Ankle Arthrodesis After Failed Total Ankle Replacement
While ankle fusion has long been considered the standard treatment for ankle arthritis, advancements in total ankle replacement (TAR) are offering new options for patients. TAR procedures have improved over time with better surgical techniques and implant designs, leading to an increase in their popularity. In the United States, the number of TAR surgeries has grown significantly over the years.
However, it’s important to note that as more TAR surgeries are performed, the rate of complications has also risen. Complications can vary widely, ranging from minor issues to more serious problems like implant fracture, infection, technical errors, implant shifting, dislocation, wound complications, and others. These complications can occur in anywhere from 1.3% to 50% of cases.
In cases where a TAR cannot be revised or salvaged, alternative options include ankle fusion (tibiotalar arthrodesis), fusion involving the ankle and heel bone (tibiotalocalcaneal arthrodesis), or in extreme cases, amputation. It’s essential for patients to discuss the potential risks and benefits of TAR surgery thoroughly with their orthopedic surgeon to make informed decisions about their treatment options.
Ensuring there’s enough healthy bone in the ankle is crucial for successful fusion after a total ankle replacement (TAR) surgery. Depending on the amount of remaining bone, different bone grafting techniques may be recommended. If the bone stock in the talus (the bone in the ankle) is greater or less than 2 cm, there are specific strategies to consider.
For small bone defects (<2 cm) where limb length shortening isn’t a concern, a fusion procedure can be done in place, with the option of adding graft material from nearby bones or the hip. It’s important to watch out for any impingement between the bones during fusion. If the bone defect is larger than 2 cm, a fusion using structural grafts is preferred. This method not only provides stability but also helps maintain proper limb length and keeps ankle muscles and tendons working effectively.
Structural graft options may include bone from the hip (iliac crest), the femur, or the lower leg (distal tibia). If there’s arthritis in the subtalar joint or the talus has collapsed due to bone death (osteonecrosis), a fusion involving the ankle and heel bones may be necessary. Your orthopedic surgeon will determine the best approach based on your specific condition and needs.
How Common It Is and Who Gets It? (Epidemiology)
TAR is an increasingly common procedure used to treat end-stage ankle arthritis. The procedure is typically recommended for individuals who suffer from severe arthritis or joint degeneration in the ankle, and where conservative treatments have not provided sufficient relief. The growing success of TAR has contributed to its rising popularity, though complications still occur in a minority of cases.
Why It Happens – Causes (Etiology and Pathophysiology)
Ankle arthritis can develop due to:
- Osteoarthritis (OA): Age-related wear and tear on the ankle joint.
- Trauma: Injury to the ankle joint, such as fractures, can lead to arthritis.
- Infections: Joint infections can lead to long-term damage and arthritis.
- Inflammatory conditions: Conditions like rheumatoid arthritis or gout can cause arthritis.
- Failed previous surgeries: Previous surgeries, such as a failed TAR or fusion, can lead to complications and the need for revision surgery.
How the Body Part Normally Works? (Relevant Anatomy)
The ankle joint, which connects the tibia and fibula to the talus, allows for up-and-down movement necessary for walking, running, and jumping. In arthritis, the cartilage in the joint wears down, leading to painful bone-on-bone contact and limited mobility. In TAR, the damaged joint is replaced with an artificial implant, while in fusion surgery, the bones of the ankle are fused together to provide stability and reduce pain.
What You Might Feel – Symptoms (Clinical Presentation)
Patients with ankle arthritis often report:
- Pain in the ankle that worsens with activity or prolonged standing
- Stiffness and limited range of motion in the ankle
- Swelling or tenderness in the joint
- Difficulty walking or bearing weight on the affected foot
In severe cases, the pain may become constant, and conservative treatments may no longer provide relief.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis of ankle arthritis is confirmed through:
- X-rays: To assess joint space narrowing, bone spurs, and signs of degeneration.
