Total Ankle Arthroplasty: Difference between revisions

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<div class="noeditbox">Welcome to [[Texas State University Evidence-based Practice Project|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!!</div> <div class="editorbox">
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'''Original Editor '''- [[User:Jeremy Brady|Jeremy Brady]]  
'''Original Editor '''- [[User:Sharon Schumacher|Sharon Schumacher]], [[User:Carlos De Coster|Carlos De Coster]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} - [[User:Jeremy Brady|Jeremy Brady]], [[User:Neha Palsule|Neha Palsule]], [[User:Jorge Solorzano|Jorge Solorzano]], [[User:Tori Westcott|Tori Westcott]], [[User:Dana Williams|Dana Williams]]
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; 
</div>  
</div>  
<br>
== Search Strategy  ==
== Search Strategy  ==


'''Databases Searched:'''&nbsp;[http://www.ncbi.nlm.nih.gov/pubmed/ PubMed], [http://www.ebscohost.com/cinahl/ CINAHL], [http://www.thecochranelibrary.com/view/0/index.html Cochrane], [http://www.jospt.org/ JOSPT]
'''<span lang="EN-US">PubMed</span>'''<span class="apple-converted-space"><span lang="EN-US">&nbsp;</span></span><span lang="EN-US">(</span>[http://www.ncbi.nlm.nih.gov/pubmed <span lang="EN-US">http://www.ncbi.nlm.nih.gov/pubmed</span>]<span lang="EN-US">)</span>
 
'''Keywords Searched''': ankle arthroplasty, ankle physical therapy, ankle replacement, total ankle arthroplasty, total ankle replacement


'''Search Timeline:'''&nbsp;June 11<sup>th&nbsp;</sup>2011 - July 15<sup>th</sup> 2011<br> <br>  
<span lang="EN-US">MeSH
terms:</span>  


== Definition/Description  ==
*<span lang="EN-US">Complications</span>
*<span lang="EN-US">Diagnosis</span>
*<span lang="EN-US">Drug therapy</span>
*<span lang="EN-US">Epidemiology</span>
*<span lang="EN-US">Etiology</span>
*<span lang="EN-US">Pathology</span>
*<span lang="EN-US">Rehabilitation</span>
*<span lang="EN-US">Surgery</span>
*<span lang="EN-US">Therapy</span>


Poor patient satisfaction, high rates of revision due to loosening, and high wound complications rates were all very problematic when total ankle arthroplasty (TAA) surgeries were first introduced in the 1970’s.<ref name="Cook" /> In 1990, noncemented prostheses were shown to allow for bony ingrowth and less bone removal as compared to cemented.<ref name="Cook" /> 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.
'''<span lang="EN-US">Medline Plus</span>'''


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.<ref name="Doets">Doets, C., Brand, R., Nelissen, R. Total Ankle Arthroplasty in Inflammatory Joint Disease with Use of Two Mobile-Bearing Designs. The Journal of Bone and Joint Surgery. 2006;88:1274-1284.</ref> 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.<ref name="Haddad">Haddad, S. et all. Arthroplasty vs Arthrodesis: Intermediate and Long-Term Outcomes of Total Ankle Arthroplasty and Ankle Arthrodesis A Systematic Review of the Literature. The Journal of Bone and Joint Surgery. 2007;89:1899-1905.</ref><br>  
<span lang="EN-US">Used
keyword:</span>  


== Epidemiology/Etiology  ==
*<span lang="EN-US">Ankle replacement</span><br>


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.<ref name="Saltzman, CL">Saltzman, C.L., McIff, T.E., Buckwalter, J.A., Brown, T.D. Total Ankle Replacement Revisited.  JOSPT. 2000;30: 56-67.</ref> <br>
== Definition/Description ==
 
<br>
 
== Characteristics/Clinical Presentation ==
 
'''Indications:'''<br>According to JOSPT, there are no exact indications for receiving a total ankle arthroplasty.<ref name="Saltzman, CL" /> 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:'''<br>Arthroplasty is contraindicated for those with neuroarthropathic degenerative joint disease, infection, avascular necrosis 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.<ref name="Cook" /> In individuals with rheumatoid arthritis (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.<ref name="Goodman & Snyder">Goodman, C., Snyder, T. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis: Saunders Elsevier, 2009.</ref> Diabetic patients may develop gouty arthritis in their ankle joint. This is caused by uric acid changing into urate crystals, which is deposited into the joint.<ref name="Goodman & Snyder" />


