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Abstract

Background:

Patient reliance on internet resources for clinical information has steadily increased. The recent widespread accessibility of artificial intelligence (AI) tools like ChatGPT has increased patient reliance on these resources while also raising concerns about the accuracy, reliability, and appropriateness of the information they provide. Previous studies have evaluated ChatGPT and found it could accurately respond to questions on common surgeries, such as total hip arthroplasty, but is untested for uncommon procedures like total ankle arthroplasty (TAA). This study evaluates ChatGPT-4’s performance in answering patient questions on TAA and further explores the opportunity for physician involvement in guiding the implementation of this technology.

Methods:

Twelve commonly asked patient questions regarding TAA were collated from established sources and posed to ChatGPT-4 without additional input. Four fellowship-trained surgeons independently rated the responses using a 1-4 scale, assessing accuracy and need for clarification. Interrater reliability, divergence, and trends in response content were analyzed to evaluate consistency across responses.

Results:

The mean score across all responses was 1.8, indicating an overall satisfactory performance by ChatGPT-4. Ratings were consistently good on factual questions, such as infection risk and success rates, whereas questions requiring nuanced information, such as postoperative protocols and prognosis, received poorer ratings. Significant variability was observed among surgeons’ ratings and between questions, reflecting differences in interpretation and expectations.

Conclusion:

ChatGPT-4 demonstrates its potential to reliably provide discrete information for uncommon procedures such as TAA, but it lacks the capability to effectively respond to questions requiring patient- or surgeon-specific insight. This limitation, paired with the growing reliance on AI, highlights the need for AI tools tailored to specific clinical practices to enhance accuracy and relevance in patient education.

Keywords

artificial intelligence total ankle arthroplasty patient education accuracy patient questions ChatGPT

Background

Widespread and accessible information on the internet has led to an increase in the number of patients who use it as their primary source of medical information.^3,5,11,21,26 There is debate regarding whether this information is reliable and if obtaining information from the internet damages the patient-physician relationship, which may affect a patient’s overall health status.^1,5,9,16 As such, alternative sources for patient education are continually being developed and researched. One potential alternative source for health information is large language model (LLM) artificial intelligence (AI) systems like ChatGPT, which is an AI chatbot developed by OpenAI.⁷ The first version of ChatGPT was first released in November of 2022, and each subsequent release of GPT offers a more advanced AI model.^{4,8,10,13,19,20,27} GPT-4 is the first iteration that draws information from internet sources as well as peer-reviewed medical journals, which may have increased its accuracy as a source of patient information (Table 3 and Appendix 1).^7,14

A recent article by Mika et al¹⁸ found ChatGPT effectively provides patients with evidence-based answers to common questions regarding total hip arthroplasty. There are approximately 572 000 total hip arthroplasty surgeries performed each year, making it one of the most common orthopaedic procedures performed in the United States.²³ Although ChatGPT was effective in providing accurate answers for questions related to this common orthopaedic procedure, its ability to provide accurate responses to questions for less common procedures, such as total ankle arthroplasty (TAA), has not yet been investigated (Table 2).^12,18 Understanding ChatGPT’s ability to provide patient-appropriate answers to questions regarding less common orthopaedic procedures is necessary before it is implemented or recommended as a patient education tool. The purpose of this study was to assess the accuracy and comprehensiveness of ChatGPT’s responses to common questions about TAA, as assessed by four fellowship-trained foot and ankle surgeons who regularly perform TAA.

Methods

A set of 12 questions (Table 1) was developed based on the wording of questions found on TAA educational websites and adapted from those used by Mika et al.¹⁸ The set of questions was further validated by the authors for their relevance and similarity to commonly asked questions by their TAA patients. These questions were posed to ChatGPT-4 in January of 2024 with no additional prompting, and the generated responses were recorded. A new ChatGPT-4 account was created for the duration of this experiment, as ChatGPT can be significantly influenced by user input over time. All questions were asked in a standardized format, with no follow-up or repeat queries to prevent AI training. Four fellowship-trained foot and ankle surgeons, with a combined 40 years of clinical experience, were asked to rate ChatGPT-4’s responses on an ordinal scale from 1 to 4, as previously described by Mika et al,¹⁸ with 1 being an excellent response not requiring clarification and 4 representing an unsatisfactory response requiring significant clarification (Table 1). Each surgeon evaluated the responses independently and recorded their ratings in isolation from the other surgeons via a RedCAP survey (Table 1).

