A fusion is a permanent joining or bonding together of (and removal of movement from) a joint. In the case of an ankle fusion the two sides of the ankle joint, the talus and the tibia, and depending on technique sometimes the fibula, are fused.
The more superficial layers of the joint (remaining cartilage and bone) are removed to reveal healthy underlying bone. This underlying, sub-chondral bone is generally not so involved in the arthritic process. When the two healthy cut surfaces of the tibia and talus are placed next to each other and compressed, new bone grows across the area of the previous joint. Effectively, a fracture healing process is occurring which will lead to a complete obliteration of the previous joint space with new bone and the formation of a single bone incorporating both the talus and the tibia where previously there were two separate bones.
Any remaining joint lining and diseased bone (which generate the feelings of pain) are removed during this procedure. The resulting surfaces of healthy, normal bleeding bone are then stabilised and compressed, usually using screws across them. This environment encourages new bone to grow across the area of the joint, causing it to fuse, effectively forming ‘one bone’ where previously there were two. Bone needs to grow across the surfaces for a successful union.
The time for fusion can vary considerably between different conditions, different operative techniques and different patient related factors. Generally, under the optimum circumstances, an ankle should be well on the way to uniting by six weeks and be united by 12-14 weeks. Just as after a fracture, the bone will continue to strengthen beyond this time.
The main ways to fuse an ankle are either with an arthroscopic (keyhole) technique, with a traditional open technique or using the Ilizarov frame (a circumferential external fixator). It is also possible to fuse the ankle, together with the joint beneath it (the sub-talar joint) by inserting an intramedullary rod through the heel to compress both of these joints. This last technique is not however simply for ankle fusion.
Generally your own surgeon will have various techniques and should be able to discuss with you which would be most successful in his hands and appropriate in your case.
- An arthroscopic ankle fusion produces minimal soft tissue disruption and generally results in the lowest level and shortest lived post-operative pain. With this technique it is possible for patients to start partially weight bearing immediately (with an Aircast boot). The minimal soft tissue disruption means that it is possible to operate in areas with very poor soft tissue cover such as skin grafted areas or where other plastic surgery procedures have occurred. The union rates are probably highest for this technique
- An open ankle fusion has its main advantage that greater degrees of fixed deformity around the ankle joint can be corrected than with the arthroscopic technique. In addition, with an ankle which is tilted inwards (known as varus) the fibula bone can become very enlarged and produce impingement pain in shoe wear. The fibula can be excised with an open technique and this brings more normal dimensions back to the ankle than would be possible with an arthroscopic technique in these particular cases. Both bone surfaces are cut back to healthy non-arthritic bone and parallel to each other.
- Fusion of the ankle with an Ilizarov frame allows the greatest degree of correction and in addition, avoids any screws routinely being required immediately at the level of the ankle joint. This has a significant advantage if infection is present as screws and other metalwear placed across the infected site tends to encourage the persistence of local infection. The disadvantages are the inconvenience of having an external frame applied to the leg and the need for regular pin site care. For infected and revision cases though it can have a significant role.
Following ankle fusion surgery a patients gait (or the way they walk) will in most cases be normal or as a minimum much improved. This is possible because there are other joints close to the ankle which, if mobile and non-arthritic , allow the foot and ankle as a whole to move well even without ankle motion.
Generally a patient will be able to wear normal shoes following an ankle fusion. If however the foot is very stiff some modification of footwear may sometimes be necessary. This may mean wearing a lightweight walking type boot for longer periods of walking or looking for shoes with a stiffer sole. It may be that the sole of a normal shoe needs to be stiffened and a rocker type sole formed.
Whether leg length is effected after ankle fusion depends very much on the extent (and depth) of the arthritic process effecting both sides of the ankle joint. It also is effected by the technique which is being used. Following an arthroscopic type ankle fusion you would usually not expect any measurable change in the limb length and no functional difference in limb length that you would notice either. Occasionally, after open fusion a slight raise may be required on shoe-wear but this is unusual.
A patient is likely to be able to return to most activities following isolated ankle fusion, assuming the neighbouring joints are arthritis free. This would certainly include returning to heavy manual duties, being able to walk distance and the use of ladders. Furthermore a patient would generally be able to break into a short light jog . The ability to run following an ankle fusion is not unheard of and is dependent on many factors , not least of which is the maintenance of a very mobile subtalar joint post-ankle fusion. It also has to start off fairly mobile pre-fusion and this is not the case in all patients.
