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Ankle fusion vs total ankle replacement?

Original Post
Jim Garrett · · Unknown Hometown · Joined Jul 2007 · Points: 0

Have to make a decision between having an ankle fusion or a total ankle replacement.  The ankle already has the subtalar joint fused, as well as a calcaneal osteotomy and peroneal tenodesis in that foot.  One surgeon thinks either option is a viable choice but is concerned about the durability of a replacement if I continue to climb.  Second surgeon thinks either option should work well, choice is up to me.  Anyone have real life experience with either a fusion or replacement?  Can you climb 10s, 11s, 12s?  How is hiking a rocky approach to the crag with a pack?  Can you ski and bike?  I am concerned about the longevity of a replacement, but at 65 less concerned than if I were younger.  I am leaning towards a fusion for less concern about future complications, but the loss of motion scares me.  Any comments or advice from anyone who has been through this would be appreciated.  Thanks.

alpinejason · · Minneapolis · Joined Apr 2010 · Points: 176

You're 65? Replacement. I have fusion but nearly 30 years younger and replacement wasn't really an option because they lack durability as you noted. I live life to the fullest but running is out of the question. Biking is ok but takes some adaptation. Climbing is fine. I've had some knee trouble and have to be more conscious about posture and other body mechanics. Most people aren't even aware of the fusion unless they see the scars or I tell them. I'd love to have the motion back though! Contact me for more info if you'd like. Cheers. 

Edit. I just noticed you have your subtalar fused. That's would further emphasis my option of replacement. My subtalar provides minimal movement necessary to have somewhat normal mechanics. 

crankenstein · · Unknown Hometown · Joined Dec 2005 · Points: 0

I was facing this decision and then found a surgeon that 'rebuilt' my ankle.  He had to chop my tib and fib and transplant ligaments and tendons, but it worked well enough that I can walk with a decent range of motion 10 years later.  He told me that replacement was for people that wanted to walk to the mailbox comfortably and wouldn't hold up to rough terrain very well.

I know a couple of people that are happy with their ankle fusion, but they aren't particularly active people and I think they occasionally have problems with other joints because of the lack of range of motion.

Message me if you want a reference to my doctor who is in Boulder.

Terry Parker · · Fort Collins, CO · Joined May 2006 · Points: 0

I'm in the same boat and the same age, 65+. After 3 opinions from Docs, they all listed the same issues of replacement versus fusion as above. The replacement gets a lot of force on a small surface area, so any long term activity or drops onto the replacement would require a new replacement or fusion. Fusion will limit range of motion, e.g. slab foot placements. However, it will be bomber and last forever. For this reason, I am pulling the trigger on the fusion. Also, the recovery and rehab on fusion is shorter over a replacement.  

Jim Garrett · · Unknown Hometown · Joined Jul 2007 · Points: 0
T L wrote:

How long did you get out of the subtalar fusion? I’m faced with an STF and trying to decide if I should hold out longer. I’m 40.

i think in your scenario the fusion would not afford you much ROM for those activities.  What symptoms are you having requiring further surgery?

I had the subtalar fusion 8 months ago, along with cutting the calcaneus in half and moving it laterally and repairing tendons and ligaments.  The STF worked fine and from what I can tell it is not having a big impact on range of motion.  My issue is that my foot has never had good alignment and rolls laterally, and now the tibiotalar joint is severely arthritic and degraded, so the choice is to fuse or replace that ankle joint.  That was always possible from the start, just wanted to see if less drastic changes would help.  The pain and laterally instability of the foot are making it hard to just walk, let alone climb.  While I do not think the STF itself was that impactful, any of these fusions start sending abnormal forces to the surrounding joints, so I would be concerned about that.  Good luck with whatever you choose.

Jim Garrett · · Unknown Hometown · Joined Jul 2007 · Points: 0
alpinejason wrote:

You're 65? Replacement. I have fusion but nearly 30 years younger and replacement wasn't really an option because they lack durability as you noted. I live life to the fullest but running is out of the question. Biking is ok but takes some adaptation. Climbing is fine. I've had some knee trouble and have to be more conscious about posture and other body mechanics. Most people aren't even aware of the fusion unless they see the scars or I tell them. I'd love to have the motion back though! Contact me for more info if you'd like. Cheers. 