Table 1.

Response Accuracy Scoring System Used to Assess ChatGPT Responses.

Score	Description
1	Excellent response not requiring clarification
2	Satisfactory response with minimal clarification
3	Satisfactory response with moderate clarification
4	Unsatisfactory response requiring significant clarification

Table 2.

Questions Asked of ChatGPT.

1.	When should I get an ankle replacement?
2.	How long does an ankle replacement operation take?
3.	What are the advantages and disadvantages of total ankle replacement in comparison to ankle fusion?
4.	Is ankle replacement safe?
5.	What are the risks of ankle replacement surgery?
6.	How common is infection after ankle replacement surgery?
7.	How long does an ankle replacement last?
8.	How successful is ankle replacement surgery?
9.	How long does recovery take after total ankle replacement surgery and how long will I be out of work?
10.	What physical limitations will I have after ankle replacement surgery? What activities can I do after ankle replacement?
11.	What are the options if an ankle replacement fails?
12.	What are the differences between a fused ankle versus a replaced ankle with regard to gait?

Descriptive statistics were used to assess each question and each surgeon’s corresponding rating, and an overall mean surgeon score was calculated for each question. Each of the four reviewing surgeons introduced variability and biases based on their years of practice and experiences with patients. To help account for this variability, additional descriptive analyses were conducted to investigate differences and identify trends between the surgeons, questions, and ChatGPT-4 responses.

The first of these analyses was performed in terms of agreement and disagreement between each surgeon and ChatGPT-4’s response. A rating of 1 (out of 4) was considered an “agreement” and anything else was considered a “disagreement,” reducing the ordinal scale to a binary classification. Next, interrater consistency between each pair of surgeons was evaluated by comparing their ratings across the 12 question responses and identifying the number of identical ratings. Each response’s ratings were analyzed for surgeon divergence, with a surgeon considered divergent within a particular question if no other surgeon provided the same rating for the same question. Finally, a question-by-question analysis was performed to identify questions with the highest- and lowest-rated responses to determine if there were trends in the question topics, as well as the type and nature of information they requested.

Results

The mean overall score across all responses was 1.8, indicating that, on average, ChatGPT-4 provided satisfactory responses that required minor clarifications.

Surgeon 1 provided the highest level of agreement with ChatGPT-4 responses, rating 83% of the answers as a 1, with an average rating of 1.2. Surgeon 2 exhibited the most disagreement, agreeing with only 17% of responses, with an average rating of 2.3. Interrater consistency varied considerably. Surgeons 1 and 2 rated every question differently than each other, whereas surgeons 1 and 4 had the most similar ratings, with 8 of 12 (67%) being identical. Furthermore, in terms of surgeon divergence, surgeons 1 and 4 were the least divergent, each having unique ratings only 17% of the time as compared to ratings of other surgeons for the same question. In contrast, surgeons 2 and 3 were far more divergent, providing unique ratings 58% and 42% of the time, respectively.

In a question-by-question analysis, the questions that received the best scores (lower was better) included the following:

• “What is the success rate of ankle replacement?” (mean score: 1.3)

• “How long does an ankle replacement last?” (mean score: 1.5)

• “How common is infection after ankle replacement surgery?” (mean score: 1.5)

On the opposite end were questions with the worst ratings, including the following:

• “When should I get an ankle replacement?” (mean score: 2.0)

• “What are the options if ankle replacement fails?” (mean score: 2.0)

• “What are the differences in a fused ankle versus a replaced ankle with regard to gait?” (Mean: 2.3)

Table 3.

ChatGPT Response Accuracy Score.

Questions	Surgeon 1	Surgeon 2	Surgeon 3	Surgeon 4	Mean	Min	Max
When should I get an ankle replacement	2	1	3	2	2	1	3
How long does an ankle replacement operation take?	1	2	2	2	1.8	1	2
Which is better an ankle replacement or an ankle fusion?	1	2	2	1	1.5	1	2
Is ankle replacement safe?	1	2	3	1	1.8	1	3
What are the risks of ankle replacement?	1	2	3	1	1.8	1	3
How common is infection after ankle replacement surgery?	1	2	1	2	1.5	1	2
How long does an ankle replacement last?	1	2	2	1	1.5	1	2
What is the success rate of ankle replacement?	1	2	1	1	1.3	1	2
How long does recovery take after ankle replacement and how long will I be out of work?	1	2	2	3	2	1	3
What limitations will I have after ankle replacement surgery? What activities can I do after ankle replacement?	2	3	1	2	2	1	3
What are the options if ankle replacement fails?	1	4	1	2	2	1	4
What are the differences in a fused ankle versus a replaced ankle with regards to gait?	1	3	4	1	2.3	1	4
Overall accuracy	1.2	2.3	2.1	1.6	1.8

