Advanced ankle replacement options can restore mobility
Chronic ankle pain or ankle arthritis can make walking, working, and staying active difficult. UI Health Care specialists offer individualized treatment for complex foot and ankle conditions, including ankle replacement, revision surgery, and custom total talus replacement when appropriate.
Treatment may include medication, bracing, injections, physical therapy, arthroscopy or open removal of bone spurs, realignment procedures, ankle fusion, or ankle replacement. For patients with complex conditions or a failed prior replacement, UI Health Care foot and ankle specialists can evaluate advanced options such as revision ankle replacement which can include a custom total talus replacement.
The right approach depends on the cause of the pain, the condition of the joint and surrounding bone, the patient’s alignment, previous treatments, and personal goals.
Common signs that it may be time to see a foot and ankle specialist include:
- Ankle pain that limits walking, work, or everyday activities
- Chronic pain after a previous ankle injury
- Repeated ankle sprains or instability
- Pain that continues despite medication, bracing, or injections
- A previous surgery or ankle replacement that has not provided relief
- Being told that treatment options are limited
An ankle injury can continue affecting the joint for years, even when the original fracture or sprain seems to be healed.
John Femino, MD, an orthopedic surgeon specializing in foot and ankle care at University of Iowa Health Care, says chronic ankle pain often develops after an earlier injury, recurrent sprains, or long-term instability. Some patients experience pain soon after the initial injury, while others do not seek treatment until years later.
Many people adapt gradually. They walk less, avoid stairs, stop exercising, or give up activities that make the pain worse.
“They just live with their pain as kind of a new normal,” Femino says. “They self-limit their activities, which is a form of nonoperative treatment.”
But a brighter future is possible. A specialist can evaluate the ankle, the foot beneath it, previous procedures, and a patient’s overall goals. Patients who have already undergone treatment may also benefit from a second or third opinion, especially if pain continues or they have been told there are few options left.
Femino says experience matters because ankle treatment can involve more than the damaged joint itself. The position and alignment of the foot below and the tibia and knee above can influence how the ankle functions and whether a replacement is likely to succeed.
Ankle treatment tailored to each patient
The right treatment depends on the cause of the pain, the condition of the bones and surrounding joints, previous procedures, alignment, activity level, and the patient’s goals.
UI Health Care specialists consider nonsurgical care first whenever appropriate.
- Anti-inflammatory medication
- Ankle bracing
- Activity changes
- Physical therapy
- Injections for selected patients
- Removal of painful bone spurs
- Osteotomy, or bone realignment
- Ankle fusion
- Ankle replacement
A brace can be a reasonable long-term non-operative option for some patients, including people who perform physically demanding work. Others may need surgery when pain remains severe or nonsurgical treatments no longer provide enough relief.
“There’s a spectrum of treatment,” Femino says. “Nonoperative treatment is something we always try first.”
When surgery is considered, ankle fusion and ankle replacement are two possible options. Fusion joins the bones so that the damaged joint no longer moves. Ankle replacement removes damaged portions of the joint and uses artificial components to preserve some motion. In other cases, realignment surgery above the ankle may be beneficial in preserving a person’s ankle mobility without sacrificing the joint.
Some patients also need procedures to correct alignment above or below the ankle, either during the same operation or through a staged plan.
These procedures can relieve pain, but they affect movement differently. Preserving ankle motion may help some patients walk more naturally and make activities such as using stairs, walking on hills, or kneeling easier.
“Having mobility in the ankle is important for having more normal function, but pain relief is the most important outcome for improving quality of life,” Femino says.
“There are a lot of different options that may be available, and treatments are always tailored to a patient’s unique circumstances,” Femino says.
Advanced options for failed ankle replacements
A previous ankle replacement may eventually require further treatment because of loosening, infection, bone loss, or failure of the implant to bond with the bone.
Revision surgery is generally more complex than a first ankle replacement because less bone remains after the original implant is removed. The talus, which is the bone beneath the ankle joint, can be especially challenging because there may not be enough healthy bone left to support another standard implant.
In the past, patients with severe talus damage or bone loss often faced a large fusion extending from the shin bone to the heel. This procedure can relieve pain, but it eliminates both ankle motion and much of the side-to-side movement of the foot.
For selected patients, a custom total talus replacement may provide another option. This procedure substitutes the damaged talus with a custom, 3-D printed implant.
- CT scans of both ankles
- A mirrored model based on the healthy talus
- Custom implant design
- Planning meetings between the surgeon and engineers
- Evaluation of foot alignment and nearby joints
- Consideration of additional procedures
“Each one is truly a custom process, and there is a fair amount of planning that goes into it before someone actually gets to the operating room,” Femino says.
