All About Ankles

Stabilizing this delicate joint is easier than you think.

Alison Whittaker is a regular bionic woman: because she has suffered from rheumatoid arthritis since childhood, she’s had both her knee joints and one shoulder replaced.

Compared to those joint surgeries, her most recent operation to replace her ankle -- a total ankle replacement, known as total ankle arthroplasty (TAA), conducted by Duke foot and ankle surgeon, Mark Easley, MD -- was “a breeze,” she says. “The recovery was so quick, and I haven’t had any pain or any problems. It hasn’t bothered me even a little bit -- it’s actually kind of bizarre.”

Bizarre because, although TAA was first performed 30 years ago, its success to date has been limited. Technically speaking, ankle replacements are far more difficult than hip and knee replacement surgeries, says Duke surgeon James DeOrio, MD, a specialist in ankle replacement surgery. Because hips and knees have large amounts of bone, surgeons can move them around during surgery to see the area in which they’re working.

The ankle, however, must be replaced where it lies. “It’s like building a ship in a bottle,” says DeOrio. And the ankle’s small surfaces and compact environment are much less forgiving, so replacements will wear out quickly if they aren’t properly aligned.

Chief of orthopaedics James Nunley, MD, says that there’s been so much emphasis on ankle arthritis in the last 10 years that there is now a surge of new prosthetic designs to more accurately mimic the human ankle. Improved surgical techniques allow for more precise alignment, which is critical in ankle replacement. Some procedures can prevent the need for a total replacement altogether in some cases.

“Many people have heard that the only thing to do for ankle arthritis is to surgically fuse it,” Nunley says. “But there are now realignment operations, ligament reconstructions, operations to control instability, and other ways to treat the pain and avoid a fusion or a total joint operation -- for years or maybe forever.”

When to Make the Move

Joint replacement surgery -- be it for ankles, knees, hips, or shoulders -- is still a daunting option for many patients. When should ankle replacement be seriously considered?

“When the pain in your ankle significantly interferes with your daily activities and the things you love doing,” says DeOrio -- whether it’s golfing, dancing, or just going for walks. “That point is unique for each person.”

But Nunley cautions that patients should make the surgical step a cautious one. “If your doctor tells you that you need an ankle joint fusion, it would be well worth your while to get a second opinion. It might be the right answer, and it is the right answer for a number of people. But there are an awful lot of doctors who aren’t aware of the progress that’s been made in the treatment of ankle arthritis in the last 10 years.”

Likewise, says DeOrio, people who have been told that their ankle is “too bad” to treat with surgery should confirm that opinion with a specialist. “We’re now helping even people with serious deformities, who may not have been surgical candidates a few years ago.”

For patients such as Alison Whittaker, who plans to spend this Labor Day weekend at the coast, these advances mean she’ll be able to do something she hasn’t been able to do in years without intense pain -- walk barefoot in the sand.

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