FAQ Category: Ankle

Ankle sprains may seem like a minor problem but they put many athletes on the bench every year. And just as you have discovered, the effects can catch up with you much later in life. Chronic ankle stability, decreased physical activity, and ankle osteoarthritis head the list of potential long-term effects of ankle sprain.

Better sports equipment today (especially protective gear) along with improved shoe-wear have really helped with injury prevention. And if you are watcing the news or sports at all, you know the focus on reducing concussions among sports players is a huge focus right now.

As far as ankle injuries go, these top all other musculoskeletal injuries in sports like basketball, baseball, and football that require sudden stops or cutting movements. Athletes who have already had one ankle sprain often wear protective tape or slip-on lace-up ankle braces. At least according to one study of high school athletes, the positive effect and benefits of wearing the brace are worth it.

Athletes still have to be concerned about injuries to the knee and other parts of the body, but at least the lace-up brace gives an edge of protection to the ankle. Thanks for writing it — the voice of common sense and experience is always welcome!

Residual pain after a total ankle arthroplasty (TAA) has been reported in up to 60 per cent of all patients receiving an ankle joint replacement. That’s a pretty high percentage. Despite efforts to improve implant design and surgical technique, the rate or persistent pain and stiffness has not gone down.

So although you are “normal” in this regard, it’s not the intended or expected outcome. Sometimes there is a simple explanation for this problem. There could be an issue with alignment or impingement. Your activity level may be too strenuous or high-impact. In some cases, the size of implant may not be the best choice for you.

Each patient must be evaluated separately in order to look for cause and effect. Only then will your surgeon be able to identify the best way to treat the problem. If you haven’t been rechecked since this symptom developed after surgery, now would be a good time to get an appointment for a reevaluation.

It could be something simple with an easy solution. Or you may need to review some of the rehab exercises or modify some of your activities. There’s an outside chance that a follow-up second surgery may be needed.

In a recent review and published update, orthopedic surgeons at Duke University Medical Center take a look at the results of ankle joint replacement. The procedure is called total ankle arthroplasty or TAA. They present a thorough examination of all aspects of TAA from studies published and evidence gained so far on this topic.

Total ankle arthroplasties have been around long enough now to be in what is referred to as second-generation implants. Second-generation means the original design has been improved and changed in a significant way. Along with improved implants come better surgical techniques and surgical tools.

Based on their review of current published analyses of total ankle arthroplasties, the authors of this report give a C grade of recommendation for the treatment of end-stage ankle arthritis with TAA. A C grade means the evidence is of poor quality and conflicting. Does this poor grade mean no one should get an ankle joint replacement?

No — a closer look at the details of various studies still gives some good information. But the need for better study designs and comparisons is pretty clear. Here are a few of the observations the authors made as they summarized study findings.

Problems that develop after surgery for joint replacement can include heterotopic ossification (bone forms in soft tissue where it doesn’t belong). This complication is not uncommon after hip and knee replacements. And we know the same holds true for ankle joint replacement.

Why does this problem develop, who is at risk, and what can be done to prevent it? These are three good questions with limited answers at this time. No one knows for sure why or how mature bone forms in the muscles and tendons around the joint. Some experts suggest both local and systemic factors.

Why do some people end up with heterotopic ossification (HO) after surgery and others do not is also something of a mystery. There are known risk factors but not all patients with those risk factors develop HO.

Some of the risk factors that have been identified so far include: male sex, older age, and infection. Bone trauma, extensive soft tissue dissection during surgery, and the formation of any hematomas (pocket of blood) during surgery are additional risk factors.

The condition of the soft tissues before surgery may be another factor. Patients who have scar tissue around the ankle (from previous injuries or surgery) may be at increased risk for heterotopic ossification. More scar tissue means longer operative times.

The more the soft tissues are disrupted and bleeding, the greater the risk of a healing, inflammatory response. And along with the movement of inflammatory cells to the area comes the migration of bone-marrow cells leading to the bone formation of HO.

From a recent study in South Korea, it also looks like selecting the correct implant size is important. The patients in their study who developed heterotopic ossification group had some problems with bone response to an implant that was too small for them. Contact between one portion of the tibial component of the implant and the tibial bone may have contributed to bone stimulation leading to bone formation.

