Ankle Replacement vs Ankle Fusion in London: Which Is Right for You?

If you have been told you have severe ankle arthritis, your surgeon may have discussed either an ankle replacement or an ankle fusion. It can be hard to know which is best, and it is not as simple as ‘ankle replacement and keeping movement is always best’. The good news however is that ankle replacement surgery has come a long way in the last ten years. For the right patient, it can offer excellent pain relief while keeping the ankle moving.

I am Mr Matthew Welck, a consultant orthopaedic foot and ankle surgeon in London, based at the Royal National Orthopaedic Hospital (RNOH). I lead a tertiary referral practice for ankle replacement, complex reconstruction and revision surgery, with particular expertise in weight-bearing CT (WBCT) guided foot and ankle reconstruction. Patients are referred to me from across North London, Hertfordshire and throughout the UK. I see large numbers of patients each year with end-stage ankle arthritis, including many who come for a second opinion or for complex reconstruction and revision ankle surgery. This guide is written in plain English to help you understand both options, so you can make a confident, informed choice about the best treatment for you.

Ankle arthritis is when the smooth cartilage that cushions your ankle joint wears away. Without that cushion, the bones rub and grind together and the joint becomes painful and stiff. Common symptoms include:

• pain when walking
• stiffness in the ankle
• swelling around the joint
• difficulty on uneven ground
• a drop in your quality of life
• the ankle can often become deformed

Unlike arthritis of the hip or knee, which are most often caused by ‘wear and tear’, ankle arthritis is most often caused by an old injury — such as a previous ankle fracture, a sports injury, repeated ankle sprains, or long-standing deformity. Inflammatory conditions like rheumatoid arthritis can also damage the ankle joint.

If non-surgical treatments — physiotherapy, ankle braces, steroid injections and supportive footwear — are no longer controlling your symptoms, it may be time to consider surgery. The two main options for end stage ankle arthritis are ankle replacement and ankle fusion.

An ankle replacement (also called total ankle replacement, total ankle arthroplasty or TAR) is an operation that removes the worn-out surfaces of your ankle joint and replaces them with new metal and plastic parts. As a London ankle replacement surgeon based at the Royal National Orthopaedic Hospital (RNOH), I perform ankle replacement, complex reconstruction and revision surgery using weight-bearing CT (WBCT) guided planning. Unlike a fusion, the joint still moves after surgery — which is one of the biggest reasons patients choose this option.

Modern ankle replacement surgery uses:

• detailed 3D planning before the operation
• patient-specific cutting guides where appropriate
• modern implant designs that move more like a natural ankle
• weight-bearing CT (WBCT) scans to plan alignment and understand the exact deformity before the surgery

The main benefits of ankle replacement are:

• the ankle keeps moving
• a more natural walking pattern
• less strain on the nearby joints in the foot, so if they already have arthritis it is theoretically protective
• excellent long-term pain relief for the right patients
• quicker and easier recovery than ankle fusion, with weight bearing in plaster allowed at 2 weeks

The main drawbacks of ankle replacement are:

• the replacement can wear out or loosen with time
• it can be difficult to correct severe deformity

For many patients with end-stage ankle arthritis, ankle replacement is now the treatment of choice — particularly when performed by a specialist surgeon who regularly carries out ankle replacement, complex reconstruction and revision surgery in a tertiary referral centre such as the RNOH. Mr Welck’s practice combines high-volume ankle replacement experience with WBCT expertise to plan each operation precisely.

An ankle fusion (also called ankle arthrodesis) permanently joins the bones of the ankle together so the joint no longer moves. The worn surfaces are removed and the bones are held together with screws or plates until they heal as one solid block of bone. The stiff, deformed and painful joint, turns into a stiff, painless and well aligned joint. It is essential to appreciate that the foot joints underneath the ankle still move with an isolated ankle fusion, so there is still up and down, and side to side movement afterwards.

The benefits of ankle fusion include:

• excellent pain relief
• a very durable, long-lasting result (it doesn’t wear out)
• a long, proven track record
• often a good choice when the bone is poor or the deformity is severe

The drawbacks of ankle fusion are:

• a slightly altered walking pattern in some patients
• a higher long-term risk of arthritis developing in the surrounding joints (the subtalar and midfoot joints) as they have to work harder
• a small risk of the bones not healing (non-union)

Ankle fusion remains a very important and reliable operation — particularly for younger, very active patients, those doing heavy manual work, those with severe deformity, or those who are not suitable for ankle replacement. This is because ankle fusions do not wear out with time, as ankle replacements can do, so can be a better option for younger, active patients. For many people, fusion is the right answer. Choosing between the two requires honest, balanced advice from a specialist foot and ankle surgeon who performs both operations regularly. As a tertiary referral foot and ankle surgeon at the RNOH, Mr Welck offers both ankle replacement and ankle fusion, including revision surgery for patients whose previous operation has not worked.

