I fractured my talus and have looked into the worst-case scenario—the death of the talus bone. My surgeon said if this happened, the best option would be an ankle fusion. I respect his surgical skills, but the more I talk to people, the more I conclude that he’s dead wrong. I haven’t heard anything good about ankle fusions and I’ve talked to two people who are happy with their ankle replacements. My PT said she would almost never recommend a fusion now that replacements are an option. Although a replacement is a new procedure, if you seek out the right specialist it sounds like you can have a good outcome. What do you think?
—TLBZLAND, Rock and Ice Forum
Dead wrong is, well, totally wrong. The two operations are not necessarily competitors for the best outcome.
Really, who would you listen to when it comes to the management of a tricky orthopedic situation? I understand you may have researched this, but your specialist
has spent years upon years learning and understanding the intricacies of surgical options. Google searches, trawling forums, or asking your friends
does not trump your specialist. If only it were that easy.
For starters, ankle replacement is usually contraindicated in patients with talus necrosis! Generally speaking, ankle replacement is for people over 50
with a debilitating form of joint disease such as rheumatoid arthritis, but with otherwise strong and healthy bones. You may also not realize that
roughly a quarter of these replacements are failing within 10 years and over half have significant
complications, considerably higher than for ankle fusion.
By the time a joint becomes a candidate for fusion (arthrodesis), the range of motion is gone or extremely reduced anyway. This operation is not a fix,
but an attempt at pain reduction and improved function, and may end up being an intermediate step to ankle replacement if you are too young or don’t
immediately fit the profile for a replacement.
Although most people will assume that an ankle replacement will allow greater range of motion (ROM) compared with an ankle fusion, there is only a marginal
difference between the two and enhanced ROM is not considered an expected upside.
Joint replacement surgery is rarely undertaken in a young patient (i.e. under 50). The prosthetic unit has a lifespan and will eventually fail—either
within the hardware or at the point where the prosthetic joins to your tissue.
I am not an expert on ankle replacements, but I would bet that aggressive replacements are more prone to failure and subsequent replacements become increasingly
unsustainable. Each time a prosthetic is replaced, a certain amount of tissue is resected. Maybe you can do it once, maybe even twice—but maybe
not at all.
My point is that arthrodesis is not second fiddle to ankle replacement. In certain situations it may be an alternative, but in others joint fusion remains
the best practice. Many factors dictate a surgical course of action.
Don’t get me wrong, spend all the time you feel necessary to research your options. Knowing what possibilities are available will keep your medicos on
their toes and help you understand what to expect.
This article was published in Rock and Ice No. 216 (February 2104).