Edit. I just noticed you have your subtalar fused. That's would further emphasis my option of replacement. My subtalar provides minimal movement necessary to have somewhat normal mechanics. 

Thanks for the feedback.  Glad to hear your fusion has been working ok for you.  Still do not know what I will do.  Wish I only had one option; I hate having to make this choice.  Meet with my original surgeon tomorrow to try to decide what to do.  Good thing is that the SLC area has lots of good orthopedic Drs.; everyone I have meet with has been great and all of them have worked on pro athletes and Olympians.

Jim Garrett · · Unknown Hometown · Joined Jul 2007 · Points: 0
crankenstein wrote:

I was facing this decision and then found a surgeon that 'rebuilt' my ankle.  He had to chop my tib and fib and transplant ligaments and tendons, but it worked well enough that I can walk with a decent range of motion 10 years later.  He told me that replacement was for people that wanted to walk to the mailbox comfortably and wouldn't hold up to rough terrain very well.

I know a couple of people that are happy with their ankle fusion, but they aren't particularly active people and I think they occasionally have problems with other joints because of the lack of range of motion.

Message me if you want a reference to my doctor who is in Boulder.

Thanks for the feedback!  I am afraid my tibiotalar joint is too far gone; it is pretty much all bone on bone.  I had extensive tendon and ligament repair along with some bone rearrangement and fusion 8 months ago, and it just wasn't enough to alleviate the problem.  I have heard the same thing about ankle replacement, that people say they are back being "really active" but that just means a little golf and walking the dog.  The replacement just can't hold up the the stress of someone putting a lot of use and force on it.  Since I started asking around I have found a couple of people who are climbing hard with a fused ankle.  Not optimal, but doable.

highaltitudeflatulentexpulsion · · Colorado · Joined Oct 2012 · Points: 35

No personal experience here but I’ll add a couple things.


- small joint fusions (toes and fingers) can later be converted into a total joint replacement, this certainly requires additional surgery and recovery. To do this in reverse order would be a lot more complicated.

- I’ve never seen a patient who is decently active get an ankle replacement. Not saying it’s impossible, but it’s not typical.


- small joint prosthetics are pretty weak.

I don’t know what you should do. I think both options suck. Can you get a brace/new shoes/nsaids/ etc to get you through active days? You’re probably already doing all that though.

Jim Garrett · · Unknown Hometown · Joined Jul 2007 · Points: 0
highaltitudeflatulentexpulsion wrote:

No personal experience here but I’ll add a couple things.


- small joint fusions (toes and fingers) can later be converted into a total joint replacement, this certainly requires additional surgery and recovery. To do this in reverse order would be a lot more complicated.

- I’ve never seen a patient who is decently active get an ankle replacement. Not saying it’s impossible, but it’s not typical.


- small joint prosthetics are pretty weak.

I don’t know what you should do. I think both options suck. Can you get a brace/new shoes/nsaids/ etc to get you through active days? You’re probably already doing all that though.

Thanks for the input.  I just scheduled surgery for the fusion in a couple of weeks.  In agreement with all your points.  Ankle replacement would not hold up to my hoped for activity level.  If I hate the fusion could possibly go to a replacement, more difficult to go from a replacement to a fusion.  Have done all the PT, braces, orthotics, they were no longer helping.  Both options do suck, but I am committed to making the best of the fusion.  My goal is leading 12a six months post surgery, at least in the gym.  Interested to see if I get there. 

Fred WS · · Unknown Hometown · Joined Oct 2021 · Points: 0

Hey Jim,

Just saw this conversation...How did things work out for you ?

Thanks Fred

.

..

..

Alexey Zelditch · · San Jose · Joined Feb 2006 · Points: 1,050

I am also 65 and my right  ankle is  pretty much all bone on bone. Still climbing, but with more and more pain. Right now I am using some SUPARTZ injection in the joint as spacer, but it is not much of the help. I assume that at some point I will face same   surgery choice.  Maybe some with experience share here.

