Ankle fusion is a surgical technique to reduce the pain associated with ankle arthritis by getting the bones around the ankle to grow together. The surgery requires the removal of the joint cartilage, proper positioning of the ankle and foot, and placement of screws, plates, rods, or pins to hold the position while the bone knits together into a solid painless structure.

The time to fusion in a cast varies between patients-from six weeks to six months, depending on many factors. Most patients are admitted to the hospital for a few days and then use crutches, walkers, or a wheelchair until x-rays show satisfactory healing. Approximately five to 10 percent of ankles fail to fuse, despite optimal treatment; these percentages are higher in smokers, diabetics, patients with nerve problems, and patients unable to limit walking or standing during the initial fusing period.

Once fused, the ankle usually is painless or far improved from the preoperative condition. In most patients, function is somewhat limited by ankle fusion-especially going up and down slopes or stairs, walking on uneven ground, and stooping to pick up objects. Over 10 to 20 years after an ankle fusion, other joints of the same foot tend to wear out and cause pain.

References

Foot Ankle Int. 1997 Mar;18(3):138-43.

Results of ankle arthrodesis for treatment of supramalleolar nonunion and ankle arthrosis.

Marsh JL, Rattay RE, Dulaney T.

Department of Orthopaedics, University of Iowa Hospitals and Clinics, Iowa City 52242, USA.

Seven patients with supramalleolar nonunions after tibial plafond fractures underwent ankle arthrodesis combined with surgical treatment of the nonunion. Stabilization of the nonunion and the ankle consisted of medial and lateral plating for two hypertrophic cases and medial external fixation for five atrophic cases. Two of the atrophic nonunions were infected, and the distal tibia below the nonunion was resected and distraction osteogenesis from a proximal level was used to fill the resulting defect. Both the nonunion and ankle arthrodesis healed in six patients in an average of 7.9 months (range, 4-20 months). The nonunion failed to heal in one patient and required a below-knee amputation. The average cost of care was $66,491 per patient. Before surgery, the average patient ankle score was 25 (range, 15-50), and at a median of 35 months' follow-up the average score was 64 (range, 18-79 months). Three patients had scores in the "good" range, two in the "fair" range, one in the "poor" range, and one was rated a treatment failure. The SF-36 scores were significantly lower than age-matched population-based normal subjects. Limb salvage was possible in six of these seven patients, but the treatment times were long, complications frequent, and the cost of care high.

Foot Ankle Clin. 2002 Dec;7(4):703-8.

Long-term outcome of ankle arthrodesis.

Muir DC, Amendola A, Saltzman CL.

University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01017 Jppll, Iowa City, IA 52242-1009, USA.

The small number of long-term studies performed after successful arthrodesis suggests that most patients are satisfied with their outcomes. Some patients, however, eventually become limited by pain and degenerative changes elsewhere in the foot. Over time, subjacent joint arthritis is highly likely, especially that which involves the subtalar and talonavicular joints. (Fig. 1)

J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28.

Long-term results following ankle arthrodesis for post-traumatic arthritis.

Coester LM, Saltzman CL, Leupold J, Pontarelli W.

Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City 52242, USA.

BACKGROUND: Ankle arthrodesis is considered by many to be the standard operative treatment for end-stage ankle arthritis; however, the long-term effect of ankle arthrodesis on other lower-extremity joints remains largely unknown. The purpose of this study was to perform a clinical and radiographic review to determine the effect of ankle arthrodesis on the development of osteoarthritis in other lower-extremity joints.

METHODS: Twenty-three patients who had had an isolated ankle arthrodesis for the treatment of painful posttraumatic arthritis of the ankle were followed for a mean of twenty-two years (range, twelve to forty-four years) after the operation. Each completed standardized, self-reported outcome questionnaires (the Foot Function Index, Western Ontario and McMaster University Osteoarthritis Index [WOMAC], and Short Form-36 [SF-36]), was examined clinically by two of the investigators, and underwent complete radiographic examination of the knee, ankle, and foot bilaterally. The radiographic grade of osteoarthritis was determined for each joint, and the levels of overall activity limitation, pain, and disability were determined for each patient from the clinical findings and questionnaire information.

