Ankles away

Hip and knee replacements are common these days. But ankle replacements?

Not so much, even though technology for ankle replacements was developed about 30 years ago.

It didn’t take off like hip and knee replacements, for one thing, because ankle arthritis is less common than that of hip or knee.

Still, federally funded research has shown that “when people get ankle arthritis, it’s equally or more disabling,” said Dr. James Brodsky, an orthopedic surgeon in Dallas and a clinical professor of orthopedic surgery at the University of Texas Southwestern Medical School.

Widespread use of ankle replacements has also lagged behind other joint replacements because early technology for the ankle prosthetics wasn’t satisfactory.

In fact, in the 1970s, “everybody gave up on them,” Brodsky said.

But since the 1990s, new and improved technology has been developed continuously, making ankle replacement a treatment option for many today.

While not everyone is a candidate for the surgery — the health of the bones is one consideration — it’s an option for people who suffer from painful arthritis in the ankle, whether brought on by rheumatoid arthritis or by injury.

“It’s a very exciting area. It does a huge amount of good,” Brodsky said of ankle replacements.

For Chris Wheat, 33, of French Settlement, ankle replacement surgery has made a remarkable difference in his life.

Wheat was 12 years old when the painful juvenile rheumatoid arthritis that he had suffered from since he was a toddler went into remission.

But, Wheat said, “The damage was already done. I pretty much learned how to live with it.”

Wheat had successful back surgery six years ago to address deteriorated discs, and this year, in March, he had ankle replacement surgery for his left ankle which had been practically destroyed by arthritis.

“It’s normal now,” Wheat said.

The ankle joint is actually formed by three separate bones: the lower end of the shinbone, the lower end of the smaller leg bone and the top of the foot bone named the talus; that’s the portion of the joint called the ankle bone.

In an ankle replacement procedure, the surgeon removes the damaged portions of those bones and reshapes them. The parts of the new artificial joint are then attached to the bony surfaces, according to the National Library of Medicine.

Recovery typically entails a partial cast or splint following surgery, followed by a hard cast, then a walking cast or boot for several weeks, before physical therapy.

The ankle joint holds different challenges for surgeons than the hip or knee, which likely accounts for the longer timeline in the development of successful ankle prostheses and technology.

“The ankle joint is a very unforgiving joint; there are basically bones on three sides of it,” said Dr. Steven Haddad, a spokesperson for the American Academy of Orthopaedic Surgeons and an orthopedic surgeon in Wilmette, Ill., who specializes in foot and ankle issues.

Also, Haddad said, “The ankle bone is about a quarter the size of the knee. It’s a small interface for the prosthesis to grow into the bone.”

Dr. Keith Melancon, assistant professor of clinical orthopedic surgery at the LSU Health Sciences Center in New Orleans, notes that the forces on the ankle are greater, too, than those on the hip or knee.

The ankle, he said, “has the weight of the entire body.”

And there’s another complicating factor in ankle replacements.

“It requires extensive knowledge about the biomechanics of the foot and ankle. It’s quite complicated. The foot and ankle have to be well-aligned,” Brodsky said.

In fact, surgeons sometimes have to do preliminary surgery to correct the alignment of the foot and ankle before doing the joint replacement.

Today, though, orthopedic foot-and-ankle specialists and podiatrists who do the surgery have advanced implants and surgical tools to meet the challenges, doctors said.

There are four prosthetics approved by the Food and Drug Administration for use in the U.S., although there are about 50 in use throughout the world, Haddad said.

Implants are now shaped more like the natural ankle than in the past, said Dr. Dan Hake, an Ochsner podiatrist in Covington, who did the ankle replacement surgery for Wheat.

Surgeons also make use of the same type of X-ray guidance systems used for hip and knee joint replacements, Hake said.

An alternative to ankle replacement surgery for those who aren’t candidates for the procedure is the ankle fusion.

In that procedure, the surgeon removes the ankle and fuses the bones of the leg and foot together with metal screws, according to Johns Hopkins Medicine, an online source of medical information.

“Both operations greatly improve the way people walk, both operations give great pain relief,” Brodsky said.

Each procedure gives satisfactory outcomes for about 70 percent of those who get the surgeries, according to Johns Hopkins Medicine.

On the plus side for ankle fusions is that they’re permanent.

On the down side, the ankle joint is rigid after the surgery, and ankle fusion may put stress on other joints of the body over time, doctors said.

A major benefit of the other surgery alternative, the ankle replacement, is that the person retains movement in the ankle joint.

On the down side is the fact that the implants aren’t permanent; they last an average of 10 years.

For that reason, doctors said, it’s rare for people in their 20s and 30s to have the ankle replacement surgery.

“Each time you have surgery, there’s some bone loss” when another prosthesis is implanted, Haddad said.

Also, not all insurance companies cover ankle replacements, Hake said.

“Some insurance companies are still calling it experimental,” he said.

According to the website http://www.costhelper.com, which provides pricing information for all types of consumer purchases, the average cost of ankle replacement surgery is $40,000.

Before joining Ochsner in Louisiana in 1999, Hake practiced in Iowa, where ankle replacements were among the surgeries he provided.

It wasn’t until 2009, however, that Louisiana medical licensing laws changed to allow podiatrists to provide the surgery, he said.

“When I came to Louisiana in 1999, podiatrists did not have the ankle replacement in their scope of training,” Hake said.

After receiving his Louisiana license to provide ankle replacements, Hake went through training again, at multiple medical sites in the country, before offering the surgery again, he said.

Ankle replacement surgery is still not commonly done, and patients sometimes have to travel to have the surgery done.

In this area, Hake said that, in addition to himself, there are a few other physicians in the New Orleans area who perform the procedure.

In 1986, when he was a child, Wheat, who received the successful ankle replacement, was featured in an Advocate story about the formation of a new support group for families with children with juvenile rheumatoid arthritis.

“Six-year-old Christopher Wheat walked into the clinic like an old man. His steps were slow and labored, and his young face was tightened into lines of pain ...” wrote the late reporter Laurie Smith Anderson.

Wheat’s arthritis later went into remission, but among the damage caused by the disease was collapse of the bone in his left ankle that left his left leg shorter than the other, he said.

“It was bone to bone,” Wheat said of his ankle, where the cartilage was gone.

He especially felt pain in his ankle before rain and in cold weather.

“It got worse and worse,” and something needed to be done, Wheat said.

These days, he walks without a limp for the first time in many years.

He and his wife, Coty, have three children, and Wheat hopes to one day be released from disability to be able to return to work in the plants.

David Manship, publisher of The Advocate, underwent ankle replacement surgery for his right ankle in late June, with Brodsky in Dallas.

Manship said that in addition to his arthritis he has an exacerbating factor for his ankle pain. “Over the years, since I was a kid, I’ve broken my ankle three times,” he said.

The first time was when he was in high school, he said. The last time was nine years ago when he was playing softball, he said.

“The ankle was swollen continuously — it was bone against bone and painful,” Manship said. “I was at the point I had to do something.”

A doctor had recommended ankle fusion to him, but he wanted to be able to continue to do such activities as bicycling, Manship said.

In Dallas, he learned he was a candidate for an ankle replacement.

Manship has just begun physical therapy, after going through weeks in a cast, then a walking boot, following surgery.

His son, Jake Manship, found out about ankle replacement surgery online, David Manship said.

“The only thing I won’t be able to do is run,” Manship said. “I would like to be able to live as normal a life as possible.”