Total Ankle Replacement 

Patient Information

Musculoskeletal Department

• Author ID: MM 
• Leaflet ref: Phy 031
• Version: 5
• Leaflet title: Total Ankle Replacement
• Last review: October 2024
• Expiry Date: October 2026

This leaflet has been written to support the advice and instructions given to you by your Consultant, Practitioner and Physiotherapist. 

Total Ankle Replacement (Arthroplasty)

An ankle replacement involves taking out the worn-out ends of your tibia and talus bones and replacing them with artificial ends made from plastic and metal known as a prosthesis. 

Unlike an ankle fusion, a replacement allows you to move your joint after surgery. 

Appearance on X-ray

Benefits of surgery

In most cases a replaced ankle will maintain the range of movement that it had prior to surgery. This means that patients can walk normally, and it is thought that the risk of putting excess strain on surrounding joints is less than would be the case with a fused ankle.

The current research suggests that, provided post-operative instructions are followed, approximately 90% of patients undergoing ankle replacement surgery can expect a significant improvement in quality of life, a reduction in pain and improved mobility. The most recent studies conclude that approximately 80 - 90% of ankle replacements will still function well 10 years after surgery.

Risks/complications of the procedure

All surgery and anaesthetics carry some risks, particularly if you have other medical problems, smoke or are overweight. The healthcare team looking after you have been trained to make sure that these are minimised, and your treatment is carried out safely. 

The risks are:

1. Infection & wound healing problems

Sometimes, despite the strictest precautions, infections can occur which may require timely antibiotic therapy:

• Superficial infection may occur at your wound site
• Deep infection may occur early after the operation or much later 
• Problems can occur with wound healing particularly if patients are suffering from chronic illness such as diabetes or rheumatoid disease or are taking certain medications which affect the immune system

2.    Loosening of the prosthesis (new joint)

This is a risk of all artificial joints and is caused by a weakening of the bond between the new joint and your bone. It is hoped that your new ankle will last at least 10+ years, but it may loosen before this time, particularly if you are overweight, damage the joint by falling on it or return to heavy employment. If it does loosen then it can be possible to remove it and replace it with another one, although this is a more complicated operation with greater risks. It is often the case that a failed ankle replacement will be revised to an ankle fusion, usually with bone graft. This is usually successful but is a more complex operation and has higher risks than a primary ankle fusion (i.e. not a revision operation).

3.   Ankle fracture

There is a small risk of fracture of the ankle during the operation as well as post-operatively.

4.    Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

Despite taking precautions to try and prevent a blood clot, this can occur in the veins of the legs after this type of surgery (deep vein thrombosis).  Occasionally these clots can dislodge and travel through the heart to the lungs. This is known as a pulmonary embolism (PE). 

5.    Very rarely life threatening complications can occur.

6.    Persistent Pain & Stiffness

The operation may not relieve all of your pain, and you may continue to experience some mild discomfort. Complex regional pain syndrome, while uncommon, may be the cause of pain, swelling and skin changes. The ankle can become stiff after surgery and physiotherapy exercises are encouraged.

7.    Nerve Damage 

Very occasionally nerves can be damaged or stretched during your operation. This usually recovers over a period of time.

Other recognised risks of surgery include bruising, urinary retention and the risks associated with anaesthesia.

Pre-operative assessment

In preparation for surgery, you will be asked to attend a Preoperative Assessment Clinic where blood tests, x-rays, infection screening and a check of your general health will be performed by the Health Care Team. If you have a long term illness, heart, lung or a metabolic (diabetes, thyroid) condition, an Anaesthetist will examine you to make sure you are medically fit for an anaesthetic. 

The Anaesthetist will discuss with you the different types of anaesthesia and pain management methods available to you. It may be necessary for you to be seen by a specialist if you have a more serious health problem. 

If you are not considered fit for anaesthetic and surgery your operation will be cancelled and you will receive an Outpatient Department appointment with your Consultant who will discuss alternative treatment options. It is important that you inform the nursing staff if you take any form of medication. If you are on blood thinning tablets such as Aspirin, Warfarin, Clopidogrel or Dipyridamole, please inform the nursing staff as you may have to stop taking this medication before the operation. This would only be under the direction of a doctor.

If you wish to speak to a member of the Pain Team before your operation, please inform the Nurse at the Preoperative Assessment Clinic. It is important to let the staff know if you normally take painkillers at home, if you have experienced any problems such as allergies or stomach upsets or if you have any worries about pain management.

It is usual for you to be admitted on the day of your surgery. You will be sent further information regarding the time to come into hospital and which ward to attend closer to the date of your operation.

Preparing yourself for surgery

It is important to look after yourself before you come in for surgery. This includes keeping your skin clean and dry. You must report any rashes or breaks in your skin to the Preoperative Clinic staff.

On the morning of your operation please take a shower/bath before coming into hospital. 

When you are admitted to hospital members of the Health Care Team will prepare you for theatre. The limb to be operated on will be marked before the operation. A member of the Health Care Team will escort you to the Operating Theatre.

If you feel you may struggle to cope at home after your surgery, you must inform a member of the preoperative or surgical team before your admission. The appropriate team will then contact you to arrange any support if necessary.

After the operation

You will spend a short time in the Recovery Area of the Operating Theatre. You will then be taken back to the ward where your care will continue until you are fit to be discharged.

