Ankle Surgery

The foot and the lower leg intersect with a connection of 14 bones along two separate joints and a complex web of ligaments and tendons making up the entirety of the ankle. 

The ankle joint itself is tasked with allowing the foot to move up and down, while horizontal movement happens on the subtalar joint, just below it. The three primary bones meeting along these joints are the tibia, or shinbone, the smaller fibula, or calf bone, and a foot bone, the talus. 

The ankle is able to absorb daily stress while the foot moves smoothly over those joints with a coating of tissue at the ends of the bones, called cartilage. The foot is pulled one way or another by tendons attached to leg muscles, including the notable Achilles’ tendon above the heel. 

The many tendons and ligaments holding the ankle together are made of tough, but flexible tissue that is able to withstand sudden strains and ongoing stress, but in both cases has limits. 

Each year about half a million Americans see a doctor for treatment of a broken ankle.

The symptoms of an ankle fracture can easily overlap with those of a severe sprain, making it important to see a doctor to diagnose the injury. Frequently an X-ray can show a doctor if there is a fracture and if it is necessary to refer the case to an Orthopedic surgeon. 

If a fracture breaks the bones out of alignment, a surgeon will need to put them back into alignment so the joint can heal properly, often in an open reduction internal fixation (ORIF) procedure. In such a case the surgeon brings the bones back into alignment (reduction) and secures them with a plate, screws, pins or wire (fixation).  

Although bones can mostly heal after six weeks, it may take longer for tendons and ligaments to repair.

Among the more dramatic ankle injuries is a ruptured Achilles tendon in which the tendon snaps and sometimes entirely detaches the calf muscle from the heel. This is most common for athletes or other people playing sports, but can also happen in other situations. 

The calf muscle powers movement of the foot, specifically pointing up at the toe or pushing down on the ball of the foot and so a full tear of the Achilles tendon can make that movement impossible. 

Although many injuries set in over time, a partial or full Achilles tendon rupture is often noteworthy for what happens at the moment of the injury as symptoms include: 

• A pop or snapping sound at the moment of injury
• A feeling of having been kicked in the calf muscle
• Potentially severe pain and swelling near the heel
• Inability to bend the foot downward or push off the injured leg
• Inability to stand on the toes of the injured leg

Often a partially torn Achilles tendon will be able to heal on its own, but in more severe cases your doctor may refer you to an Orthopedic surgeon to repair the tendon.  

Ankle Tendon Repair

An Orthopedic surgeon may stitch a partially torn tendon to assist and speed up the healing process, or in the case of a complete tear, the tendon is reconnected between the calf and heel. 

The surgeon will often use sutures to fix the tendon back together to heal, or in other case may use tissue from another part of the body to help reinforce or replace the damaged portion of the ankle’s tendon.

Over the course of recovery, a cast is often replaced by a boot as weight is slowly allowed to be placed on the foot again and movement is reintroduced with physical therapy. In total it is often six months before a patient may return to full activity and up to a year before there is full recovery.

Gastroc Release Surgery 

A problem that can follow an ankle tendon injury or lead to the injury in the first place is a chronically strained calf muscle and tendon. An Orthopedic surgeon can help relieve this issue and provide the ankle with that tiny additional slack it needs.

Gastroc release, or calf lengthening, is a tendon treatment dating back to the 19th century, and is now performed by several approaches, one of the most common methods is referred to as the Strayer Procedure.

The calf muscle is made up of two smaller muscles, the gastrocnemius, or gastroc, and the soleus. The gastroc is the larger of the two and combines with the soleus in the Achilles’ tendon.

Generally, in a gastroc release, an Orthopedic surgeon enters the calf through the middle of the muscle, where the gastroc tendon is located and cut. When the muscle heals, it heals in a longer position, relieving stress that had been pulling on the ankle and foot.

After the procedure, patients often wear a protective boot for several weeks as the muscle heals. Irritation or numbness may be felt at the heel, but usually are temporary side-effects. 

Ankle instability appears with chronic pain and a frequent feeling that the joint is going to fail or give out under weight. It often results from a sprained ankle, which makes a person more susceptible to future ankle sprains and further ankle issues.  

A doctor can diagnose chronic ankle instability through an examination by assessing the alignment of the foot and ankle, the midfoot arch, and the strength and range of motion of the foot at the ankle joint. If a doctor suspects chronic ankle instability they may refer you to see an Orthopedic surgeon for treatment. 

Chronic pain that accompanies ankle instability is often caused by three specific issues: ankle ligament tear injury, synovitis, and the presence of scar tissue or bone fragments. 

An Orthopedic surgeon can often treat the condition with an arthroscopic procedure, in which the surgeon will make a small incision at the back of the ankle and insert a tiny camera in a tube, which allows for direct viewing of the joint on a nearby monitor. 

With the aid of real-time imaging, the surgeon is able to remove bone fragments or other floating debris that cause pain in the joint, and reduce irritation through debridement — trimming and removing frayed cartilage and tendon tissue. 