Your concern is a valid one and should be discussed with your surgeon before the procedure. There are things the surgeon can do to prevent heterotopic ossification. Minimizing the operative time and amount of surgical dissection along with prescribing antiinflammatories for you top the list. Other aspects of surgical technique and preparation of the implant are within his or her control as well.

Heterotopic ossification (HO) is the formation of bone in soft tissue where it doesn’t belong. These pieces or fragments of bone are called islands. They can range in severity from mild (class I) to severe (class IV).

This complication is not uncommon after hip and knee replacements. Studies show the same holds true for ankle joint replacement. How often this happens seems to vary from study to study. A prevalence rate as high as 60 per cent has been reported. A 25 per cent (one of every four patients) seems to be more the average.

Only about 10 per cent of the patients who develop heterotopic ossification after ankle replacement have actual symptoms. Ankle pain, stiffness, limitation of motion, and altered function can create considerable disability.

What can be done about heterotopic ossification once it develops? If it’s not painful, nothing is required. Mild-to-moderate pain and stiffness can be managed with antiinflammatory medications. Stretching the calf muscle may help maintain flexibility and function despite the bone formation.

Severe, limiting pain and loss of motion may require surgery to remove the extra bits of bone. Your surgeon is the best person to advise you on this. Based on his or her knowledge of your case and understanding of your particular risk factors will help guide the treatment decision.

There are more and more studies all the time comparing ankle fusion to ankle joint replacement. There are studies comparing results from the various implants that are out there now. And there are even some new studies coming out that look at the complication rate after fusion versus joint replacement.

There aren’t as many studies that look at the effect of complications and compare them between fusion and joint replacement. But we found one study from the University of British Columbia in Canada that might have the kind of information you are looking for.

They compared two groups of patients with severe, disabling ankle arthritis that did not respond as hoped to conservative care. As you might suspect, one group had the fusion procedure.

The second group received a total ankle replacement (TAR), also known as an ankle arthroplasty. The ankle replacement group did not all get the same type of implant. There were four different implants used. Not everyone had the same surgical approach either. Some patients had open incision surgery while others were treated with arthroscopy.

Besides looking at final function after two years, they also paid attention and compared complications along the way for both groups. X-rays were used to evaluate the joint itself. CT scans added information on the status of the healing process. The Ankle Osteoarthritis Scale (AOS) was used as a measure of pain, function, and disability. Before surgery and postoperative values were recorded for each patient.

Everyone in both groups had significant (and fairly equal) improvements. Pain relief, increased ankle range-of-motion, and improved function (e.g., walking, going up or down stairs, managing uneven terrain) were observed. The complication rate was high for both groups, but twice as high in the ankle arthroplasty group compared with the fusion group.

As it turned out, the affect different complication varied. For example, an implant that had come loose often required a second surgery, whereas even a deep infection could be treated and cleared up with antibiotics.

Anyone in either group with ongoing pain and discomfort from a nerve lesion caused by the surgery was less likely to be satisfied with the long-term results compared with patients who had less significant complications.

The authors concluded that some complications can have significant effects on outcomes in both groups (fusion and joint replacement). Patients receiving a total joint replacement are more likely to have problems. Older, less active adults seem to weather the complications better than younger patients who expect to do more and expect to have fewer problems so are surprised when they have any.

No doubt you will talk with your surgeon about your concerns. Perhaps this information will help you express your concerns clearly and get the kind of information you are looking for. Good luck!

Years ago, your only option would have been a fusion. But things are changing in the treatment of severe ankle arthritis. What was once treated with ankle fusion can now be managed with a joint replacement. Improved surgical techniques and better implant designs have made the shift possible. So that’s the good news.

As you suspected, there are some potential problems. And that’s true for any surgery. Let’s take a look at the kinds of complications that can occur with either fusion or joint replacement.

Fractures, skin and deep wound infections, and chronic pain after surgery are possible with either procedure. Likewise, infection that spreads to the bone called osteomyelitis can develop after any surgical procedure that disrupts bone as these two procedures do. Then there is the risk of cutting or damaging nerves and/or blood vessels.

Ankle fusion is well-known for complications such as off angles, poor alignment and deformity, nonunion, and arthritis in the surrounding joints. Altered gait or abnormal walking pattern is typical with an ankle fusion. And of course, activities like jogging or running will never be the same if even possible.

