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When conservative methods of relieving painpainAn unpleasant sensation associated with actual or potential tissue damage, and mediated by specific nerve fibe... or deformities in the ankle are unsuccessful, a surgical procedure called ankle fusion (arthrodesis) is sometimes considered.

The procedure dates back to the end of the 19th century. Multiple techniques are used, and the intended results are relief from pain and regained stability. This article discusses some of the medical conditions where ankle fusion may be considered.

The most common cause of degenerative arthritisdegenerative arthritisDisease that leads to the gradual deterioration of a joint; also called Osteoarthritis. of the ankle is an ankle fracturefractureA disruption of the normal continuity of bone.. Many years after a serious fracture, the jointjointThe junction or articulation of two or more bones that permits varying degrees of motion between the bones. may wear out and become painful. A jointjointThe junction between the ends of two adjacent bones. that is out of balance after it heals from a fracture can wear out faster than normal. Other types of arthritisarthritisInflammation of a joint or joints resulting in pain, swelling and stiffness. can lead to a painful ankle joint as well. Rheumatoid arthritisRheumatoid arthritisGeneralized inflammatory joint disease. can destroy the ankle leading to a painful joint.

Before the development of artificial joints, ankle fusion was the primary operation available to treat an extremely painful joint. In some cases, fusion is still the best choice. If successful, an ankle fusion is not in danger of wearing out like an artificial ankle.

In primary ankle fusion surgerysurgeryThe branch of medicine concerned with the treatment of disease, injury, and deformity by operation or manipula..., the ankle joint is removed, allowing the tibia (shinbone) to grow together, or fuse, with the talus boneboneThe hard tissue that provides structural support to the body. It is primarily composed of hydroxyapatite cryst... (the first large bone of the foot). Pins, plates, screws or rods often are inserted through the bones to hold the bones together until they heal. More severe clinical indications may warrant fusing other joints, including the subtalar joint. Though the procedure results in the loss of some movement of the foot and ankle joints, it can be very effective in reducing pain, correcting deformities and stabilizing the joints.

Several different operations have been developed to perform an ankle fusion. The basic procedure in each operation remains the same, however. The most common way that an ankle fusion is done is by making an incisionincisionA cut or surgical wound. through the skin to open the joint. Once the joint is opened, the articular cartilagearticular cartilageA resilient tissue that covers the surface of bones where they meet in a joint. The cells of articular cartila... surfaces of the joint must be removed.

Once the articular cartilagearticular cartilageCartilage that covers the articular surfaces of bones. is removed on both sides of the joint, the body will try to heal the two surfaces together just as if it were fractured or broken.

Once the cuts are made the bones must be held in place while they fuse. This can be done using large metal screws and metal plates if necessary. The screws are usually under the skin and are not removed unless they begin to rub and cause pain.

In some cases, especially if the fusion is being done because of an infection or a failed initial fusion, an apparatus called an "external fixator" is used to hold the bones together while they heal. This apparatus has metal pins that are inserted through the skin and into the bone. The metal pins are connected to metal rods and bolts outside the skin that hold the bones in position while the ankle fuses. The fixator is removed after the bones have healed, usually in twelve to fifteen weeks.

Some surgeons have performed ankle fusions with the help of the arthroscope. The arthroscope is a miniature TV camera that is inserted into the ankle joint through a small incision. Using the arthroscope to watch, other instruments are inserted into the ankle joint to remove the cartilage surface. The cartilage surface is removed using a small rotary cutting tool. Once the surfaces are prepared, screws are placed through small incisions in the skin to hold the bones together as they heal, or fuse. This procedure is not significantly different from the open procedure except that the incisions are smaller.

Because of the wide range of patient needs, surgeons can choose from many different options for fusion surgery. One such option, called TTC fusion (TTC stands for tibiotalocalcaneal), is one type of ankle fusion.

In TTC fusion, the tibia, talus and calcaneal bones are fused together using sophisticated metal implants called intramedullary nails (intramedullary means within the bone). DePuy OrthopaedicsOrthopaedicsThe medical specialty involved in the preservation and restoration of function of the musculoskeletal system t... offers a TTC implant called the VersaNail^® made of high-tech metals (titanium alloy). Using this system, surgeons can adapt the implant for the specific size and anatomy of each patient, and help achieve optimum alignment of the bones of the foot and ankle. TTC fusion is considered for certain patients with advanced osteoarthritisosteoarthritisArthritis characterized by erosion of articular cartilage, either primary or secondary to trauma or other cond... or rheumatoid diseases, injuries from accidents, ankle deformity and complications from diabetesdiabetesA disease where the body does not produce or use insulin correctly (This leads to: hyperglycemia - an increase... (Charcot), as well as to treat conditions such as avascular necrosisavascular necrosisA condition where bony tissue dies because of insufficient blood supply.. (See related article on medical conditions for which TTC is considered.)

TTC is generally used in advanced cases (called "end-stage ankle disorder") where more conservative treatments like medication and other surgical treatments have not worked. It is also indicated for some patients who have had prior surgeries with inadequate results.

In TTC fusion, special screws help eliminate rotation, preventing the calcaneuscalcaneusHeel bone, the largest bone in the heel, (the one that forms the round part of the heel) from "rocking" on the implant when the patient puts weight on it.

The choice of primary ankle fusion or TTC fusion is made by the surgeon, based on many clinical factors. As with any medical treatment, individual results may vary. Only a surgeon trained in foot and ankle surgery can determine which method is best for a given patient. There are potential risks, and recovery takes time. The performance of the new joint depends on weight, activity level, age and other factors. These need to be discussed with a doctor.