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Introduction: At Bryan Health, we care for patients, educate tomorrow's healthcare providers, motivate our community with fitness and health programs, and collaborate to continually improve how we serve others. That's why we are proud to present another Bryan Health Podcast. Here's Melanie Cole.

Melanie Cole: Welcome. This is Bryan Health Podcast. I'm Melanie Cole, and today we're discussing ankle replacement. Joining me is Dr. Eric So, he's a Fellowship Trained Foot and Ankle Surgeon with Capital Foot and Ankle. Doctor So, it's a pleasure to have you on with us today. Tell us a little bit about what causes the majority of ankle pain that people come to you with, whether it's arthritis or they've strained their ankle or whatever it is. When you see things like this and mostly arthritis, how has that happened? What are the causes?

Dr. Eric So: Well, ankle arthritis, the most common form of ankle arthritis is actually a previous trauma. You may have had a car accident, you may have had a surgery for it, previous injury. And that is actually the, by far the most common reason you might have ankle arthritis, which is a little bit different in the hip and the knee. Arthritis in the hip and the knee, the most common form is osteoarthritis, which is general, you know, simply wear and tear arthritis. The joints simply wears away over time. But because of traumas and other things with the ankle, we can actually see some deformities of the ankles that we don't always see with arthritis in the hip and the knee. We do see osteoarthritis of the ankle, but it's much less common.

Host: Well, I think that what you just said is so interesting, as the hip and the knee do develop that wear and tear arthritis, ankle is from some sort of trauma. That's very interesting. So what are the symptoms of that and some options to relieve ankle pain if we suffer from it?

Dr. So: Well, it depends on the grade of arthritis. There is grade one, grade two, grade three arthritis. You know, with grade one, it's a very mild form of arthritis. Patients may have pain with certain exercises or with a certain duty at their job. Pain might be localized to a specific area of the joint. They might have good days and bad days. Pain might come and go. With grade two arthritis, it's a little bit more of a moderate form where you actually have a significant portion of the cartilage that's lost. There's more pain, more inflammation. There's more limited range of motion. These patients have a little bit more limited function, so they might have a hard time walking to the grocery store, to the mall. You know, by the end of the day they're feeling pretty sore. They can detect weather changes because their ankle will swell and it is painful. The grade three is really sort of that what we consider end stage arthritis, and what happens is that now all of a sudden you get bone on bone arthritis.

And what that is that the two bones are now grinding and without the cartilage, that provides a nice gliding surface and provides a nice lubricating joint fluid. The ankle joint now all of a sudden becomes like an engine without motor oil and you get a lot of grinding and friction which causes inflammation and it causes the ankle to break down even more. And eventually the bone can start to deform and when the bone starts to deform, the ankle can start to change shape. It might role in, it might roll out and it can actually create a situation where even the ligaments and the tendons and the muscles around the ankle start to lose their flexibility and function, and the ankle becomes very unstable. And so instead of having pain that comes and goes, patients with grade three arthritis might have persistent pain. It might pop, a little crack, pain going up and down steps, severe limited range of motion. The flexibility is gone. You know, you go out to the mailbox and step on a little pebble and all of a suddenly your ankle overturns because your ankle is so unstable.

Host: And what can we do about that? Whether if we're in grade one and two, do ankle braces work, should we be icing, resting? Certainly not wearing heels. What do you want us to do to help our ankles before we discuss surgery?

Dr. So: Sure. Anti-inflammatories and bracing are all sort of the, the first step, shoe modifications. We can sort of prescribe a rocker bottom type of shoe that can help people propose off of their, during their gait, activity modifications, injection therapy is helpful. Physical therapy to kind of strengthen the muscles in the attendance around the ankle. That all, those are all the things that we kind of start with. Sometimes we can do an arthroscopic procedure to go in and kind of clean up some of the scar tissue that might be in the joints. Sometimes there's little pearls of bone or cartilage that get broken off, and just like a pearl that floats around in the ocean that gets rolled around in the ankle joint, that causes pain every time the patients take a step. So sometimes we can go in and take those pieces out. But those are really the kind of the things. A lot of things that we do for grade one we can do for grade two but more aggressively or more frequently. And once you get to that grade three stage is where really where all those treatments really start to become ineffective and we start the conversation of having an ankle fusion or ankle replacement surgery.

Host: Then let's talk about that. So who would be a good candidate for ankle replacement surgery or fusion, and how do you decide the difference of which one you're going to choose? How do you decide between the two? Tell us just briefly a little bit about each one.

Dr. So: Sure. Well ankle fusion is really the gold standard. It's the tried and true method of treating end stage ankle arthritis. It's been around for a long, long time. It's been described in the medical literature since the 1850s believe it or not. And what we do is actually take out the arthritic bone and we weld the joints shut and we hold it at a 90 degree angle with plates and screws. And what this does is that eliminates that grinding effect and eliminates the inflammation and pain. And so the ankle becomes very stiff. It does a very good job of relieving pain. And so the other benefit of ankle fusion is it's very strong. And so people who have to perform a high impact activities or are heavy laborers, sometimes this is a better choice for those folks because it's sturdier than an ankle replacement. With that being said, though, there are some drawbacks to an ankle fusion. The downside is that an ankle fusion, when you take away that joint, well now all of a sudden the joints around the ankle have to do more work. They have to pick up the slack, so to speak. You know, there's a joint in front of the ankle, underneath the ankle, and even the knee, to a certain scent, all have to pick up the slack.

