Ankle Replacement vs. Ankle Fusion: Understanding Your Options

If you have advanced osteoarthritis in one or both ankles, there are two surgical treatments available: ankle fusion and ankle replacement. We’ll discuss the pros and cons of each in this article.

Ankle Osteoarthritis: What’s Causing All This Pain?

Osteoarthritis is the most common form of arthritis, affecting about 33 million Americans. If you have osteoarthritis, you know how debilitating and painful it can be. It’s caused by a loss of cartilage—the smooth tissue that acts as a shock absorber between bones in your joints— causing painful bone-on-bone contact.

In knees and hips, the breakdown of cartilage is usually the result of wear and tear over many years. In ankles, however, osteoarthritis is most commonly caused by an earlier injury.

“About 80% to 85% of ankle arthritis is post-traumatic—somebody's had an ankle dislocation or fracture, a bad ankle crush injury or multiple sprains,” said foot and ankle surgeon David Thordarson, MD, director of Cedars-Sinai’s Foot and Ankle Fellowship Program. “Other causes include rheumatoid arthritis, hemochromatosis or misalignment that causes the joint to wear out on one side versus the other.”

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We prefer to use nonsurgical options as long as possible.

When Nonoperative Ankle Treatments Are No Longer Enough

Thordarson says there are many nonoperative ways to treat early-stage ankle arthritis, including lifestyle changes such as engaging in low-impact activities. Medications can also help, including nonsteroidal anti-inflammatory medicines (ibuprofen or naproxen) and injections (cortisone and platelet-rich plasma, for example).

“At Cedars-Sinai Orthopaedics, we prefer to use nonsurgical options as long as possible,” said Thordarson. “We can often manage ankle arthritis for years with just cortisone shots and bracing.”

Cedars-Sinai orthopedic surgeon Brent Kokubun, MD adds, “But once the cartilage is too worn down, there's no way of restoring it. The best way to get rid of the pain is to eliminate the arthritis at the joint with an ankle replacement or ankle fusion.”

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What Is Ankle Fusion Surgery?

Ankle fusion surgery, or ankle arthrodesis, removes the joint and fixes the bones together permanently.

“We clean the joint surfaces of remaining cartilage and then use screws or plates to hold the bones together,” said Kokubun. “In a few weeks, they heal into one bone instead of an arthritic joint.”

Fusion is very durable—since there are no longer any moving parts, it doesn’t wear out. But surgeons point to a couple of drawbacks.  

First, the fused ankle is no longer as flexible, so your foot’s natural range of motion is reduced.  

“Walking up or down stairs or a steep hill is a little more challenging because you can’t lift the front of your foot up and down in the same way,” said Thordarson. “And you can’t wear more than a one-inch heel.”

The reduced movement in the fused joint makes nearby joints work harder, which over time often results in those joints becoming arthritic.

“About half of all patients will end up with arthritis in the other joints over about a 20-year period,” Thordarson said. “And if we need to fuse more of those joints, the foot gets very stiff and a lot less functional.”

What Is Ankle Replacement Surgery?

Total ankle replacement surgery preserves the joint and its natural range of motion by replacing its arthritic elements.

Metal caps are attached to the ends of the bones separated by a plastic bearing that acts as the joint’s cartilage.

As the technology has improved, more people now opt for a replacement.

“Fusion used to be the gold standard,” said Kokubun. “But as the technology has improved, more people now opt for a replacement because it lets them keep their foot’s natural movement.”

Unlike fusion, ankle replacements will wear out over time. But Thordarson says newer replacements can last twenty years or more.

Who Is a Candidate for Ankle Fusion?

Fusion is often recommended for younger patients because it’s more durable.

“I recommend most patients under age 50 to go with fusion,” said Thordarson. “A young, active patient will wear a prosthetic joint out pretty quickly.”

There are also situations in which fusion is the only option, he says, such as weak or deformed bones, an infected joint or nerve damage. It is also recommended for patients in general poor health, with diabetes or who smoke.  

Who Is a Candidate for Ankle Replacement?

Patients with ankle osteoarthritis are good candidates for replacement surgery if they:

• Are older—Thordarson recommends 50 years of age

• Are relatively healthy

• Have sufficient bone quality  

• Have no significant deformity

• Are concerned about preserving their ankle mobility

Revision Surgery: Replacing the Replacement

Improved technology helps ankle replacements last longer and makes it easier to partially or completely replace an artificial joint if it wears out. There is a limit to the number of times this can be done.

“The new technology is great because you cut away much less bone to fit the replacement,” said Kokubun. “But additional replacement surgeries are more difficult and not guaranteed to be successful.”  

Artificial joints can also be removed and the ankle fused if the replacement fails.  

In some cases, fusions can be unfused and a replacement joint inserted, although Thordason warns that after 10 or 20 years, a previously fused ankle joint won’t recover its entire range of motion.

What to Expect During Recovery

Ankle fusion surgery requires a longer rehab period than replacement to allow the bones to properly knit together into a single whole.  

Kokubun says fusion patients should wait six weeks before placing any weight on the fused ankle, followed by six weeks in a walking boot. After six months, they will be mostly healed and can be active.

The replacement timeline is a little shorter: about four weeks with no weight bearing and another four weeks in a walking boot. After about four months, most patients are back to being active.

Thordarson says patients will feel good enough after either surgery to get back to playing sports, but he advises they stick to low-impact activities such as hiking, biking or swimming.

“I have quite a few patients who play pickleball after an ankle replacement because they feel so good, but I don’t recommend it.”

How Cedars-Sinai Approaches Ankle Surgery

At Cedars-Sinai, ankle fusions and replacements are outpatient surgeries, not requiring an overnight stay in the hospital. Our orthopedic surgeons are highly experienced and perform many of these procedures.

“We are one of the highest volume providers in the state,” said Thordarson. “And when you do something a lot, you get proficient at it.”

The surgeons also have access to the most up-to-date equipment, and they work with the most advanced implant technology.  

Minimally invasive techniques are available for some surgeries, and the multidisciplinary care team works individually with each patient to determine the right procedure based on their specific anatomy, activity goals and overall health.

“We make it easy, because we have everything you need in one system,” said Kokubun. “From preoperative care, to your surgery and postoperative care, physical therapy, braces and mobilization—it’s all here and at a very high level.”