I am a woman in my seventies with rheumatoid arthritis (since 1985).
My left
ankle has recently been X-rayed (because of extreme pain). This showed
virtually all cartilage had been worn away.

I was referred by my rheumatologist to an orthopedic surgeon
specializing in
foot and ankle. He prescribed a wedge insert which has helped, but
only
CAN'T READ . His next step would be fusion of the joint.

I realize that joint replacement for the ankle is a new procedure,
available
only in certain places (not in the city where I live or anywhere
within 200
miles).

My options seem to be:
1 wait and see - have the fusion if the pain gets worse
2 wait and see if the replacement procedure becomes more widespread
and if
it is successful
3 a treatment for replacing cartilage which I have heard of on E and W
coasts - but is this medically acceptable?

I would like to know what results patients have experienced. For
example,
after fusion does one need special shoes and can one walk normally?

Can it be true that one must stay completely off the foot for 3 months
after
fusion surgery? For a person who lives alone, this must be extremely 
difficult, not to say impossible.

I would also really like to hear the experience of any patients who
had surgery on the ankle, especially fusion.

Hello,
Thanks for requesting me to answer this question.  You asked the
following:
"I would like to know what results patients have experienced. For
example, after fusion does one need special shoes and can one walk
normally?
 
Can it be true that one must stay completely off the foot for 3 months
after fusion surgery? For a person who lives alone, this must be
extremely
difficult, not to say impossible."

1) Ankle joint replacement surgery

A description of ankle replacement surgery can be found in this
University of Washington Handout:
"Surgical options include arthrodesis and ankle replacement (or total
ankle arthroplasty).

Arthrodesis is the connection between the tibia, fibula and talus.
This operation is excellent for pain relief but sacrifices the
up-and-down motion of the foot that normally occurs through the ankle.
The talus is permanently fixed to the end of the leg bone.

Ankle replacement is a procedure that has been available for
approximately 25 years. However, it has not been as successful as hip
and knee replacement surgery. Because the ankle is not as often
involved in arthritis, there has been less study devoted to this area.
Over the last 10 years ankle arthroplasty has been growing in
popularity as the implants available for replacement have improved.
Current studies indicate about a 90 percent patient satisfaction rate
in the first four years after surgery. One anticipated problem in the
future may be loosening of this artificial ankle. An orthopaedic
surgeon should help you make the decision if you might be a
candidate."
http://www.orthop.washington.edu/faculty/Hansen/anklereplacement/02

You normally can bear weight with crutches shortly after the surgery:
"Patients are discharged home from the hospital when they can walk
safely using crutches and when their pain is controlled without
intravenous medication.

You will return to the clinic in two weeks for suture removal but
continue to have the leg protected and maintain crutch usage. At six
weeks after surgery, X-rays will be performed and a decision will be
made whether to advance weight bearing or continue the crutch usage.
You will put about 50 percent of your weight on the operated leg for
about four weeks.

The rapidity of the progress in weight bearing will depend on what
other procedures need to be done to correct your individual
deformity."
http://www.orthop.washington.edu/faculty/Hansen/anklereplacement/05

Dynomed.com totes the benfits of ankle replacement surgery here:
"For many people, ankle replacement surgery also offers better
movement and coordination of the foot and leg. Another benefit is an
improvement in the appearance of a deformed joint. Ankle replacement
surgery may mean the difference between walking with a crutch (or
being confined to a wheel chair) and regaining true mobility."
http://www.dynomed.com/encyclopedia/encyclopedia/foot_and_ankle/Ankle_Athroplasty_(Replacement).html

Here is an patient account from the alt.support.arthirits group
regarding her ankle replacement surgery:
"Well it has been 4 months now since my ankle replacement surgery and
I must
say:
I would certainly recommend the surgery to anyone in need!
Don't wait until the last minute to have the surgery (like I did : (  
)
I was almost running, and now, due to my foolishness, I am suffering a
stress
fracture (weak bones from prednisone) and in a cast until the upcoming
Tuesday.
I will be happy to answer any questions about
surgery/recovery--anything.

I'm just plain lovin' the ankle!"
http://groups.google.com/groups?q=ankle+replacement+surgery&hl=en&lr=&ie=UTF-8&oe=UTF-8&selm=20000128192836.25880.00000136%40ng-fe1.aol.com&rnum=5

2) Ankle fusion surgery

Here is a description of ankle fusion surgery:
"Ankle fusion makes the tibia, or shin-bone, grow together with the
talus, the bone immediately under it. This stiffens the ankle. You
lose much of the up-and-down motion of the back of your foot, but you
still have some from the other joints around the ankle. In addition,
you will still have the side-to-side rocking motion that comes from
the joint below the ankle. Ankle fusion is about 95% successful in
getting the ankle bones to grow together. Once healed, the fusion is
very durable, and you can even do heavy labor with the foot. Most
patients walk without a limp and get excellent relief of pain.

The downside of ankle fusion is that it places extra stress on the
other joints around the ankle, and these develop at least some
arthritis within about 15 years.

The surgery is done through an incision on the outside of the ankle.
We usually add a very short incision on the inside of the ankle as
well. Two or more screws are put in; they usually do not bother
patients, but occasionally need to be taken out later."
http://www.orthoneuro1.com/patiented/ankle-fusion.htm

You are correct in that you cannot walk on the foot after ankly fusion
- however, this site suggests that period to be only 6 weeks, not 3
months:
"One night's stay is usually required. You will have a lbulky dressing
in place. Keep your foot elevated above your heart as much as possible
for the first week. YOU CANNOT WALK ON THE FOOT. Some patients like to
practice with crutches before surgery.