RESULTS: Osteoarthritis of the ipsilateral subtalar (p<0.0001), talonavicular (p<0.0001), calcaneocuboid (p<0.0001), naviculocuneiform (p = 0.0012), tarsometatarsal (p = 0.0009), and first metatarsophalangeal joints (p = 0.0012) was consistently more severe than the osteoarthritis of those joints on the contralateral side. Osteoarthritis did not develop more frequently in the ipsilateral knee or lesser metatarsophalangeal joints than it did on the contralateral side. Significant differences between the two sides were found with regard to overall activity limitation (p<0.0001), pain (p<0.0001), and disability (p<0.0001), with the involved side consistently more symptomatic.

CONCLUSIONS: To our knowledge, the present series represents the longest follow-up study of ankle arthrodesis to date. Our cohort of patients all had isolated post-traumatic ankle arthritis, and each underwent a successful isolated ankle arthrodesis. At a mean of twenty-two years, the majority of the patients had substantial, and accelerated, arthritic changes in the ipsilateral foot but not the knee. They were often limited functionally by foot pain. Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction.

J Bone Joint Surg Am. 1999 Oct;81(10):1391-402.

Triple arthrodesis: twenty-five and forty-four-year average follow-up of the same patients.

Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV.

Department of Orthopaedic Surgery, University of Iowa, Iowa City 52242, USA.

BACKGROUND: Triple arthrodesis is used to treat major deformities of the hindfoot and is often performed in young patients. The purpose of this study was to assess the long-term outcomes of triple arthrodesis in young patients.

METHODS: Sixty-seven feet of fifty-seven patients were evaluated at an average of twenty-five and forty-four years after triple arthrodesis. The most common indication for the operation was neuromuscular imbalance of the hindfoot, which was secondary to poliomyelitis in thirty-seven feet (55 percent), Charcot-Marie-Tooth disease in six (9 percent), spinal cord abnormalities in four (6 percent), cerebral palsy in three (4 percent), and Guillain-Barre syndrome in one (1 percent).

RESULTS: Fifty-two feet (78 percent) had some residual deformity after the arthrodesis. However, these deformities appeared to be nonprogressive between 1973 and 1994. Pseudarthrosis occurred in thirteen feet. Thirty feet or ankles (45 percent) were painful at the first follow-up evaluation, and thirty-seven feet or ankles (55 percent) were painful at the second follow-up evaluation. Of the thirty feet or ankles that were painful at the first follow-up evaluation, twenty-three were painful at the second follow-up evaluation. Of the thirty-seven feet or ankles that were not painful at the first follow-up evaluation, fourteen were painful at the second follow-up evaluation. Eighteen patients (32 percent) needed walking support at the time of the first follow-up, and thirty-nine patients (68 percent) needed it at the time of the second follow-up. Two of the patients who needed support at the first follow-up evaluation did not need it at the second follow-up evaluation. At the first follow-up evaluation, twenty-one ankles (31 percent) had no radiographic evidence of degenerative changes. However, by the second follow-up evaluation, all of the ankles had some degenerative changes. Similar progressive arthritic findings were noted at the naviculocuneiform and tarsometatarsal joints. According to the system of Angus and Cowell, the overall result at the time of the first follow-up was rated as good in fifty feet (75 percent) and as fair in seventeen feet (25 percent). At the time of the second follow-up, nineteen feet (28 percent) were rated as good, forty-six (69 percent) were rated as fair, and two (3 percent) were rated as poor.

CONCLUSIONS: Despite progressive symptoms and radiographic degeneration in the joints of the ankle and midfoot, fifty-four patients (95 percent) were satisfied with the result of the operation. The triple arthrodesis was a satisfactory solution for imbalance of the hindfoot in this group of patients.