UKC

Any climbers out there with first hand experience of either ankle replacement or tibiotalar fusion I could talk to?

I'm heading towards this. Seen a very good surgeon so I've got the low down. I've got an old injury with OA.

Im interested to know how much it affects things like alpine long days, ice climbing, rock etc. 

At present I'm grinding along with steroid injections and orthotics but there comes a point where replacement is no longer possible.

I've posted before about my sodding ankle so sorry to repeat and I know it's a relatively common thread. 

Ta peeps.

Roger

I've had a tibiotalar fusion and have written quite extensively on here about it. Rather than repeat it all I'll link to the threads I can find. If you want to ask anything further just ask.

https://www.ukclimbing.com/forums/rock_talk/long_term_ankle_fusionists-7321...

https://www.ukclimbing.com/forums/off_belay/ankle_fusion-643924?v=1#x832547...

https://www.ukclimbing.com/forums/rock_talk/climbing_with_a_fused_ankle_any...

Thanks. My options are a replacement but they end in a second op often at 10 to 15 years which is often fusion. I'm 50 so youngish for the op. Or straight to fusion. Recovery from replacement is a lot quicker.

It's that decision of struggling on, and when. There comes a point where you can't do a replacement with my issue. Talus rocking over.

You've replied to a previous post of my mine.

I think there's no great solution but Im getting pissed off with the chronic pain.

Such is life. 

Would there be more of a chance of sending other parts of your affected leg and pelvis and core etc out of whack with a fusion than with a replacement? If there would be, I might go for a replacement and embrace the extra chapter of life of being more active without those potential issues, and think about those when I get to having them with a fusion. 

I have no experience of replacement, just that I was told at the time of my fusion they didn't last very long and weren't suitable for very active people. Perhaps they've got better and last longer now?

I think you'd need to discuss that with your consultant. If you aren't entirely satisfied that you can discuss it with him at the lengths you would like to then get a private consultation with someone who offers both fusion and replacement. It will cost you about £200 but it's worth it. I saw two private consultants before my fusion and spent around 45mins discussing things with each of them. You just don't get that kind of time on the NHS and you might not even see the top man anyway, just one of his juniors.

I'm now 10 years post fusion and still skiing, climbing (including Alpinism) and walking regularly. I have got some arthritis in the other ankle joints so I take ibuprofen in advance of long days but the chronic pain of a throbbing ankle all day everyday and constantly limping about in pain is a thing of the past and has been life changing. As far as normal daily life is concerned I wouldn't know I'd had a fusion.

From what you say you're at about the stage I was when I had my fusion and my advice would be to choose one of your options soon, don't carry on in pain any longer than you have to.

Wish I could be more helpful re which option to choose but do bear in mind fusion is a long, long recovery and you may not be able to work or drive for a few months (depending on what your job is). And definitely don't take ibuprofen (or other anti inflammatories) until the fusion is fully completed (6 months or more) as it inhibits the inflammatory process needed to fuse the bones. If the idiot physio at the hospital had told me that I'd have saved myself a year or more of further treatment.

Good luck.

Yeah, OA in the other joints in the foot can happen. And yeah I think a fused ankle will probably affect knees, hip , back. Thing is.....a stiff OA ankle makes you walk awkward anyway so to an extent, that issue is already present. But yeah I think keeping some ankle movement for as long as can is possibly better. Amazingly, you can walk 2w post op on replacement.

Thanks again. Yeah I saw a private surgeon with a great reputation. To have surgery private is 1700 quid. So I'm off to see what NHS can offer. Getting a few steroids injected in mean time but if they don't work I guess I'll try find the money. I suspect it's a long long wait NHS.

Do you mean 17000? I'm looking at knees at the moment and they are that sort of price.

I wondered as much, I did a google and found out about the foot joined to the related ankle being affected by fusing. Pesky biomechanics.

Yeah. Sorry. 17000. Fookin expensive.

I guess you could take up cycling/mountain biking, and see if that extended the lifespan of a replacement ankle joint?

A friend of mine rather buggered his talus in a mountaineering accident.

After months of hoping it would heal and going through all the available options, he opted for below the knee amputation, reasoning that that would give him the best result and quality of life compared to a fusion.

Haven't seen him for a number of years, but last I saw him he had a climbing foot, a watersports foot and so on.

It is, admittedly, the extreme option, but, for him, it seems to have been the best option.

Is that £17k for ankle replacement or fusion? When I had my private consultations they quoted about £2.5-3k for fusion. That's 11 years ago but it can't surely have jumped that much?

This website quotes £4.7k as the UK average price for fusion

https://www.privatehealth.co.uk/conditions-and-treatments/ankle-fusion-oper...

I was thinking further about this thread today and your situation.