Good descriptions of what patients from the clinic have been able to do are to be found in the testamonials section.
If the neighbouring joints of the ankle are already arthritic at the time of an ankle fusion this can result in increased symptoms or pain from them. Under such circumstances the options are either for an ankle replacement combined with a fusion of these other joints or a fusion of all the joints involved. Generally in the younger, more active person a fusion of more than just the ankle joint results in far more functional restriction and lower satisfaction rates following surgery. In the older patient, with lower demands upon the foot and ankle, the results of such multiple fusions are generally much better.
Very few things in life and procedures in surgery come ‘free’. In the case of ankle fusion the ‘payback’ is that the joints which have ‘taken over’ the ankle function do so at their own expense, often suffering degenerative change themselves eventually. There is a probability that between ten and twenty years following a fusion the main joint beneath the ankle (subtalar joint) will become arthritic. An ankle replacement will not result is such later onset arthritis but its longevity of the replaced ankle joint is the issue .
If significant deformity of the ankle is present then this can also be corrected to normal at the time of an ankle fusion .
Arthroscopic Ankle Fusions.
I attended the Foot and Ankle Clinic several times and felt the Clinic to be efficient and well run. The staff where friendly and reassuring and there was the use of the lifts and a wheelchair if needed. The Clinic is second to none. My surgery has been a great success. I spent approximately threes months post op wearing an Aircast boot, which was comfortable and could be removed for showering etc. I had regular checkups afterwards to make sure bone was forming to fuse the ankle. Going across to the x-ray department was always quick and efficient. The Surgeon always explained things to me clearly throughout the process. Finally I would like to say that my ankle fusion has turned my life around. Beforehand I was in much pain when weight bearing and I am now completely pain free. I am able to walk for miles again, including over rugged ground. I regularly cycle and ride my horse without limitations. I walk perfectly normally and no-one would be aware that I have had an ankle fusion.
Mrs S Rollo Birmingham
It is with pleasure I write this testimonial to the Foot and Ankle Clinic. The experience has helped me turn my life around. I am now able to enjoy my life on the golf course playing twice weekly. The Foot and Ankle Clinic was first class with very helpful and friendly staff in all departments. The surgery was again excellent – over and done before I realised it and now bearly noticeable. I would have no hesitation in recommending anyone (and I have done) to the Foot and Ankle Clinic. Thank you most sincerely for what you were able to do for me. Wishing you all the best for the future.
Mr G Hilditch Northern Ireland
I had my complex ankle fusion operation performed at the Foot and Ankle Clinic in Edgbaston in October 2006. I had spent over a year putting this off as other surgeons had left me with a feeling that an open procedure was a major operation and that whilst the arthritic pain would be gone my future mobility was not guaranteed. Indeed I was told that there was no chance of me being able to run again which was very difficult news for a sportsman such as myself. My first consultation at the Foot and Ankle Clinic easily convinced me that I should entrust my ankle operation to the surgeon (Mark Herron). Not only did he discuss things with me as a person rather than a human with a bad ankle but he explained that he could do the procedure via arthroscopy rather than open surgery thus reducing the recovery time. The staff at the Clinic were excellent and the operation went well and I was soon up and about in an Aircast boot which gave me good mobility. It was hard to stop myself wanting to do things too quickly during the recovery process but you cannot rush it. However I am now back at the gym, run 5K regularly and play golf as often as I can, not bad for 57, even without an ankle fusion.
Mr J Barnes London
Ankle and subtalar fusion
“As promised, just a short note to let you know how things are going. As far as my ankle goes, I am having no problems whatsoever. I am not able to cope with ladders, scaffold and uneven surfaces with no problem. … I can’t thank you enough for making my quality of life so much better after all the years of pain I put up with, I should have had the operation sooner.”
Mr P Talon, 2013
I first had an appointment at the Foot and Ankle Clnic in May 2010 having suffered for many years with severe ankle pain. I completed tests and x-rays and diagnosed a problem with my subtalar joints. From the outset the treatment options where explained and I had my operation two weeks later at the Priory Hospital in Birmingham. I was impressed throughout with their caring attitude and how well I was kept informed at all stages. Following a short stay at the Priory Hospital I spent 4 weeks in plaster before being fitted with an Aircast boot. Now I am pain free and for the first time in many years I am able to enjoy long walks and take part in exercise. I cannot thank the Clinic enough for the excellent care I received and the beneficial results achieved. I am so pleased with the results that I have arranged to return to have my other ankle treated.