Discussion

The growing reliance on internet resources for medical information has brought about opportunities and challenges for patient education. Generative artificial intelligence tools such as ChatGPT, powered by large language models, have the potential to reshape the landscape of patient education. Mika et al¹⁸ demonstrated ChatGPT’s ability to provide accurate answers about total hip arthroplasty, showing that 20% of the responses required no clarification, whereas 40% required minimal clarification. Similarly, McCarthy et al¹⁷ found ChatGPT-generated information was less suitable for patients than society-provided educational materials, but it did produce factually correct outputs 88% of the time.

This study sought to extend this evaluation to TAA, a far less common orthopaedic procedure, by assessing ChatGPT-4’s ability to answer common patient questions about TAA. The results revealed an overall mean score of 1.8, indicating that ChatGPT-4’s responses were satisfactory and required minimal clarification. Although this performance is consistent with prior research, focusing solely on average scores may obscure the nuances and variability of individual responses. This study extends beyond these metrics, exploring the underlying trends and factors that influence these ratings to offer a more nuanced perspective on ChatGPT's responses.

Analysis of surgeon ratings revealed substantial variability. Surgeons generally agreed that ChatGPT-4 performed best when answering discrete, factual questions, such as "What is the success rate of ankle replacement?" or "How common is infection after ankle replacement surgery?" Responses to these types of questions are informed by precise, numeric data, which ChatGPT-4 handled effectively.

Responses that required more nuanced, patient- or surgeon-specific information, however, were rated more poorly. For instance, the response to question 9, "How long does recovery take after ankle replacement and how long will I be out of work?" was rated poorly by surgeon 3. This surgeon, who usually performs TAA as an outpatient procedure, rated ChatGPT’s response as a 3 out of 4, likely because of its suggestion of a hospital stay being likely. In contrast, surgeons 1, 2, and 4, who frequently admit their patients when performing a TAA, rated the same response quite favorably (1, 2, and 2, respectively). This divergence highlights how differences in surgical practice can impact the perceived accuracy of AI-generated content.

The findings of this study suggest that although ChatGPT can provide accurate, general information, its responses often falter when dealing with more personalized or practice-specific inquiries. The growing reliance on AI is evident, with 45% of adults in the United States reporting the use of generative AI tools. This trend is particularly pronounced among younger generations, with 70% of Gen Z reporting using such technology, and 52% of them trusting AI to assist in making informed decisions.²⁵ As more patients inevitably turn to these tools for healthcare guidance, the potential for incomplete or misleading information increases. This phenomenon mirrors the rise of platforms like WebMD, where patients frequently used online resources to self-diagnose, sometimes leading to misguided conclusions that can be problematic for physicians.

To mitigate these risks, physicians should consider taking a more proactive role in shaping AI's use in healthcare. A key takeaway from this study is that while ChatGPT-4 performed well with general facts about TAA, it struggled to provide nuanced and tailored information—a limitation inherent to the data it was trained on, as it does not contain a surgeon’s preferences. However, recent advancements suggest that customizing an AI model to align more closely with a specific surgeon’s preferences is feasible. Sanjaya et al²² found that even individuals with limited experience can train generative AI chatbots to their own specific guidelines, offering an opportunity to provide patients with an enhanced version of the tool they are highly likely to use. Softić et al²⁴ further demonstrated this potential by developing a custom health-focused AI application that received positive user feedback. Such customization could address discrepancies between generalized AI outputs and surgeon-specific practices, enhancing patient knowledge by bridging the gap between internet-based education and real-world medical practice. As Leocádio et al¹⁵ noted, this technological paradigm shift may be inevitable; therefore, physicians can take a guiding role in this process.

