle.
Maintaining ankle motion can be particularly attractive for patients who already have arthritis or stiffness in the joints around the ankle, as those neighbouring joints may otherwise have to compensate for a fused ankle.
Importantly, the scientific evidence does not support saying that one operation is universally better than the other.
There was a large multicentre TARVA randomised trial that compared ankle replacement with ankle fusion in 303 patients aged 50 to 85 years with end-stage ankle arthritis. Both groups experienced substantial improvement. At one year, the trial did not demonstrate a statistically significant advantage for ankle replacement over fusion in its primary walking and standing outcome.
That is why the choice needs to be individualised.
For one person, fusion may be the most reliable solution. For another, preserving ankle movement may provide an important functional advantage.
How successful is ankle replacement?
Modern ankle replacement can provide substantial improvements in pain, walking and day-to-day function.
When we have surgery we look for certainty. -There are only two things in life that’s certain, -death and taxes. Having said that, there have been studies as well as joint registries demonstrating that ankle replacements can last in general with an implant survivorship ranging from approximately 66% to 94%, -these include lots of different variables including types of replacements, the people who have them, and how and why they needed to be redone.
The objective is therefore not simply to put an implant into the ankle. It is to select the right patient, restore alignment and stability, position the components accurately and protect the replacement over the longer term.
What happens during the operation?
The operation is performed under anaesthesia.
An incision is made over the ankle and the arthritic joint is carefully exposed.
Using specialised instrumentation, the damaged surface of the tibia and talus is removed with precise bone cuts. Trial components are used to assess:
alignment
component size
ligament balance
stability
ankle movement.
The definitive metal components are then inserted with a polyethylene bearing (special robust plastic lining similar to that in hip and knee replacements) between them.
X-rays are used during the operation to check positioning and alignment.
If necessary, associated problems may also be addressed. Depending upon the individual ankle, this can include correction of deformity, ligament balancing, Achilles or calf lengthening, or procedures elsewhere in the foot.
For that reason, not every ankle replacement operation is exactly the same.
What happens after surgery?
Recovery needs to protect both the wound and the new ankle while allowing movement to return progressively.
The precise protocol depends on the patient, implant, bone quality, the condition of the soft tissues and whether any additional procedures were required.
My typical pathway usually includes:
The first couple of weeks
The ankle is protected in a moon boot straight up. -And I allow my patients to touch weightbear in the boot immediately.
Swelling is expected and elevation+++ is particularly important during this period. The level of the ankle above the level of the knee. Patients initially use crutches or another walking aid.
Around 2 weeks
The wound is assessed. -No need to remove sutures for me because I use dissolvable stitches.
Depending on the operation, patients may begin or progress weight bearing in a protective boot ( I allow my patients to walk at this stage) and commence gentle ankle movement.
Approximately 6 weeks
Further X-rays are usually obtained.
Walking can progressively increase, and patients may begin transitioning out of the boot when clinically and radiographically appropriate.
6 to 12 weeks
Walking becomes increasingly natural and physiotherapy may focus on:
ankle movement
gait
strength
balance
swelling control.
3 to 6 months
Most patients are functioning much more comfortably, although swelling can continue for several months.
6 to 12 months
The ankle can continue improving throughout the first year.
Recovery should be thought of as a gradual progression rather than a race. Protecting the wound and allowing the tissues to settle during the early weeks is particularly important.
Will I be able to exercise after an ankle replacement?
The purpose of ankle replacement is to help people become active again.
Activities such as:
walking
hiking
cycling
swimming
golf
gym-based exercise
are often realistic goals following successful rehabilitation.
Repeated high-impact loading is a different question.
Running, jumping and other high-impact activities subject the components to substantially greater forces and may not be advisable as regular long-term activities after ankle replacement.
Your desired activities should therefore form part of the decision before surgery.
Could ankle replacement become day surgery?
Possibly, and for carefully selected patients, it can be.
Traditionally, patients undergoing ankle replacement remain in hospital at least overnight. This allows monitoring of pain, mobility, wound condition and general recovery.
However, advances in:
regional anaesthesia
multimodal pain relief
modern surgical techniques
early mobilisation
physiotherapy
patient education
structured discharge pathways
are making same-day discharge after ankle replacement increasingly possible for selected patients.
Potential candidates would generally need:
good overall health
a relatively straightforward ankle replacement
effective pain control
safe mobility using crutches or another walking aid
appropriate support at home
no concerning wound or anaesthetic issues
easy access to help if a problem develops.
Patients with more complex reconstruction, significant medical conditions, difficult pain control or limited support at home may be better served by staying overnight or longer.
My priority is a safe and comfortable recovery, rather than simply getting you home as quickly as possible. If you do need to spend a little longer in our “chateau” (hospital), then it is time well spent.
What are the risks?
All significant surgery carries risk.
Specific risks associated with ankle replacement include (but are not limited to):
infection
wound-healing problems
nerve irritation or numbness
bleeding
blood clots
fracture
stiffness
persistent pain
malalignment
instability
abnormal bone formation
wear of the polyethylene
cyst formation around the implant
loosening or subsidence of the components
further surgery
revision or removal of the ankle replacement.
Ankle replacement surgery deserves particular respect for the soft tissues at the front of the ankle. In the TARVA trial, wound-healing problems were more common following ankle replacement than fusion.
Good patient selection, careful surgery and attentive postoperative wound management are therefore extremely important.
What if an ankle replacement wears out in the future?
An ankle replacement can sometimes be revised.
Depending on the problem, treatment might involve replacing one component, exchanging the polyethylene bearing, bone grafting areas of bone loss, or performing a revision ankle replacement.
In other circumstances it may be appropriate to remove the replacement and convert the ankle to a fusion.
Revision surgery is considerably more complex than the original operation, which is another reason why the decision to undergo ankle replacement deserves thoughtful planning from the beginning.
Preserving movement. Relieving pain. Keeping people on their feet.
Ankle replacement has evolved substantially.
For the right patient, it offers the opportunity to relieve the pain of advanced ankle arthritis without sacrificing movement through the ankle joint.
But it is not the right operation for every painful ankle.
The most important part of the process is therefore deciding whether your symptoms, alignment, bone quality, neighbouring joints, lifestyle and expectations make replacement the right option for you.
A consultation usually includes examination of the entire lower limb and weight-bearing X-rays. CT imaging or other investigations may sometimes be helpful for surgical planning.
From there, we can consider the full range of options, including continued non-operative treatment, joint-preserving procedures, ankle fusion and total ankle replacement, and work out which approach best suits your ankle and the way you want to live.
Considering an ankle replacement?
If ankle arthritis is beginning to dictate how far you walk, where you travel or what activities you can enjoy, it may be worthwhile having it assessed.
Book a consultation to discuss whether joint-preserving treatment, ankle fusion or total ankle replacement may be appropriate for you.
The information on this page is general information and does not replace individual medical assessment or advice.
Selected scientific evidence
Goldberg AJ et al. Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial. Annals of Internal Medicine. 2022.
St Mart JP et al. Contemporary modern total ankle arthroplasty: A systematic review and meta-analysis of indications, survivorship and complication rates. The Surgeon. 2024.
Long-term Outcomes After Total Ankle Arthroplasty: A Systematic Review. 2024. American Orthopedic Foot and Ankle Society Journal.
Kipp JA et al. Age Influence on Total Ankle Arthroplasty Outcomes: A Systematic Review. Journal of Foot & Ankle Surgery. 2024.
The Safety Profile of Same-Day Outpatient Total Ankle Arthroplasty. Journal of Foot & Ankle Surgery. 2021.