- MRI: To evaluate soft tissue damage and cartilage loss in the joint.
- CT scans: For detailed imaging, especially in cases where joint deformity is suspected.
Classification
TAR can be classified based on the extent of the joint damage:
- Primary Ankle Arthritis: The joint degenerates due to aging or injury without any other underlying systemic condition.
- Post-Traumatic Arthritis: Arthritis resulting from previous ankle fractures or injuries.
- Inflammatory Arthritis: Conditions like rheumatoid arthritis or gout causing joint degeneration.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that may mimic ankle arthritis include:
- Achilles tendinopathy: Pain in the Achilles tendon that can radiate to the ankle.
- Tendonitis: Inflammation of the tendons around the ankle.
- Subtalar arthritis: Degeneration of the subtalar joint, which can cause pain similar to ankle arthritis.
Advanced imaging helps differentiate these conditions from true ankle arthritis and guide appropriate treatment.
Treatment Options
Non-Surgical Care
- Physical therapy: To improve mobility, strength, and reduce pain.
- Orthotics: Shoe inserts to provide cushioning and support to the affected joint.
- Medications: NSAIDs to control pain and inflammation.
- Injections: Corticosteroid injections to reduce inflammation and pain.
Surgical Care
- Total Ankle Replacement (TAR): A surgical procedure where the damaged ankle joint is replaced with an artificial implant.
- Ankle Fusion: A procedure in which the bones of the ankle are fused to provide pain relief and joint stability.
- Tibiotalocalcaneal (TTC) Fusion: In cases of severe arthritis, fusion of the ankle and heel bones may be necessary.
Recovery and What to Expect After Surgery (Recovery Process)
After TAR surgery, patients typically need to follow a rehabilitation plan that includes:
- Wearing a protective boot or cast: To stabilize the joint during the initial healing phase.
- Physical therapy: Focused on restoring ankle strength, range of motion, and improving mobility.
- Gradual weightbearing: Initially, patients are restricted from weightbearing, but can begin partial weightbearing after a few weeks.
Possible Risks or Side Effects (Complications)
As with any surgery, TAR carries risks, including:
- Infection: In rare cases, infection can develop at the surgical site.
- Implant failure: The artificial joint may fracture or shift over time.
- Dislocation: The implant may dislocate, causing pain and instability.
- Wound complications: The wound may become infected or fail to heal properly.
Prognosis (Long-Term Outlook)
Most patients experience pain relief and improved joint mobility after TAR. However, complications such as implant failure or infection can occur in a small percentage of patients. In general, TAR is considered successful in improving quality of life and reducing pain for patients with advanced ankle arthritis.
Out-of-Pocket Costs
Medicare
CPT Code 27702 – Total Ankle Replacement (TAR): $226.36
CPT Code 27870 – Fusion Salvage Procedure After TAR Failure (Ankle Fusion): $236.43
Medicare Part B covers 80% of the approved cost for these procedures once your annual deductible has been met. The remaining 20% is typically the patient’s responsibility; however, most individuals with Supplemental Insurance, such as Medigap, AARP, or Blue Cross Blue Shield, will have this portion covered. These supplemental plans are designed to work with Medicare, ensuring that your out-of-pocket expenses are minimized or eliminated for Medicare-approved procedures.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it will act as a secondary payer after Medicare. These plans usually cover any remaining costs, including coinsurance or small deductibles, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your Total Ankle Replacement (TAR) or fusion salvage procedure is related to a work injury, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and follow-up care. You will have no out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved treatments.
No-Fault Insurance
If your ankle injury and resulting surgeries are due to an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including the Total Ankle Replacement and salvage fusion procedure. The only potential out-of-pocket cost may be a small deductible or co-payment, depending on the terms of your policy.
Example
Carlos Ramirez required Total Ankle Replacement (CPT 27702) due to severe arthritis and later needed a fusion salvage procedure after the TAR failed (CPT 27870). His estimated Medicare out-of-pocket cost for the TAR was $226.36. Since Carlos had supplemental insurance through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for both procedures.
