It seems nearly everybody knows someone with an artificial knee or hip. Far fewer people know that ankles can also be replaced.   

If you've had a traumatic injury to the ankle, or suffer from ankle arthritis, total ankle replacement surgery—and the comprehensive rehabilitation that follows—are available from the experienced orthopaedic surgeons at Yale Medicine. 

Although ankle arthritis is similar to hip and knee arthritis in terms of symptoms (pain, swelling, and stiffness), it is less common and differs in other important ways.

“Most hip and knee arthritis is considered primary arthritis, which is normal wear and tear of the joint, whereas most ankle arthritis is caused after a trauma such as a fracture or a bad sprain that may have occurred even 10 to 20 years earlier,” explains Raymond Walls, MD, a Yale Medicine orthopaedic foot and ankle surgeon. “Plus, the cartilage in the ankle is thinner and slightly different in its makeup compared to cartilage in the knee or hip, which also partly explains why it doesn’t wear the same way.”

And unlike the hip and knee, the ankle is surrounded by several other joints in the foot that can compensate if the ankle is hurt and not moving properly. While this is helpful in some ways, it can be problematic in that it can mask significant deformities of the ankle, Dr. Walls says, further adding to the value in seeking care from a foot and ankle specialist.  

The main symptoms are of pain, swelling and stiffness. The pain, which can be debilitating, typically starts either first thing in the morning or after sitting for a period of time.

Researchers have ranked pain from ankle arthritis as being more severe than what people experience during a heart attack or with advanced hip arthritis. Given that all of a patient’s weight goes through a relatively small joint, the necessary stability and support required for balance, walking, and running is affected and in severe cases, even standing can be a problem.  

Ankle arthritis is a fairly straightforward and easy diagnosis for doctors to make.

It is based on the patient’s description of symptoms and medical history, a physical exam, and relevant imaging studies. Usually only an X-ray is necessary; however, higher level imaging such as a CT scan or magnetic resonance imaging (MRI) may show evidence of a previous ligament injury or fracture and eroded cartilage within the joint.

“Patients often think the problem is the ankle joint, but sometimes, it may be a problem with one or more of the adjacent joints, so it’s important to obtain a solid history from patients, perform a thorough examination and then usually an X-ray is sufficient,” Dr. Walls says.

Surgery is the last resort, Dr. Walls says. Conservative treatments, including wearing an ankle support brace, image-guided cortisone injections (which can last up to six months), weight loss, and physical therapy are effective for most patients especially in those with mild to moderate stages of disease, he adds.

“There are different levels of severity and for some people, taking anti-inflammatories and wearing a shoe that has a curve at the bottom, which we call a rocker sole, can make a big difference and take a lot of stress off the ankle,” Dr. Walls says. “In some cases, even a simple orthotic that can correct a misalignment can be very effective. There are a variety of braces with different degrees of rigidity that provide support, effectively relieving pain.”  

But if conservative measures fail, there are two main options: ankle fusion or a total ankle replacement. Although ankle fusion, long the gold standard of treatment, resolves pain, it will immobilize the joint. Patients can walk but will lose some flexibility in the ankle after a fusion.

“The neighboring joints in the hindfoot have to work harder to compensate for the loss of ankle motion. This can actually work very well in the short-term but long-term, it puts more stress on those joints and they may in turn develop arthritis,” Dr. Walls says. “The advantage of a total ankle replacement is that it preserves normal motion and walking patterns which prevents excessive stress on the adjacent joints.”

With input from Yale Medicine Orthopedics & Rehabilitation, the ankle prosthetic (total ankle replacement) has been improved to the point where we are hopeful it will last 15 to 20 years.

Patients are typically in the hospital for one or two nights, primarily to receive pain relief via a nerve block, although increasingly we are doing this as outpatient surgery where patients will some go home the day of the surgery.

Ankle replacement patients are placed into a splint/cast postoperatively and use a wheeled device called a knee walker for the first four weeks. This is to give time for the swelling to settle after surgery, allow the wound to fully heal and allow the bone to grow into the implant. 

After that, patients begin to learn to walk on the new joint with progressive weight-bearing and physical therapy that typically lasts three months. There are few activity restrictions once they have healed and are generally similar to hip and knee replacement precautions.

Yale Medicine Orthopedics & Rehabilitation has been highly involved in pioneering new techniques and materials to improve total ankle replacements.

“More total ankle replacements have been done at Yale than any other institution in Connecticut and we receive referrals throughout the state and country,” says Dr. Walls. “Our surgeons tailor implants to the patient by using 3-D modeling techniques to make patient specific guides which can improve implant alignment and in turn long-term success.”

But Dr. Walls stresses the value of finding an orthopedic foot and ankle surgeon who will walk you through the available options for treating ankle arthritis as not all foot and ankle specialists are trained in all techniques. “Surgery is the last step in the process, and only considered after we have exhausted all other options,” he says. “And at that point, we would thoroughly discuss surgical options, be it a fusion or total ankle replacement.”