Ankle Fusion Surgery - What to Expect
After 3 years of ankle pain, I decided to proceed with an ankle fusion of the main ankle joint (tibiotalar joint) in 2016. I did a significant amount of research before deciding to go through with the surgery so I thought it may be useful to document my experience for others who are contemplating a fusion. My particular case was uncommon so I’ll only briefly touch on it at the end of this post, but I expect that my surgical experience and recovery would follow a similar path to others.
Lead Up to Surgery
My diagnosis and surgical plan developed over the course of over 3 years (summarized at the end of this post under “My History”). I saw a number of specialists before deciding to proceed with an ankle fusion. It took a while to rule out other interventions and I only opted for fusion surgery once I really was unable to walk for more than a couple hundred metres.
Before surgery, I prepared my house as best as possible to accommodate being on crutches. I was told I could be non-weight bearing for up to 12 weeks (it ended up only being 8 weeks before partial weight bearing), and it was never really clear how long afterwards before I’d be walking crutch free. I purchased a shower stool and bought/rented a number of mobility devices, which I’ll elaborate on later.
I was told to show up a couple hours before my morning surgery. After speaking with my surgeon and anesthesiologist, I was brought into a surgery preparation room where they applied a nerve block in the back of my leg. It numbs the nerve that runs down to your foot/ankle and continuously injected a numbing agent for about 24 hours. This presumably really helped with my post-surgical pain. At this time, they’re also putting in an IV line. There’s discomfort - a lot of pushing and prodding - but not all that much pain.
Once that was done, I was brought into the operating room where there must have been nearly a dozen people hovering around – nurses, anesthesiologists and my surgeon with his team. They put me under and the surgery lasted almost 5 hours, but I should note that my fusion was particularly complicated and required bone grafting (from my hip mainly), three screws and two plates. I understand most fusions just require one or two screws to adequately secure the bones in place, but my situation was unique where I required more hardware and bone graft to ensure a good fusion.
I responded poorly to the general anesthetic wearing off, so was kept in the recovery room for 2-3 hours until my nausea subsided. There wasn’t much pain – probably because of the nerve block – although I was quite sore and stiff when I woke up.
After that, I went up to my room where I had family waiting and I was in the hospital for two nights. Once the nerve block was removed the following morning, the pain was quite bad but was adequately managed by the drugs. I worked with a physiotherapist in the hospital to make sure I could move around on the crutches before being discharged. I understand that often patients only stay in hospital one night.
I stayed in bed mostly for the first week or so. I was quite weak and got tired just trying to move around the house. The pain didn’t last long for me however. I went off the OxyContin within 5 days post-surgery and was just taking Tylenol for the next few weeks (ibuprofen and naproxen weren’t allowed, as they may interfere with the fusion). The general sense of weakness lasted a few weeks as well.
- 2 weeks - I had my post-surgery follow-up appointment where they removed my splint and stiches, and put on a fiberglass cast. The new cast felt much lighter than the splint I had post-surgery.
- 8 weeks - I was non-weight bearing for the first 8 weeks, after which I was given a walking boot in place of the cast and began to put partial weight on my foot with the support of crutches.
- 12 weeks - I was given permission for full weight bearing in the walking boot. I found it quite difficult at the beginning and would limit my walking without crutches to within the house and with the support of a cane. I began physio around this time.
- Between 12 and 16 weeks – I gradually stopped using the crutches, then walking boot, then cane around the house. If I were going a long distance, I would use the boot and both crutches to take some pressure off my ankle, but around the house I could move around awkwardly with no supports.
- 16 weeks – I stopped using the walking boot completely, but continued to use my cane outside of the house. The cane helped me improve my gait.
- 18 weeks - I was given permission to start driving since it was my right ankle that was fused. I didn’t drive consistently until week 20 as I was worried that my reaction time would be slower, but it isn’t significant enough to be noticeable. My movements at the start were a little awkward (e.g., I would brake a little too quickly), but I’ve since adjusted.
- 20 weeks – First large snowfall where I live. It wasn’t comfortable to walk on an uneven surface, but I was able to do it without much pain. I used the cane for support. Around this time, I stopped noticing swelling on my ankle in the evening. Swelling gradually reduced over time, but it was quite significant up until week 16 or so.
- 24 weeks – I stopped using a cane completely. I was still limited in my motions (e.g., hesitant to make quick turns and pivoting) and wouldn’t want to walk long distances, but fairly comfortable for walks up to 20 minutes or so without support. I could comfortably walk much longer distances with the use of the cane.
- 30 weeks – Stopped seeing physio and have done little specific rehab since.
Update at One Year
I believe that I’ve been fully recovered for a few months now and am firmly in my “new normal”. I have observed several limitations with the ankle fusion, but not as many as expected. Most importantly, the pain that I was experiencing is gone completely. I have experienced some discomfort with the hardware still in my ankle, but it is minimal and will get it removed if it becomes more of a bother. It sometimes feels like I have some bruising around the areas where I have plates and screws.
