Total joint replacement (TJR) surgery has seen an evolution over the last few decades highlighted by changes in implant design, a better understanding of biomechanics, and improved surgical technique. Over 750,000 Americans underwent total hip arthroplasty (THA)¹ and total knee arthroplasty (TKA) in 2008 and 2009.² This number is on track to expand to over 4 million by 2030.³ Total ankle arthroplasty (TAA) has also seen a constant rise in implantation and success since the 1970s. Increasing evidence suggests that TAA, in the proper patient, is an equivalent, if not better, alternative to ankle arthrodesis.⁴ As with THA and TKA, demand for TAA is expected to grow over the next few decades.^5,6

Along with advances in technique and implant technology, we have seen an evolution in the perioperative protocols and rehabilitation practices after TJR surgery. Rehabilitation has progressed to include an increased awareness for preoperative planning and education along with postoperative rehabilitation.⁷ Total hip and knee replacements performed 30 years ago had an average inpatient acute care stay of more than 9 days, with women staying slightly longer than men. By 2000, the average acute care stay was shortened to 5.3 days with the gender gap nearly closed.⁸ Inpatient rehabilitation has focused on mobilization, pain management, transfer training, and range of motion, and has become condensed as the hospital length of stay has decreased, resulting in lower acute care hospital costs.⁹ There has been increasing evidence that patients benefit from early progressive rehabilitation in THA and TKA with comparable functional results.^10,11

Similar to THA and TKA, postoperative range of motion is a factor to success with TAA.¹² Multiple studies have showed that the kinematics of ankle range of motion does affect the gait postoperatively.¹³ Queen et al.¹⁴ showed that ankle range of motion could be maintained at 2 years postoperatively with high patient satisfaction. Stiffness following primary THA and, more specifically, primary TKA is dealt with in the rehabilitation phase, with an incidence of 8% to 12%.¹⁵,¹⁶ and ¹⁷ Stiffness can be defined as an inadequate range of motion that results in functional limitations in activities of daily living. To prevent adhesions and contractures, aggressive physical therapy (PT) in the first 6 weeks may be beneficial. Use of continuous passive motion (CPM) postoperatively is controversial and not routinely performed for THA and TKA.¹⁸,¹⁹ and ²⁰ Postoperative use of CPM after TAA has also not been well studied and remains questionable postoperatively.

The normal postoperative course for a primary total ankle replacement (TAR) varies from THA or TKA by virtue of its soft tissue envelope, blood supply, and weight-bearing status. Authors have defined the angiosomes and surgical anatomy of the distal one-third of the anterior leg.^21,22 This information has led to the common incisional approach for TAA in the interval between the tibialis anterior and extensor hallucis longus tendons, which lies just medial to the neurovascular bundle. The tendons should be maintained within their respective sheaths to decrease any skin tension postoperatively. This incision has long been a perceived source of wound care complications following TAA, with a rate less than 11%.²³ Farber and DeOrio²⁴ attempted to screen patients preoperatively by determining their operative extremity oxygen tensiometry. They found no significant difference with respect to transcutaneous oxygen tension between patients with and without wound healing problems.²⁴ The authors recommended a more judicious use of deep retraction and less superficial retraction. In addition to meticulous surgical technique, the timing, scope, and duration of PT and rehabilitation are important to optimize outcomes in TAA.

Our current approach to rehabilitation in TAA is based on the concept of integrated, multidisciplinary care across a time line that ranges from the preoperative evaluation and surgical decision-making process through the formal postoperative rehabilitation protocol. With this in mind, “rehabilitation” for our patients begins before surgery. The concept of preoperative physical therapy (POPT), or “prehabilitation/prehab,” is
described in the literature, but the precise definition and effectiveness of prehabilitation remain controversial. Studies have demonstrated a need for “prehab” as intense preoperative exercise training to increase hip and knee strength, range of motion, and, ultimately, function postoperatively.²⁵,²⁶,²⁷,²⁸,²⁹ and ³⁰ Alternatively, prehabilitation can be seen as a single PT session preoperatively with the goals of reviewing basic postoperative activities of daily living and discussing expectations for surgery and recovery. This also allows for a preoperative assessment of patient needs and leads to planning for the appropriate type and intensity of postacute care rehabilitation services.

A case report by Brown et al.³¹ analyzed the functional recovery of a patient who underwent staged bilateral TKA. The initial TKA did not incorporate POPT and the second TKA was preceded by a 4-week home-based prehabilitation that consisted of resistance training, flexibility, and step-training. The outcomes of interest were knee strength, functional ability, and pain. The addition of POPT led to decreased pain and increased knee strength and functional ability prior to surgery. The strength gain was maintained in the nonoperative leg postoperatively, and the authors suggest that POPT was effective in facilitating the recovery after TKA. A similar case study by Jaggers et al.³² reported favorable functional results after a 4-week prehabilitation program.

Other studies in TJR have reported unfavorable or equivocal results with prehabilitation. In a prospective randomized trial, Gocen et al.²⁶ studied 60 patients with osteoarthritis of the hip, randomized into two groups with and without POPT and education. Their primary outcomes of interest were the Harris Hip Score, visual analog scale, and hip range of motion. No significant differences were found between the groups and the time of discharge. In a randomized controlled trial of 160 patients, Mitchell et al.³³ evaluated the cost and effectiveness of prehabilitation in TKA patients. Their primary outcome of interest was patient-perceived health outcomes, which was not improved by preoperative home-based PT, as compared to hospital outpatient PT. The POPT group was also noted to be more expensive. McKay et al.³⁴ examined the effects of a 6-week preoperative training program on outcomes in 22 TKA patients. The primary outcome of interest was quadriceps strength, with secondary outcomes related to pain, function, and quality of life. They concluded that the program resulted in clinically meaning increases in quadriceps strength, walking speed, and mental health before TKA, but did not result in lasting benefits to patients in the first 12 weeks after surgery.

In a national survey of health care leaders across Canada, Landry et al.³⁵ evaluated the factors that affect the demand for rehabilitation services after TJR. The results of the study indicated that the demand for rehabilitation services after TJR is increasing and that new, innovative approaches to care are needed to align the increasing demand with supply. Prehabilitation was noted in their paper as a promising area for more research.

Our PT protocols were developed as a joint effort between surgeons and physical therapists, with a goal of maintaining consistency of care before and after surgery. Protocols help to generalize knowledge from centers of large volume to the therapist with less specific experience. A protocol will assist the therapist in knowing not only when and which interventions to use, but also which milestones to look for and what signs and symptoms to watch out for. This ultimately guides the quality and level of recovery for the patients. TAA has gained acceptance in the foot and ankle community worldwide, but many PT clinics, depending on their location, will not treat this surgery on a consistent basis.