Total Ankle Arthroplasty

Welcome to Texas State University's Evidence-based Practice project space. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editor - Jeremy Brady

Lead Editors - Jeremy Brady, Neha Palsule, Jorge Solorzano, Tori Westcott, Dana Williams

Search Strategy

Databases Searched: PubMed, CINAHL, Cochrane, JOSPT

Keywords Searched: ankle arthroplasty, ankle physical therapy, ankle replacement, total ankle arthroplasty, total ankle replacement

Search Timeline: June 11^th 2011 -

Definition/Description

Poor patient satisfaction, high rates of revision due to loosening, and high wound complications rates were all very problematic when total ankle arthroplasty surgeries were first introduced in the 1970’s(JOSPT & Cook & O’Malley-TAA). In 1990, noncemented prostheses were shown to allow for bony ingrowth and less bone removal as compared to cemented.(Cook, O’Malley) Beyond the transition to cementless, further advances in technology over the years has led to new surgical arthroplasty techniques, primarily moving from a two-component design to a 3-component model.

An observational study analyzed advantages of arthroplasty over arthrodesis stating individuals with monoarticular or polyarticular disease who undergo arthroplasty have less gait abnormalities and fewer adverse effects to other joints in the lower extremity (Cornelis TAA InflammJtDz). A systematic review provided that in 852 individuals undergoing TAA’s, there was a 78% implant survival 5 years post-op and 77% at 10 years post-op and overall only had a 7% revision rate. This provides evidence that the procedure yields satisfactory results and should be considered for potential candidates that are appropriate for surgical corrections. (Haddad, Coetzee Intermediate & Long Term)

Epidemiology/Etiology

The ankle joint, formed by the tibia, fibula, and talus, has articular cartilage that differs from that in the hip and knee due to the fact it preserves its tensile stiffness and stresses better. However, the small contact area may indicate higher contact stresses than the hip or knee experience. (JOSPT).

Characteristics/Clinical Presentation

Indications:
According to JOSPT, there are no exact indications for receiving a total ankle arthroplasty. The “ideal” patient who would typically undergo this intervention is one who is elderly with a healthy immunity, normal vascular status, good bone density, and a proper hindfoot-ankle alignment who has not had success with conservative treatment measures. Individuals with debilitating ankle arthritis, unresponsive to nonoperative approaches, or have failures with the outcome of their ankle arthroplasty are typically treated with an arthrodesis procedure to fuse the joint.

Contraindications:
Arthroplasty is contraindicated for those with neuroarthropathic degenerative joint disease, infection, AVN of the talus, osteochondritis dessicans, malalignment of the hindfoot-ankle, severe benign joint hypermobility syndromes or soft tissue problems, or decreased sensation or motion in the lower extremities.(JOSPT & Cook, O’Malley-TAA) In individuals with RA, inflammatory processes may occur before signs of swelling, tissue reaction, and joint destruction are seen. In the first and second year of this disease process, structural damage (ie. joint erosion) can be seen with X-ray imaging. Diabetic pts may develop gouty arthritis in their ankle joint. This is caused by uric acid changing into urate crystals, which is deposited into the joint.

Thus, RA and diabetic individuals may or may not be candidates for ankle arthroplasty depending on the severity of joint degeneration found with radiographic imaging.

Differential Diagnosis

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Outcome Measures

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Examination

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Medical Management

Notes to Incorporate

• Agility ankle is currently the only ankle prosthesis currently approved by the US FDA (in 2007)
  • it is a 2 component design that completely resurfaces distal tibia and talar dome
  • also incorporates fusion of the distal tibiofibular syndesmotic articulation. This fusion allows the medial border of the fibula to provide additional support to the prosthesis, while providing additional surface area for biologic fixation
  • prosthesis we use for our patients who decide to undergo total ankle arthroplasty
• STAR is the design choice for Europe

Physical Therapy Management

Guidelines for Rehabilitation Following Total Ankle Arthroplasty (Using the Agility Ankle)
Immobilization
0-2 weeks 2-6 weeks >6 weeks	Short leg cast Removable splint Discontinue immobilization
Weight Bearing
0-6 weeks >6 weeks	Non-weight bearing Weight bearing as tolerated
Exercises for the Involved Ankle & Foot
2-6 weeks	Active & passive ankle dorsiflexion and plantar flexion Active toe flexion & extension
>6 weeks	Active inversion & eversion Aggressive ankle stretching and mobilization emphasizing dorsiflexion Progression to weight-bearing stretches to increase dorsiflexion range of motion Weight-bearing toe- and heel-raising exercises and standing-balance activities

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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