Ankle Fusion From a Patient Perspective

 

by Janice Grathen (janny01@earthlink.net)

 

Many years ago, I experienced a life changing injury that eventually required surgery to alleviate pain and allow me to regain mobility. I considered my options (either ankle replacement or ankle fusion) and determined that ankle fusion was the right choice for me. Once that decision was made, I turned to the internet to seek answers to my many questions about the procedure. I did find information, but most of it was of a clinical, statistical nature. What I really wanted was for someone to tell me what to expect, not only concerning the procedure and recovery, but also what I could expect in the long run concerning my ability to walk without an ankle joint.

We are living in a time when many people are faced with making a decision of this nature since those who have been in car accidents where the foot is snapped back at the ankle, are prime candidates for this surgery. I hope that the information presented here will help people to make an informed decision when the time comes for them to act.


Disclaimer:This web page is an attempt to answer questions about ankle fusion. Unless otherwise noted, all information given here is based on my own experience. It is hoped that it will give you some insight from a personal perspective. Consult your orthopaedic doctor for further information.


Major Points

This web page will cover several aspects of the ankle fusion experience. Click on the ones that interest you:

         What is ankle fusion?

         Who needs ankle fusion?

         Which questions should you ask before fusion?

         What is the surgery experience like?

         What should you expect during recovery (short-term)?(Please note that this section includes graphic pictures.)

         What should you expect during recovery (long-term)?


What is ankle fusion?

The medical term for fusion is arthrodesis and according to the Online Medical Dictionary, arthrodesis is the surgical immobilisation of a joint.

For a definition on ankle fusion, I give to you a quote by Carol Eustice, one of the experts at About.com:

"The ends of two bones are fused together in arthrodesis with screw fixation and possible bone grafting. The goal is pain relief and regained stability and strength. The bones are aligned in the most functional position, but lose their natural motion." - Carol Eustice

Carol's information at Q & A About Joint Fusion is one of the only places that I was able to find information about ankle fusion and there are many helpful links.

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Who needs ankle fusion?

I want to emphasize that the decision to have any surgery should take place after very careful consideration. The fact that you are reading this web page probably means that you are experiencing arthritis in your ankle for some reason. My own injury took place in 1975 as the result of a fall from a height of approximately 20 feet. I literally turned my foot around sideways on my leg (dislocation) and broke the small bone. I had a couple of surgeries and was on crutches for 14 weeks. However, I want to stress that my arthritis did not get really bad until MUCH later.

I began seeing an orthopaedic surgeon in 1995 at the onset of pain. When I asked my doctor (in Florida at that time) about the possibility of having fusion surgery, he let me know in no uncertain terms that I was not ready for surgery because it was possible to manage my pain through the use of medication and an orthotic device. He concluded by saying that I would know when it was time to have surgery!

In 1997, I began to consider the surgery because of the following factors:

         inability to work full time

         an unwillingness to continue with potentially harmful drugs

         poor quality of life - inability to do anything that required a lot of walking

         PAIN and I mean the kind of pain that feels like someone is hitting you in the ankle with a sledgehammer.

A rear view of Janice's ankle prior to surgery. The ankle was swollen (like this) and painful at the end of each day. You can see that the ankle is tipped out. This is due to the erosion of the bone which required grafting to correct.

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Which questions should you ask before fusion?

There are many things to consider when making the decision to have ankle fusion. The ultimate goal of this surgery is alleviation of pain however, this pain alleviation does come at a cost. I believe that the following questions are important and the answers that you receive from your doctor will help you to make an informed decision.

         What limitations will I have as a result of this surgery? (For example, I was told that I would never be able to run again.)

         Am I a candidate for arthroscopic ankle fusion or will I need open ankle fusion? (According to my surgeon Dr. James Nunley, open ankle fusion takes less time to perform but requires more time for healing. Also important to note is the fact that arthroscopic surgeries of this nature have a 5-8% better chance of achieving fusion.)

         Do you think that I will need a bone graft and if so, what will that entail?

         How often do first attempts at fusing the ankle fail?

         How often do ankle fusions fail completely?

         If a fusion fails completely, what is the resulting condition?

         What is the recovery time for the surgery?

         How long does surgery take and will it be done on an out-patient basis?

         Will there be long-term negative effects of the surgery (e.g. development of mid-foot arthritis)?

***This may be unpleasant for you, but I think that it is imperative that you question your doctor about his credentials in the area of ankle fusion. Ankle fusion is best performed by a doctor who has had a lot of experience with it. The critical positioning of the bone makes a huge difference in the comfort level you will have after surgery and this comes with practice, practice, practice.***

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What is the surgery experience like?

Interesting Fact: This surgery is routinely performed on an outpatient basis.

Prior to the Operation

I went for a presurgery workup where I was told that I would be given a light anesthetic and a regional block. The regional block is similar to an epidural in that you are given medication that will make you completely numb (from the hip down) during surgery and for an undetermined amount of time (usually one to two days) following the surgery.

