Innovations in Ankle Arthritis: Total Ankle Replacements

A year ago, Dr. Steven Neufeld partnered with INOVA Hospital to launch the first Total Ankle Replacement Program in the country.

His goal? To establish a team of the leading foot and ankle surgeons, primary care providers, physical therapists and researchers to perform this surgery and rehabilitation under the same protocols, conducting cutting-edge research with a broad base of patient data. This model of a dedicated surgical and research center has proven successful in understanding and advancing hip and knee replacements, but it was not replicated for ankle replacements until the INOVA program was established.

Compared to joint replacements of the hip and knee, total ankle replacements are a more recent – and much less common – medical procedure. But thanks to the research and technological advancements of the last decade, successful ankle implants have been developed. And as a result, demand for the surgery is rising rapidly among Baby Boomers who want to stay active despite ankle arthritis.

We sat down with Dr. Neufeld, founder of The Orthopaedic Foot & Ankle care center, to discuss treatment options for ankle arthritis, the advantages of total ankle replacements and his current research at INOVA.

What does total ankle replacement entail?

It’s similar to replacing the hip or knee joint. In total ankle replacement, a foot and ankle surgeon resurfaces two bones – the tibia and the talus, the lower ankle bone – with metal components. We then put a plastic piece in between the metal components. This essentially re-creates the ankle joint, preserving the original mobility and reducing stress elsewhere in the foot. Patients can expect to spend a night in the hospital following the surgery, or at times can go home the same day. It usually takes about two to three weeks for the incision to heal, and then you can put weight on the foot and begin physical therapy.

Are there any non-surgical options for patients with ankle arthritis?

Yes. In fact, we typically try several non-surgical options to manage the pain and improve mobility before moving forward with a surgery. These treatment options include:

• Shoes with orthotics to change the alignment of the foot and/or ankle
• Braces
• Physical therapy to strengthen the ankle muscles and improve stability
• Anti-inflammatory medications
• Steroid injections to reduce inflammation and pain
• Modifying activities – especially sports – to put less pressure on the foot and ankle

Who can develop ankle arthritis?

Ankle arthritis typically stems from a previous ankle injury, such as a fracture or repeated ankle sprains. It can also be hereditary, or associated with conditions like rheumatoid arthritis. It’s less common for patients to develop ankle arthritis due to normal wear and tear on the joints and aging.

For a patient with arthritis, what are the advantages to total ankle replacement vs. ankle fusion, which was the former standard surgery?

An ankle replacement preserves a patient’s mobility, which reduces the likelihood that other joints in their foot will develop arthritis from unnecessary stress. They can return to their active lifestyle. But the downside, as with all joint replacements, is that the implant has a finite life. It will only last around 10 or 12 years before we have to replace some of the parts.

In comparison, an ankle fusion lasts forever. It never wears out, and it does take away the pain and disability from ankle arthritis. This is why it’s still a good option for some patients. However, a patient’s range of motion is limited. They won’t be able to run again, but they can do normal activities comfortably. The challenge with an ankle fusion is that the adjacent joints in the foot must compensate for the lack of motion, which exposes them to unusual stress. Within 10 years, those joints may develop arthritis, and then you have to perform additional fusions – further limiting the range of motion.

What has been the patient response to total ankle replacements?

It’s been fabulous. In fact, I would say that I get as many referrals from patients as I do from other doctors. They are some of my happiest patients, because the surgery has a dramatic effect on their quality of life.

Total ankle replacements are relatively new. What sparked your interest in this field?

I was an engineer before medical school, and I have always liked using technology to find better solutions for common problems. We have been performing ankle fusions for the last 60 years for patients with ankle arthritis, but many of them weren’t happy with the surgery and their limited mobility. That’s when I began to research total ankle replacements. It’s been amazing to watch ankle replacements evolve over the last 15 years. When I first started in this field, we were in the second generation of ankle replacements. Now, I think we’re in the fourth generation. It’s changing rapidly.

What is your team currently researching in the INOVA Total Joint Replacement Program?

Right now, we’re looking at helping patients walk sooner. We’ve learned that they can begin putting weight on the new ankle as early as two weeks after surgery. The previous protocol was to keep them in a cast and on crutches for about six to eight weeks – because that’s the recovery process needed for ankle fusion surgery. But you don’t need a cast for an ankle replacement, and patients can begin walking as soon as the skin is healed in about two weeks. It’s a faster recovery time. 

We’re also researching the involvement of different medical teams. Because we have a supervised rehab program and follow patients very closely, we’re able to catch complications and treat them immediately. If there are any infections, for example, we involve a plastic surgery team right away. Infections or wound complications have historically caused some challenges, but with this approach we haven’t had any failures. In addition to this, our team is also in the process of researching narcotic and pain pill usage with nerve blocks, and how it can be decreased.

Dr. Steven Neufeld is a foot and ankle surgeon and the founder of The Orthopaedic Foot & Ankle care center, offering a variety of foot and ankle procedures including the total ankle replacement. Dr. Neufeld is a Clinical Professor in the Department of Orthopedic Surgery at Virginia Commonwealth University and a Clinical Instructor at Georgetown University Department of Orthopaedic Surgery. He is active in clinical and biomedical research, and is a fellow of the American Academy of Orthopaedic Surgeons, a board member of The Centers for Advanced Orthopaedics and a board member of the American Orthopaedic Foot & Ankle Society Foundation.