UI Health Care serves as a referral center for patients from Iowa and surrounding states, giving the foot and ankle team experience with failed implants, prior infections, bone loss, deformity, and other complicated conditions.
“We commonly see complex, end-of-the-line types of problems,” Femino says. “Our team has gained a lot of experience and expertise by treating many complex cases over time.”
The program also has specialized operating room teams and access to advanced imaging and diagnostic studies that can help guide treatment.
Explore your ankle treatment options
Persistent ankle pain does not have to become your new normal. A foot and ankle specialist can evaluate your condition and explain which nonsurgical or surgical treatments may be appropriate.
Real-world impact of complex ankle problems
Melissa Blum’s ankle problems began with an injury in college. Over the following decades, she underwent multiple corrective procedures, including a total ankle replacement in 2023 that never healed as expected.
She spent years in a boot or brace and experienced significant pain every day.
“Pain kept me from even just being able to walk,” Blum says.
The limitations extended beyond physical discomfort. She missed a work trip to Europe, reduced other professional travel, and could not lead some of the teacher-training workshops she normally held. At her daughter’s wedding reception, she completed one slow dance but had to sit out the rest.
“It impacted my professional life, my personal life, and just my ability to do fun, active things,” she says.
When Blum came to UI Health Care for her ankle issues, Lance Christensen, MPAS, PA-C, a physician associate on the foot and ankle team, carefully reviewed years of Blum’s medical records, identified concerns that had not previously been addressed, arranged additional testing, and helped her obtain a different brace for day-to-day relief. He put her in touch with Femino, whose careful, transparent approach helped her trust the process.
“I always felt like they were 100% focused on what I needed for this case, and I wasn’t just on a list of cases,” Blum says.
Complex revision care requires detailed planning
Revision ankle replacement may require the care team to evaluate implant stability, bone quality, infection risk, foot alignment, and the health of nearby joints. Imaging, laboratory testing, and findings during surgery can all affect the final plan.
Blum’s case required this level of individualized planning. Her previous ankle replacement was loose, and avascular necrosis, which refers to the death of bone tissue due to a lack of blood supply, had left her talus without enough healthy bone to support a traditional revision.
Her options included a large fusion or revision ankle replacement with a custom total talus. Because preserving mobility was important to her, the team explored whether total talus replacement could provide a better fit for her goals and anatomy.
Femino reviewed Blum’s imaging, consulted with colleagues, and adjusted the surgical plan as new information became available.
“He took the time to figure out the right approach and how he wanted to do this,” Blum says.
One of the advanced tests showed the likelihood of potential soft tissue infection next to the ankle joint. With her history of multiple prior surgeries, it was recommended that her treatment be performed in two stages. During the first, the team removed the damaged talus and prior hardware and placed an antibiotic cement spacer. After she completed six weeks of intravenous antibiotics, the second surgery placed the custom total talus and completed the revision ankle replacement.
Preparation and recovery involved more than surgery. Blum underwent bone-density testing, met with a nutritionist, and completed months of physical therapy at UI Health Care’s North Liberty campus.
“It really did feel like he was doing everything in his power, even the things that aren’t in Dr. Femino’s direct area, to make sure it was a good outcome,” Blum says.
She adds that the new orthopedic facility’s convenient parking, easy navigation, and coordinated services made a complicated course of care feel more manageable.
Recovery takes time, but mobility can improve gradually
Recovery after complex ankle surgery depends on the procedure, the patient’s health, the condition of the bone, and whether treatment must occur in stages.
Patients may spend time without bearing weight on the ankle before gradually progressing to a walker, cane, and independent walking. Physical therapy can help rebuild strength, improve movement, and support a safe return to daily activities.
Patients should also understand that progress may continue well beyond the first few months. Recovery can include temporary setbacks, swelling, stiffness, or difficult days even as overall function improves.
Blum gradually progressed from a walker to a cane and then to walking independently. By the end of the first summer, she was already experiencing less pain than before surgery. Her improvement continued over the following year.
One of her goals was to walk 2 miles. She can now do that without having the rest of her day “derailed,” she says.
“I’m living the life that I used to have,” Blum says. “I can ride my bike, I can walk, I can do all those things.”
She can also wear matching shoes again after years of wearing a boot or brace.
“I can’t express how many different people I run into who tell me they've never seen me wearing a matching pair of shoes,” Blum says. “I love shoes, so that’s been a fun thing.”
Not every patient with chronic ankle pain needs surgery, and not every patient is a candidate for ankle replacement or total talus replacement. But patients with a failed procedure, major bone loss, or a complex history may benefit from another evaluation.
Blum encourages others not to assume they have reached the end of the road.
“Do not give up hope,” she says. “Surgery is not fun, but that is absolutely short-term pain to get a much better quality of life.”
