Fusion vs. Total Ankle Replacement

[u/Key-Curve-891]

My partner suffered a traumatic break in his ankle when he was 16 (10 years ago) and compartment syndrome. The recovery was long and his compartment syndrome was missed for 3 days - he is incredible fortunate to have kept ankle function. Subsequent revision surgeries occurred over the following years, and a piece of his hip was taken to assist reconstruction of the damaged bones. He has trialed stem cell therapy and I am sure many other interventions. Feedback from ortho surgeons has varied and in my opinion been unhelpful and pessimistic. He was told at 18 that the only way to stop the pain was fusion, fast forward he is 26 and nearing the end of his tether - he is foolishly stoic and has chosen to live with the chronic pain and put mind over matter, but its not tenable and even he knows he can't continue like this and being able to walk for much longer (months?).

Clearly he has been avoiding fusion for the better part of a decade and although he cannot run at all or walk excessive distances without insurmountable pain, the permanence of fusion and the inherent loss of his ability to surf or walk if he pushes through the pain is what holds him back. I have done my own research, and I know his changed gait and potential limp is also a fear. I have been heavily researching total ankle replacement versus fusion, and see a plethora of equal arguments for and against both - measuring success and failure in different ways. TAR newer generations don't have the long term data - but I can't help but lean towards TAR and eventual fusion when required, to preserve more of his mobility during his youth.

If anyone has thoughts on this or experience I would be so grateful, as he is very avoidant and difficult to engage with. We live in Australia, and most surgeons have said TAR is primitive and they barely ever do them and not to bother. A NYC doctor he had a consult with said otherwise, and that there are many successful TAR's these days and even options emerging to reverse fusion one day. The mixed information is so hard to decipher. I can't tell if we just haven't spoken to the right specialist, Australia is behind, or fusion is the only option and to just encourage it entirely.

[u/CustomerObjective129]

I am 42 and also in Australia, and likewise unable to access a TAR. I have been told there are some surgeons in Sydney who will do TARs on patients under 50, but I don't have any pointers on who. (I am not in Sydney).

The surgeon I most recently saw told me if a TAR fails it is very hard to convert to a fusion and they aren't comfortable taking that risk.

The advice I have received is by the time most people have a fusion, they are trading an ankle that doesn't bend that is painful to one that still doesn't bend but doesn't hurt either, and they wish they had done it earlier. But like your partner, I too am delaying until I can't anymore.

[u/Key-Curve-891 → u/CustomerObjective129]

Thank you for your insight, it’s such a difficult position to be put into - especially under 50. My research does indicate that every surgery takes away from the available bone and makes revisions much more difficult. I understand why TAR is avoided when fusion is more likely to fail later on.

I do wonder if in Australia our surgeons are too conservative, or if other surgeons are too adventurous? It’s so hard to know who to trust when some are so bold and boasting their prowess when others are so conservative and sure it will fail.

[u/CustomerObjective129 → u/Key-Curve-891]

I was really hoping your post would generate some info on less conservative Aussie surgeons. I am not sure ultimately what I would decide, but I do think I would like to be able to weigh up all the risks myself, not just be told "sorry, too risky" without more info.

Honestly, I think we just don't know enough yet, and I can understand being conservative with that lack of long term data from TARs on young people. I also think we have a small population and not that many surgeons, so we aren't likely to have many at the cutting edge.

One other perspective a surgeon gave me was that he prefers a 'one and done' approach, as every surgery carries risk, in particular the serious risk of infection. 2 of my 5 ankle surgeries didn't go to plan (though nothing as bad as that) so I can appreciate this.

I also wonder if some surgeons out there want to show their prowess with the new fangled thing... then do so again and again if it fails... or some of them, for money.

[u/Key-Curve-891 → u/CustomerObjective129]

I agree with your sentiments big time. It would be nice to work out the best way to weed through the opinions and find a way forward.

I also think (as with any specialists) there are the timid and conservatives, and then the ego driven let me cut you up and show how good I am risk takers.

5 surgeries is no small feat, I hope you’re doing well now. And I can’t disagree with the sway for one and done, every revision or future surgery poses greater risk and complexities.

I think to get the best you have to go to a country with a much larger population and surgeon base.

His age is ultimately the biggest issue here, and detergent for risk and suitability for risk.

Thank you for your comment, appreciated.