Jim Garrett: how is climbing post surgery? can you update,

thanks

Jim Garrett · · Unknown Hometown · Joined Jul 2007 · Points: 0
Alexey Zelditch wrote:

I am also 65 and my right  ankle is  pretty much all bone on bone. Still climbing, but with more and more pain. Right now I am using some SUPARTZ injection in the joint as spacer, but it is not much of the help. I assume that at some point I will face same   surgery choice.  Maybe some with experience share here.

Jim Garrett: how is climbing post surgery? can you update,

thanks

Climbing with the fused ankle has been going better than I expected.  I was weak coming out of the surgery and recovery.  Spent 3 months on a knee scooter then a walking boot.  Started back in the gym on stationary bike and rowing machine, then weights and hang board.   Started top roping in the gym ~6 months post-surgery.  At first climbing was a bit weird getting used to no flexibility in the ankle, but I quickly adapted and now for the most part I do not notice it much while climbing.  Every once in a while, there is a foot placement that I cannot do, but usually can figure out an alternative.  I am climbing 11c-11d and do not feel like the ankle is holding me back.  There is no real pain in the ankle, just a numb sensation that is always there, but that could be from tendon and ligament repair that was done on the foot.  I have not tried any crack climbing; I suspect that will be difficult if not impossible.  For the most part I do not really think about the ankle while I am climbing a route. I am careful about falling.  I do not want to hit the ground, I do not boulder anymore, and once I fell on a route and the foot hit the wall pretty hard and that really hurt and took a week or two to recover.  I am skiing this winter and that is going well.  My stance is a bit altered and feels different, but I am adjusting and having fun.  Just walking up and down steep ground is what is really impacted.  The ankle doesn't bend, so I have to do a side-step sort of a shuffle.  Running is pretty much impossible.  Having a totally fused ankle is certainly not great, but it has not been as terrible as I thought it would be.  I was in a lot of pain and had increasingly limited mobility before the surgery, so it has been a great improvement, and I am still having lots of fun with the climbing, skiing and biking.  And I am certainly glad that I went with the fusion rather than ankle replacement.  I do not think an ankle replacement would have held up very well.

Alexey Zelditch · · San Jose · Joined Feb 2006 · Points: 1,050

thank you Jim, climb on!, my problem that I mostly enjoy crack climbing, and looks like fusion is not an option for this type of climbing. I read here on MP about  ankle distraction arthroplasty procedure - but there can be age restrictions [over 60] and I found clinics on east cost only.

alpinejason · · Minneapolis · Joined Apr 2010 · Points: 176
Alexey Zelditch wrote:

thank you Jim, climb on!, my problem that I mostly enjoy crack climbing, and looks like fusion is not an option for this type of climbing. I read here on MP about  ankle distraction arthroplasty procedure - but there can be age restrictions [over 60] and I found clinics on east cost only.

I'll just add that you can't "have your cake and eat it too". Life beyond the normal ankle that god gave you, whether fusion or replacement, will be different. It's kind of naive to think you'd be able to do everything you did beforehand at the same capacity. I assure you life after the ankle fusion (or replacement) will be fine, if you have an open mind. My hobbies as a whole have changed but my life is no less fulfilling, maybe moreso. I suspect in a year or two you won't miss crack climbing and your life will be great. You'll discover or rediscover other aspects of climbing (or other sports or hobbies) that fill the hole left by crack climbing. Or you'll figure out how to crack climb at a lower capacity and still have fun. 

highaltitudeflatulentexpulsion · · Colorado · Joined Oct 2012 · Points: 35
alpinejason wrote:

I'll just add that you can't "have your cake and eat it too". Life beyond the normal ankle that god gave you, whether fusion or replacement, will be different. It's kind of naive to think you'd be able to do everything you did beforehand at the same capacity. 

A version of this should be in bold letters at the top of every surgical consent. 