Frequently Asked Questions (FAQ)
How soon can I walk after TAR?
Patients typically begin partial weightbearing after 6–8 weeks, with full weightbearing possible after 12 weeks.
Will I have scars?
Scarring is minimal with minimally invasive techniques, but open procedures may leave more visible scars.
Can I return to sports?
Most patients return to light activities within 6 months. High-impact activities may take up to 12 months.
Is TAR the best treatment for all ankle arthritis?
TAR is suitable for patients with advanced arthritis who have not found relief from conservative treatments.
Summary and Takeaway
TAR offers significant benefits for patients with advanced ankle arthritis, providing pain relief and improved mobility. However, like all surgeries, TAR carries risks, including complications such as infection, implant failure, or dislocation. In some cases, ankle fusion may be considered as a salvage procedure if TAR fails.
Clinical Insight & Recent Findings
A recent multicenter study from Japan examined how well the Forgotten Joint Score-12 (FJS-12)—a questionnaire designed to measure whether patients can “forget” their operated joint in daily life—works for those who had either total ankle replacement (TAR) or ankle fusion (arthrodesis).
The study followed 115 patients and found that the FJS-12 is both reliable and valid in this group, showing strong consistency and good correlation with other ankle-specific quality-of-life measures. Importantly, it could distinguish between patients with good and excellent outcomes, without showing “floor” or “ceiling” effects that often limit other tools.
These findings suggest the FJS-12 can be a practical way to assess patient recovery and satisfaction after surgery for end-stage ankle arthritis. (“Study on a simple survey to measure ankle surgery success – see PubMed”)
Who Performs This Surgery? (Specialists and Team Involved)
TAR is typically performed by orthopedic surgeons specializing in foot and ankle surgery. The surgical team also includes anesthesiologists, nurses, and physical therapists to assist in all phases of care.
When to See a Specialist?
You should see a foot and ankle specialist if you experience significant pain, swelling, or limited mobility due to arthritis in the ankle joint. If conservative treatments have not provided relief, surgery may be considered.
When to Go to the Emergency Room?
Seek emergency care if you experience sudden severe pain, swelling, or instability in the ankle after surgery. This could indicate a complication such as infection or implant failure.
What Recovery Really Looks Like?
Recovery varies, but most patients can return to light activities within 6 months. Full recovery, including return to high-impact activities, typically occurs within 12 months.
What Happens If You Delay Surgery?
Delaying surgery can lead to worsening arthritis, increased pain, and limited mobility. Early intervention helps improve outcomes and reduce the risk of complications.
How to Prevent Recurrence or Failure?
To prevent complications, follow all post-surgical instructions, wear the recommended footwear, and engage in physical therapy to support healing and mobility.
Nutrition and Bone or Joint Health
A diet rich in protein, calcium, vitamin D, and omega-3 fatty acids supports bone and joint healing after surgery. Maintaining overall health is key to a successful recovery.
Activity and Lifestyle Modifications
Engage in low-impact exercises such as swimming or cycling during recovery. Avoid high-impact activities until cleared by your surgeon. Regular stretching and strengthening exercises will help maintain joint health.
Do you have more questions?
What are the common causes of failed total ankle replacement (TAR)?
Common causes of failed total ankle replacement (TAR) include implant loosening, component wear, infection, instability, malalignment, and bone loss.
How is the decision made to proceed with ankle arthrodesis after failed TAR?
The decision to proceed with ankle arthrodesis after failed TAR is based on factors such as the extent of implant failure, patient symptoms, functional limitations, and surgical candidacy.
What are the goals of ankle arthrodesis following failed TAR?
The goals of ankle arthrodesis following failed TAR include pain relief, restoration of stability, improvement in function, and prevention of further joint deterioration.
What are the different surgical techniques used for ankle arthrodesis?