G Greenhill Birmingham
I would like to update you on my progress after the two operation that you performed on both my ankles last year 2007. I had advanced osteoarthritis in both ankles and was becoming increasingly less mobile and more overweight. I came to your consultancy rooms at the Priory Hospital Birmingham in April 2007. At that time you examined me and estimated my walking time at 5 minutes. On the 16th May 2007 I had my first operation which was a fusion of my left ankle and sub-talar joints this was a great success and I left hospital after 3 days. On the 24th October 2007 I had my second operation, which was a fusion of my right ankle. This again was a success and I left the hospital after only 2 days. The situation now is that I am completing bicycle rides in excess of 25 miles and have just completed a 6.5 mile walk (new personal record). I go from strength to strength on a daily basis and I am looking forward to completing a 10 mile walk in September for the Heart Foundation. These two operations have transformed my life for which I will be eternally grateful to the Priory Hospital, its staff and especially to the Surgeon for accepting me as a patient and using his unbelievable skill to return me to a mobility situation that I have not enjoyed for almost 20 years. If any future patients should consider the same treatment and are somewhat apprehensive, I suggest they be referred to the excellent and informative Foot and Ankle Clinic. I found this most useful as it gave me the opportunity to understand my problem, the surgery and to ask the right questions. Finally at 64 years old this year I walk without pain, I have no walking aids and I walk in the same types of shoes (off the shelf) as I did before my problems began many years before. Once again I am eternally grateful for your skill and dedication to people who suffer from the terrible pain of osteoarthritis.
Mr D Young South Staffordshire
During 2015 my left ankle began to cause me severe pain and difficulty walking. Both ankles were swelling up even when I took a short walk. I was seen by Mr Mark Herron shortly before Christmas and he informed me in great detail what was the best option for me. This was to have my ankle “fused” by screws. I was operated on at the end of January 2016 at the Priory Hospital. I was able to move about on crutches initially and then moved into an Aircast boot for a few months. I was regularly seen by Mark Herron, monitoring my progress. He told me to buy a high fitting hiking type boot which I would require to support my ankle and made sure I had to correct one.
I now walk without a limp and for some distance without any problems. Since the operation there has been no swelling of either ankle. I am not going to take up tap dancing but I am not now walking around like an old man. If I speak to anyone having ankle problems I strongly recommend them to make an appointment with Mark Herron and get some help. I cannot thank him enough for sorting out my ankle so well.
B Baston 2016-2017, Birmingham
Revision ankle fusion
“I, Graham Appleby, was in a considerable amount of pain in my left ankle when a friend recommend I go and speak to Mr M Herron. I found him very thorough and considerate, he showed me an x-ray of my ankle which should have been fused and then arranged for my ankle to be injected with some fluids. Afterwards he asked me how it felt to walk on it, it was great, no pain. Mr Herron said that’s how it would feel after he had operated on it, very true, after over a year later I have no pain whatsoever.”
Mr G Appleby, 2016
I am a 66 year old male who has valued being physically active all my life. I took up running in my late twenties and have enjoyed fell running and orienteering as well as hill walking. A couple of years ago a twinge in my ankle developed into constant pain such that I had to give up running although cycling was still o.k. During 2008 deterioration continued and I was walking in discomfort and with a bad limp. I suddenly felt like an old man. My G.P. diagnosed arthritis as the problem, suggesting an ankle fusion as a solution and he made an appointment to see a specialist at a local hospital though I had to wait 3 months for this. The arthritis was confirmed and an open surgery fusion was offered. I was hesitant about this being aware of infection issues given that my problem was not life threatening – just life inhibiting. I did come away with a website link to the Priory Hospital however, which immediately inspired confidence. I got a quick consultation and was assured that an arthroscopic fusion would be the best option for regaining an active lifestyle, so I immediately booked an operation date. I had my operation early in February 2009 at the Priory and I have no hesitation in saying that the whole experience was easier than I had anticipated. The surgeon (Mark Herron) and his Team were reassuring in their friendly professionalism. Post – operative care by Priory staff was excellent and after two nights I was discharged. Living with an Aircast boot and crutches for a few months is not ideal but one adjusts and tries to be patient with anticipation of a positive outcome. I came out of my boot and was discharged on 1st May 2009. It took a few weeks to get walking comfortably again due to my foot operating in a different way. A holiday in Scotland encouraged me to try a few walks of up to 5 miles and the foot ache gradually subsided. At the end of June I was confident enough to climb Snowdon. I experienced no ankle pain but a little swelling the day after – which did not last. Over the summer I have completed four orienteering events on rough terrain with no ankle problems whatsoever. I have even started (slowly) to run again. So all in all I am really pleased I bit the bullet and went for the ankle fusion operation. I suspect that the procedure undertaken by the surgeon and his team at the Priory Hospital Birmingham would take some beating.
