Ankle replacement surgery, though far less common than knee and hip replacement procedures, gradually is gaining favor as baby boomers age, people become more aware of it as a medical option, and medical technology improves, orthopedic surgeons here say.

Ankle replacement is used mostly to treat ankle pain caused by age-related osteoarthritis, injury-induced post-traumatic arthritis, or the chronic autoimmune disease rheumatoid arthritis. It's among a number of procedures—including hip and knee replacements—encompassed by the medical term arthroplasty, which is surgery performed to relieve pain and restore range of motion by realigning or reconstructing a dysfunctional joint.

Surgeons here say one of the rewards for them with the still comparatively unpublicized ankle replacements, as with other joint replacements, is seeing immediate positive results.

"Most patients with severe arthritis feel better right away," says Dr. Craig R. Barrow, of Orthopaedic Specialty Clinic of Spokane PS. "It's not uncommon for someone to say the next day after surgery that they feel better already."

Patients have to meet certain conditions to be considered eligible for ankle replacement surgery, but for some, it can be a welcome alternative to ankle fusion, Barrow says. That last-ditch procedure, which uses screws to lock the ankle in place until bone grows over and replaces the scraped-out joint, "takes care of the pain, but it removes all mobility," he says.

Barrow says he is one of four fellowship-trained foot and ankle orthopedists here who do ankle replacement surgery, and he knows the other surgeons personally. They include Drs. Brian J. Padrte and Khalid Shirzad, both of Northwest Orthopaedic Specialists PS, and Dr. James Dunlap, of Providence Orthopedics. That compares with a much larger number of surgeons here who do hip and knee replacements, he says.

Shirzad, who has been at Northwest Orthopaedic for three years, estimates he's performed around 100 ankle replacement procedures, counting those he did during fellowship training at the Duke University School of Medicine, in Durham, N.C., in 2009 and 2010. He says he says he's seen many of his patients who had extremely limited mobility because of ankle pain and stiffness return to very active lifestyles.

"I think in the right candidate, it's great," he says.

Barrow, who has been in practice for about 10 years, says ankle replacement procedures typically take one to two hours to perform. Patients normally remain in the hospital for one to three nights, and don't walk on the ankle at all for about a month, wearing a splint and getting around on crutches or with the help of a walker, he says.

Once they begin to walk on their surgically rebuilt ankles, he says, it typically takes them a week or two to feel comfortable doing so.

The surgery itself uses an anterior, or front-of-the-ankle, approach and requires carefully retracting tendons, nerves, arteries, and veins to create adequate space for working on the joint, Barrow says.

"It's normally the cartilage that has been destroyed for different reasons" and thus allows bone-on-bone contact, which causes the pain, he says. Therefore, part of the surgery involves removing the remaining cartilage and reshaping and drilling adjoining bone surfaces to accommodate a prosthesis, or artificial joint.

The joints consist of highly engineered metal alloy implant pieces that are anchored into the tibia, or shinbone, and talus, or ankle bone, and a high-density, medical-grade polyethylene insert that rests between the upper and lower metal surfaces and allows for smooth motion of the joint.

"The positions of the implants are vital. If they're not put in correctly, they'll fail," Barrow says. "That's the majority of the surgery, to make sure the alignment is as perfect as can be."

Barrow says he isn't able to provide an estimate for the total cost of an ankle replacement procedure, but some online sources say the overall tab can be $20,000 to $40,000 or more for those without medical insurance and counting follow-up care, physical therapy, and other nonsurgical expenses. Some insurance companies cover ankle replacements, but others don't, characterizing the procedure as experimental, he says.

Not enough data is available yet on the most recently introduced ankle replacement prosthetics to project accurately how long they'll last, but 15 years would be considered a good goal, before the procedure would need to be repeated, if appropriate, or a possible ankle fusion performed, he says. For that reason, active young people and even older people who work at labor-intensive jobs often aren't good candidates for them, he says.

Barrow says ankle replacement patients might range in age from their mid-30s to their 80s or 90s, but the bulk of his patients probably are in their 50s and 60s. He says he probably sees five patients a day who suffer from some type of ankle arthritis, but currently only performs perhaps 15 to 20 ankle replacements a year.

Barrow says he works a lot with his foot-and-ankle patients on alternatives to surgery, such as orthotics, braces, or pain-relieving injections, adding, "A conservative care plan, I think, should always be done first."

Demand for ankle replacement surgery likely will continue to increase in the years to come, though, he says, due partly to the aging boomer population and to continuing improvements in ankle-replacement prosthetics.

"The ankle replacements that are on the market now are relatively new. We're encouraged by their results," he says.

There are four or five implant products available currently, Barrow says, adding that he's most familiar with three of them. Examples of the products include the INBONE Total Ankle, manufactured by Wright Medical Technology Inc., of Arlington, Tenn., and the Star Ankle, made by Small Bone Innovations Inc., of New York City., both of which he uses.

Shirzad says he probably averages about one ankle replacement procedure a month and uses the INBONE Total Ankle and Star Ankle products.

Both he and Barrow say they plan to attend an upcoming conference in Las Vegas to check out another new knee replacement product that's being introduced.

Shirzad says, "I think there will probably be an increase in the number we're doing just as people become more educated about their options, and ankle replacement options," rather than necessarily because of more demand from baby boomers.

Barrow says surgeons first began doing ankle replacement procedures around the 1960s, but the results were poor, and by the late 1970s, they were largely abandoned as orthopedists went back to doing ankle fusions. Interest in ankle replacements picked up again some years later as new products emerged, he says.

Shirzad says he believes interest has increased particularly just within the last 10 years or so, following study findings that brought into question the commonly held belief that ankle replacements were inferior to fusion for treating pain.

Noting the small percentage of orthopedists here who currently perform ankle replacement procedures, he adds, "I think as more people get trained in them, we'll start to see an increase" in the number of patients having synthetic joints installed.