Revision Ankle Replacement Surgery - Purpose, What to Expect

Revision Ankle Replacement Surgery is performed to revise the non-functional prosthetic components inserted during the primary ankle surgery. The procedure also involves repairing the damaged soft tissues or ligaments near the ankle joint if required. 
Primary ankle replacement surgery replaces the deformed or damaged ankle joint with an artificial implant.
Although the availability of the newer types of prosthesis has increased the success rate of the surgery, many patients still need to undergo a revision ankle replacement after five to ten years. 

Surgery Name	Revision Ankle Replacement Surgery
Alternative Name	Ankle Arthroplasty
Conditions Treated	Ankle deformity, Infection after the primary ankle replacement surgery, Segmental bone defects, Damaged soft tissues around
Benefits of Surgery	Relief from chronic pain, Increased joint stability, Improved range of motion, Increased quality of life
Treated By	Orthopaedic Surgeon

The ankle joint combines three bones- the tibia, fibula, and talus. 

1. Tibia: It is the anterior bone in the lower leg. The tibia bears most of the body weight and is an important part of the knee and ankle joint. 
2. Fibula: The fibula is located on the lateral side of the lower leg. It is positioned behind the tibia and is relatively smaller and thinner. It also runs from the knee joint to the ankle joint. 
3. Talus: It forms the lower part of the ankle joint that allows the foot’s upward and downward movement.  

The tibia, fibula, and talus join together to form a synovial joint that allows ankle mobility due to lubricating fluid between the bones. 

1. Ankle deformity
2. Infection after the primary ankle replacement surgery
3. Segmental bone defects - injury resulting in a shattered bone or a bone with a significant gap
4. Damaged soft tissues around the ankle joint
5. Arthrofibrosis - a fibrotic joint disorder which develops too much scar tissue resulting in restricted motion and pain

Those who are experiencing the following conditions may need a revision ankle replacement surgery: 

1. Loosening of the prosthetic component 
2. Sinking of the prosthetic component inside the bone (component subsidence)
3. Bone fragmentation or fracture in the ankle joint
4. Instability in the ankle joint
5. Stiffness in the joint restricting the motion of the joint

Depending on the reason for the revision of ankle replacement, the surgery may involve repair, realignment, and repositioning of the bones, ligaments, and tendons in the ankle. If the previous implant is damaged and not functioning properly, a surgeon carefully removes it and replaces it with the revision components.
The procedure of revision ankle replacement surgery is more challenging than the primary surgery, and it may also involve more risks. 

The procedure typically involves:

1. Placement of antibiotic cement spacer to fight infection 
2. Use of trabecular metal cage (metal revision shells) in case of severe bone loss to provide stability to the joint until the biological growth of the bone
3. Bone grafting to compensate for the bony deficits
4. Repair or replacement of the prosthetic components

Before the Surgery

1. The patient tells the doctor about all the medicines they have been taking, including non-prescription drugs such as Aspirin.
2. Blood thinners, including certain anti-inflammatory medicines and vitamin supplements, should be avoided before the surgery as per the doctor’s advice, as they can increase bleeding. 
3. Imaging tests like an X-ray are required to examine the surgical site. It also helps in determining if the components have loosened up or dislocated. The presence of bony fragments can also be detected through an X-ray.
4. The doctor may also require an MRI or CT scan to identify any damage in the ligaments or tendons which is not visible in the X-rays. 
5. The patient must also inform the doctor if they have ever experienced any wound-healing issues in the ankle. 
6. The patient must clear all doubts regarding the risks and benefits of the procedure.

On the Day of Surgery

1. An anesthesiologist evaluates the patient and asks about their preference for a general or a nerve block (local anaesthesia).
2. General anaesthesia renders the patient unconscious, whereas a nerve block only numbs a group of targeted nerves to reduce pain while the patient remains awake during the surgery. 

