Bum Ankle: Fusion, Replacement or… Amputation?!

I was in a cycling accident and broke my leg in multiple places. After two surgeries my ankle is at end-stage degeneration. I’m 38, an ultra runner, upper-level equestrian and climber. Not the typical candidate for a fusion or replacement. The ankle is super stiff. My research on replacements isn’t turning up positive outcomes. I have started looking at amputation as an option. Do you agree?

—Melissa

That you have arrived at entertaining amputation as a real option tells me that a) you have been through the absolute wringer with this, and b) that you are refusing to lie down.

I assume you have had a physical therapist working on your ankle in an endeavor to improve its range of motion. That is a starting point and needs to be exhausted before you consider anything else. Also, sit on your ankle and bend it in every way it doesn’t want to go for at least 30 minutes a day. Read on when you have done a month of this!

Your options are three: a) fusion, b) ankle replacement or c), cut the foot off.

A complete fusion will provide an outcome similar to what you have now—a stiff ankle—sans joint pain. I will put the nerve pain aside, as it is a separate entity.

[Also Read Tom Herbert Sets New Speed Record on The Muir Wall, First Climbed by His Father in 1965]

Running is a bad idea, not because it will hurt your ankle (it’s essentially welded in a fixed position) but because the peculiar gait you’ll need to accommodate the ankle restriction will damage other joints, namely knees and hips. In general, I think riding will be the least affected by a fusion. Climbing? You’ll lose some reach, but heck, one of my friends has one eye and no hair, and he is a weapon.

At best an ankle replacement may buy you some time. In the family of joint replacements, the ankle is the problem child. A joint of considerable complexity and chronic impact load, an artificial ankle has almost guaranteed failure within a decade (or much less). If you sign up for this, you are resigning yourself to further surgeries (deliberately plural). Running on it, even slowly, will deliver you there at warp speed. Riding horses, as in jumping, where there is huge load at the toes, may transport you there instantly! Climbing will probably be better, albeit a brief improvement.

The arc of travel that brings you to amputation as an option is long, but only because it seems so radical in today’s medical environment of “Anything is possible.” Still, joint-replacement surgery, born nearly a hundred years ago, has yet to decipher the ankle conundrum.

While traveling in India with Klem Loskot many years ago, he laughed at my shaved head, and uttered a German phrase that meant “fleeing to the future.” Rather than go through the slow torture of balding like Friar Tuck, I opted to embrace the final outcome with a set of clippers.

Prosthetic limbs (above ankle) are pretty super duper these days and have a significant capacity to improve even further. Bear in mind that it’s possible you will end up at this point anyway, so fleeing to the future may just save you some pain. You will need task-driven adaptations but even running is well within a viable outcome.

Though amputation is not imminent, it entirely depends on the metric of functional outcome that you apply to your decision-making process over time. Certainly, an ankle replacement is temporary. A fusion will at least give you the cosmetic outcome of having a foot, as well as a broadly functional appendage. I would try a fusion before amputation.

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This article appeared in Rock and Ice issue 262 (March 2020).

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