Several limitations of this study should be noted. First, OpenAI continually refines ChatGPT; therefore, the results of this study are specific to the ChatGPT-4 model.⁷ However, these same questions were posed to Gemini (1.5 Flash) and Claude (3.5 Sonnet), each providing nearly identical content.^2,6 Additionally, although the question protocol was standardized, this may not accurately reflect real-world patient interactions with AI, as patients may ask for clarification or pose follow-up questions. Moreover, responding to straightforward questions does not use the full extent of LLM’s or AI’s capabilities. Finally, the rating system used in this study has been previously described but lacks external validation.¹⁸ Despite these limitations, this study is one of the first to evaluate the performance of ChatGPT in orthopaedic surgery, particularly in a less common procedure like TAA.

Conclusion

ChatGPT-4 demonstrated the capability of delivering satisfactory answers to common questions about TAA, particularly when discrete or numerical information was requested. However, it struggled with open-ended, patient- or surgeon-specific queries. These findings, combined with emerging evidence supporting the customization of AI for specific clinical settings, underscore the importance of continued research and physician involvement in the development of medical chatbots. By doing so, physicians can ensure that generative AI serves as a reliable, accurate tool for patient education.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251322784 – Supplemental material for ChatGPT-4 Effectively Responds to Common Patient Questions on Total Ankle Arthroplasty: A Surgeon-Based Assessment of AI in Patient Education

Supplemental material, sj-pdf-1-fao-10.1177_24730114251322784 for ChatGPT-4 Effectively Responds to Common Patient Questions on Total Ankle Arthroplasty: A Surgeon-Based Assessment of AI in Patient Education by Heidi C. Ventresca, Harley T. Davis, Chase W. Gauthier, Justin Kung, Joseph S. Park, Nicholas L. Strasser, Tyler A. Gonzalez and J. Benjamin Jackson in Foot & Ankle Orthopaedics

Footnotes

Appendix

Appendix 1.

ChatGPT Question and Response.

Question 1. When should I get an ankle replacement

I’m not a doctor, but I can provide some general information about when ankle replacement surgery might be considered. Ankle replacement is typically considered when conservative treatments for ankle pain and dysfunction, such as physical therapy, medications, and braces, have not provided relief.
Here are some common reasons for considering ankle replacement:
1. Severe Arthritis: Ankle arthritis, particularly if it’s advanced and causing significant pain, stiffness, and limited mobility, can be a reason for ankle replacement.
2. Failed Conservative Treatments: When other non-surgical treatments have failed to provide relief or improve ankle function.
3. Chronic Pain: If you’re experiencing chronic pain in your ankle that affects your quality of life and daily activities.
4. Difficulty Walking: Ankle arthritis or injury can lead to difficulty walking or bearing weight on the affected ankle.
5. Ankle Deformity: Significant deformity of the ankle joint that impairs its function may also be a factor.
Ultimately, the decision to get an ankle replacement is a medical one, and you should consult with an orthopedic specialist or surgeon to evaluate your specific condition and discuss whether ankle replacement is the right option for you. They will consider your overall health, lifestyle, and the severity of your ankle issues before recommending surgery or alternative treatments.

Question 2. How long does an ankle replacement operation take?

The duration of an ankle replacement operation can vary depending on several factors, including the complexity of the procedure, the surgeon’s experience, and the patient’s specific condition. On average, ankle replacement surgery typically takes around 1 to 2 hours to complete. However, in some cases, it may take longer if there are additional complications or if the surgeon needs to address multiple issues during the procedure.
It’s essential to consult with a medical professional or orthopedic surgeon for more precise information about the expected duration of the ankle replacement surgery, as they can provide you with specific details based on your individual circumstances.

Question 3. What are the advantages and disadvantages of total ankle replacement in comparison to ankle fusion?