Ankle arthroplasty (total ankle replacement) comes with its own set of potential problems. Common complications with ankle joint replacement include loosening of the implant, impingement (pinching), and malalignment. There can also be subsidence (implant sinks down into the bone), the wrong implant size used, and/or excessive wear on any part of the implant. Though rare, the implant can also fracture or break as well.

You should know that studies show a fairly high complication rate with both procedures. Ankle replacement has a much higher (sometimes twice as high) complication rate compared with fusion. Surgeons are making efforts to reduce the complication rate. Studies just on complications after these two procedures are helping bring useful data and insights.

Your surgeon will review your particular situation. Any specific patient risk factors will be noted and changed if possible. To be honest, surgeon error can be a potential area of concern as well. Selecting the wrong sized implant for joint replacement is possible. Cutting nerves or blood vessels that are difficult if not impossible to see during the procedure is another operator error that could be improved.

On the plus side are the benefits of either one of these procedures. Number one is the reduction of pain, not to mention improved motion and function. There’s no doubt that complications after either procedure can impact the long-term outcomes. Surgeons do everything they can to maximize the benefits and minimize the problems.

Studies show the risk of disease transmission from donor bone is very low — currently estimated at one case in a million for human immunodeficiency virus (HIV). Other diseases that can (but rarely) get transmitted through donor bone include hepatitis B or C.

The bone bank puts all donor tissue through careful testing and processing before it can be released for patient use. The surgeon also irrigates (cleans) the donor bone carefully and thoroughly before putting it in the patient. This step is an additional precaution against disease transmission.

Not to bring up other potential problems, but your risk of implant failure or infection is much higher than any risk of disease transmission. Graft failure is one possibility — either the donor bone doesn’t take, gets reabsorbed by the body, or fragments into pieces. There is also the possibility of the intended area filling in with fibrous scar tissue instead of bone.

Wound and skin infections are also complications the surgeon will watch out for. Once you finish your Internet search and gather all the information available, don’t hesitate to make a pre-op appointment with your surgeon to finish asking any questions or raise concerns about this issue. It’s better to go into surgery with peace of mind than to worry and wonder about all the “what ifs”.

Don’t take it so hard. All your good efforts to be healthy and stay healthy may actually be why you didn’t have a worse injury. Someone else without all those things to their credit may have broken even more bones. And, it’s entirely possible that the same injury in someone half your age would have resulted in the exact same injury.

In the past, osteoporosis (decreased bone density or “brittle bones”) was blamed for most ankle fractures in adults 65 years old and older. Osteoporosis is linked with hip, wrist, and shoulder fractures. But new data suggests there are other possible more important risk factors. One of those risks is taking multiple medications called polypharmacy.

Being overweight appears to be the most common risk factor. The heavier body mass increases the force on the soft tissue and bony structures when a fall happens. But diabetes, cigarette smoking, and inactivity may be the real underlying culprits.

If none of these risk factors describes you, it could be just a case of bad luck. If you landed just right (or wrong as it were), the twisting motion may have just been enough to tear one or more of the many supportive ankle ligaments (e.g., anterior and posterior talofibular ligaments, calcaneofibular ligament, deltoid ligament, tibiocalcaneal ligament, tibiotalar ligament).

Without this important soft tissue structure, the force continues through the bone causing a spiral or oblique (at an angle) break in one or both of the bones along side the ankle.

Identifying risk factors for fractures is good in that it can help you address these problems and reduce your risk for future falls and/or fractures. But if none of this describes you, set your course for recovery and put your mental, emotional, and physical efforts toward healing.

Studies show that more and more older adults are being treated for ankle fractures. Not only are there more of these injuries, but they are more severe. In the past, osteoporosis (decreased bone density or “brittle bones”) was blamed for most ankle fractures in adults 65 years old and older.

But new data suggests there are other more important risk factors. One of those risks is taking multiple medications called polypharmacy. Being overweight appears to be the most common risk factor. The heavier body mass increases the force on the soft tissue and bony structures when a fall happens. But diabetes, cigarette smoking, and inactivity may be the real underlying culprits.

A sedentary lifestyle leads to weakness and deconditioning resulting in decreased balance and increased risk of falls. People who have to push up with their arms to get out of a chair are more likely to suffer a fall and broken ankle. Your father’s injury sounds suspiciously like it might fall into this risk category.

We point out all of these risk factors because dealing with the current damage and preventing future fractures is part of the conservative (nonsurgical) care. This approach is often taken for patients who have too many risks for surgery.