And so what we found over time is that sometimes these surrounding joints can actually develop arthritis themselves. And if those are allowed to progress, then we have to do additional surgery to fuse those joints, which relieve pain but can, it can leave a very stiff foot. And so that's where ankle replacement can be a benefit, which is a much newer procedure then fusion. You know, the first ankle replacement was performed in 1973 in Germany by two doctors named Dr. Lord and Merote. And what they did was they actually took a hip replacement. They put it in upside down and they called it an ankle replacement. And so you can probably imagine it didn't work out so great. But since then we've actually gone through four different evolutions or four generations of ankle replacements. And what an ankle replacement is, is that we take out the arthritic joint and we replace it with two metal surfaces and a plastic liner in the middle, which allows the patient have some flexibility and range of motion. And the goal of it is to eliminate pain and preserve as much motion as possible. It does allow patients to have a more normal gait compared to a fusion, but it doesn't completely restore a normal ankle range of motion, like before you had arthritis.

And what we found is that this is a great option for people who had a low demand activity. You know, people who like to walk the dog, they like to hike, swim, golf, doubles tennis, you know, an ankle replacement is also a nice for people who already have arthritis or have had previous fusion surgery in the surrounding joints. So ankle replacement is nice to kind of maintain whatever motion is there. A good candidate for an ankle replacement surgery would be someone with end stage arthritis who's later in their years, let's say in their fifties, sixties or even seventies. And they have to have a pretty low demand on their activities. You know, someone with a low demand who just wants to walk the dog, you know, that's going to be a better candidate than somebody who's, who needs a high demand activity level on their ankle because of whatever recreational activities they'd like to do or because their job, you know, the person with a lower demand is going to be a better candidate for an ankle replacement. We also look for people who have good blood flow, good feeling in their ankle. So if you're someone who has neuropathy, you may not be the best candidate for ankle replacement surgery.

Host: Well that was a lot of really good advice. Dr. So, is there a height loss as a result of either one of these?

Dr. So: Not necessarily if performed correctly, you know, there's really not a difference in limb length discrepancy.

Host: So then what is recovery like whether or not you have a fusion or a full on replacement, is it similar to a knee replacement or a hip? Few weeks, physical therapy modification and then it pretty much good to go for you?

Dr. So: Yeah. So after your ankle replacement surgery, I would expect to be non weight bearing to the ankle, anywhere from two to six weeks after surgery, depending on your surgeon. And when you are allowed to start weight bearing, that's when physical therapy is usually allowed to start to really work on the range of motion, the strength and the balance. And then you go through physical therapy for several months and then once you have a joint replacement surgery, you're going to follow up with that surgeon periodically, every six months or even every year to survey that joint makes sure it's still in good position, that the pain is still relieved. And so you're going to be following that surgeon for a while after that surgery. And so I would also expect to stay in the hospital for one night after the surgery, although sometimes these can be done outpatient. I would expect to be on a blood thinner for a short period of time to decrease the risk of blood clots. And your surgeon may want you to be on antibiotics for the rest of your life, before any dental procedure or any other invasive procedure like a colonoscopy or biopsy procedure.

Host: Well, that's really great information. Can you still sprain an ankle after a fusion? And while you're telling us that, wrap it up with your best advice, any new technology, anything you'd like to share on the horizon that's exciting about ankle surgery or feet in general?

Dr. So: Yeah, there's a lot of new exciting technology coming up. You know, the plastic piece actually, the science behind engineering that piece is actually pretty amazing. You know, there are scientists and textbooks dedicated to just talking about how they take the fibers and weave them together and they create this ultra high molecular weight polyethylene plastic piece that allows us to have range of motion. And so the technology gets better every year and it actually gives us a lot more longevity to these implants. Another new technolog is that sometimes before surgery we can actually get a cat scan of your whole leg. And what this does is that it actually makes us more accurate with the surgery. It allows us to make a patient specific or very custom made cut guide and it allows us to make very accurate cuts with very good precision. And so that's been very helpful. And then the last thing too, is I would say is we now have ankle replacements that are specifically designed as a revision ankle replacement option. So if someone had an ankle replacement years ago and for whatever reason they needed to have it redone, well now we have revision specific options available. And so hopefully we don't do that very often. Thankfully it's pretty rare, but it does give us that revision specific ankle replacement that we didn't have previously. And so that's been very helpful.

Host: What an interesting topic and something that I think is underappreciated that we don't really realize the stress we put on our ankles and really what they do for us. So thank you Dr. So for coming on and sharing your expertise with us today. That wraps up this episode of Bryan Health Podcast. Please visit our website at bryanhealth.org for more information to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Bryan Health Podcasts. For more health tips and updates such as this, please follow us on your social channels. I'm Melanie Cole.