During the Surgery

1. At first, the healthcare providers place the patient in a supine position and apply a tourniquet to the ankle (a device used to prevent the blood flow in a limb by applying pressure). 
2. The surgeon cuts the anterior part of the ankle, following the line of incision made during primary ankle replacement surgery. However, the incision may be longer than the previous one to allow the removal of the old implant. 
3. The surgeon then fully exposes the ankle joint to examine the components and remove any damaged tissue. 
4. They also check the metal and plastic parts of the implant to identify the worn-out or loosened parts.
5. If required, the prosthetic components made of plastic or metal are removed while saving as much bone as possible.  
6. In case of significant bone loss, cement and bone grafts are used to support the revision components to compensate for the bony deficits. 
7. Bone graft materials are rarely used. But in case of a significant bone loss, the surgeon may take the graft from the patient’s bone (autograft) or a donor (allograft). 
8. Finally, the surgeon inserts the revision components, repairs the surrounding soft tissues if damaged and checks the ankle joint's balance and range of motion. He/she also ensures that the ankle and foot are properly aligned. 
9. Once the components are positioned properly, the surgeon closes the wound with stitches and sutures. 

After the Surgery

1. The healthcare providers monitor the patient's vitals and the after-effect of anaesthesia in the recovery room.
2. Once the patient's condition is stable, they are transferred to a hospital room, where they must stay for several days.  
3. After the surgery, pain and swelling are normal. The healthcare providers give pain-relieving medicines for faster recovery. 
4. The doctor or a physical therapist suggests specific exercises to restore mobility in the ankle joint. 
5. The doctor gives blood-thinning medicines to reduce blood clotting.
6. They may also prescribe antibiotics before and after the surgery to prevent infection. 

At Home

1. The patient must ensure the use of crutches or a walker as per instructed by the doctor
2. They must also wear a splint or a cast to immobilise the joint for proper healing

Physical therapy can help the patient recover faster. It may include:

1. Strengthening exercises
2. Massage to reduce the swelling 
3. Gait training exercises to help the patient move and walk
4. Stretches to improve the flexibility of the joint
5. Weight-bearing exercises 
6. Increasing hip and knee core strength
7. Elevating ankle upto the level of heart

Restrictions

The patient must avoid doing the following activities until the doctor approves:

1. Participation in activities that causes an impact on the joint such as jumping or running 
2. Heavy lifting or manual labour
3. Dependent positioning of the foot for long time intervals
4. Complete elevation of the ankle

Recovery

1. The length of recovery varies depending on the complexity of the surgery. But it generally takes six to twelve months to restore the normal functioning of the joint. 

First Follow Up Appointment

1. The patient usually needs to visit the hospital a few weeks after the surgery.
2. The doctor examines the incision during the appointment to ensure the wound is healing properly. He/she may also order imaging procedures to confirm the surgery’s success.
3. The doctor also informs about the next follow-up visits to remove the stitches and check the healing progress. 

The benefits of Revision Ankle Replacement include:

1. Relief from chronic pain
2. Increased joint stability 
3. Improved range of motion
4. Increased quality of life

Like any other surgery, the revision ankle replacement also bears the risk of certain complications. They may include:

1. Post-surgical infection
2. Increased pain in the ankle
3. Improper bone healing
4. Incorrect alignment of the joints
5. Impingement (chronic pain due to increased pressure on the tendon or friction between the tendon and its adjacent structures)
6. Damage to the nerves or blood vessels during the surgery

When to Consult a Doctor? 

If the patient notices any of the following symptoms, they must consult the doctor immediately:

1. Drainage from the incision site
2. Increased swelling in the foot or ankle
3. Fever or chills
4. Any sign of infection

The risks of delaying the surgery include:

1. Instability in the ankle joint may increase over time, disabling the foot movement
2. Excess build-up of scar tissue can cause stiffness and chronic pain while using the joint 

The cost of Revision Ankle Replacement Surgery ranges from ₹2,00,000 to ₹3,00,000. The cost varies based on the following factors:

1. Type of surgery
2. Age of the patient
3. The medical condition of the patient
4. The type of hospital facility availed - individual room or shared.

Procedure Name	Cost Value
Revision Ankle Replacement Surgery	₹2,00,000 to ₹3,00,000