Hyperlife Medical Centre

010 020 5050 | 80 Van Bergen St,
Brackenhurst, Alberton

Morningside Mediclinic

011 883 1719 | Rivonia Rd, Hill Rd,
Sandton, 2057

TOTAL ANKLE REPLACEMENT

Hallux valgus and the bunion

What is it?

An ankle replacement as the name implies is a procedure for ankle arthritis when the ankle joint has worn out all of its cartilage resulting in a painful and stiff ankle and greatly impacts the patient’s activities of daily living.

In order to replace the ankle joint the tibial plafond (shin bone) and the talus (ankle bone) need to be removed and replaced with a mechanical orthopaedic implant.

The tibial component is often a combination of specialised metal (trabecular metal) and plastic (polyethylene) and the talus component steel alloy.

It is important to realise that this is a mechanical moving part and specifically designed for low demand patients and is not suitable as a result for young patients is the average life span of a total ankle replacement is approximately 15-20  years.

In the very and this would require multiple surgeries every 15 – 20 years and hence is not feasible and an ankle arthrodesis (fusion) is more suitable and can at a later stage be converted to a total ankle replacement once day-to-day physical requirements decrease.

General Recovery Facts

  • You will not be walking on the leg for about 10 days
  • The surgery is obviously painful and although you are allowed to put weight on the foot as soon as you tolerate it, this is initially difficult.
  • You will therefore be using crutches, a walker, a wheelchair or a scooter device called roll-about during the first few weeks of your recovery until you are able to put full weight on the foot.
  • There will be a large bandage hard bandage applied to the leg for 10 days.
  • Your first follow up visit with wound sister will be at approximately 10 days to change the dressings.
  • Once the bandage is changed you will now have a below-knee cast applied for 4-6 weeks.
  • There are no stitches that are used that need to be removed. I only use dissolving stitches.
  • If the surgery is on your left ankle, you should be able to drive an automatic vehicle at two weeks. If the surgery is on the right ankle, you may drive at about 4 weeks, but this varies from patient to patient. If you want to drive sooner, you may buy a “left foot accelerator”. This is easy to purchase, and you can buy this on line and take it to your garage where they are able to add it to the pedals quite easily.
  • You will be wearing the boot for approximately 4-6 weeks following the surgery.
  • Please wear the boot at night. It keeps the ankle in a good position and prevents the Achilles tendon in the back of your leg from getting tight. If this gets tight you will lose motion in the ankle.
  • There is a scarring of the big toe tendon that will occasionally develop at around 2-3 weeks. If this happens you will note that you are not able to bend the big toe downwards well. This is very important and if the big toe gets still, you must let me know since it can be easily treated. See below for the exercises to the big toe that need to be done.

Exercise

  • Exercises and range of movement of the ankle and big toe are started at about 4-6 weeks after surgery.
  • Exercise may depend on how quickly the skin incision heals. If there is any inflammation of the skin, we may want you to hold off on the stretching exercises of the ankle to give the skin a chance to heal.
  • If you have access to a swimming pool, we encourage you to use this as soon as the incisions are completely dry and healed, which will be at about 6 weeks. Swimming will significantly improve your recovery and allow you to begin bearing weight on the leg in the pool. The best way to regain movement is to put fins or flippers on to the foot and move the ankle up and down in the water.
  • The exercises are described in more detail below.

Driving following ankle replacement

You may drive by about 4 weeks if it is your left foot that has been operated on and you drive an automatic transmission vehicle. If you have surgery on the right foot it is not easy nor safe to drive with the boot and you may need to make alternative plans to drive for 6 weeks plus…

Walking and physical therapy

  • You may begin to walk without the boot at about 10 weeks, depending upon your level of discomfort and instructions given to you by Dr. Nunes. There may be certain circumstances where because of additional surgery to the foot and ankle we limit the time out of the boot.
  • Physical therapy is very important and begins at 6 weeks.
  • I have a specific protocol for your physical therapist and please make sure that I give you this outline.
  • You should plan to use a physical therapist for about 3 months.
  • There will be moderate swelling of the ankle and leg for about 9 months.
  • It is helpful to use a compression stocking to help reduce the swelling. You can also ask your therapist about the use of a compression bandage called “Coban” which you can purchase at the pharmacy. The same bandage can be bought at any pet store and is called “vet wrap”.
  • You should plan to ride a stationary bicycle and use machines to help regain your strength and movement.
  • You will continue to improve your strength and movement for about 9 months.

