Am I a good candidate for ankle replacement surgery?

Q: I'm trying to find some information on ankle replacement surgery. I've seen two surgeons who both think I'm a pretty good candidate for this type of surgery. I've talked with two other patients who seem very happy with their results. What's the general word on the street about doing this? I know it's a fairly new-ish procedure and that it hasn't been perfected yet. What do you think I should know?

A: There is one recent study from Duke Medical Center that may have the answers you are looking for. In this study, one surgeon from Duke University Medical Center shares the results of 82 patients who received the STAR total ankle replacement.

This surgeon performed all of the procedures himself using the Scandinavian Total Ankle Replacement (STAR) over a 10-year-period of time. The STAR prosthesis has been in use since the early 1980s with good results. It remains one of the most widely used ankle implants.

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn't a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) can also develop causing some difficulties.

Studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It's a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

The surgeon who conducted this study was particularly interested in knowing how the patients viewed the results. Measurements were taken before surgery and compared to the same measurements after surgery. Pain, ankle motion, and function were the main areas assessed. Patients' satisfaction with the results and self-reported quality of life were important means of determining patient reaction to the outcomes.

After analyzing all the data, he found there were improvements in all areas measured but especially in patient quality of life and satisfaction. Everyone was followed for at least two years and some patients were in the study for almost 10 years. This is probably one of the most comprehensive, long-term studies of patient perceived outcomes currently available.

The surgeon reminds the reader that these are self-reported results for a particular ankle implant (the STAR prosthesis). The more objective measures (number of patients requiring further surgery, number of failed implants, and implant survival rate) were also favorable. There was a revision rate of four per cent early on that increased over time. The survival rate was 88.5 per cent after 10 years.

It should help you to know that surgeons agree total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, as this study showed, it is a reasonable approach for some patients. And is still considered an acceptable alternative to ankle fusion (or amputation). As the patients in this study report, function and quality of life are improved. Patient satisfaction is ranked high enough to make this a procedure worth considering.

Reference: James A. Nunley, MD, et al. Intermediate to Long-Term Outcomes of the STAR Total Ankle Replacement: The Patient Perspective. In The Journal of Bone and Joint Surgery. January 4, 2012. Vol. 94A. No. 1. Pp. 43-48.

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