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Ankle replacement vs fusion

Discussion in 'Foot Surgery' started by Pod on sea, Jun 27, 2014.

  1. Pod on sea

    Pod on sea Active Member

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    Dear Colleagues,
    I have a 49 y/o female patient who suffered a medial malleolar fracture. She has significant pain in the ankle and as conservative measures (orthoses, footwear changes etc) failed to bring relief, I referred her to an Orthopaedic consultant for imaging and his opinion (I was thinking steroid injection). Turns out O.A. is extensive and he advises replacement or fusion, says she is a candidate for either. If she opts for replacement then future fusion is a possibility. The consultant is actually very conservative in his approach, and I tend to think that if he suggests surgery then it really is the only option.
    Aside from debating conservative measures, does anyone have any opinion based on experience? I have seen a fair few fusions (post op) but no post-op replacements.
    There are a few articles on google scholar, but none that I have access to, so if anyone has a PDF of anything that would be appreciated too.
    Many thanks
  2. Admin2

    Admin2 Administrator Staff Member

  3. Emma Cowley

    Emma Cowley Member

    Hi Helen
    I can offer you both personal and professional thoughts here. I suffered with post-traumatic ankle OA for years waiting for a decent total ankle arthroplasty (total ankle replacement or TAR) prosthesis to be developed and I really shouldn't have! I was forced to opt for arthrodesis at 37 in the end and an open one at that but it was a good decision. The thought of a short leg resulting from salvage arthrodesis is much worse than having a stiff ankle in the interim years. If successful, both surgeries will alleviate pain but the talus is a tiny bone to receive a prosthesis into and if the erosion of the talus is significant a salvage fusion will be trickier after even more bone has been taken to shape it for the prosthesis. It will also be likely to need salvage sooner.
    I'd suggest arthrodesis until TARs have better long term outcomes as your pt is young for TAR and will likely have to endure another anaesthetic and time off work for another big op in a few (poss only 5) years.
    My surgeon used bone hammers rather than saws bone so resorption was minimised and union achieved more easily as the bone was not cauterised. I had a tibial graft to improve stability of the fusion too and tbh the graft was the worst bit for post op pain.

    All in all, replacing the 2nd rocker with footwear works well with fusion and I am now 7 yrs post op with no complaints.
    Remember though, the mantra of ankle arthrodesis is 'thou shalt not varus'. Ensure the standing angle is accounted for in planning surgery ie tibial angle (from genu varum / valgum). I'm sure the surgeon will have all this in hand but the success of the surgery is dependent on factors like this. If your pt has significant genu varum, ensure they mention it to the surgeon and ask how they work out the angles. You'll love the answers...

    Hope this helps - I vote arthrodesis!
  4. Pod on sea

    Pod on sea Active Member

    Re: Ankle arthrodesis vs athroplasty and quality of life

    Thank you so much. This will keep me busy over the weekend. Much appreciated.
  5. Craig Payne

    Craig Payne Moderator


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