Ankle Surgery: Bone Fusion vs. Joint Replacement

Get the facts on two surgery alternatives for osteoarthritis.


The gold-standard surgery for treating bone-on-bone ankle pain has been ankle fusion or arthrodesis. Within the last decade, medical device companies have introduced artificial ankles that are designed to better mimic the natural movements of this complex joint, making joint replacement an increasingly popular choice.

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

But some 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.

Considering Ankle Fusion

Daniel, a 52-year-old electrician was considering total ankle replacement forty years after the injury to a shattered left ankle never healed properly. He was still relatively young and wary of getting a replacement joint that could 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 (the bone that makes up the lower part of the ankle joint). 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 fantastic 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.

Daniel says, “It is not worth suffering and putting it off. Find a good doctor, get it done and get on with your life.”  

Evaluating Joint Replacement

After years of playing basketball, football and Ultimate Frisbee, 50-year old, Craig’s 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.

Because Craig was relatively young and active, he wasn’t considered 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 artificial ankles on the market, four two-component models (Agility, Eclipse, IN-BONE and Talaris), and a three-component system (STAR), Craig chose the most durable of the two-component designs.

All promised 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,. “But it’s not the pain I had before the surgery.”

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