Total Ankle Replacements: A Controversy Among Surgeons

Apr 19, 2018
In 2009, Tom Harper was involved in a devastating motorcycle accident, which shattered his ankle, pelvis, and hip; landing him in the hospital in critical condition.

In 2009, Tom Harper was involved in a devastating motorcycle accident, which shattered his ankle, pelvis, and hip; landing him in the hospital in critical condition. In the crucial weeks and months following, he underwent multiple surgeries to put his body back together. His pelvis and hip were rebuilt using an artificial joint, which took four months of recovery in a wheelchair. Finally his ankle was repaired, requiring screws and bolts to hold it together. It wasn’t until the following year, that he was ordered to walk on it using his full weight, but tragically, as soon as that happened the ankle began to swell, giving him constant pain.

To Tom’s horror, his ankle completely collapsed two weeks later. His wife rushed him to his doctor in Las Vegas who told Tom that his case was too advanced and that the only option was to fuse the joint, which would limit the ankle’s flexibility. Being a very active person, Tom hated the sound of this. The whole ordeal extremely worried his wife and she immediately began researching other surgeons and alternate options.

The couple’s situation was looking grim. They met with a total of nine doctors, who almost unanimously agreed that ankle fusion was indeed the only choice for Tom. A very small handful of them also offered a procedure called “Total Ankle Replacement” (TAR), however, these surgeons were terrified to perform this surgery on him because the damage to his foot was too severe. When Tom had his first consultation with Dr. Armen Hagopjanian, a podiatrist in Burbank, California, he couldn’t put any weight on his foot without excruciating pain. The screws were protruding into other tissue, which made standing for even a few seconds almost unbearable. “I chose Dr. Hagopjanian because he makes you feel confident in his abilities,” Tom says. “He’s sincere and genuinely wants you to get better.”

Dr. Hagopjanian told Tom that he was a candidate for Total Ankle Replacement Surgery, which the FDA approves for patients with a severely arthritic or degenerative ankles who are ideally over the age of fifty and in relatively good shape. But Tom’s case was unique, since he was missing half of his talus, the bone that connects the leg to the foot, which is very crucial to this procedure. Even Hagopjanian’s teacher, Dr. Jack Schuberth, a podiatric surgeon from San Francisco who has performed more ankle surgeries than any other surgeon in California, thought that fusion would be an easier option. But easy surgery was not in Dr. Hagopjanian’s mind. He wanted to make it easy for his patient to walk in the future.

Total Ankle Replacements have been a controversial topic among surgeons for decades because of the early prosthesis, which were ineffective. In the late 1980’s, new and improved prosthesis began to emerge, making total ankle replacement more effective than arthrodesis, which is the fusing of the joints to limit up and down movement. Current prosthesis designs are more closely replicating the biomechanics of the ankle joint for more effective long term results. Two of the most popular are the STAR and the In-Bone (which is a more complex implant, used for more difficult procedures).

“First of all it’s better than ankle fusion because it improves the functionality of the ankle,” says Dr. Hagopjanian. “Every time you fuse something you limit the motion to that particular joint. Nobody talks about fusing knees or hips these days - they were fusing them right and left about 30 or 40 years ago. When the knee replacement came about, everybody was skeptical and after the first few years when everybody was failing, they were afraid they were never going to do it again. But now you look around and every orthopedic surgeon does the knee and hip replacements. However until recently the majority of the medical community is scared of the ankle replacement because they are not very well trained.”

Total Ankle Replacement is usually performed under general anesthesia and patients are typically hospitalized for up to four days.The surgeon makes an incision in the front of the ankle, exposing the joint. The damaged bone is removed before the tibia (lower shin bone), fibula (lower leg bone), and talus (top foot bone) are reshaped. Then the prosthetic is attached to the bony surfaces with a bone cement and screws to hold them in place.

Prior to the procedure, Dr. Hagopjanian took Tom Harper’s case to a conference to be reviewed by other surgeons and determined that if he was going to indeed move forward with surgery, the In-Bone prosthetic was the only option because the talus bone was 50% gone. Tom’s condition was so complex, his surgery had to happen in stages. The first order of business was to remove all of the hardware from his ankle and let him heal from that.

“That surgery was a God-send,” says Tom. “I was in so much less pain.” Once Tom had completely healed, the surgery for the implant was scheduled for March 6, 2012. Dr. Hagopjanian did a graph to rebuild the talus, taking layers from Tom’s pelvic bone. The implant was put in at the same time and three screws were added for extra support. The entire surgery lasted six hours.

Three months later, Tom began putting weight on his foot. Thus far he has had three hard casts and a boot and began physical therapy shortly after surgery. Now he only has to wear high top sneakers and no longer walks with the aid of crutches. He reports “100%” less pain and says “The only pain or discomfort I felt after the surgery were the scars from the incisions.” Tom is infinitely healthier...and his wife is a lot less stressed!

Some people are still wary of having this surgery because the introduction of the latest prosthesis is relatively new. As late as the early 1990’s, feedback about complications from the old prosthesis began to emerge. Out of 204 primary Mayo TAR surgeries, the success rate was 79% at five years, 65% at ten years, and 61% at 15 years only 42% of patients under fifty seven years kept the implant in place.

Dr. Hagopjanian is successfully performing 2-3 Total Ankle Replacements per month. His wide range of patients have recently included an 84-year-old man who is now able to golf again because of the surgery, a woman who lost one leg in an accident and wanted the surgery so she would be able to continue using her good leg, and his youngest patient, a 35-year-old man who smashed his ankle in a motorcycle accident and is now walking again without pain.

“Very few surgeons do ankle replacements a lot,” says Dr. Hagopjanian. “I have done over 40 over the last four years. The last year on average I’ve done two a month. And we have a line-up of the patients who are coming in. Because now all of a sudden it works and when people see that it works they start referring people. We also go and teach orthopedic surgeons who don’t do this procedure and show them that this is a viable option that can give patients a higher quality of life.”

To learn more about Total Ankle Replacement and Dr. Hagopjanian, visit