It sounds very much like you've reached the end of the road without some surgical intervention. I don't know whether your dilema is whether to have surgery or not, or whether you know you need surgery but can't decide which.

When I was in your position I was desperate to put off fusion for as long as possible. I'd built it up in my head that it was some kind of voluntary disability that was going to take away the life I loved.

In fact the opposite was true. It was the arthritis that was slowly taking away my lifestyle and fusion gave me it back. In terms of joint mobilty, the arthritis had reduced it so much that fusion didn't make any difference. I could go back to doing everything I did before but without the pain, I'd forgotten what it was like to not be in constant pain.

Unfortunately I can't advise whether replacement or fusion is better for you but you should do one of them. Replacement might be your better option but fusion won't be the wrong option if you see what I mean.

The only issue regarding fusion is the length of the recovery and the practical issues of day to day living when you can't put any weight through one leg for 3 months, need to keep it elevated most of the time and can't use your hands freely because you need them for your crutches. Working, driving, cooking, shopping, washing and anything else you can think of become problems, especially if you live alone. You need to think these through in advance. If you want I can go into more detail on what I found during my enforced idleness.

Surgeon says climbing cycling walking is all ok. Running is possible but wears out the implant quicker. 

I have tried to put off surgery as you say hoping to manage with ibuprofen etc. And thinking I'll be compromised following anything surgical. But, yes, the OA causes plenty of compromise. I have reasonable spells with low grade pains but with frequent flare up where I'm pretty lame.

It's the unknown that's the concern I guess.

How bad is your pain now with the OA in surrounding foot joints? Is it well controlled with ibuprofen. You say you'll take ibuprofen before a day out. 

I'm not apposed to surgery and plan to have something done next few months I suspect. It's choosing which option. Surgeon says it's a personal choice. Part of me thinks I may be better just getting fusion as they're maybe more robust and cope with some abuse. I'm cautious I'll wear out a replacement pretty quick. I suspect things like Scottish walk ins have a similar result to running. They feel the same to me afterwards.....ie pretty hobbly lame.

I'm getting intro articular steroids which I haven't tried yet but surgeon says at best that'll work for 2 years.

Thanks for chatting. Your perspective is very helpful

I perhaps might be looking into the long term effects on the body of OA in the foot of the ankle affected following a fusion, with you being 40, and if it's more of a thing in just the foot following a fusion. If you wear out the replacement joint, then go for a fusion, it would be another OP, which would be a certain level of grimness, but I guess that needs to be balanced against what the longer term effects of a fusion are, if they can increase over time?

That is, if you're 40, and a replacement joint lasts for ten or fifteen years, and then you have a fusion, and then it takes however many years for the extra wear on the foot of the affected ankle to have an effect, that's maybe 15 to 20 years of not having OA in the foot of the affected ankle.  I'm wondering if though a replacement joint wouldn't last forever, it could put off the point at which the extra wear on certain joints resulting from a fusion become apparent, which could add to quality of life in the longer term.

Edit: I am the kind of person who can overthink things to the nth degree, though.

I'm 51 now. Need to update my profile.

Yes you could be right.

Surgeon said fusion leads to OA in subtalar jnt and another joint....not sure name. I think there's pros n cons with either.

I'm working now but will reply to your post above (at 10:11) this evening.

OK, to answer your post above.
I already had some OA in the other ankle joints so it wasn't brought on by the fusion. It has perhaps got fractionally worse over the last 10 years, it's hard to say but no more than fractionally.

For day to day activities and light outdoor stuff, e.g. easy walks up to say 5 miles, general cragging with shortish walk ins I wouldn't need to take ibuprofen. These activities don't normally cause any problem. Sitting awkwardly putting pressure through my foot doing DIY or standing on an awkward stance etc may cause temporary mild pain but it quickly eases off once I move.

For longer walks and mountain crag walk ins, especially with a lot of steep descent and if carrying a heavier pack I'll start taking ibuprofen 1 to 3 days in advance depending on just how demanding it's going to be.

e.g a day cragging on Scafell I'd start the day before, a weekend of Scottish winter climbing 2 or 3 days before. Towards the end of long days it may stiffen up a bit but quickly clears up. I don't get the days of throbbing pain and limping I used to get.

I have found that the softest, lightest footwear I can get away with for any activity helps so I've dropped from B3 to B2 winter/alpine boots and wear goretex/fabric walking boots intead of leather.

There's nothing I used to do that I can't do now, e.g. just got back from a week's skiing, did a 20 mile overnight backpack a few weeks ago and in the Pyrennees the summer before last, did 21 hour day with a 2 mile walk in, 16 pitches of climbing and a 6 mile walk out.

Shortly before my fusion I just about managed to reach Stanage popular end using trekking poles with my mate carrying the full rack and ropes.