Adjusting to my mobility limitations has been an ongoing discovery. Walking on flat surfaces has been painless and easy. I wouldn’t hesitate walking for an extended period in the city (an hour or so), though may experience a bit of fatigue or very mild soreness if I did spend several hours walking. Biking and swimming feel normal, though I probably adjusted my biking motions to account for the lack of ankle mobility. Even when I was experiencing pain and throughout my recovery, riding my bike was the only real option for me to commute to work and as a mode to get around the city. It offered me the freedom to leave my house independently.
There are three situations where I really notice my limitations on a fused ankle on a regular basis:
Running: It’s impossible for me to run with any fluidity. I can run 20 feet for a bus or to hurry across the street, but it’s more like a quick hobble. I may be able to head back to physio to re-learn how to run, but I’d be worried about putting undo stress on my ankle.
Climbing stairs: Going up and down stairs is painless, but I’m only able to go one stair at a time. I’m no longer able to take two steps at a time or move hurriedly. Have a fused ankle means there’s no more “spring” in your step.
Uneven terrain: I’ve done quite a bit of hiking and now need to be much more conscious of where I step. I’ve found that I’m not in fear of “rolling” my ankle (which I’m not sure is even possible) so much as losing my balance when stepping on a tree root or similar terrain. Also, navigating steep hills are challenging as I must put all my weight on the ball of my foot (ascending) or heel (descending). This is tiring and slow moving, but has not been a complete impediment to me yet.
Overall, a year in and I’m very happy with my decision to have an ankle fusion. That said, my ankle issues resulted in me being fairly immobile outside of my home and was a pretty big drain emotionally as well as physically. I’d say the recovery was slow, but very smooth. Being as mobile and pain-free as I am is beyond where I expected at this point.
I am concerned about the associated arthritic issues that will result from my fusion. The adjacent joints in my foot and ankle will experience additional stress and will result in arthritis in the next 10-20 years from what I understand. I will need to deal with that when the time comes.
- Stairs are a bit tricky on crutches, as it’s easiest to take just one crutch on the stairs while using the handrail with the other. My solution was to have two sets of crutches in the house. I kept my favourite set on the main floor, would leave one there when ascending the stairs, and then have another pair waiting for me upstairs. I did this for the first 4-6 weeks, after which I was comfortable enough to quickly go up and down the stairs with two crutches and not using the handrail.
- I preferred forearm crutches to underarm ones – particularly on stairs. With underarm crutches, it’s much more difficult to ascend stairs because the top of the crutch is stuck under your armpit. This is not a problem with forearm crutches. I found it much easier to maneuver in forearm crutches in general.
- I have two young children so I was eager to be as helpful as I could during my recovery, or at least be less of a burden on my wife. I bought the IWalk 2.0 online (I think for $150 cdn) and while I didn’t find it comfortable enough to use for any distance outside the house, it was very useful inside. Because it frees up both hands, I was able to cook and carry my own things around the house. It wasn’t that easy to use on stairs however, and fairly jarring on your knee if using for an extended period.
- I also rented a knee scooter, but didn’t really use it. I’m perhaps too tall for it to be comfortable, but found it unstable and didn’t hold up to city sidewalks. That said, using crutches is exhausting, so I never really found a good solution to extended periods of walking.
- I biked a lot, even when I was just partial weight bearing and using crutches. I had crutches that could be collapsed to a smaller size and strapped to a knapsack. This won’t be a solution for many people, but provided me with some freedom and independence within the city.
I was 33 years old when my ankle was fused. I’ve continuously sprained my ankle over the years, with the most recent playing basketball in early 2013 - three years before my surgery. My ankle didn’t recover like it normally did after a sprain so I started looking into it. Later in 2013, I was diagnosed with a small spur on an x-ray and the beginning of osteoarthritis. In 2014 the pain worsened and an MRI detected an osteochondral defect in my talus. A subsequent CT scan later that year showed that the defect (also referred to as a “cyst” in the imagery) was very large and the arthritis in the ankle was advanced. Because of the size and placement of the defect, both foot/ankle surgeons that I saw thought any kind of bone grafting on its own wouldn’t work. Also, the severity of the arthritis was pretty bad at the end, so fusion was really the only way forward. To delay the inevitable fusion, I started on Naproxen (1,000 mg/day) which really worked for me until early 2016. I started to decline quickly at this point, unable to walk for more than 10 minutes or so without fairly severe pain. Some final imagery in April 2016 suggested I had a rare joint condition called Pigmented Villonodular Synovitis (PVNS), which was confirmed from samples taken during the surgery. PVNS damages the cartilage in the joint, then proceeds to damage the surrounding bone. Thankfully, there is little evidence to suggest that it would affect any other joints in my body.
Hopefully my story provides some insight to others who are contemplating ankle fusion surgery.