Medical problems such as high blood pressure, heart disease, diabetes, osteoporosis are just a few. Any of these (and especially a combination of two or more) can increase the risk for poor wound healing, high rates of infection, and malunion (fracture doesn’t heal in an aligned position).

The potential for life-threatening blood clots, poor wound healing and/or infection may outweigh the benefits of the surgical procedure. The management approach chosen for your father may be “what’s next” — give the ankle a chance to heal followed by a rehab program.

A physical therapist will work with your father to restore joint motion, muscle strengthen, and proprioception (joint sense of position). All of these skills are needed for everyday activities and to prevent future ankle sprains or other injuries.

He may use a kneeling walker or scooter now but eventually he will be able to progress to partial and then full weight-bearing. The cast may be replaced with a protective book (depending on surgeon preference). Don’t expect a quick return to full function. This process can take weeks to months.

All post-operative care, whether it’s how much weight you can put on the foot, when to start physical therapy, or if/when the screws come out are determined by the surgeon. The decision is based on the type and extent of injury as well as what had to be done in surgery to repair or reconstruct the ankle.

At the time of the surgery, the surgeon looked to see if the joint cartilage was affected. This is a major determining factor in what and how the surgery is done. The presence of loose fragments (usually bits of bone, cartilage, or other debris) require removal and affect post-op decisions.

Likewise, a impacted fracture (broken ends of the bone compacted against each other or displaced (separated apart) must be handled differently during surgery with careful follow-up after surgery.

Sometimes the patient can put weight on the foot right after surgery but full weight-bearing isn’t usually allowed for several weeks. It may be necessary to wear a cast for six to eight weeks (sometimes longer). If there is any concern about the stability of the ankle, the patient will be transitioned from a cast to a walking boot.

Joint motion exercises are started around six weeks post-op for those who didn’t have a cast or when the cast is removed. The surgeon uses X-rays to see how well the bone is healing and advise the patient and therapist when to advance weight-bearing, joint range-of-motion, and exercises.

Hardware (e.g., screws, metal plates, wires, rods, locking plate system) used to fix (hold) the fracture stable during healing is often removed eight to 10 weeks later. The goal is to remove the screws or other instrumentation before bone and scar tissue grow over and around it making removal more difficult. Timing is important because removing it too soon could leave the ankle unstable.

In some cases, it may be necessary to leave the hardware in permanently. The choice to leave the hardware in may be made right from the start based on how and why it is being used. Or that management approach may become more apparent as follow-up X-rays are taken and the condition of the healing fracture is seen.

This is one question that will ultimately be answered by your surgeon. Having this information will help you focus your questions more specifically when the time comes for your next appointment. Good luck!

As you have discovered the hard way, arthroscopic reduction and internal fixation (ARIF) of ankle fractures is an emerging procedure. Until now, the complexity of the ankle joint has required an open procedure called open reduction and internal fixation, more commonly known as ORIF.

Arthroscopic surgery is image-guided through a tiny TV camera on the end of the scope. A picture is projected up on a screen for the surgeon to see. This technology makes it possible to reach places in the joint that would require extensive dissection (cutting and opening) to see otherwise.

Arthroscopic surgery is less invasive than an open incision that cuts through soft tissues that protect and stabilize the joint. With less tissue disruption, there is much less swelling and potentially faster healing. One other advantage of arthroscopic ankle surgery is the reduced risk of accidentally cutting a nerve or important blood vessel.

For all those positive factors associated with arthroscopic reduction and internal fixation (ARIF), there are a few disadvantages. The procedure takes longer than an open reduction and internal fixation (ORIF). The risk of complications from anesthesia and surgery itself go up with increased time on the operating table.

In terms of costs, the ARIF is more expensive in the short-term. But if it prevents the chronic pain that can develop after ORIF, ARIF could potentially lower overall costs in the long-run.

There are some procedures for which arthroscopy has been done successfully with good outcomes. There are six conditions for which arthroscopic reduction and internal fixation (ARIF) can be used. These include: 1) transchondral fracture, 2) talar fracture, 3) distal tibial fracture, 4) syndesmotic disruption, 5) malleolar fracture, and 6) chronic ankle pain after treatment. Arthroscopic surgery should not be used when there is a fracture and dislocation.

