Photo Courtesy of Cheri Haring
Cheri Haring, 66, didn’t realize she had a problem with her ankles. She just thought they were weak. It wasn’t until she was walking one day that she experienced a painful crunch and knew something must be wrong.
“I didn’t know what it was. I thought I had twisted my foot or something ... I didn’t think I could make it home,” Cheri said.
Cheri is one of two million Americans who go to the doctor with ankle pain every year, as estimated by the New York Times in 2010.
But unlike most others, Cheri is one of 50,000 Americans who experience end-stage ankle arthritis, according to the New York Times. End-stage ankle arthritis is a form of arthritis caused by degeneration of the cartilage in the joints, creating bone-on-bone contact and what can be an excruciating pain.
“I started babying the ankle, I would stay off of my feet a lot, I wouldn’t go an extended time on my legs ... every day it got a little bit worse,” Cheri said.
Cheri had what is commonly referred to as degenerative arthritis, a condition where the cartilage of the ankle joint wears out and becomes painful.
What Causes Degenerative Arthritis?
Arthritis has become a commonly used term to describe pain and corrosion within a joint. Arthritis is widespread in the United States and is the leading cause of disability.
There are three different types of arthritis which the joints in the foot and ankle can experience, leading to degenerative arthritis.
1) Osteoarthritis is a type of arthritis caused by wear and tear. The cartilage on the joints degenerates over time. Osteoarthritis is most commonly found in middle-aged people.
2) Rheumatoid arthritis is an inflammatory disease which affects the whole body as the person’s immune system destroys cartilage.
3) Post-traumatic arthritis can develop after an injury or fraction in the area. In fact, an injured joint is seven times more likely to become arthritic and can happen years after the incident.
Cheri's case of degeneration made her a strong candidate for a surgery that would reduce her pain but cost her mobility in the ankle.
Before choosing to have the procedure done, Cheri's doctor gave her a brace. This is one option people with degenerative arthritis in their ankle may choose to help ease the pain.
Other alternatives to surgery can include treatments like pain medication or steroid injections in the weakening area.
There are several alternatives that can be made or bought. Walking aids like canes, scooters, walkers or chairs, or specially formulated contoured shoes can make walking less of a challenge.
Some people with arthritis, like Cheri, will also reduce the amount of physical activity they engage in to reduce the pain.
No treatment or therapy will eliminate the effects of an arthritic ankle. For some, though, an alternate choice may relieve pain minimally or temporarily. For others, such a choice can be a source of permanent relief.
Deciding to Have Surgery
Cheri wore her brace for six months, all the while still experiencing pain. After showing no improvement in all that time, she decided that surgery could be necessary.
That surgery is called ankle fusion, also known as ankle arthrodesis. The outcome reduces pain caused by degenerative arthritis, but also eliminates some mobility.
According to the New York Times there were about 25,000 ankle fusion operations performed in the United States last year.
Although Cheri did try an alternative option for months, she had a severe bone-on-bone case, leaving her mobility before surgery limited at best.
“It was so debilitating, I couldn’t walk, I had to get off the foot. There was no other way out,” Cheri said.
The pain and lack of mobility ultimately sealed her decision to partake in the procedure.
What is an Ankle Fusion?
The foot itself consists of 28 bones and over 30 joints. The ankle is made up of three main bones: the tibia, the fibula and the talus. Ligaments on each side of the foot keep bones in place. The talus is responsible for the up and down movement of the foot.
A large tendon at the back of the foot called the Achilles tendon connects the heel bone to the calf muscle, giving people the ability to run, jump and walk.
When ankle fusion is performed, the cartilage between the joints is removed, the bones are then held in place with some sort of hardware, allowing the tibia to fuse together with the talus. Once healed, the foot is at a 90-degree angle with no up-and-down mobility in the ankle.“It leads to a lot of limitations, you can’t run and push off with that foot because it doesn’t bend,” Cheri said.
In total there are three techniques used by surgeons in preforming an ankle fusion.
The first is an open technique with screw fixation, where small incisions are made on the face of the ankle. The surgeon can open the joint, remove the cartilage, and then secure and set the bones with metal hardware.
The second is an open technique with external fixators. The operation is done in the same way as the first, but the screws protrude from the skin. This type allows for earlier weight bearing, and is beneficial to those with lower bone quality.
The third technique that can be used is referred to as arthroscopic ankle arthrodesis. The arthroscopy uses a thin fiber-optic camera to project video onto a larger screen. It is minimally intrusive.
Of all three techniques, the first is the most common.
Most active individuals like Cheri typically prefer ankle fusion to a full ankle replacement, allowing them to remain active and eliminating the risk of wearing out the replacement.
But learning how to adapt to new mobility limitations, and continuing to live an active lifestyle, can present challenges.
Cheri was 62 years old when her surgery was performed. Prior to the fusion, she had always lived an active life.
She was a cheerleader in high school, and skied into her early fifties. She maintains and builds houses, and creates art through pottery. She is a realtor. She enjoys walking her dogs and line dancing.
After the surgery, Cheri was given a cast, and when the cast was removed she received a brace. She used a one-leg scooter, allowing her to continue to show houses, create her pottery, and go on with her everyday life.
“The whole time I was recovering with the scooter I was out walking the dogs with one leg up and one leg on the ground ... it never really slowed me down!” Cheri said.
When it came to showing houses, Cheri told me she would go up and down the stairs on her butt. She was back to line dancing the moment she could put weight on her foot with the brace.