Tim Stich · · Colorado Springs, Colorado · Joined Jan 2001 · Points: 1,520

 A good friend of mine did the ankle fusion, then total replacement once that wore out. She was very active. Unfortunately, her ankle replacement did not work out and her ankle hardware is now on the recall list. Inflammation has not gone down years after the surgery and it's sounding like she will never be whole. I have no idea what her options are now. 

Alexey Zelditch · · San Jose · Joined Feb 2006 · Points: 1,050

thank you for information and vise advise like "you can't "have your cake and eat it too". I also have one more option-  just do what I can , accept the pain and continue to use my ankle until it bearable 

Turd Burgler · · Unknown Hometown · Joined Jun 2019 · Points: 5

Sad to see folks mulling over the ol' crap sandwich that is the fusion versus replacement debate.  I went with a third option - the distraction arthroplasty.  I am only 1 month out of the frame, so its too early to tell how effective it will be.  Realistically, this procedure is a 1 year commitment off rock climbing - 3 months in the frame, and then 9 months of intensive rehab.    Luckily its just my leg thats getting the year off, I am doing plenty of 1 legged climbing, as well as campusing and fingerboarding.  

The distraction doesn't close any doors, but there are no guarantees that it will be effective.  If its not, I will be back to fusion vs replacement. I think personally, I am leaning towards fusion.  I am in my 30s and just don't think the replacement would be viable for my level of activity.  If you are curious about the cutting edge of replacements though, I would go to Duke University (Mark Easly) or HSS (Dr. Demetracopoulos).  Replacements are improving rapidly, so if you go to a doctor who isn't on the cuttting edge, their information will be dated.   For ankle distraction, I wouldn't see anyone except for Dr. Rozbruch at HSS.  

I would absolutely love to hear more testimonials about folks with fusions and how they are getting on climbing.

Richard Hunter · · Boston, MA · Joined Apr 2009 · Points: 1,962

Cool to see someone who has had the distraction surgery done Turd Burgler! how is the rehab going? I'm going in for a consult with Rozbruch next month. I think I can tolerate the pain level for a few more years if I need to, but I'm afraid to wait on the distraction for fear I'll loose too much cartilage for it to regenerate with distraction. What was your initial injury? 

Harry Manback · · Fort Collins, CO · Joined Oct 2020 · Points: 0

When I was 28 I crashed a motorcycle. I had essentially a compound fracture of my fibula and a dislocation/separation of the rest of the joint. The word severed is appropriate. I spent 6 months fighting an infection and in the end I had to have a piece of my fibula removed because the break wouldn't heal due to infection. The plan was to surgically fuse the joint and graft the fib back together but after the long battle with infection the Doc said, "lets see what you can do with what you have before we risk another surgery/infection" and diagnosed me with end stage arthritis in the joint. I spent that summer stubbornly riding my mountain bike every day and icing my foot/leg to combat the ridiculous pain I would be in after a ride. At the end of that summer I had 0 range of motion and drastically less pain. Doc speculated that, through continued trauma, aka mountain biking, I had caused the joint to auto-fuse. He said it's common in wild animals, but people generally won't put themselves through that kind of thing. Now, 12 years later I'm still missing a chunk of my fibula and have almost no ROM in that ankle but I'm pretty much pain free, can walk, hike 20 miles with a multi-day pack, race mountain bikes at a respectable level but running is out of the question. My footing isn't great on chunky trail, but I've learned to just deal with it. Better than sitting on the couch. I haven't tried skiing or snowboard but I'm really not interested in that anyway. My guess is that it would be less than awesome. However, I think xc skiing might be doable because of the way the bindings work. But IDk yet. 

I am curious, for those who have fused ankle(s) did you have to overcome any fear of taking lead falls?  I have a huge mental block about falling with regards to my ankle. I've taken a bunch of whips in the gym with no incident, but outdoor moderates where the angle is lower and there are ledges and such is really living in my head. I keep telling myself once I'm getting on the harder 10s and into the 11s this will be less of an issue. 