Some discomfort will be experienced following the operation so pain-killing medication will be given when required.

Exercises- ask your Physiotherapist if you are unsure of any of these exercises

The following exercises should be practiced hourly unless otherwise instructed by your Physiotherapist. Perform each exercise on both legs. 

If unexpected pain develops you must stop exercising and inform your Physiotherapist and Nurse. 

Deep breathing exercises 

Ensure you are sitting upright in bed. Take three or four deep breaths (no more as you may feel lightheaded). Breathe as deeply as possible, forcing the air out on your fourth breath. This may stimulate a cough. 

Foot exercises 

Gently paddle your non operated ankle up and down. You can also do this with your operated ankle if you have been placed in a walking boot – this should be discussed with your Physiotherapist

Repeat this five times.

With both feet, alternately bend and straighten your toes ten times. 

Leg exercises (perform on both legs)

With your legs straight in the bed, press the back of your knees into the bed. Your thigh muscles should tighten up. 

Hold for five seconds then gently release. 

Repeat this ten times. 

Clench the muscles in your bottom together. 

Hold for five seconds then gently release. 

Repeat this ten times. 

Lying in bed, keeping your knee straight, lift your leg approximately ten inches from the bed. 

Hold for five seconds then gently release. 

Repeat this ten times, with each leg. 

If you are sitting in the chair or on the edge of the bed, straighten your knee out in front of you. 

Hold for five seconds then gently release. 

Repeat this ten times. 

Walking

Your Physiotherapist will discuss your individual post-operative instructions with you including how much weight you are permitted to put on your operated leg and whether you will mobilise in a ‘back-slab’ cast or surgical boot.  It is important that you do not attempt to walk until seen by your Physiotherapist after your operation.

Most people will begin to walk the same day of their operation, once recovered from the effects of anaesthesia.

You will be put into a walking boot before being allowed to walk unless you have a ‘back-slab’ cast applied in theatre

Once you have been given your post-operative information, your Physiotherapist will assess and provide you with an appropriate walking aid, and you will practice mobilising initially under supervision. You must use the walking aids until you return to clinic for your review with the surgical team, usually at six weeks after your operation. 

Walking Boot

Some patients are required to wear a boot on the operated leg, your Physiotherapist will provide this and teach you how to apply/remove and manage your boot. At what point the boot is applied for the first time is dependent on the Surgeon’s instructions / pain / swelling / wound healing. 

If the ankle is particularly swollen the decision may be taken to place you in a below knee plaster until your clinic review at 2-3 weeks, where this will be swapped for a fresh plaster or boot.

When wearing the boot, it is important that it is applied correctly e.g. your heel is back in the boot and your foot is flat. It may be removed for hygiene and wound inspection purposes, and when dressing/undressing. Take time while the boot is off to check the skin around your ankle for pressure sores. If you are concerned, please contact the ward staff during your stay or the Foot & Ankle Practitioner or your General Practitioner (GP) when at home. 

The boot can be wiped clean with a damp cloth. The soft inner liner can be washed in a mild soap solution.

Always ensure the air pockets in the boot are inflated when walking and deflated at rest. 

If you have any problems or queries regarding the boot, please contact the Foot and Ankle Practitioner or Physiotherapy Department

For the first three weeks after your operation, the boot must be worn for 23 hours per day.  Do not walk without the boot.

From week four until your follow up appointment with your Surgeon (6 weeks), the boot must be worn when walking but can be taken off at rest.  Do not walk without the boot.

Stairs / Steps

Once you are walking well you will be taught how to manage stairs or a step (according to your needs). 

• Take one step at a time
• Going upstairs:  use the banister on one side and the crutch/stick on the other side. Leading with your non-operated leg first, place your foot on the step, then follow with your operated leg, placing your foot on the same step followed by the crutch/stick
• Going downstairs:  use the banister on one side and the crutch/stick on the other side. Place your crutch/stick down onto first on to the step, followed by your operated leg onto the same step and then the non-operated leg 

Walking up and down kerbs or steps without rails: as above but use crutches / sticks together.

On Discharge 

Once you are medically fit, safely mobile, and can safely manage the stairs or step (if required) you will be discharged home. Mobilise in the boot or plaster within the limits of pain and keep the foot raised when resting.

Wound Dressing

If you have been placed in a walking boot you will have a surgical dressing in place. If this becomes saturated with ooze and blood from the wound it will need to be changed. While in hospital this will be done by the ward staff, after discharge you can return to the Outpatient Department any time to have your wound re-dressed. If you live out of area your GP Practice Nurse or District Nurses can be contacted. 

Please contact the Outpatient Department or Foot & Ankle Practitioner (telephone numbers on page 9) if you have any concerns or queries regarding your dressing or wound.

Driving

You will not be able to drive while you are in the boot / plaster, routinely for 6 weeks.

Routine Post-Operative Appointments

Nurse Led Clinic Appointment 2-3 weeks for removal of stitches

Consultant Clinic 6 weeks

If you have any problem with any follow up appointments, please do not hesitate contact the Foot and Ankle Practitioner Team on the number below.

Contact Information

If your call is connected to an answering machine, please clearly leave your name, date of birth, telephone number and a brief description of your enquiry.