Total ankle replacement (TAR) and ankle fusion (also known as ankle arthrodesis) are two surgical procedures used to treat ankle arthritis and other ankle joint conditions. Each has its own set of advantages and disadvantages, and the choice between them depends on the patient’s specific condition, lifestyle, and preferences. Here’s a comparison of the two:
Total Ankle Replacement (TAR):
Advantages:
1. Preservation of motion: TAR aims to retain some degree of natural ankle joint motion, which can lead to improved walking and functional outcomes.
2. Reduced risk of adjacent joint problems: Unlike ankle fusion, which eliminates ankle joint motion, TAR may reduce the risk of developing arthritis in adjacent joints.
3. Potential for quicker recovery: Some patients may experience a faster recovery and return to activities compared to ankle fusion, as they retain ankle joint mobility.
4. Pain relief: TAR can provide pain relief and improve overall joint function in patients with severe ankle arthritis.
Disadvantages:
1. Limited durability: TAR implants may not last as long as ankle fusion, and revision surgeries may be necessary in the future.
2. Complex surgery: Total ankle replacement is a more complex surgical procedure than ankle fusion, and it may have a longer recovery period.
3. Risk of complications: Like any surgical procedure, TAR carries risks of complications such as infection, implant loosening, and nerve damage.
4. Cost: Total ankle replacement can be more expensive than ankle fusion due to the cost of the implant and the complexity of the surgery.
Ankle Fusion (Arthrodesis):
Advantages:
1. High success rate: Ankle fusion has a high success rate in terms of pain relief and improved stability, and it is generally considered a reliable procedure.
2. Durability: Ankle fusion is a durable solution, and once the joint is fused, there is no risk of implant wear or loosening.
3. Lower risk of complications: Ankle fusion is a simpler procedure compared to TAR and may have a lower risk of complications.
4. Lower cost: Ankle fusion tends to be more cost-effective than TAR.
Disadvantages:
1. Loss of motion: The main drawback of ankle fusion is that it eliminates ankle joint motion, which can affect walking and mobility.
2. Adjacent joint problems: The lack of motion in the fused ankle joint can lead to increased stress on adjacent joints, potentially causing arthritis in those areas.
3. Longer recovery: Patients undergoing ankle fusion typically have a longer recovery period and may take longer to return to normal activities.
4. Potential for revision surgery: In rare cases, ankle fusion may require revision surgery if complications arise.
Ultimately, the choice between total ankle replacement and ankle fusion depends on the individual’s specific condition, lifestyle, and goals. Patients should consult with their orthopedic surgeon to determine the most appropriate treatment option for their situation.

Question 4. Is ankle replacement safe?

Ankle replacement surgery can be safe and effective for certain individuals who have severe ankle arthritis or other conditions that have led to significant joint damage. However, like any surgical procedure, there are risks involved. It’s essential to consult with a qualified orthopedic surgeon who can assess your specific situation and provide personalized recommendations.
Some potential risks and considerations associated with ankle replacement surgery include:
1. Infection: There is a risk of infection following surgery, although steps are taken to minimize this risk.
2. Implant Wear and Tear: Over time, the artificial ankle joint may wear out, and additional surgeries may be needed to replace it.
3. Implant Loosening: The artificial joint may become loose or fail to integrate with the surrounding bone.
4. Blood Clots: Blood clots can occur after surgery, which can be potentially dangerous.
5. Nerve Damage: There is a possibility of nerve damage during surgery, leading to numbness or tingling in the foot.
6. Pain or Swelling: Postoperative pain and swelling are common and should be managed with pain medications and physical therapy.
7. Limited Range of Motion: While ankle replacement can improve function, it may not restore full range of motion to the ankle joint.
8. Allergic Reactions: Some individuals may experience allergic reactions to the materials used in the implant.
9. Rehabilitation: Post-surgery rehabilitation and physical therapy are essential for a successful outcome.
It’s crucial to discuss these risks and benefits with your surgeon and thoroughly evaluate whether ankle replacement is the right option for your specific condition. The decision to undergo ankle replacement surgery should be made in consultation with your healthcare provider after a thorough evaluation of your medical history and current health status.

Question 5. What are the risks of ankle replacement?

Ankle replacement surgery, like any major surgical procedure, carries certain risks. Although the surgery can greatly improve the quality of life for many patients, it’s essential to be aware of potential complications. Here are some of the risks associated with ankle replacement surgery:
• Infection: All surgeries carry a risk of infection. If an infection occurs after ankle replacement surgery, it could potentially require additional treatment, including more surgery or long-term antibiotic use.
• Blood Clots (Deep Vein Thrombosis): Ankle replacement surgery increases the risk of developing blood clots in the deep veins of your legs, which can be serious if the clots travel to your lungs (pulmonary embolism).
• Nerve Damage: There’s a chance of nerve damage during surgery, which could lead to numbness, weakness, or a tingling sensation in the foot or leg.
• Loosening or Failure of the Implant: Over time, the artificial joint may loosen or fail, leading to pain or loss of function. This could potentially require revision surgery.
• Bone Fractures: During surgery, there’s a risk of fracturing the bones in the ankle. Fractures may also occur after surgery, particularly if a fall or accident occurs.
• Allergic Reaction: Rarely, a patient may have an allergic reaction to the metal used in the joint implant.
• Difficulty with Wound Healing: Certain conditions like diabetes, poor circulation, or certain lifestyle habits (like smoking) can interfere with the healing process.
• Change in Ankle Alignment or Length: The replaced ankle may not have the same alignment or leg length, which could impact gait and balance.
• Pain: Some patients may continue to experience pain after the procedure.
It’s important to discuss all these potential risks with your surgeon before making a decision. They will provide you with information tailored to your specific health situation and help you weigh the benefits and risks of the procedure. Not everyone will experience these complications, and many people have successful ankle replacements with significant improvement in their quality of life.