Instability can also be reduced by tightening the joint through tendon reconstruction, replacing the strained tissue.  

Ankle arthritis is less common than arthritis in other joints in the body, but for many, growing pain with a loss of motion in the ankle can make day-to-day life difficult and many activities impossible. 

Typically ankle arthritis pain can be traced back to rheumatoid arthritis or osteoarthritis. Rheumatoid arthritis is a disease that causes the body’s immune system to attack joint tissue, causing swelling, loss of movement and over time wearing of the cartilage between bones, then damage to the bones themselves. 

Osteoarthritis, or degenerative joint disease, is a wear-and-tear arthritis in which the cartilage between the bones wears down over years of stress and activity. The breakdown of cartilage leads to greater friction, more joint pain, and with the loss of that protective layer, more damage to the joint. 

The ankle is unique among joints for being at risk of post-traumatic arthritis. Post-traumatic arthritis is a long-term condition sparked by an acute injury or series of injuries. Although bones and tissue may heal from a fracture or severe sprain, the parts of the joint may remain out of alignment, causing friction and eventually, degradation of the joint. 

Post-traumatic arthritis accounts for over half of all cases of ankle arthritis. It is more common among younger, active people, and while osteoarthritis often causes a general pain and stiffness in the joint and the surrounding area, post-traumatic arthritis often causes a specifically located pain. 

Symptoms of post-traumatic arthritis can include: 

• Catching
• Locking
• Clicking
• Painful incidents of the joint giving out
• Changed gait when walking
• Severe loss of function 

Typically, your Orthopedic surgeon will offer non-surgical treatment options first. If these treatments do not adequately relieve the symptoms of ankle arthritis pain, your Orthopedic surgeon may discuss whether you are a good candidate for ankle surgery such as total ankle replacement surgery or joint fusion surgery. 

Ankle Joint Fusion Surgery

There are several variations of ankle fusion surgery, or arthrodesis, which can be performed as open surgery or as an arthroscopic procedure. Many Orthopedic surgeons prefer using an arthroscopic method to minimize incisions and blood loss, while allowing for shorter recovery time. 

In either case, the patient is often given general anesthesia and will sleep through the surgery. The Orthopedic surgeon will then make an incision at the heel and begin the procedure by cleaning the area around the joint, removing tissue debris and bone spurs, and trimming damaged and frayed cartilage. 

Articular cartilage is removed from the area between the two sections of the ankle joint, with healthy bone exposed. The two parts are then aligned and fixed together with screws. The exposed bone allows the separate parts of the ankle to heal together as a single bone, like a bone healing from a fracture. 

The screws usually remain in the ankle unless an issue of pain or irritation presents itself following surgery. 

After surgery, your foot is often wrapped for about two weeks, after which, you are given a short-leg cast. 

During recovery, your foot and ankle cannot bear weight until the separate parts of the ankle begin to heal together, which may take between eight and 12 weeks. 

When your ankle is fully healed you can expect to return to most of your previous activity without complication. Most patients recover and are able to walk without any visible difference in gait or permanent limp, although the fused joint often affects a person’s gait when running.  

Osteochondritis dissecans of the ankle, or OCD, is a condition that primarily affects children and young teenagers, in which changes in bone structure and repetitive stress can cause damage to the end of a bone. Though it can often be treated with rest and stabilization, more serious cases — particularly in older teenagers and adults — may require Orthopedic surgery. 

Typical symptoms of OCD include pain in the ankle, particular when running, but in more extreme circumstances, such as when a piece of the bone breaks, symptoms can include: 

• Swelling around the ankle
• A popping or locking sensation
• Weakness or instability
• Limited range of motion 

There are generally three conditions that require an Orthopedic surgeon: failure of previous non-invasive treatment, detachment of the bone fragment, or decreased ability of the bone to carry blood in the future. 

Often an Orthopedic surgeon is able to treat the ankle with minimally invasive arthroscopic techniques, which also, with the use of a tiny camera into the joint, allow the surgeon to directly see the condition of the joint. Depending upon the seriousness of the injury and size of a bone fragment, a surgeon has several options for treatment: 

• Debridement, smoothing the frayed and broken edge of the bone
• Internal fixation, using pins or screws to put the broken piece of bone back in place
• Removal of a broken bone or tissue fragments from the joint
• Stimulating new blood flow through microfractures or drilling into the ankle
• Transplant of bone or tissue from another part of the body to the ankle 

Left untreated, OCD can contribute to the development of arthritis later in life. Your Orthopedic surgeon will help determine if surgery is right for you and what options are available. 

The different approaches of OCD treatment, more than representing a difference in preferred techniques, have different end goals, from reduction of internal irritation, to resetting a dislodged piece of bone to stimulating the body’s ability to grow and heal bone and tissue in the ankle. 

Recovery often entails several weeks of using crutches to avoid putting weight on the ankle, followed by two to four months of physical therapy. For many active young patients, they may be cleared to return to playing sports four to five months after surgery. 

Fellowship-Trained Foot and Ankle Surgeon: 
Andrew M. Ertl, MD