One of my most upsetting moments, prior to the actual surgery, was learning that I would be semi-conscious for the procedure. I am a wimp and a coward - I DID NOT wish to be aware of anything during my operation!! I am happy to report that, after telling my doctor this, he responded that I could make the choice concerning my level of consciousness during surgery. I made my decision and was blissfully unaware of anything once the drugs were administered.

The Operation

Because I was unconscious for the surgery, I cannot tell you anything about the actual procedure.

In the Recovery Room

Upon waking in the recovery room, I was extremely groggy but still aware of pain on the inside of my ankle. When I complained of this pain, I was immediately given a second regional block near my knee. Within an hour of receiving the second block, I was out the door and on the way home.

The surgery took place on March 25, 1999 and lasted approximately three hours. I was in recovery approximately three hours and the total experience, from start to finish was approximately seven hours. Surgery times will, of course, vary depending on the level of your injury.

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What should you expect during recovery (short-term)?

On a very happy note, I would like to share with you readers that one of my biggest fears - the fear of pain - was absolutely unfounded.

My original injury was so painful that I lived in absolute misery, dreading this experience for several months. I am a Christian and the only thing that gave me the courage to go forward, was my faith that God would see me through. The major difference between emergency surgery and elective surgery is the fact that your pain can be and is managed! YAY!! You will have some pain and you will definitely be uncomfortable during your recovery, but I have a very low threshold for pain and I can honestly say that I was never in terrible pain. Between the regional block and the use of pain medication, I had a very easy time of it.


And now I present to you a diary of recovery (major milestones ONLY) along with accompanying photos:

March 25

I return from the hospital and find it difficult to get into the house. My leg, being completely numb, is not under my control. I finally navigate the two steps on my rear end and head for the bed. I retire to the bed and keep my leg elevated as instructed. I begin to relearn the joy of crutches knowing that it is imperative that I not put any weight on my foot!

March 27

My leg is housed in a splint which consists of a rigid strip wrapped by cotton and gauze. There is a drain attached and it has been emptied several times over the past two days. It is now time to remove the drain, which my mother (who has come to nurse me) does with great speed. OUCH!! This hurts, but only for a moment.

These photos show the splint that you will have on your leg for approximately two weeks. The drains are inserted in your incisions and help eliminate accumulating fluids. The drains are removed 48 hours after surgery. Note the red bull's eye above the splint in the first photo. This is the site where the second regional block was administered.

March 29

I have experienced the onset of sudden pain in my heel. I phone my doctor who says that it sounds like I am developing a pressure sore (which can be serious) and orders me to report to the clinic. My splint is removed and there is, indeed a red spot which is a precursor to a pressure sore. I also get the first view of my ankle and manage to not feel faint in the process. (Remember, I am a wimp!!) My cast technician, Glenn (an extremely talented and competent man), pads my heel very carefully and reapplies my splint. While, I don't have any further problems, I spend my entire time in splints and casts with my my heel feeling tender and uncomfortable.

These pictures show the incisions on both sides of the ankle. Note the small incision in the first photo. This incision was made to acommodate the insertion of one of the screws that have become a part of Janice's ankle.

 
 

April 5

Today, I return to the clinic for my first scheduled post-op appointment. I look forward to each visit because it is another step down the road of recovery. The next four months seem to stretch out like a highway across the state of Texas that I must cross on crutches. I am told that my ankle looks great for an open ankle fusion. Before my cast is applied, Glenn must push my foot backwards so that my foot will be at a 90 degree angle to my leg. Otherwise, I run the risk of "walking on my toes the rest of my life." This is not a pleasant experience but mostly because I am so nervous and protective of my ankle. My cast is applied and, instantly, I am miserable. The splint allowed for a little movement but the cast is an unforgiving, hard fiberglass beast. I hate it and the idea of wearing it for six weeks is just appalling! In this instance, it's nice to NOT have a choice - if you want to walk again, you gotta do what the doc says.

April 22

This truly must be the low point. My mother left on Monday and up until she left, I didn't have to worry about taking care of the day-to-day things in life. However, today, I thought I would try to tidy up a bit. While trying to carry some items in one hand (while navigating on crutches) I swing my good foot into my crutch. OUCH!! I'm thinking that I surely must have cut my toe and when I look down, I am horrified to see my little toe sticking straight out at a 90 degree angle to my foot. Even though I am in terrific pain (worse than anything with the fusion) I manage to get to a chair without putting any weight on my fused ankle. I call my husband who comes and takes me to the hospital where I learn that I have dislocated and broken the little toe on the left foot. For a while, I am unable to get around at all unless I sit and scoot along. I worry that I will be on my butt forever but within three days, I am hobbling around again. However, I cannot wear shoes at all for a month and it isn't the warmest time of year!!

