Alex Kline earned his medical degree from the University of Virginia Medical School before completing his residency at UPMC, in 2009. Following a foot and ankle fellowship at OrthoCarolina, he returned to UPMC, where he serves as a clinical assistant professor and director for the foot and ankle fellowship.

Question: What is a total ankle replacement?

Kline: An ankle replacement is a procedure that we do for patients with end-stage ankle arthritis, meaning the joint is completely worn out. And it’s very similar to a knee replacement, in that we basically put metal caps on either side of the joint. So there’s a metal cap on the end of the tibia, and then there’s a metal cap on the top of the talus, which is the bone at the bottom portion of the ankle, and there’s a piece of polyethylene plastic in between.

Q: What can cause arthritis in the ankle?

A: There are a number of different causes of arthritis in the ankle. Far and away, the most common for ankles is what we call post-traumatic, which makes up probably 85% or 90% of ankle arthritis. That’s a lot of patients, who had either prior fractures or the very common chronic instability — so, chronic ligament injuries to the ankle over time — that can lead to arthritis.

Other causes of arthritis that we see would be any of the inflammatory arthritides, like rheumatoid arthritis, which can also go on to require an ankle replacement. Then there’s some more rare conditions; there’s a condition where patients lose some of the blood supply to their talus bone, and it can collapse. That’s called avascular necrosis. Those are the most common reasons that we see it. But, ultimately, the condition is damage to the cartilage of the joint from one of those underlying causes.

Q: Who is an ideal candidate for a total ankle replacement?

A: Patients who want to stay as functional as possible. Historically, before ankle replacements became more popular, most of these patients received an ankle fusion, which is where you go in and you put in plates and screws, and the ankle doesn’t move afterwards. When they’ve looked at studies that compare the two, if you look at pain control, the outcomes are fairly equivalent. But if you look at how well patients function, how they can do sports and exercise activities, they all favor the replacement, because you keep the motion you have.

We’ve done them in patients as young as their 20s and as old as their 80s. I’d say most of the patients would fall in the 50, 60, 70 range. But there are conditions or outliers, and a lot of it depends on the patient’s functional status as to whether they’re a good candidate for it.

Q: What happens during a total ankle replacement surgery?

A: We make an incision right in the front part of the ankle. We go in and move the tendons and nerves out of the way, to expose the joint. Then the current system that we use takes a CT scan of the patient before the surgery, and they actually make the cutting block specific for that patient’s anatomy, to make sure the alignment is perfect afterwards. So we pin those guides in position and check them under the X-ray to make sure everything lines up well. Then we make the cuts and take out the bone, from the end of the tibia and the top portion of the talus. Once the bone is removed, then we prepare both of the bones for the implant, and we put the metal caps on the end of the tibia and the top of the talus, and then we trial different sizes of plastic to get the one that gives them the best motion and stability.

Q: How long does the replacement last?

A: We generally tell patients they should last between 10 and 20 years now.

Q: Describe the recovery process.

A: We’re probably doing about 75% of them now as an outpatient, so they go home the same day. Some of the older patients will spend one night in the hospital. After the surgery, it’s three weeks, typically with no weight on that ankle. So for three weeks, they’ll be either on crutches, or a lot of patients now use the knee scooters to get around for those first three weeks. After three weeks, most patients go into a walking boot and can walk on it. We have them do home range-of-motion exercises, and then at a total of six weeks from the time of surgery, most patients get back into a regular shoe and start outpatient physical therapy.

In general, just like a hip or knee replacement, we tell most patients they’ll improve for a full year after surgery, for it to feel kind of normal. But most of the recovery is within that first three months. Most people are walking pretty well by the three-month point.

Q: What technological advancements have you seen in your field?

A: I think the biggest thing is the implant design, along with the patient-specific cutting guide. So now, before surgery, we take a CT scan that actually scans from the knee all the way down to the ankle, to get the alignment perfect. These are customized for each individual patient, depending on the degree of arthritis and their deformity. The cutting blocks are made specifically for that individual patient, and that’s made a big difference in terms of getting the alignment perfect, which makes a big difference longer term. The newer replacements also take less bone, and seem to be holding up much better by taking less bone than some of the older designs.

Q: What is your goal for patients who have a total ankle replacement?

A: The goal is to maximize patient function and minimize their pain, and, in that regard, these have been very, very successful. We’ve seen patients five years out, and they’ll tell us it’s the best decision they ever made, and how much less pain they’re having and that they’re able to do things they weren’t able to do comfortably in years.