Both operations can give excellent pain relief. The right choice depends on you — your age, activity level, alignment, bone quality, previous surgery, and personal goals.

Mr Welck will discuss both options and tailor the treatment to exactly your conditions and needs.

There is no one-size-fits-all answer. The decision between ankle replacement and ankle fusion is based on a careful assessment of several things:

• your age
• your activity level
• any deformity in your foot or ankle
• any previous ankle surgery
• the quality of your bone
• the overall alignment of your foot and ankle
• whether arthritis is also present in the surrounding joints

Patients who often do well with ankle replacement include:

• people with painful end-stage ankle arthritis
• patients in their 50s, 60s and 70s (although age alone is not the deciding factor)
• those with reasonably good bone quality
• those with a well-aligned foot, or a deformity that can be corrected during surgery

Patients who may do better with an ankle fusion include:

• young, very high-impact athletes or heavy manual workers
• those with very poor bone quality
• those with severe deformity that cannot be corrected with a replacement
• some patients with a previous ankle infection

Being seen in a tertiary referral foot and ankle practice matters because these decisions are rarely simple. The widest range of surgical options is available in centres that routinely perform both ankle replacement and ankle fusion, including complex reconstruction and revision surgery when earlier operations have not worked. Mr Welck runs a tertiary referral practice at the RNOH for exactly these cases.

Every patient is different, but a typical recovery after ankle replacement looks like this:

• 2 weeks — the wound heals, you wear a half plaster to allow for swelling, and you do not put weight on the ankle. The ankle is strictly elevated.
• 2–6 weeks — gradual increase in weight-bearing in a plaster.
• 3 months — significant improvement, walking comfortably.
• 6–12 months — ongoing recovery and strengthening; most patients reach their best result around 9–12 months.

Recovery after an ankle fusion follows a longer timeline, as the bones need to fully heal together:

• 2 weeks — the wound heals, you wear a half plaster to allow for swelling, and you do not put weight on the ankle. The ankle is strictly elevated.
• 2–4 weeks — plaster, non weight bearing.
• 4–8 weeks — plaster, crutch weight bearing.
• 8–12 weeks — plaster, full weight bearing.

Whichever operation you have, your recovery is supported by a structured physiotherapy and rehabilitation programme tailored to you — especially important after complex reconstruction or revision surgery.

Ankle replacement today is very different from the operation done even ten years ago. Modern advances include:

• improved implant designs with better long-term wear
• 3D imaging and surgical planning
• weight-bearing CT (WBCT) scans for accurate alignment
• personalised, patient-specific cutting guides
• better techniques to correct deformity at the time of replacement
• more revision options when older implants wear out

These advances mean ankle replacement can now be offered safely to a wider range of patients, including those with deformity or previous surgery who in the past would only have been offered a fusion. If you are looking for the most up-to-date care, choose a surgeon working in a specialist tertiary referral centre — one that not only performs ankle replacement routinely, but also handles complex reconstruction and revision ankle surgery.

Both ankle replacement and ankle fusion can give excellent pain relief. The best choice for you depends on your arthritis, lifestyle, alignment, bone quality and personal goals. A careful assessment by a specialist foot and ankle surgeon is essential to find the right treatment for you.

If you are thinking about surgery for ankle arthritis, the most important first step is a thorough, balanced consultation with a surgeon who carries out both operations regularly. As Mr Matthew Welck — Consultant Orthopaedic Foot & Ankle Surgeon, London, based at the Royal National Orthopaedic Hospital (RNOH) — I see patients from North London, Hertfordshire, across the UK and internationally for ankle replacement, ankle fusion, complex reconstruction and revision surgery, with particular expertise in weight-bearing CT (WBCT) guided foot and ankle reconstruction.

To arrange a consultation, please visit matthewwelck.com.

A useful video discussing Ankle Replacements and Ankle Fusions can be found at the RNOH fusion forum video. See https://www.youtube.com/watch?v=ovmAo_gmeN0

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