The most important factor is effectiveness of these two procedures (ORIF and ARIF) when compared against each other. And that’s where research has not yet been done. Without the assurance that ARIF is indeed superior to ORIF when treating ankle fractures, most ankle fractures will continue to be managed using the open method.

Patients who go to large teaching or university-based hospitals are more likely to benefit from advanced surgical techniques. Senior, experienced surgeons help guide younger, more junior surgeons learn and practice these skills. Your successful results is a testament to this model. Congratulations! In time, arthroscopic technique will be available on a more routine basis to a larger number of people.

Holes or defects in the surface of a joint that extend down through the cartilage to the bone are called osteochondral lesions. Various treatment approaches have been tried for this problem with some success. One particularly challenging area of the body to treat these defects is the talus bone of the ankle.

The very complex ankle joint with its many bones makes it difficult to reach areas of osteochondral lesions. The talus is one of those problem areas. It is sandwiched in between the calcaneus (heel bone) and the tibia-fibula bones of the lower leg.

The tibia (larger bone of the lower leg) sits over the top of the talus and extends down along one side of the talus creating an area referred to as the talus shoulder. Repairing osteochondral lesions of the talar shoulder is the topic of this study.

Damaged cartilage in older adults doesn’t make new chondrocytes (cartilage cells) and can’t seem to repair itself. Therefore, the use of bone graft material has been studied as one possible treatment approach. Using fresh bone graft placed into the defects along the talar shoulder seems to have good results.

The defect must be large enough to warrant this type of treatment but not so large that a bone replacement is required. The shape of the talar shoulder makes it unlikely that bone plugs inserted into the holes will work (another repair method) — there just isn’t enough structural support for this approach.

Problems the surgeon will watch for are graft failures (e.g., body resorbs the graft without making new bone, graft breaks up into small pieces, body rejects the donor tissue). Another potential problem is the defect filling in with fibrous scar tissue instead of bone.

The beauty of bone graft to treat this problem is that the procedure can be done again before considering other more invasive or permanent procedures. Treating osteochondral lesions of the talar shoulder with fresh allograft delays the need for ankle replacement or fusion.

There are new and wondrous developments in the area of bone grafts including new techniques for bone grafting in the foot and ankle. But sometimes, it’s still easier, faster, and better to go with the old tried-and-true method of harvesting bone from the pelvic bone.

Most often, bone is taken from the iliac crest. The iliac crest is the top of the pelvic bone — it’s located where you place your hands on your hips.

Bone harvested from this area is plentiful but can cause excessive bleeding and postoperative pain. For some procedures, like ankle and foot reconstruction, the patient could go home the same day if it wasn’t for problems with the bone graft donor site.

Because of major complications with graft site pain, deep infections, ugly scars, and sensory loss, surgeons started looking elsewhere for another source of autograft with fewer problems. With the advances in graft techniques, it’s now possible to take bone from places other than the iliac crest.

The most popular sites have become the front of the tibia (lower leg bone) just below the knee, the lower part of the tibia (just above the outer ankle), the calcaneus (heel bone), and the greater trochanter (area of bone at the top of the femur or thigh bone).

If the graft donor site is close to the area where the donor bone is needed, it’s considered a local source of autogenous graft material. If the bone is harvested from an area away from the main surgical site (usually in order to get more bone), it’s referred to as a regional bone graft.

Despite the drawbacks and potential problems, harvesting bone from the iliac crest has several advantages. For one thing, it contains two types of bone: cancellous and cortical. Cancellous bone is the spongy, less dense bone between the outer layer (perisoteum) and inner layer (bone marrow).

Cancellous bone has a better blood supply and that’s helpful in getting new bone cells to survive. There’s also more of it compared with cortical bone. And it is easier to form and shape cancellous bone around difficult or tight spots during bone grafting procedures. This last benefit is important when working in the ankle because of the many oddly shaped bones and joints.

Cortical bone is the stronger, denser, supportive bone that forms the outer shell of most bones. It provides good mechanical support. But with less of a natural blood supply, it is much slower to build blood vessels for the new bone.

It’s likely that the surgeon and his nurse explained some of these things to you. But whenever new information is presented the first time, the importance and specifics don’t always sink in.

Don’t hesitate to ask again for a quick review of the important points and how/why they matter in your case. The fact that they spent so much time making sure your understand all the potential risks is a good sign that the surgeon will do everything possible to prevent complications and problems.

