Total ankle replacement operation

Welcome to this edition in The First Aid Show. In this edition, we are going to follow on from a couple of other videos we have done, where we have talked about some operations actually I have had. This video is on the total ankle replacement. Just to give you a little bit of history, 30 years ago, I was hit by a drunk driver, had broken ankles very badly, gave me trouble a lot of times. And in the last two years, had a series of six operations. The first one was the ankle arthroscopies, and they were covered in a separate video. And then after that had subtalar fusion; this is where you have a bolt driven in through your heel, and it actually secures the bone joint in your heel. Over time, the bone grows and then you do not have that joint anymore. And the idea there is primarily pain relief.

Also, the subtalar fusion is often done before the ankle replacement, because you need to have a good structure of the foot there and no other problems before you can have the ankle replacement. It is quite common to have the subtalar fusion and then the ankle replacement because the key difference between the two operations is, subtalar fusion, you need to be in plaster for a long period of time, whereas with the ankle replacement, you are only in plaster for two weeks and then into the boot. So, you do need to be able to move the joint. That is why they do the operations separately. Looking more at the total ankle replacement, the idea here is to remove the ankle joint and replace it with nylon and titanium. Within this, it is quite a straightforward operation from the patient’s point of view, which you attend hospital; the usual requirements, you cannot eat beforehand, so you need to make sure you do not eat before you have the operation. But also, anything, sometimes a few days or a week beforehand, you will also have a pre-assessment. This would include having swabs and having tests and having some medical data taken, just to make sure that there is no other risk, or there are no other conditions, and they know your blood group and things like that prior to the surgery.

On operation day, you will see, usually, the surgeon and you will see the anaesthetist, and then you will be taken down for surgery. With my operations, they took round about two hours, I suppose, in total in the time before you come around. The actual surgery itself was relatively straightforward, have no major problems with those. There was a little bit of difference between the left and right ankle and the size of the actual ankle replacement there. When you come around, you will have a half cast plaster. That is just plaster around the back of the ankle and then bandaged at the top. The reason for this is to allow swelling so the bandage will allow the swelling to increase because you will find your feet start to get a little bit puffy.

During the surgery, they will often give a pain blocker, which is like an anaesthetic, directly into the joint. And the theory is, that it will take then the pain away so when you come around, your foot is actually numb. In my case, just being awkward, that just did not seem to work. Only after one of the operations, I had a very slight numbness for about half an hour, and that was it. But, that is a reason, something different with me to others. Generally speaking, the pain is controlled. They will also give you pain relief so you may have intravenous pain relief and tablets because the important thing is to keep the pain levels down to a controllable level. Different hospitals will keep you in a hospital for different lengths of time. With my hospital, I was out the next day. I had the surgery about 9:00 in the morning, 9:30, and then by about lunchtime the second day, I was out. When you are coming out if you have got… In my case, it was two feet, so I was actually second one walking on a more injured ankle. But generally speaking, you will be up on crutches. The next day, I was up on crutches with the physio to check, making sure I could walk okay. But, you will find yourself tired. You have just had an anaesthetic, so you do need to be taking it really, really carefully.

You usually use a wheelchair, get to the car, get yourself home. The key thing is, you are going to be stuck, at least for those two weeks, in a state where you cannot put your foot down, you are walking around on crutches. A good thing to do before the operation is to make sure that your home is ready, that you have got everything you need. You have maybe a bed downstairs if that is easier, and just everything you need is in place so when you come out, it is a lot, lot simpler. You are going to need someone to help look after you as well, that is absolutely vital because you are just going to be restricted with what you can do. During those first two weeks, it is literally a matter of keeping your foot elevated. You will notice if you put your foot down, to just go to the loo, you will find it will turn a bright pink colour. And then lift it up, and it goes back to normal. That is just normal, that is nothing to worry about.

So, keep the foot elevated for two weeks. And then normally after that two-week process, you will then go to your surgeon, and they will check over the joint, maybe do x-rays; in my case, not. But, they will take that cast off and then put you into the boot, and this is Aircast boot. We have covered how to use the boot in other videos. Once they take the cast off, you can then start to see the sorts of levels of the scarring that is involved. Looking at the scarring you will end up with after the operation, obviously, I have had both feet done so you can see two sites there, but the initial line down here is where they do the main cut. Both operations are slightly different in how long the cut is, that depends on the act of the surgery. But you also might get some brace marks down here. This is how they hold the skin back. With this foot, when I first came out after the first operation, there was quite a lot of marks down here, but those marks go. They start off like blisters, and they come off, and they vanish. As you can see here, this is around about six weeks after the operation, so most of the marks have actually gone already. The key mark down here… I had a lot of odd other little cuts, like these up here, they are just used when they are securing the equipment.

