Ankle fusion recovery: casts, weight bearing, driving and getting back to activity

An ankle fusion, also called ankle arthrodesis, permanently joins the shin bone (tibia) to the uppermost bone of the foot (the talus) so that a painful arthritic joint no longer moves. The Royal National Orthopaedic Hospital describes the aim as turning a stiff, painful joint into a stiff, painless one. For the joint to become solid, bone has to grow across the gap, and that is what sets the pace of recovery.

The leaflets from three NHS hospitals read for this page describe a similar shape of recovery. There is a short hospital stay of a few days at most, a period in plaster or a cast with the foot kept up, a long stretch of no weight or limited weight on the foot, an X-ray at about three months to check that the bones are joining, and a gradual return to normal footwear and activity. The detail varies, and the next sections show where.

Most of the early weeks are about protecting the surgery. Milton Keynes University Hospital says that in the first few weeks you should keep your leg elevated as much as possible to reduce swelling and aid wound healing, and that your cast should remain dry. The Royal National Orthopaedic Hospital asks for the leg to be elevated above groin level for 55 minutes in every hour for the first two weeks.

No single timetable fits everyone. The table sets three published schedules side by side. They are not contradictory so much as different surgical habits: some hospitals allow partial weight at about the fourth week, others wait until the sixth, and the length of time in plaster depends on how the bones are fixed and how quickly they join.

A common thread is that the first outpatient visit is around two weeks after surgery, when stitches are removed and a lighter cast is fitted, and that the three-month X-ray decides whether the cast can come off. The Royal Orthopaedic Hospital adds that some people need to stay in plaster longer than three months, and the Royal National Orthopaedic Hospital says some patients take longer to fuse, especially those who smoke.

On driving, the leaflets agree on the principle and differ on the date. The Royal Orthopaedic Hospital says most people prefer not to drive until the plaster is off, they can wear a shoe and are able to fully weight bear, and to drive short distances before long ones. The Royal National Orthopaedic Hospital says that after a left-foot fusion, an automatic car can usually be driven four weeks after the operation, provided you can perform an emergency stop, and that your insurer must be told about the operation so your cover is valid. Milton Keynes University Hospital says you can start driving when you are comfortably walking in your own footwear, and that an automatic car and a left-leg operation may allow you to start sooner if safe.

Both the Royal Orthopaedic Hospital and Milton Keynes University Hospital warn that if you cannot safely make an emergency stop, your insurance will not cover you in the event of an accident. That is the practical reason to wait for the surgical team's go-ahead rather than rely on a calendar figure.

Work depends on the job. The Royal Orthopaedic Hospital says that if your foot is comfortable and you can keep it up and wear a special shoe, you might go back within 3 to 4 weeks, but a manual job on your feet may need up to 6 months off. The Royal National Orthopaedic Hospital gives four weeks for a desk job where you can elevate the limb, and up to six months for physically demanding work. Milton Keynes University Hospital says a desk-based job is possible at six weeks and that physical work may need significantly longer.

Flying is a separate question. Milton Keynes University Hospital notes an increased risk of blood clots when flying after recent surgery and asks you to seek individual guidance from your surgeon on how long to wait, and to check airline rules.

A fused ankle does not move up and down. The Royal National Orthopaedic Hospital explains that the operation removes ankle movement completely, but that you may retain as much as 50% of the up-and-down movement of the foot because the other foot joints are still mobile. It also says your calf may become thinner because of decreased muscle tone.

People often do more after fusion than before it, because the pain is gone. The Royal Orthopaedic Hospital says that many people find the foot is more comfortable than before surgery so they can do more than they could before, and that most can walk a reasonable distance on the flat, on slopes and on stairs, drive and cycle. Walking on rough ground is more difficult because the foot is stiffer, and vigorous sports such as squash or football are rare. Milton Keynes University Hospital similarly says golf is possible but running sports are rare.

The Royal National Orthopaedic Hospital reports that most patients with a successful fusion are able to walk without a limp, cycle and play golf. It describes a 90% success rate for ankle fusion.

Milton Keynes University Hospital adds that fusing the ankle places increased stress on the joints in your foot, which can subsequently develop arthritis and may need further treatment. It says generally it takes up to 12 months to gain the full benefit of an ankle fusion.

Failure to fuse is the main concern. The Royal Orthopaedic Hospital says that 5 to 10 in 100 ankle fusions do not heal properly and need a further operation, while Milton Keynes University Hospital quotes a 10% risk of non-fusion. Both say smoking sharply raises that risk. The Royal National Orthopaedic Hospital says that if you smoke your risk of non-union or major complications is greatly increased, that it is essential to stop before surgery and until all bones have healed, and that you will be advised against a fusion if you smoke.

Other issues named in the leaflets include infection (the Royal Orthopaedic Hospital says fewer than 1 in 100 develop a serious bone infection, and Milton Keynes University Hospital says the risk of infection after foot and ankle surgery is up to 5%, mostly minor), nerve irritation causing numbness or tingling, a position that is not exactly as intended, and prominent screws that may need removal. Milton Keynes University Hospital says that after nine months the ankle fusion will be solid, so screws or a plate can be removed if they become a problem.

Blood clots are rare but important. The Royal National Orthopaedic Hospital says to tell the team if you have had a DVT or pulmonary embolus before or have a family history of clotting disorders, and says an anti-embolic stocking and blood thinning medication are usually given. Ask your team which symptoms should prompt same-day advice, and tell them about any previous clots.

Healthy habits help. The Royal Orthopaedic Hospital lists keeping fit, maintaining a healthy weight and considering vitamin C and D supplements as measures that may improve the outcome. Milton Keynes University Hospital similarly says a healthy diet, regular exercise and not smoking are linked to quicker recovery with a more successful outcome.

The Royal Orthopaedic Hospital notes that some arthritic ankle joints can be treated by replacing the joint, but this is only suitable in older patients without major foot deformities, or those with rheumatoid arthritis or similar disease. It lists reasons replacement would not be suitable, including being young (usually under 45) or very active, severe foot deformity, an unstable ankle, previous infection and a collapsed talus. It also says it is generally not possible to change a fusion to an ankle replacement later because the foot becomes too stiff for a replacement to work.

That is why the choice between the two is made before surgery and is individual. The recovery pattern for replacement is different, with movement preserved but its own restrictions, and is covered on the linked pages.