Exercise and sporting activity after your total ankle replacement

For many individuals, a return to an active lifestyle is our goal following this surgery.

For some, this may mean the ability to walk without pain, and for others, a more regular exercise routine may be more important. Regular exercise in a gym is always to be encouraged, and the use of all machines including a stationary bicycle, treadmill, stair climber, and elliptical machines are excellent to regain strength and movement of the ankle.

It is not recommended that you run. You may however engage in golf, prolonged hiking or walking, doubles tennis and bicycling, and skiing.

As noted above, swimming and cycling are excellent and will help regain the movement in the ankle.

Specific post-operative recovery

  • Foot is wrapped in a below knee splint with bandages if swelling is a concern alternatively will be placed in a below-knee cast.
  • Elevate the leg on some pillows when awake however when sleeping elevate the base of the bed with 2 bricks or thick books so that the limb does not fall of the pillow at night and you wake up swollen.
  • Apply ice packs.
  • Take pain and DVT prophylaxis medication as prescribed.
  • Expect numbness in foot 4-12 hours, followed by pain for usually one more day.
  • Do not allow foot to hang down and under no circumstances bare weight.
  • If you are travelling, move the toes as much as possible to stimulate the calf muscle however travel during this time is not advisable.
  • First follow-up in the office.
  • Wound inspection for any possible complications or irritable areas.
  • Application of below-knee cast for 4-6 weeks.
  • Strict non-weightbearing in cast with post-operative shoe and crutches initially to pain and swelling.
  • May weight-bear in cast once cast feels loose.
  • Can allow foot to hang down at 3 weeks provided no pain and swelling occurs.

CAST REMOVED

  • Control x-ray is taken.
  • Cast is removed by my dressing Sister and wound inspected.
  • If incision is dry and completely healed, swimming is permitted for rehabilitation purposes taking care to not jump in the pool or apply any unnecessary force.
  • Gentle exercise on bicycle or swimming in a pool with a flipper permitted preferably guided by physiotherapist.
  • At this stage removable Moon boot is fitted and foot is prevented from taking excessive load and must be used for 6 weeks for any form of walking however patient does not need to sleep with this boot.
  • 30lbs/13.63kgs body weight on the leg is allowed 5 minutes twice a day when washing/bathing.
  • Control x-ray is taken.
  • If swelling is problematic you may require the use of a compression sock.
  • Start physical therapy under supervision with my protocols and this will focus on scar desensitisation and joint motion mostly.
  • Start ankle motion out of the boot as instructed. You will usually be asked to do lunging exercises with the replaced ankle in front to improve the range of motion of the ankle. Hold on to a support while doing these exercises. While you are allowed to put full weight on the ankle, it is painful at the beginning. These exercises should be done for five minutes five times daily.
  • Start exercises for motion of the big toe. It is common for the big toe to lose downward movement due to scarring around the ankle and you should gently manipulate the big toe downwards three times a day to ensure it does not become stiff. Occasionally if the big toe is stuck and cannot bend down, you must let us know so that Dr. Nunes can manipulate it for you in the office.

  • You can shower after boot is removed, provided the incision is clean and dry. Please do not stand barefoot in the shower. Use a stool or bench. You may get the ankle wet and clean it with soapy water. Following showering, apply antibiotic ointment to the incision.
  • As soon as you are comfortable you must begin lunging exercises of the ankle. This is very important. It is obviously difficult to do at first because of pain. When you lunge forward the knee must extend in front of the ankle.

  • You need to apply a dry micropore dressing to the ankle for 4 weeks with Bactroban ointment. After this it is not necessary to have any dressing on the ankle unless there are problems with the incision.
  • More vigorous exercise with Biokineticist for the next 8-12 weeks in order to achieve strength within 10% of the unaffected side hence clearing you for return to sport.
  • Can discontinue boot at this stage and use a shoe with a supportive sole and a slight heel lift (heel cup) inside the sole of the shoe.
  • May require gait analysis and custom orthotics to be made on an individual basis in order to assist with rehabilitation.
  • Followup in my consultation rooms.
  • Control x-ray taken.
  • Photographs and video taken of range of motion and strength.
  • Final followup in my consultation rooms.
  • Photographs are taken of range of motion and strength.
  • Control x-ray taken.
  • Patient outcome score taken.
  • Swelling and residual weakness can often be expected up until this point.
  • Patient is usually discharged at this stage.