Bone grafting is often used with severe fractures and/or the need to fuse a joint because it provides a basic structure called a scaffold.

Basically that means the bone graft as a scaffold functions like a garden trellis. But instead of plant vines climbing up and around the structure and filling in the holes, it’s bone cells. This process occurs in several stages.

In the first few weeks, the bone graft does its job of encouraging bone cells to form and fill in around it. Then the second phase begins. The new bone cells develop their own blood supply. That takes another four to eight weeks.

Then in the final phase, the new bone cells integrate with the bones of the body (in this case, your brother’s ankle bones) to create a strong, supportive structure. When used to fuse a joint, the intended goal is to stop all motion by filling in the joint with solid bone.

Fixation with hardware such as metal plates, screws, pins, and wires is a process called instrumentation. These devices provide support and stability until the fusion is solid and hardened. Putting weight on the bones while the bone graft is trying to fill in could disrupt the bone graft and prevent proper healing.

Even with conservative care and an aggressive rehab program, Achilles tendon ruptures simply take a long time to heal. Part of the time delay is the fact that the worry with Achilles tendon rupture has always been that the tendon would re-rupture with too much too soon. So, in the past, these injuries were always treated with cast immobilization with no weight on the foot. That protocol was used for both conservative care and after surgery.

Now there is some evidence that introducing two key components (early weight-bearing and early motion) really helps speed up the healing and recovery process.The first two weeks after injury is a period of non-weight-bearing and immobilization. During that two-week period of time, patients are put in a special splint and keep weight off the foot.

After two weeks (and for the next four weeks), the splint is exchanged for a boot brace with a heel that protects the healing tendon. During that time, ankle motion is allowed from a toe pointed down position (called plantar flexion) to a neutral alignment. By the end of eight weeks, patients are out of any protective boot at all and allowed to move the foot freely and put full weight on it.

With this protocol, athletes can go from injury to retraining for a return-to-sports in as little as eight weeks. That is the best case scenario to date. Eliminating the added risks that come with surgery improves the odds that the athlete will stay on course and get full recovery without delays. Researchers will continue investigating this topic. There may be other ways to aid recovery and reduce the amount of time it takes to go from injury back to the field or court. Hopefully future studies will bring those to light and further reduce the time it takes to fully recover after an acute Achilles tendon rupture.

You ask a good question and one that others have dealt with quite a bit. The debate continues among surgeons about the best way to treat Achilles tendon ruptures early on after they have happened. The first question is whether to operate and repair the torn tendon or treat it conservatively (without surgery).

It would seem that whichever way gives the best results is the way to go. But the problem is that different studies come up with different outcomes. There just don’t seem to be consistent results to support one approach over the other.

In a recent study by this author (Dr. Kevin R. Willits), a high-quality study was designed to put this argument to rest. Dr. Willits recognized that one reason study results vary so much is because different post-operative rehab programs are used. He started to wonder if the patients who had the best results were doing so well because of a more aggressive rehab protocol. He based this hypothesis on the fact that so many studies that had poor outcomes used a very conservative, slow rehab program.

So he put his idea to the test. He compared two groups of patients. They all had an acute Achilles tendon rupture. They all followed the same fast-paced (called accelerated) rehab program. The only difference was that one group had surgery right away and the other group didn’t.

There are two key features to the accelerated functional rehab program. One is getting up and putting weight on that foot and leg. The second is early ankle motion. Scientists have already shown that load and pressure on healing collagen tissue speeds up the healing process.

But the worry with Achilles tendon rupture has always been that the tendon would re-rupture with too much too soon. So, in the past, these injuries were always treated with cast immobilization with no weight on the foot (just as you have been instructed). That protocol was used for all patients whether they had conservative care or surgery.

Now this study showed that, in fact, the early mobilization group had the best results. There were less (not more) re-ruptures. They did have a period of non-weight-bearing and immobilization– but only for two weeks. During that two-week period of time, they were put in a special splint and kept weight off the foot.

The conclusion of the study was that early motion and early weight-bearing were keys to a successful outcome. With equal results between conservative (nonoperative) care and surgery, the natural conclusion is that surgery isn’t needed after all. An aggressive functional rehab program is what people really need.

You may want to go back to your care giver and ask your question directly. There could be specific reasons why you have been prescribed the specific treatment you mentioned. But it’s possible that based on the results of this new study, you might be someone who could benefit from this change (more aggressive) in approach.