The other key area of pain is just up onto the knee, you will get a very small cut just underneath the knee. It is what they use to line the ankle up. As they are doing the ankle replacement, they put a brace on to make sure they put it in the right way. Because what you do not want in an ankle replacement is, them putting it in place, but actually, your foot is pointing in the wrong direction. I am not sure the exact way, but basically, it was described to me, is they put a screw straight into your bone. You might think, “Oh, a little cut like that is no problem.” After the surgery, that became a little bit of a problem. Because if you are hopping around on one leg and you go to kneel down, just rest your leg against the bed or on the sofa or something, that I found was very, very painful, so just be aware of that. It is a very small mark, but now six weeks after, it is reasonably flat, but it has cleared it quite well.

Moving back down to the ankle itself, I had a subtalar fusion beforehand. For that, you will get a scar around on the side and other little scars, but that is the key scar there where they actually fuse. And also, where they put the bolt in through the bottom of your foot, you will have a mark there, but it comes out very, very quickly. The mark vanishes on the soles of your feet, and the scar around here is minimal really and, again, depending on the surgery. The key difference you will notice when you put your feet down, is you are going to notice that straight after your operation, the feet will become very red. You might also notice swelling after the operation. Actually, you get it… Sometimes, just literally the line of a sock there can mean you have a swelling up here, and you literally see a big dent in your leg. That is quite common, as you just about see it on here now. But really, the scarring, it goes.

While we are down in this area, other things you notice after the operation is numbness. This foot here is about eight months since the first operation. All the area around inside here is reasonably numb. I can feel my fingers going down it, but it is a lack of sensation. I am told that will go or it may stay, but it is no real major thing. The only real time you notice it is if you are putting your shoes on and you do the laces up, it just feels a bit odd, but generally speaking, that is not a problem. With this foot, obviously, it is near the operation, but it is quite a lot of numbness straight across here. This area here is virtually numb altogether. I did not have that on that one, but very, very numb in this area. But also, around here, quite a lot of numb area. It is just really a matter of waiting and seeing how that numbness develops. But, I would not worry about the numbness long-term on this, it is not a major problem.

Now we have looked at the scarring element, you got an idea what the actual wound is like, you will need just to keep an eye, just in case there is any infections or anything like that come up. But, after you have done that, two weeks in the plaster, and then typically four weeks in the orthopaedic boot. And while you are going with the boot, often you do not need to sleep in the boot. So, it starts to get a lot more comfortable in the evenings. You can just take the boot off if you are just sat watching telly with your foot up, it is no problem. You can start walking, you can start balancing. Over time, you will find you will be able to put a little bit more weight on the foot, and you can start to balance yourself much, much better.

At the six weeks post op, after you have done the four weeks in the boot, typically then you would have x-rays. And these often will be weight bearing x-rays, so that the surgeon can actually see that the ankle joint is functioning correctly, and everything is all okay. And then, he will give you guidance on what physiotherapy you are going to need, and also what other care you need to do with the ankle. The important thing is to get it moving, get it working. Now, just a brief look at pain. Pain will be different for everybody. If you have had a bad car accident or sports injury and you have had to have ankle replacement surgery, you may well find that you put the ankle in, the pain goes away, absolutely brilliant. Mine was a little bit different, and others may be the same. Because I have had a long-term issue with the ankles, the problem then is my ankles now move in ways they have not moved for nearly 30 years. So, the problem being, as they start moving, they are putting more pressure on all soft tissues, more pressure on all the other bones in your foot. You may well find the pain gets quite serious.

I do not like taking painkillers, but sometimes you have to. There are lots of cases, and you can talk to your GP or your surgeon about some sorts of painkillers you can take. It may well be, just have something like ibuprofen to reduce swelling and take the pain away, maybe paracetamol codeine mixes. There are lots of other pain treatments you can have, the likes of Tramadol or other drugs, but you have got to obviously be careful you do not become reliant on the painkillers. The other thing is patches. Pain relief patches are given to some people. They can be quite useful for longer-term chronic type pain. Not any use for short-term pain, but for a longer period of time. But the key thing with my ankle is, what I am going to have to do is start pushing through now. Both ankles are done, more physiotherapy, start to walk correctly again and learning to walk in the right way, getting through the pain, getting through the elements, starting to walk, and then hopefully, you should have a much, much better pain-free time.

Talk about how long it takes to get over the ankles to be somewhere in the region of a year, year and a half, depending on how long you have had the problem. If it is initial problem, then you are thinking like a straightforward break then no worries, but with mine, probably will be quite a considerable time for recovery. The hope is as time goes on, the better and better I can walk unaided, get out and about. Then, as far as the actual ankles, how long will they last? Again, depends on what use you have with them. It is not really there. I am not going to start taking up loads and loads of sports and things and putting a lot of effort and damage onto them, but it is a joint that can wear out. But they are hoping around about the 10-year life on them. Then, maybe they can do a replacement of the ankle replacement. You can literally have that replacement out and another one put in, which hopefully will then give me another 10 years. And after that, then other options can be maybe another ankle replacement. In that time, they might be able to do all sorts of fancy things, or maybe ankle fusion to actually just fuse the entire ankle joint, so that it just does not move. But then, theoretically, that takes the pain away, but also, in turn, that actually puts more and more strain on other parts of the foot.

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