By LAURA LANDRO
Replacing hips and knees has become a common affair. Now, people are increasingly swapping out weakened or injured ankles to get back on their feet.
Ankle replacement is an alternative to the more common fix, ankle fusion restoring more range of motion and flexibility. Newer artificial joints can include parts such as mobile bearings that make moving up and down on an incline easier. That helps patients climb stairs, hike, or ski, without putting undue stress on adjacent joints.
First introduced in the 1970s, ankle-replacement devices often failed, with high rates of infection and complications. They sometimes loosened after three to five years. Newer models are more durable, though they will generally have to be replaced again in 10 to 15 years. More insurers are covering the procedures, which can cost upward of $40,000 including hospital charges.
“The results with new implants are more predictable and outcomes far better than a decade ago,” says Mark Myerson, medical director of the Institute for Foot and Ankle Reconstruction at Mercy Medical Center in Baltimore.
Due to injury, repetitive stress, diseases including rheumatoid arthritis or just simple aging, ankles can suffer degenerative changes that can make walking, exercise and climbing stairs painful. As cartilage in the ankles wears away, bones are left rubbing against bones in a condition known as end-stage ankle arthritis, of which there are an estimated 50,000 new cases annually.
Many patients opt for nonsurgical treatments including taking anti-inflammatory medicines, steroid injections, doing physical therapy and using braces. But, when those no longer work, patients are often faced with a choice of either fusion or replacement, two radically different procedures.
Fusion uses screws and plates to fuse the joint into one continuous bone, sometimes using a piece of bone from elsewhere in the body. Though fusion relieves pain, it also dramatically limits the ankle’s motion.
The newer replacements also help younger patients who were athletic and active in their teens and 20s and now find that repetitive injuries have led to early arthritis. While in the past, candidates were usually over 50 and sedentary, “there are now patients in their 40s who are good candidates for ankle replacement, who can continue with their active lifestyle,” Dr. Myerson says.
Steven Haddad, former president of the American Orthopaedic Foot andAnkle Society and senior attending surgeon at the Illinois Bone and Joint Institute in Glenview, Ill., says older patients who want a permanent solution and to avoid more surgeries may still opt for ankle fusion. But he also warns that could strain other parts of the foot, which in turn may require fusion of adjacent joints.
For younger patients who want better function, and are willing to accept a repeat surgery in a decade so, he will perform a replacement. Dr. Haddad acts a consultant to ankle replacement device maker Wright Medical Group Inc. but says it doesn’t influence his choice of devices.
Kurt Hansen, 51, fell off a ladder in the summer of 2011 while trimming trees, severely fracturing his right ankle. He had two surgeries immediately to stabilize the bones and allow the foot to heal, but says that even after recovering three months later, he was always in pain unless lying down with his foot elevated. He had a third surgery in January 2013 to remove some screws and plates and consulted with Dr. Haddad about fusing or replacing his ankle as the next step.
A sales and marketing executive for student loan company Sallie Mae Inc., he often travels. With five children between the ages of 14 and 20, he wanted to be as active as possible. He opted for the replacement in September 2013, and was in the hospital for three days.
“I knew immediately it was the right choice,” Mr. Hansen says. “I was in no pain by the time I left the hospital and stopped taking pain meds within three days of the procedure.”
After three months of physical therapy he resumed many activities, continuing to improve each month, and now feels he is 90% back to where he was before his accident, he says. “I’ve resumed my active life of playing ball, hiking, sailing and even ice skating,” he says. Recently he climbed the summit of the Chimney Tops in the Smoky Mountain National Park, a strenuous four-mile hike. “There was no way I could have made this trip a year ago,” he says.
Data on the number of both types of ankle surgeries are scant, but a study in the journal Foot and Ankle International last December estimated that 26% of all ankle surgeries were replacements in 2010, up from 13% in 2007.
Todd Green, director of product management for Stryker Corp.’s Star ankle, the first three-part ankle replacement device approved in the U.S. says the global market for total replacement has grown 15% to 20% annually for the last several years, with a projected 16,000 procedures completed in 2014. By contrast, there are now about 80,000 ankle fusions performed annually. Mr. Green expects the number of fusions performed to continue declining.
Jonathan Deland, co-chief of the foot and ankle service at New York’s Hospital for Special Surgery, says there aren’t enough long-term studies yet to determine a clear winner among ankle devices. Dr. Deland worked on the design of a new ankle replacement model by device maker Zimmer Inc., and says he prefers to use it because its design is more like a natural ankle, with curved rather than flat parts that help dissipate the body’s weight load and make the ankle less likely to loosen or slide from front to back.
Surgeons often work on new designs, and it is important for patients to ask if they have any relationship with a device maker that might influence the choice of ankle hardware. Risks include complications such as infections and blood clots, bone cysts or the failure of the implant to heal into the bone.
Surgeons generally discuss patients’ lifestyles to determine which ankle procedure is best. After a fusion, patients can “play golf, walk, cycle and swim, but not much more than that while a replacement gives better motion, and allows you to walk better and be more active,” says Christopher Hubbard, chief of foot and ankle service at Mount Sinai Beth Israel Hospital in New York.
Some patients who had fusions in the past may be candidates for ankle replacements. Shannon Rush, a podiatrist who performs foot and ankle surgery at the Palo Alto Medical Foundation’s Mountain View, Calif., center, says he sees one or two patients a month whose ankles were fused in a poor position.
Erika Spencer Brose, 44, a former dancer who now works as an emergency 911 operator, had her ankle fused after a car accident in 1992, but it was fused at a slight angle so she could wear a heel or boot. She says she became addicted to painkillers for a time, and was unable to walk very far. “It totally threw my life into a tizzy,” she says. On a trip to Hawaii, she wanted to walk on the beach, but instead felt “like the hunchback of Notre Dame.”
Two years ago, Dr. Rush removed the fused bone and put in a new ankle joint. “Overall it has made a huge difference,” says Ms. Brose. “It turns, it flexes, and it does things it never did before.”