Any surgical procedure comes with some risks. There can be problems intra-operatively (during the surgery) or post-operatively (after the operation). There can be technical problems related to the procedure itself or the anesthesia. Afterwards, there is an increased risk of blood clots, infection, and poor wound healing. With bone fractures, failure of the bone to heal (or failure to heal properly) can lead to nonunion or malunion.

The surgeon and surgical staff do everything they can to prevent and if not prevent, then minimize problems and complications. Many of the common problems associated with surgery have been reduced and even eliminated with improved surgical techniques and tools.

The use of real-time X-ray called fluoroscopy has really boosted results as the surgeon can see what he or she is doing as they are performing the procedure. This has cut down on the number of blood vessels and nerves cut by mistake during the procedure.

Having said all that, studies have reported complication rates with internal fixation (use of hardware to fix a bone fracture) as high as 54 per cent for the type of injury your wife has experienced. According to a recent study on this topic, the complication rate does not seem to be linked with age. (There’s some thought that older patients are at greater risk for problems than younger patients).

Anyone with a poor health history or presence of serious conditions or illnesses such as diabetes or high blood pressure may be at increased risk of complications. Hopefully your wife doesn’t fall into any of these categories and will come through this operation in good shape.

The ankle is a very complex joint and a bad break affecting the joint itself can lead to considerable pain and disability. Older age and certain health factors can add misery to an already difficult situation. That’s been the case with intraarticular (inside the joint) calcaneal fractures.

The calcaneal bone is your heel bone. It sits right under the tibia (lower leg bone) and right above the talus and forms part of the ankle joint. A break on the inside of the joint at the heel is referred to as an intra-articular calcaneal fracture.

Surgery to fix a fracture affecting this area in an older patient has traditionally had a dismal record for recovery. Results are unpredictable. This uncertainty is a major reason why many surgeons recommend conservative (nonoperative) care for a fracture of this type — especially in anyone over age 65.

Tobacco use and especially cigarette smoking has clearly been proven as a negative risk factor in healing. This is true for bone healing as well as soft tissue wound repair. The risk of malunion, nonunion, infection, and poor wound healing is much higher for a smoker compared with a nonsmoker.

And if there are other health risks, the surgeon may be firm in recommending conservative care. Health problems that can compromise results of surgery could include problems such as diabetes, high blood pressure, and heart or lung disease. These are the most common side effects of long-term cigarette smoking. Anyone with poor circulation, or decreased immune function is also at increased risk for poor outcome after a fracture of this type.

You can trust your father’s surgeon to make a recommendation that is in his best interest. The “No” is for a reason. You might feel better if you were able to consult with the surgeon and find out more about the risks your father faces in having this type of injury. Knowing why a nonoperative approach was advised would be helpful for everyone in accepting this decision.

In the last few years, scientists have discovered that injecting platelets from blood into damaged tendons helps them heal faster and better. This has been good news for professional athletes like yourself who are eager to get back to work on the playing field (or golf course as in your case).

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has much more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

There haven’t been too many studies using PRP for the Achilles tendon. Reported results have been mixed. One study showed that patients were able to get back on their feet and return-to-sport activity faster than athletes undergoing traditional treatment. But a second study from Sweden could not reproduce those same good results.

In the Swedish study, they used platelet-rich plasma (PRP) injections in the Achilles tendon of 16 patients. They were not all professional athletes but the injury did occur while engaged in recreational sports.

Results were compared to another group of patients who also had a recent Achilles tendon rupture (within three days). The second group was the control group — they did not have the PRP injection. Patients in both groups ranged in age from 18 to 60 and were in good general health.

The authors were surprised to find no differences between the two groups. The PRP group did not heal faster or have a stronger Achilles tendon at any point in the follow-up. In fact, if anything, the PRP group had slightly worse functional results. Functional refers to their ankle motion, ability to rise up on toes, and jump vertically. The PRP group did not see themselves as limited in daily activities but there is still a concern that their risk of re-injury is greater than normal.

Platelet-rich plasma as a treatment for tendon injuries is still a new enough approach that all variables and factors have not yet been discovered. You may be a good candidate for this treatment. Check with your sports surgeon and see what he or she has to say. Each patient is different and may have a unique response to this type of treatment.