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Arthritis Today

Ankle Surgery: Bone Fusion vs. Joint Replacement

Get the facts on two surgery alternatives for osteoarthritis.

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Ask a doctor what you should do about a hip or knee that’s been ground down by arthritis, and he’s likely to suggest joint replacement surgery. But when the joint in question is an ankle, the answers aren’t as clear-cut.

The longtime gold-standard surgery for treating bone-on-bone ankle pain has been ankle fusion, or arthrodesis.

But within the last decade, medical device companies have introduced a new generation of artificial ankles that are designed to better mimic the natural movements of this complex joint, making replacement an increasingly popular choice.

Industry estimates predict some 4,400 people in the U.S. will have ankle replacement surgery this year.

In March 2010, in fact, the American College of Foot and Ankle Surgeons gave these newer devices a vote of confidence, saying the safety profile of ankle replacements has become comparable to that of ankle fusion.

But early studies suggest that ankle replacements may wear out relatively quickly, leading to more complicated and perhaps riskier second surgeries within just a few years.

How do you know which option is best? Here’s how two patients weighed the pros and cons.

The Fusion Fix

Daniel Ward’s troubles began when he shattered his left ankle during a high-school football game. The injury never healed properly, and some four decades later, Daniel, a 52-year-old electrician in Alvarado, Texas, says the pain was so bad that he had to take frequent rest breaks just to cross the parking lot at the General Motors plant where he works.

Daniel is considering total ankle replacement, but because he is still relatively young he was wary of getting a replacement joint that would wear out quickly, leading to the need for more surgery.

Because Daniel is a bit bow-legged, his doctor, James Brodsky, MD, an orthopaedic surgeon in Dallas, advised against ankle replacement.

In fusions, surgeons use pins, screws, plates and bone grafts to permanently joint the tibia, or shinbone, to the talus bone in the ankle. The procedure eliminates pain by stopping bone-on-bone grinding at the expense of some mobility. But it doesn’t cause the Frankenstein lurch that some people fear.

“People can have fantastical functional results from fusions,” Dr. Brodsky says. “While it sounds terrible, it just stiffens the one bad joint – which is probably very stiff already – while leaving the surrounding joints flexible. The majority of people with fusions do not limp.”

Other activities are limited. Daniel says going up and down stairs, for example, requires him to step sideways.

The major advantage of an ankle fusion is that it should last a lifetime. But fusions also change the mechanics of the foot, increasing the likelihood that arthritis will strike some of the 30-plus adjacent joints.

For now, Daniel says his only regret is that he didn’t have surgery sooner: “It is not worth suffering and putting it off,” he says. Find a good doctor, get it done and get on with your life.”  

Right for Replacement

Years of rolling his foot while playing basketball, football and Ultimate Frisbee finally caught up with Craig Homenko Rockville, Md. When he was 50, X-rays showed that the cartilage in his left ankle was nearly gone, causing excruciating pain.

When medications and braces no longer offered relief, Craig decided he could either stew about it from a chair or have surgery.

Like Ward, because Craig was relatively young and active, he wasn’t considered to be a good candidate for ankle replacement. Active people are usually counseled against replacement, because higher levels of activity are thought to wear out replacement joints more quickly.

At 250 pounds, his weight was also a strike against him. More weight puts more stress on artificial joints, leading to early failures.

But being an active dad was important to Craig, and he knew an ankle fusion would put him on the sidelines for a lot of favorite family pursuits.

After researching the five different artificial ankles on the market, four two-component models (Agility, Eclipse, IN-BONE and Talaris), and a newer three-component system (STAR), Craig chose the most durable of the two-component designs.

All promise better functional results than ankle fusions, and at least in this respect, studies show that they deliver.

But when durability is a concern, an ankle replacement may not be the right option. A 2010 study of ankle replacements in Finland over more than 20 years found that nearly one in five replacements failed within five years, usually because of loosening of the components or instability.

Newer designs may be more durable.

 “We think they will last longer than in the past, but it’s too soon early to tell,” says Charles L. Saltzman, MD, Chairman of the Department of Orthopaedic Surgery at the University of Utah in Salt Lake City.

Although Craig knows he’ll probably have to have surgery again when the components wear out, he’s pleased with his choice.

 “There’s some soreness, which I was told will last a year,” says Homenko, who had surgery more than six months ago. “But it’s not the pain I had before. It’s great to be able to jog again.”

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