Different surgical techniques for ankle arthrodesis include open fusion, arthroscopic fusion, and minimally invasive fusion procedures using screws, plates, or intramedullary devices.
How is bone fusion achieved during ankle arthrodesis?
Bone fusion during ankle arthrodesis is achieved by removing any remaining cartilage from the joint surfaces, compressing the bones together, and securing them in the desired position until new bone growth occurs across the joint.
What is the typical recovery process after ankle arthrodesis?
The typical recovery process after ankle arthrodesis involves immobilization in a cast or brace for several weeks, followed by gradual weight-bearing and physical therapy to regain strength, mobility, and function.
What are the potential complications of ankle arthrodesis?
Potential complications of ankle arthrodesis include nonunion (failure of bone fusion), malunion (improper alignment of fused bones), infection, nerve injury, stiffness, and arthritis in adjacent joints.
Can ankle arthrodesis be performed as a revision procedure after previous failed fusion attempts?
Yes, ankle arthrodesis can be performed as a revision procedure after previous failed fusion attempts, but the success rate may vary depending on the underlying cause of failure and the condition of surrounding soft tissues.
How does ankle arthrodesis compare to other salvage procedures for failed TAR?
Ankle arthrodesis is one of the salvage procedures for failed TAR, with the goal of providing pain relief and functional improvement, but comparisons with other salvage options such as revision TAR or ankle arthroplasty revisions depend on individual patient factors and surgical outcomes.
Can ankle arthrodesis be performed using minimally invasive techniques?
Yes, ankle arthrodesis can be performed using minimally invasive techniques, such as arthroscopy or percutaneous fusion methods, which may offer advantages such as smaller incisions, reduced soft tissue trauma, and faster recovery times.
How long does it take for bone fusion to occur after ankle arthrodesis?
Bone fusion after ankle arthrodesis typically takes several months to complete, with the timing varying depending on factors such as patient age, bone quality, surgical technique, and post-operative rehabilitation.
What is the expected prognosis and long-term outcomes after ankle arthrodesis following failed TAR?
The expected prognosis and long-term outcomes after ankle arthrodesis following failed TAR depend on factors such as patient age, activity level, severity of joint degeneration, surgical technique, and rehabilitation compliance.
Are there any alternative treatments or procedures for failed TAR besides ankle arthrodesis?
Yes, alternative treatments or procedures for failed TAR may include revision TAR, ankle arthroplasty revisions with different implant designs, or salvage options such as ankle distraction arthroplasty or arthroscopic debridement, depending on the specific circumstances and patient preferences.
How does the presence of underlying conditions such as arthritis or osteoporosis affect the success of ankle arthrodesis?
The presence of underlying conditions such as arthritis or osteoporosis may affect the success of ankle arthrodesis by influencing bone quality, healing capacity, and the risk of complications such as nonunion or implant failure.
Can ankle arthrodesis be performed bilaterally if both ankles have failed TAR?
Yes, ankle arthrodesis can be performed bilaterally if both ankles have failed TAR, but careful consideration of patient factors, functional goals, and potential risks is necessary to ensure optimal outcomes and rehabilitation.
What is the role of physical therapy in the recovery process after ankle arthrodesis?
Physical therapy plays a crucial role in the recovery process after ankle arthrodesis by helping restore strength, mobility, and function, as well as improving gait mechanics and balance to optimize patient outcomes.
Are there any age limitations for undergoing ankle arthrodesis after failed TAR?
There are typically no strict age limitations for undergoing ankle arthrodesis after failed TAR, as long as patients are medically fit for surgery and have realistic expectations regarding the procedure’s goals and outcomes.
Can ankle arthrodesis be performed in patients with previous ankle surgeries or implants besides TAR?
Yes, ankle arthrodesis can be performed in patients with previous ankle surgeries or implants besides TAR, but the presence of hardware or bone alterations from prior procedures may pose challenges and require individualized surgical planning.
Dr. Mo Athar