“There is always a way to move. Even when you have no weight on your foot, you can still be active,” Cheri said.
According to the American Orthopedic Foot and Ankle Society, the average healing period for people who undergo ankle fusion surgery is an initial 6-12 weeks with a cast, and then an additional four to six weeks with a brace and some sort of walking device.
Cheri recalled about eight or 12 weeks where she was still in recovery. Despite her lighthearted and positive manner, it wasn’t an easy time.
“There was a lot of hardship in the recovery process," she said. "I forgot how hard it was, there was a lot of pain during that period.”
The Challenges Ahead
As with any surgery, complications can arise. After an ankle fusion there can be infection, a stiff foot, or a need for further surgery. Other possible issues are progression of the deformity, delayed union (the bone takes longer than usual to heal) or nonunion (the bone does not heal).
The results of ankle arthrodesis following trauma were monitored in a long-term study conducted by the National Center for Biotechnology Information. Out of 60 patients, there were 48 complications occurring in 29 of the participants.
The study continued to follow 41 participants for seven and a half years. Of those who participated, 34 people (more than 80 percent) were satisfied with the procedure.
Although many are satisfied long-term, there can be an extreme initial shock when the patient realizes that they can’t move like they used to.
“When [the doctor] took the boot off and I started walking on it I was horrified. I couldn’t believe the impact of feeling an extremity that no longer moved, it was devastating ... I was crushed. I told her, ‘You’ve mutilated me!’” Cheri said.
In an examination post-surgery, her doctor told her that she believed from the bottom of her heart performing the surgery was the right thing. But Cheri thought otherwise at that time. “I was at the point after the boot was off that I said I would rather have my foot amputated.”
Her doctor also told her that she needed to realize bad cartilage was in her genes. It would continue to deteriorate for the rest of her life, which Cheri said has proven to be true.
The Unexpected Repercussions
Eventually the initial shock wore off. She has learned to cope with it. She has since said that overall, she is happy she had the surgery, because now she can walk like a normal person.
“It took a while for me to get adjusted, but we’re very resilient human beings and I gradually became accustomed to it to the point where I don’t even think about it anymore,” Cheri said.
Cheri knew the possible repercussions. She knew her calf muscles would atrophy. What she didn’t know was that her hip muscles would as well.
Once Cheri began walking again, she didn’t place importance on the hip exercises.
“If I would have known the hip was going to be so bad I would have done intensive physical therapy,” Cheri said. “I had physical therapy and I couldn’t understand why the exercises were all about my hip ... Somebody really needed to tell me ‘this is serious.’”
She said, “I was not told I needed to support my hip muscles and I needed to do these exercises daily, for the rest of my life.”
According to SantaCruzOrtho, it may not happen to everyone, but the stiff foot can lead to an abnormal gait, putting additional pressure on other joints which can affect the knee, hip and back.
As a result Cheri's hip also began to atrophy just two years after her ankle fusion, leading her to need another surgery. Now, a year since her hip replacement, Cheri does not regret the fusion.
She regrets not knowing how important the hip exercises were. Cheri says she hopes that her story can help prevent others from needing a hip replacement after an ankle fusion.
She has heard from orthopedic surgeons that muscle support is the best thing you can do for your joints, and she knows now that this is true.
According to WebMD, the best thing you can do for your joints is to keep your muscles, bones and ligaments strong.
Building muscles can support your joints by allowing the muscle to take pressure away. Building a strong core also releases tension and can prevent falling that could damage ligaments and joints.
Eating right is another simple way to give your joints a boost by supplying them with nutrients. How you eat will also affect your weight. If you weigh less, there will be less wear and tear.
The Light at the End of the Tunnel
For people like Cheri who have a genetic makeup of poor joint strength, deterioration from wear and tear can be inevitable. But through it all she continues to partake in the activities that she loves, regardless of the physical set backs she has had.
“It was a very emotional experience and I think somehow psychologically it would be good if people could be prepared for that. In the end it was really a beneficial thing to do because I could not have continued walking,” she said.
What Cheri wants people to realize is, “after an ankle fusion you do regain almost all of your mobility, you can have a normal life. I didn’t think I would ever have a normal life again and I feel like I do.”
Houston Methodist Orthopedics and sports medicine. A patient’s guide to ankle fusion. Retrieve Feb. 25,2015.
American Orthopedic Foot & Ankle Society. Ankle Arthrodesis. Retrieved Feb. 25,2015.
American Health Network. Ankle Fusion/Arthrodesis. Retrieved Feb. 25,2015.
NCBI. External ring fixation versus screw fixation for ankle arthrodesis: A biomechanical comparison. Retrieved Mar. 2,2015.
American orthopedic foot and ankle society. Ankle Arthroscopy. Retrieved Mar. 2,2015.
Ortho Info. Arthritis of the Food and Ankle. Retrieved Feb. 25,2015.
NCBI. Complications and long term results of ankle arthrodesis following trauma. Retrieved Feb. 25,2015.
About Health. Ankle Fusion Surgery. Retrieved Feb. 25,2015.
NY Times. A New Joint Gains as a Candidate for Replacement. Retrieved Feb. 25,2015.
SantaCruzOrtho. Ankle fusion surgery: an option for the treatment of degenerative arthritis. Retrieved Mar. 2,2015.
WebMD. Healthy Joint Tips. Retrieved Mar. 2,2015.
Reviewed March 23, 2015
by Michele Blacksberg RN
Edited by Jody Smith