Ankle Arthroplasty

Ankle Arthroplasty

May Fong Mak, FRCSEd (Ortho)

Xavier Crevoisier, MD

Mathieu Assal, MD, PD Dr.

Dr. Crevoisier or an immediate family member serves as a board member, owner, officer, or committee member of the Swiss Foot and Ankle Society. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Assal and Dr. Mak.


Ankle arthroplasty was developed in the 1970s as an alternative to ankle arthrodesis for the treatment of end-stage ankle osteoarthritis (OA). Conservation of a functional range of motion (ROM) of the ankle remains a primary advantage of total ankle arthroplasty (TAA) over arthrodesis. Forty years of progress, through three generations of prosthesis designs and improvements in surgical technique, have seen a rise in TAA survivorship in ranges of 70% to 98% at 3 to 6 years, and 80% to 95% at 8 to 12 years, as well as patient return to light recreation and sports, in terms of overall function.

This chapter focuses on postoperative rehabilitation following TAA. Optimal rehabilitation starts with identification of relevant preoperative factors, is dependent on good surgical technique, and relies heavily on a team-based approach to postoperative care. Rehabilitation should not be viewed only as a postoperative activity. Elderly patients with decreased muscle strength and coordination may benefit from therapy preoperatively. In addition, the value of patient education in the consultation room cannot be overlooked, as an informed patient is better equipped to understand and anticipate the process that is to come.

Surgical Procedure

Surgical success is a synthesis of systematic preoperative assessment, meticulous surgical planning, and methodical performance of the operative procedure.

A prerequisite for success is correct patient selection. The ideal candidate is an elderly individual with limited physical demands, low body mass index, a well-aligned and stable hindfoot, normal bone stock, good preservation of peripheral vascularity, and healthy periarticular soft tissues. TAA is indicated to preserve remaining motion in special circumstances in which end-stage OA affects both ankles, or is present in a foot stiffened by adjacent joint degeneration or previous subtalar or midfoot arthrodesis. TAA should be avoided in young patients with high functional demands, severe hindfoot malalignment, neuroarthropathy, active infection, talar avascular necrosis, and poor soft-tissue envelope.

Modern TAA designs are cementless three-component systems comprised of two metallic components and an interposed ultra-high-molecular-weight polyethylene (UHMWPE) insert. Irrespective of manufacturer, the surgical approach and general operative principles are similar.

Most surgeons favor an anterior approach to the ankle. A 15-cm longitudinal incision is made over the anterior aspect of the ankle. The extensor retinaculum is incised, the interval between the tendons of the tibialis anterior and extensor hallucis longus (EHL) is entered, and the joint capsule is incised longitudinally to expose the ankle joint. The most distal part of the anterior tibial margin and its osteophytes are removed with an osteotome to expose the tibial plafond and talar dome. The tibial resection parameters that must be considered for correct component placement are varus/valgus alignment, slope, height, rotation, and translation. The tibial and talar cuts are made with the specific instrumentation provided. The medial and lateral gutters must routinely be cleared of osteophytes and impinging soft tissue. Trial implants are sized and inserted, and their position and ankle alignment verified by fluoroscopy and on-table clinical assessment of ankle ROM. The final prosthesis is subsequently implanted, and once again final position and alignment are confirmed clinically and radiologically. Meticulous hemostasis is ensured to avoid a postoperative hematoma that can exert pressure on the surrounding soft tissues, leading to skin necrosis, or can act as a source of infection. Careful closure is performed, beginning with the joint capsule. Careful attention is given to the extensor retinacular repair, as it forms an important barrier between the ankle joint and the more superficial incision. The subcutaneous layer and skin are closed in layers. Staples are not recommended for closure, particularly in the tenuous central portion of the incision directly overlying the ankle joint. A soft dressing and postoperative splint are carefully applied.

The TAA procedure can be fraught with technical errors, as demonstrated by the literature validating the existence of
a “learning curve” during which surgeons acquire skills and experience before they become proficient at performing TAA. Keeping in mind several technical pearls will contribute to a better surgical outcome. Careful soft-tissue dissection, the avoidance of unnecessary retraction, and methodical wound closure cannot be overemphasized since good soft-tissue handling is paramount to successful wound healing. Repair of the extensor retinaculum is crucial, as it prevents bowstringing of the tibialis anterior tendon exerting direct pressure on the undersurface of the surgical wound, which can rapidly culminate in disastrous wound necrosis or dehiscence. Long-standing soft-tissue contractures must be recognized and released in order to balance the ankle joint. Clearance of the gutters must be a routine part of each surgery to avoid postoperative impingement pain. Preexisting ankle instability may predispose to prosthesis subluxation or dislocation, and must therefore be recognized and corrected through ligamentous reconstructive procedures during TAA surgery. Tendon pathology—such as fissures, ruptures, or dislocations—should be addressed. Achilles tendon lengthening is indicated in patients with heel equinus contracture, but should be used sparingly and cautiously due to the risk of chronic heel cord pain postoperatively. Symptomatic peritalar joint arthritis should be considered for fusion in the same setting. Hindfoot and first ray osteotomies and tendon transfers may be required in some cases to balance the foot.

Postoperative Rehabilitation

The final outcome following ankle arthroplasty is subject to a multitude of factors, including (1) preoperative ROM, strength, functional level, and related comorbid conditions; (2) intraoperative restoration of the anatomic ankle joint line, the accuracy of tibial and talar cuts, prosthesis design, instrumentation, positioning, and fixation; and (3) postoperative complications and rehabilitation.

Postoperative rehabilitation is integral in influencing the final outcomes pertaining to ROM, strength, proprioception, balance, and gait. The ideal rehabilitation protocol should be supervised, well defined, structured, goal oriented, and can be adjusted with consideration for tissue healing, joint mobility, muscle strength, and capability of the individual patient.

In TAA, the goals of rehabilitation are:

  • Decrease pain and edema, and protect through immobilization.

  • Achieve full ROM.

  • Achieve full power and endurance.

  • Achieve full proprioception and coordination, and adoption of normal gait.

A multidisciplinary team comprising foot and ankle surgeons, anesthesiologists, rehabilitation physicians, physical therapists, occupational therapists, and social workers must work closely together to support the patient through the rehabilitative process. Advancement from one phase to the next is determined by the patient’s progress in achieving rehabilitation milestones, and should not be based solely on a generic time frame. A rehabilitation protocol is represented in Table 56.1.


Rehabilitation Phase Estimated Time Frame Emphasis Components
Acute First 2 weeks Protection

  • Pain relief
  • Wound care
  • Immobilization
  • Basic rehabilitation
Early Next 10 weeks Weight bearing

  • Static weight bearing
  • Unsupported weight bearing
  • Early ROM exercises
  • Strength training
Late Beyond 12 weeks Neuromuscular

  • Proprioception
  • Balance
  • Coordination
  • Gait retraining
  • Terminal ROM exercises
  • Intensified strength training
ROM = range of motion.

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Oct 14, 2018 | Posted by in ORTHOPEDIC | Comments Off on Ankle Arthroplasty

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