Question 6. How common is infection after ankle replacement surgery?

The risk of infection after ankle replacement surgery can vary depending on several factors, including the patient’s overall health, the surgeon’s skill, and the surgical facility’s infection control measures. In general, the risk of infection after joint replacement surgery, including ankle replacement, is relatively low but not zero.
Some studies suggest that the infection rate for ankle replacement surgery is in the range of 1% to 3%. However, it’s essential to note that this can vary from one patient to another. Patients with underlying health conditions, such as diabetes or a compromised immune system, may be at a higher risk of infection.
To get more specific information about infection rates for ankle replacement surgery, it’s best to consult with your orthopedic surgeon. They can provide you with personalized information based on your medical history and the specific details of your surgery.

Question 7. How long does an ankle replacement last?

The longevity of an ankle replacement can vary from person to person depending on various factors, including the type of implant used, the patient’s activity level, age, and overall health. On average, ankle replacements can last around 10 to 20 years or more. However, some may wear out sooner, while others may last longer.
Advancements in medical technology and surgical techniques have improved the durability of ankle replacements in recent years. It’s important for individuals who have undergone ankle replacement surgery to follow their doctor’s recommendations for post-operative care and rehabilitation to maximize the lifespan of the implant.
Ultimately, the specific lifespan of an ankle replacement is a complex issue that should be discussed with a surgeon, as they can provide more personalized information based on an individual’s unique circumstances. If you or someone you know is considering ankle replacement surgery or has concerns about an existing implant, it’s best to consult with a healthcare professional for guidance.

Question 8. How successful is ankle replacement surgery?

Ankle replacement surgery, also known as total ankle arthroplasty (TAA), can be successful in relieving pain and improving the function of a damaged or arthritic ankle joint. However, the success of the surgery can vary depending on several factors, including the patient’s overall health, the extent of ankle joint damage, the surgeon’s skill and experience, and post-operative rehabilitation.
Here are some key points to consider regarding the success of ankle replacement surgery:
1. Pain Relief: Ankle replacement surgery is generally effective in reducing or eliminating pain associated with arthritis or joint damage. Many patients experience significant pain relief after the procedure.
2. Improved Function: The surgery can improve the range of motion and functionality of the ankle joint, allowing patients to perform activities they couldn’t do before surgery.
3. Patient Selection: The success of ankle replacement surgery is often influenced by appropriate patient selection. Candidates for the surgery should have realistic expectations and be in good overall health.
4. Surgeon Experience: The expertise of the surgeon performing the procedure is crucial. Experienced orthopedic surgeons with a history of successful ankle replacements tend to have better outcomes.
5. Rehabilitation: Post-operative rehabilitation and physical therapy are essential for a successful outcome. Patients must follow the recommended rehabilitation plan to regain strength and mobility.
6. Risks and Complications: Like any surgery, ankle replacement carries risks, including infection, implant failure, and complications related to anesthesia. Patients should be aware of these potential risks.
7. Long-Term Results: Ankle replacements can last for many years, but they may eventually wear out and require revision surgery. The longevity of the implant can vary among individuals.
8. Alternative Treatments: Before opting for ankle replacement surgery, patients may explore alternative treatments such as physical therapy, medication, or ankle fusion. These options should be discussed with a healthcare provider.
It’s important for individuals considering ankle replacement surgery to have a thorough discussion with their orthopedic surgeon to assess their specific situation and determine if the procedure is a suitable option. Success rates can vary, but many patients experience significant improvements in pain and function after ankle replacement surgery when it is the appropriate treatment choice.

Question 9. How long does recovery take after ankle replacement and how long will I be out of work?