Mr N Forrest Cumbria
I am a 69 year old and still fit and active thanks to the skill at the Foot and Ankle Clinic. My right ankle was becoming increasingly disabled through osteoarthritis and my ability to run and even walk was diminishing and my horizons were shrinking and my frustration increasing. I had seen surgeons through the NHS who offered a variety of solutions over a 5 year period, and frankly I always chose the “do nothing” option because I was afraid things would go wrong or infection would be acquired. At Easter 2009 I was orienteering in Northumberland when I came across a fellow orienteer who was on crutches and in an “Aircast boot”. He had recently had an ankle fused at the Foot and Ankle Clinic. I followed the orienteers progress through the year and was eventually satisfied that what had been done for him would probably work for me with a good outcome. Late in 2009 I had my first appointment and felt very confident in the surgeons ability to get me back into a more active life. Given that my other ankle is already showing signs of osteoarthritis that was also checked to ensure that the treatment for the worst ankle would be consistent with my long term needs overall. I was offered fusion rather than ankle replacement on the basis that with the active lifestyle I was living and intended to live more vigorously in future, I would be likely to wear out a replacement whereas the fusion is for life. I had the operation in January 2010 and the recovery period was tedious at the time but it led to a good fusion. I recall that at the 12 week “boot off” stage it was suggested that I might start a little very gentle cycling on a static bike – but I had already been out on my mountain bike three times with the boot on for about 10 minutes each time – but no damage had been caused. I had been walking as much as I could initially on the crutches but later unaided. At the Foot and Ankle Clinic I was always treated with the utmost courtesy and treated as a person with an ankle issue and not a patient. Every question was fully answered and the level of reassurance was significant and personal. The short stay in hospital was much better than I had feared and I was well looked after and was pleased to find a wine list available with the menu options. Now nearly 18 months after the procedure my full range of abilities has been restored and I can walk further than for some years, have been skiing, climbed mountains and improved orienteering. I have even added golf to the activity list – which would not have been a comfortable option previously. With all I have achieved the other ankle is now complaining! I will know where to go to get that fixed when the time comes.
B Alderson Nottinghamshire
My experience of the Foot and Ankle Clinic is that it is professionally and efficiently run. I felt at ease and a real person in pleasant surroundings. Knowledgeable, concerned staff that cared what happened to me was also my experience. The ankle fusion surgery at the Foot and Ankle Clinic was successful and remedied the faults with my ankle. After being unable to walk unaided for 14 months my quality of life has practically returned to normal. Followup treatment was also very good with no stone left unturned. An example of this was a query DVT which was immediately checked and reported back on. Again very good supportive nursing staff in attendance. Physiotherapy and occupational therapy treatment was particularly good both before and after my ankle fusion surgery. The staff completely put my mind at ease and answered all necessary and possibly unnecessary questions I put to them.
Mrs Y Ogden Birmingham
I had many years of pain and increasing difficulty walking following osteoarthritis as a child. In July 2008 I had two titanium screws inserted to fuse my ankle using arthroscopic (keyhole) surgery. The pre and post operative care was excellent and also my stay in hospital. You have to be a patient patient as anything orthopaedic is a long business but worth it in the end.
Mrs S Moffett Leicestershire
I can honestly admit I was more than a little concerned with the prospect of undergoing surgery on, by now my very degraded and painful ankle. My options were fully explained and after careful consideration I finally requested the fusion procedure. The surgeon and his team kept me up to date with all details and what to expect; even to the extent of showing me videos of previous patients walking after the operation. After the operation in 2005 I experienced some discomfort for approx 6 weeks, but always thought that my ankle movement would be greatly restricted, resulting in curtailing my two main passions; motorcycling and my local gym. It could not have been further from the truth, as virtually full movement had been achieved and gymnasium and motorcycle activities are back to normal. I do not limp when walking and still manage to run on occasions. I have experienced no adverse effects from the operation and have not missed out on any of my previous activities. Overall, the operation, pre and after care was a complete success and I must fully endorse this procedure.
Mr T Solomon West Midlands