A few further thoughts on the replacement v fusion decision.

Putting myself back in your position, I'd definitely have been tempted by the replacement if it was realistic but I'd want reliable answers to a few questions.

1) How long is the recovery time for replacement? Fusion recovery is a big negative but you might have to go through it anyway at some point.

2) Can a replacement really stand up to the sort of punishment you're likely to give it? I'd try and be totally frank with the consultant about this, their idea of heavy use might not be ours!

3) How does a replacement affect or complicate the possibility of a later fusion? With fusion they trim off a few mm from the tibia and talus and screw them together to fuse. With a replacement don't they have to embed the artificial joint into the surfaces of these bones which would presumably require more bone removal which then has to grow back during fusion or need grafting?

If fusion is inevitable at some point I wouldn't want to make it more complicated than it needs to be.

It sounds like pec really knows what he's talking about, I just have a mind which looks for problems ahead of time, towards circumventing them.

Thanks pec. 

You should write a book on this. It's the stuff that the surgeon can't necessarily tell you.

Yeah, youre doing great by the sounds of it. I'm assuming you're 10 ish years post op.

I've googled around Abit and it seems there is a concern that if the replacement fails which is likely at 10 15 years, your needing fusion and this would be a more complicated op then. The bone stock is less, less healthy, will have a shorter leg. So replacement is good while it lasts (so long as it heals properly) but you'd have Abit of a cloud looming over you sort of waiting for the next surgical onslaught. At present these replacements are converted to fusion but this may change. Hmmm. Not sure if that's going to happen or not.

I read that the secondary OA in surrounding joints is seen in people who don't have fusion and are treated conservatively. So, as you maybe suggest, the link of fusion to subtalar OA occuring is maybe not the full story and maybe is......mashed tibiotalar joint leads to knock on effects to other joints no matter what you do. Your thoughts pretty much describe the pros and cons to it all that I've read.

One website said if below 55, then fusion maybe better as it avoids further surgery hopefully. 

So I'm thinking after turning my brain inside out that fusion may suit my needs and my mind set better. But also, both options are viable. I'm going to see the GP and hopefully be referred into the NHS Ortho system. Get opinions there. In the mean time I'm waiting to get some joint steroid injection. I'm not adverse to going private especially if it's the 5000 fusion. But 17000 is a big ask. 

Thanks for chatting. I'll let you know how I get on.

Thanks timmd. I think it's wise to overthink these things. 

Yes, its 11 years since the operation.

Whilst non weight bearing there was almost no pain, except when I stood upright and all the blood rushes to your foot, then it stings like buggery! Once I statred weight bearing there was some pain (to be expected)  and because of the bad advice I'd been given, I took ibuprofen which inhibited the fusion. Hence after the 6 months recovery only about 15% of the joint had fused and you need about 50% (I think) to be successful.

The hospital wanted to do the whole operation again but with an Illizarov frame like this

http://www.stuffsandthings.co.uk/wp-content/uploads/The-Frame.jpg

to which my thought was f*** that for a game of soldiers, so I asked to be referred to another consultant who specialised in failed fusions at Oswestry, a specialist orthopaedic only hospital.

This added a 6 month delay, but once I saw him he got some funding for an experimental ultrasound treatment trial. This entailed putting a device on the ankle for 20 mins twice a day to bombard it with ultrasound of the right frequency which stimulates bone growth without any pain.

After 6 months of this my joint fused properly, but altogether it was 18 months after the op before full fusion so 9.5 years ago now.

It seems like the replacement option offers a better outcome in the short to medium term (say 10 years) but could complicate things in the long term unless you're willing to adopt a sedentary lifestyle.

I think this is what you should clarify with a consultant. How long will a replacement last with your activity level and how difficult does it affect future fusion.

Fusion offers less ankle mobility which means I can't run without an obvious limp, though I walk without any noticeable limp, and walking up steep slopes is a bit like front pointing with that leg. I avoid running so as not to wear out the other joints quicker but apart from that it makes almost no difference and I don't get a tired calf on that leg when I'm actually front pointing on ice I have had to modify my ski boot to add extra heel left to tip the knee forward to a more normal skiing position.

One more thing, about 4 years ago I developed a Moreton's Neuroma in my foot, a pinched nerve in the forefoot which causes little "electric shocks" in your toes. Apparently it's not rare post fusion. It was treated with a single steroid injection and has not occurred since. If it does recur and streoids ever fail to treat it they just snip the nerve, my father in law had this done. It's not a big deal, just something to be aware of.

BTW, was the £17k for replacement or fusion?

Good luck.

17000 for replacement. I didn't ask about fusion cost. I was sold on the replacement. 

Yeah.....I do the front pointing thing up hills. 

That makes sense, fusion should be sub £5k

It'll get easier once your ankle's fused