Peter Cole · · New Hampshire · Joined Mar 2018 · Points: 3,366

Well ... my long story - I'll try to keep it short. High school football ruined both ankles. They expressed themselves, increasingly so, by coming out of joint. I'd fall to the ground and they would snap back in place. Ligament damage for sure. The long term result of this was rotation of the talus bone, loss of cartilage and bone on bone grinding. Tape and braces were never all that useful.  I would say though that at least the braces (swedo) keep the joint from dislocating even if there was movement.


All this time I lived the life I'd always wanted and was an active climber / mountaineer from 1972 onwards. But, by 2005 it really became obvious that it was time for an intervention. So the left ankle fusion happened first in Sept of 2005. By Oct of 2006 I was back to normal with complete joint stability and pain free hiking etc. My right foot took its time but it too eventually reached the point where the talus bone was so rotated it looked more round than anything else. So Jan of 2017 I had the fusion done there too. Two screws each time as you can see in this image of the left foot.

One thing learned from the 2nd fusion is that NSAIDS are NOT good for bone fusion. And I would say this is more than a little true in that I was back hiking in six months after the right foot fusion!

Now everything seemed was good and I was so happy to be pain free and able to do more or less everything : rock, ice and mountaineering. Take a look at this page and click any number of years post surgery to see what I mean.
https://amountainlifetime.net/content/chronology.php

I never really paid any attention until now, but one thing I was aware of is that talus fusions will eventually cause osteoarthritis in the subtalar joint as you are asking this joint to do more than it was designed to do. I've always been very careful not to jump off of anything (except into snow) unless I absolutely have to. Long story short - it took 18 years but this past summer the left foot artritis caught up with me in a big way. Mid way thru what I had hoped was going to a great season in the Winds and just after a good warm up on a snowy Wind River Peak I woke up to pain that was followed by limping. I did two other outings with the help of one little white pill each day, but it was just a waste of emergency medicine so I came home to NH. Five and a half months latter it is still the same. The odd thing is that it works and then it doesn't. Stepping up with a full flat foot is more beneficial than ones toes or the ball of my foot. Sometimes, the lateral/posterior side will panic and the muscles will weaken without notice. Very weird. Other time the same move is painless. That's why I thought it was bone spurs. A CAT scan earlier this month put that idea to rest. Clearly bone on bone contact in the subtalar joint. After a worthless corticosteroid shot into the joint a month ago next week I am going to get a floroscopic corticosteroid injection. This from what I understand may bring 2-3 months of relief. If that's the case, I will get another shortly before heading out west this summer. Come fall I think the inevitable subtalar fusion is the only option I have if I want to keep at it.

For those of you facing similar circumstances I'll update this post from time to time as it may be helpful for others to know more about these x-ray injections and what a combined ankle and subtalar fused foot can and can not do. My podiatrist has said there will definitely be a loss of pronation and supination of the foot (not that there is all that much at the moment anyhow). What I am more concerned with is the loss of dorsiflexion and plantar flexion.

March 5th 2024
Yesterday was a big day. The highly arthritic left foot subtalar joint was fused. First they removed the two screws from the ankle fusion in 2005. Joint space between the talus and subtalar bones was cleared of all remaining cartilage and the fusion progressed in a normal fashion. The procedure was preceded by a nerve block in the back of the knee. 24 hours later I still can't move my toes nor do I feel any pain. Four meds are being taken in this post-op environment. Oxycodone for muscle/tissue pain, Gabapentin for nerve pain, Meloxicam - anti inflamatory and baby aspirin EC. In two weeks the stitches will be removed and I'll get a cast. Four weeks after that, if xrays show good bone fusion, the cast will be removed and I'll get a walking boot and can begin PT. 

So, I now have a completely fused left foot. Will be relying on the mid foot joints for dorsiflextion. Having lived with the fused ankle for so long I am pretty used to not have alot of supination or pronation to begin with. Hasn't really affected my mountaineering etc. We'll see what this further loss of flexibility has to say about how thing go moving forward. The trade off has been worth it as the bone on bone pain and instability would only have gotten worse and my days in the alpine would have been over.

Meanwhile my situation at home has been made infinitly more enjoyable by using a knee scooter.

Guideline #1: Don't be a jerk.

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