Recovery time after total ankle replacement surgery can vary from person to person, depending on various factors including your overall health, the extent of the surgery, and how well you follow your doctor’s post-operative instructions. However, here’s a general timeline:
1. Immediate Post-Operative Period (Days to Weeks):
- You’ll likely spend a few days in the hospital after the surgery.
- During this time, you’ll need to keep your ankle elevated and avoid putting weight on it.
- You may be provided with crutches or a walker for mobility.
2. First 6 Weeks:
- In the initial weeks, you’ll gradually start bearing weight on your ankle with the help of a walking boot or cast.
- Physical therapy may be recommended to help regain strength and range of motion.
- You may need assistance with daily tasks.
3. 6 Weeks to 3 Months:
- You’ll continue physical therapy and slowly increase weight-bearing activities.
- Mobility and strength in your ankle should improve during this phase.
4. 3 Months to 6 Months:
- Most people can start returning to light activities and work at this point, depending on the type of job they have.
- Physical therapy may continue as needed.

Question 9. How long does recovery take after ankle replacement and how long will I be out of work?

5. 6 Months to 1 Year:
- You’ll gradually increase your activity level and may be able to return to more physically demanding work or activities.
- Full recovery can take up to a year or longer for some individuals.
It’s important to note that you should follow your surgeon’s recommendations closely and not rush the recovery process. Returning to work will depend on your specific job requirements. Sedentary or desk jobs may allow for a quicker return to work compared to physically demanding jobs. Your surgeon and physical therapist can provide guidance on when it’s safe for you to return to work.
Please consult with your orthopedic surgeon for personalized advice and a more accurate estimate of your recovery timeline based on your individual circumstances.

Question 10. What limitations will I have after ankle replacement surgery? What activities can I do after ankle replacement?

I’m not a medical professional, but I can provide some general information on ankle replacement surgery. Please consult with a healthcare provider for specific advice related to your situation.
Ankle replacement surgery is a procedure where a damaged ankle joint is replaced with an artificial implant. After the surgery, there may be some physical limitations and restrictions, which can vary depending on the individual, the type of implant used, and the surgeon’s recommendations. Here are some common considerations:
1. Weight-Bearing Restrictions: Initially, you may have limited weight-bearing on the operated ankle to allow for proper healing. Your surgeon will specify when you can start putting weight on the ankle.
2. Mobility: Ankle replacement surgery aims to improve mobility and reduce pain, but the range of motion may not be the same as before the surgery. You may have some restrictions in terms of ankle movement.
3. Physical Activity: The ability to engage in physical activities may vary. Low-impact activities like walking and swimming are generally encouraged, but high-impact activities and sports may be restricted or limited.
4. Pain Management: While the surgery is intended to reduce pain, some discomfort or pain may still be present, especially during the recovery period.
5. Follow-Up Care: Regular follow-up visits with your surgeon are essential to monitor the progress and address any concerns or limitations.
6. Occupational Considerations: Your ability to perform certain job-related tasks may be affected, especially if your job involves a lot of standing, walking, or physical labor.
It’s crucial to follow your surgeon’s post-operative instructions and rehabilitation plan. Physical therapy may be recommended to help regain strength and mobility. Your surgeon can provide you with specific guidance on what activities you can safely engage in based on your individual circumstances.
Remember that the outcome of ankle replacement surgery can vary from person to person, and your surgeon will provide you with the most accurate information regarding your specific case.

Question 11. What are the options if ankle replacement fails?

If an ankle replacement surgery fails or if the patient experiences complications or issues after the procedure, there are several options that may be considered:
1. Revision Surgery: In cases of implant failure or complications, revision surgery may be necessary. This involves removing the failed implant and replacing it with a new one or exploring alternative surgical options.
2. Fusion Surgery (Arthrodesis): Ankle fusion surgery may be recommended if the artificial ankle joint fails or if there are severe complications. This procedure fuses the bones of the ankle joint together, eliminating motion but often providing pain relief and stability.
3. Ankle Salvage Procedures: Depending on the specific problem, various ankle salvage procedures may be attempted to repair or improve the function of the ankle joint. These procedures may include debridement (cleaning out damaged tissue), bone grafting, or soft tissue reconstruction.
4. Physical Therapy: Physical therapy can be beneficial both before and after ankle replacement surgery. If the implant fails or complications arise, physical therapy may be used to help manage pain, improve mobility, and strengthen the ankle joint.
5. Pain Management: Medications and other pain management techniques may be employed to alleviate discomfort if the implant fails. These can include over-the-counter pain relievers, prescription medications, and injections.
6. Assistive Devices: In cases where ankle function cannot be fully restored, the use of assistive devices like braces, orthotics, or canes may be recommended to improve mobility and stability.
7. Lifestyle Modifications: Lifestyle modifications, such as weight management and avoiding activities that put excessive stress on the ankle joint, may be advised to minimize discomfort and prevent further complications.
It’s important for individuals who have undergone ankle replacement surgery to work closely with their orthopedic surgeon and healthcare team to determine the most appropriate course of action in the event of implant failure or complications. The choice of treatment will depend on the specific circumstances and the patient’s overall health and goals.