 
 
 

The fiberglass beast. This little cast (which extends to just below the knee) was the source of much discomfort for six weeks. Note the discoloration on the left foot at the base of the toes. This was as a result of the traumatic breaking and dislocating of the little toe on April 22.

 
 
 
 
 

May 5

It is the day that I have been longing for: It has been six weeks and I will be getting this awful cast off. At least that's what I thought. To my tremendous dismay, I am ordered back in a cast for another six weeks. It is now that I truly hit my lowest point. Not only must I go back in the cast (torture enough) but I have terrible fears about whether my ankle is healing. And this is where I must emphasize how important it is to communicate with your doctor even if he is (like mine was) extremely busy and you feel like you are imposing. If I had questioned him at that time, I probably would not have been so worried. The up side of this terrible time (when I entertained all sorts of terrible visions, including being lame for life) is that I grew tremendously in my faith and came out a much stronger person for the experience.

June 9

Well, I have finally come to the end of the second six weeks of confinement. The all-important appointment (where I will learn if I have healed) is today. I am practically breathless with anticipation. The faithful side of me is not worried but waiting to hear the words is entirely too suspenseful. Oh Happy Day!! My foot is healing and my cast is coming off. I am so happy and so relieved that I burst into tears! My ankle and leg looked pretty pitiful after nearly 14 weeks of no use but I don't care. I am just happy to no longer have to deal with the fiberglass beast. Instead, I am given a brace which I am to wear until the middle of July. I feel nervous about starting to put weight on my foot again and it definitely is a bit awkward, but I am just ecstatic about making progress and being able to swim again and being able to take a shower again and ... well, you get the picture. I continue to use my crutches with the brace but only part of the time! Not having to use crutches is very liberating - I can actually carry something from one room to the next!

The picture on the left shows what Janice's foot looks like after 14 weeks in a cast: a bit scrawny but intact! The picture on the right shows the pneumatic cast (brace) that she will wear for approximately six more weeks.

 
 
 

July 14

I am returning to the clinic today to see if my ankle is continuing to fuse. At the last visit, the x-ray showed that there was a small spot that had not fused. Today I learn that my ankle is almost completely fused and I get a copy of my x-rays showing my ankle as it is now. One of the consulting doctors tells me that my ankle looks beautiful. You know, beauty really is in the eye of the beholder. I take my first step without my brace and the doctor tells me not to wear it anymore. I must say that even though I don't like casts and splints and braces, I am going to feel so vulnerable without something on my ankle!

These images show the x-rays of Janice's ankle. The ankle is almost completely fused and the five screws that will remain in the ankle are evident. (Right down to the threads!) Although difficult to make out, the fifth screw can be seen at the very top of the first picture.

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What should you expect during recovery (long-term)?

July 14th Doctor Appointment-I asked many questions because my ankle felt so stiff and hard with all those screws in place.

         My doctor reassured me that most of that feeling would subside.

         He told me that the more I walked, the better I would walk. This is partly because the mid-foot becomes more flexible to compensate for the lack of ankle movement and partly because the scar tissue breaks up over time making the ankle feel less stiff.

For a while, I felt discouraged because my gait was so awkward and the progress was so gradual that I didn't see it. However, on November 7 (eight and a 1/2 months after the procedure), I walked around a lake at one of our nature parks. It wasn't a long trek - about a mile and a half - but in completing this trek, I did something that I literally had not done for years.

My doctor has said that I should expect to see the full benefits of this surgery at the one year mark and I look forward to that. Walking is still a bit weird at this point and there is still discomfort as my rusty old foot adapts and becomes more pliable. However, I can unequivocally state that the "deep to the bone" pain that I used to experience is no longer present.

These are pictures taken of Janice's ankle on November 12, 1999. The leg is in alignment and is considerably less swollen. In the first picture (back view of the ankle), the leg appears to have an indentation on the right side. This is the site of the bone graft. A portion of the fibula was removed and used to rebuild the main leg bone.

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Acknowledgements

Any time you go through something like this, there are people who bless you with their care and concern. I wish to thank my husband, Gary, and my mother, Pat Parrish, for all of the loving attention they showed in nursing me back to health.

Janice is pictured with the two people who were primarily responsible for seeing her through this ordeal: her mother, Pat Parrish, and her husband, Gary Grathen. This picture was taken in Savannah, Georgia in October of this year.

Many thanks also to:

         Dr. Nunley, my brilliant surgeon at Duke University Medical Center

         Dr. Penny Jo Lawin, consulting physician on my case

         Glenn Duncan, the cast technician extraordinaire

I would also like to thank my friends - Joan Piggotte, Caren Lucas, Karen Hotchkiss, and my sister Melissa - who were faithful about emailing me and encouraging me on almost every day of my recovery.

Last and certainly not least, I thank my God for healing me and sustaining me during this difficult time. I have been healed inside and out!


I welcome any questions or comments you may have. You can write to me at janny01@earthlink.net. Web page written and developed by Janice Grathen.
Last updated:
December 12, 1999.
Thanks for visiting!

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