2 WEEKS: We will take out your stitches and put on a fiberglass cast.
Keep the cast dry. If you accidentally get a little water on it, use a
blow dryer. If it is very wet, call us.

6 WEEKS: If your X-rays show healing, we will change your cast and let
you slowly start putting weight on the foot.

3 MONTHS: Most patients can start using a removable cast boot (with
full weight on the foot).

3-6 MONTHS: When your X-rays show complete healing, we will let you
get back to normal activities and shoes. The exact timing varies
between patients."
http://www.orthoneuro1.com/patiented/ankle-fusion.htm

Here is an account from Carol Eustice on About.com, who had right
ankle fusion surgery.  She addresses the type of shoes that can be
worn and the issues of reduced mobility:
"In theory, the ankle replacement should be preferable over a fusion
since motion would be preserved. Statistics reveal though that 95% of
total ankle replacements fail within 5 years. This extremely high
failure rate makes it a less than favorable procedure. Relief from
pain and regained stability are attainable results from fusion

Q: Does the fusion really alleviate all the pain?

A: Speaking from personal experience, yes, it does alleviate all the
pain. The best result is derived from surgery without any
complications and from expert technique by the surgical team. Failure
to place the ankle in the "optimal position" can lead to a poor
clinical result.

Q: How much motion is sacrificed for pain relief?

A: Essentially all. The joint is placed in a fixed position. If the
ankle is fused in the optimal position, some compensatory increase in
motion can be expected at the midtarsal joints. Rocker bottom shoes
are usually recommended to compensate for loss of motion but I
personally never felt the need for them.

Q: Is it harder to walk barefoot than with shoes after an ankle
fusion?

A: I have not found it to be more difficult to walk with or without
shoes. For patients with a well-aligned ankle fusion, the walking gait
in an appropriate shoe (obviously high-heels are out!) is nearly
normal. Running gait or walking on uneven ground is made more
difficult."
http://arthritis.about.com/library/weekly/aa060998.htm

These threads on the newsgroups gives various patient accounts on
ankle fusion surgery:
http://groups.google.com/groups?hl=en&lr=&ie=UTF-8&oe=UTF-8&threadm=20000910233719.29055.00001282%40ng-cg1.aol.com&rnum=3&prev=/groups%3Fq%3Dankle%2Bfusion%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26selm%3D20000910233719.29055.00001282%2540ng-cg1.aol.com%26rnum%3D3

http://groups.google.com/groups?hl=en&lr=&ie=UTF-8&oe=UTF-8&threadm=5ulnpc%246df%241%40gte2.gte.net&rnum=6&prev=/groups%3Fq%3Dankle%2Bfusion%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26selm%3D5ulnpc%25246df%25241%2540gte2.gte.net%26rnum%3D6

Here is another thread from the alt.support.post-polio newsgroup
regarding ankle fusion:
http://groups.google.com/groups?q=ankle+fusion&hl=en&lr=&ie=UTF-8&oe=UTF-8&selm=199611021435.HAA07981%40merlin.sedona.net&rnum=5

Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.  
   
Thanks,    
Kevin, M.D.    
   
Internet search strategy using Hotbot.com and Google Groups:
ankle replacement surgery
ankle fusion surgery

Links:
University of Washington - Ankle Replacement Surgery for Arthiritis
http://www.orthop.washington.edu/faculty/Hansen/anklereplacement/01

Ortho Neuro - Patient Education: Ankle Fusion
http://www.orthoneuro1.com/patiented/ankle-fusion.htm

Arthiritis Insight - Total Ankle Replacement Surgery
http://arthritisinsight.com/medical/surgery/ankle.html

Dynomed.com - Ankle Replacement Surgery
http://www.dynomed.com/encyclopedia/encyclopedia/foot_and_ankle/Ankle_Athroplasty_(Replacement).html

You may want to ask your questions in the alt.support.arthritis
newsgroup to receive more patient perspectives:
http://groups.google.com/groups?hl=en&lr=&ie=UTF-8&oe=UTF-8&group=alt.support.arthritis

Thankyou, kevinmd, for a really helpful answer.  You have given me
real ways to come to a decision based on knowledge.

Hello there!

First, thanks for putting me in such esteemed company.  I would have
enjoyed answering your question as well, but that Dr. K, he must be
hyperreflexic. ;-)

The cartilage replacement aspect of your question had me intrigued. 
I'm out of the orthopedic loop and didn't even know this existed.  On
quick review, it seems this is only available in Europe but I'd have
to do some further research.

Is SaluCartilage the product you'd heard about?
http://www.lef.org/newsarchive/disease/2002/04/19/pr/0000-1440-ga-salumedica-ce-mark.html

And it looks like the Danes are working with Cartilink-1 used in
conjunction with autologous chondrocyte implantation.
http://www.aci.dk/arthroscopic_aci.htm

I can certainly understand your concern about any of these procedures
if you live alone.  I'll see what I can find out about cartilage
replacement surgery in the U.S. as it pertains to ankles.  I'd be
happy to post something for you next weekend since I need to get up to
speed on this anyway.

Thanks for the very interesting question!  It's a Brave New World out
there.
V (it's "Voila" but I answer to almost anything)

Thank you for the rating and the tip.

Kevin, M.D.