Question 12. What are the differences in a fused ankle versus a replaced ankle with regards to gait?

A fused ankle and a replaced ankle, such as an ankle arthroplasty or ankle replacement surgery, have significant differences when it comes to gait (walking pattern) and mobility. Here are the key distinctions:
1. Mobility and Range of Motion:
- Fused Ankle: In ankle fusion surgery, the ankle joint is fused together, which eliminates motion in the ankle joint. As a result, the patient loses the ability to dorsiflex (bend the foot upward) and plantarflex (point the foot downward) the ankle. This limited range of motion can lead to a more rigid and stable gait pattern.
- Replaced Ankle: Ankle replacement surgery aims to maintain or restore some degree of motion in the ankle joint. While it may not provide the same range of motion as a healthy ankle, it allows for more natural movement compared to an ankle fusion. This can lead to a more flexible gait pattern.
2. Pain and Discomfort:
- Fused Ankle: Ankle fusion is often chosen when the ankle joint is severely damaged and causes significant pain. After fusion, the pain originating from the arthritic joint is typically eliminated. However, the lack of motion can lead to altered walking mechanics and may result in discomfort in other joints, such as the knee and hip, over time.
- Replaced Ankle: Ankle replacement surgery is also performed to alleviate pain associated with ankle joint arthritis. It may be associated with less post-operative pain compared to fusion, and it aims to maintain a more natural walking pattern.
3. Gait Pattern:
- Fused Ankle: Patients with a fused ankle tend to have a more rigid and stable gait. They often walk with a slight limp or reduced heel-to-toe motion. The loss of ankle motion can affect their ability to adapt to uneven terrain or absorb shock during walking.
- Replaced Ankle: Those with a replaced ankle may have a gait that is closer to a natural, heel-to-toe walking pattern. While it may not be identical to the gait of a person with a healthy ankle, it allows for better adaptability to various walking surfaces and shock absorption.
4. Recovery and Rehabilitation:
- Fused Ankle: The recovery period after ankle fusion surgery can be shorter compared to ankle replacement surgery. Physical therapy is still essential to help patients regain strength and adapt to their altered gait.
- Replaced Ankle: Ankle replacement surgery often requires a longer recovery period and more intensive physical therapy to maximize the range of motion and strength of the replaced joint.
It’s important to note that the choice between ankle fusion and ankle replacement depends on the individual patient’s condition, including the extent of joint damage and their activity level. The decision should be made in consultation with a healthcare professional who can assess the specific needs and goals of the patient.

Ethical Approval

Ethical approval was obtained from the authors’ Institutional Review Board.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Joseph S. Park, MD, reports general disclosures as a consultant for Stryker Corporation, Johnson and Johnson Medtech, Rivanna Medical, and LifeNet Health; and is an Orthopaedic Foot & Ankle Foundation Board Member. Nicholas L. Strasser, MD, reports general disclosures of research support from Stryker and consulting/teaching Arthrex, Vilex, Hyalex, and Bioventus. Tyler A. Gonzalez, MD, MBA, reports general disclosures as a consultant for Treace Medical Concepts Inc, Surgical Fusion Technologies, Stryker, Enovis, Exactech, and Surgebright and royalties from Surgical Fusion Technologies, Treace Medical Concepts, Vilex. Disclosure forms for all authors are available online.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Heidi C. Ventresca, MD,

Harley T. Davis

Chase W. Gauthier, MD,

Justin Kung, MD,

Nicholas L. Strasser, MD,

Tyler A. Gonzalez, MD, MBA,

J. Benjamin Jackson, MD, MBA,

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