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.<br>  
Ankle replacement surgery has been available for over two decades however it is a far less common procedure than hip or knee arthroplasty owing to the less frequent incidence of osteoarthritis ankle pathology. The majority of ankle osteoarthritis is secondary to trauma.<ref>Ankle Replacement Surgery. Annals of the Royal College of Surgeons of England. 2006 July;88(4):417-418</ref><sup></sup>  


<br>  
Until relatively recently, ankle joint arthrodesis (fusion) was the gold standard of treatment, but this was not without its complications, e.g. non-union,[[Osteoarthritis|Osteoarthritis]] in the other mid/hind foot joints and stiffness and loss of proprioception<sup><ref>Ankle Replacement Surgery. Annals of the Royal College of Surgeons of England. 2006 July;88(4):417-418</ref></sup>  


== Outcome Measures  ==
<sup>&nbsp;&nbsp;&nbsp;&nbsp; </sup>Total ankle replacement was developed in the 1970's but initially was plagued with high long term failure rates. The older prosthesis loosened or malfunctioned and frequently needed to be removed<sup></sup><ref>[http://www.medicalnewstoday.com/articles/11222.php http://www.medicalnewstoday.com/articles/11222.php]</ref>.&nbsp; In the late 70's Dr. Frank G. Alvine an orthopedic surgeon from Sioux Falls, SD developed the Agility Ankle which was the first FDA approved total ankle implant in use in the United States<ref>[http://www.medicalnewstoday.com/articles/11222.php http://www.medicalnewstoday.com/articles/11222.php]</ref>. Since its introduction the Agility Ankle System has gone through several modifications. Currently the Agility Ankle System is the most widely used ankle prosthesis. With more than 20 years of experience it has the longest followup of any fixed bearing device<sup></sup><ref>Cerrato R, Myerson MS. Total Ankle Replacement:the Agility LP prosthesis. Foot and Ankle Clin. 2008 Sept; 13(3): 485-94.</ref>.


*[[Foot and Ankle Disability Index|Foot and Ankle Disability Index]]
On May 29, 2009 the medical news today announced the FDA approved the first mobile bearing device called the Scandinavian Total Ankle Replacement System (STAR). As a condition of FDA approval the company (Small Bone Innovations Inc.) must evaluate the safety and effectiveness of the device during the next eight years<ref>[http://medicalnewstoday.com/printerfriendlynews.php?newsid=151776 http://medicalnewstoday.com/printerfriendlynews.php?newsid=151776]</ref>.
*[[Foot Function Index (FFI)|Foot Function Index (FFI)]]
*[[Foot and Ankle Ability Measure|Foot and Ankle Ability Measure (FAAM)]]


<br>  
&nbsp;&nbsp;&nbsp;&nbsp; In a systematic review of the literature published in the Journal of Bone and Joint Surgery in 2007, the intermediate outcome of total ankle arthroplasty appears to be similiar to that of [[Ankle arthrodesis|ankle arthrodesis]] however data was sparse<ref>Haddad SL, Coetzee JC, Estok R. et al. Intermediate and Long-Term Outcomes of Total Ankle Arthroplasy and Ankle Arthrodesis. The Journal of Bone and Joint Surgery (American). 2007;89:1899-1905.</ref>.<sup>&nbsp; </sup>In a study comparing reoperation rates following ankle arthrodesis and total ankle arthroplasty SooHoo, Zingmond and Ko confirmed that ankle replacement is associated with a higher risk of complications as compared with ankle fusion, but also has potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion<sup></sup><ref>SooHoo NF, Zingmond DS, Ko CY. Comparison of Reoperation Rates Following Ankle Arthrodesis and Total Ankle Arthroplasty. The Journal of Bone and Joint Surgery (American). 2007;89:2143-2149.</ref>.&nbsp; In a seven to sixteen year follow up on the Agility Total Ankle Arthroplasty, Knecht, Estin, Callagham et al concluded that the relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging<sup></sup><ref>Knecht SI, Estin M, Callaghan JJ et al. The Agility Total Ankle Arthroplasty: Seven to Sixteen-Year Follow-up. The Journal of Bone and Joint Surgery (American). 2004;86:1161-1171.</ref>.


== Examination  ==
&nbsp;&nbsp;&nbsp;&nbsp; Although interest in total ankle replacements is increasing, midterm clinical results to date are few and often have not been validated by independent pratitioners. In addition no level I or II studies have been published<sup></sup><ref>Cracchiolo A 3rd, Deorio JK. Design features of current total ankle replacements: implants and instrumentation. Journal of the American Academy of Orthopedic Surgeons. 2008 Sept:16(9):530-40.</ref>.


===== '''Precautions and Contraindications:''' =====
== Clinically Relevant Anatomy ==


It is essential to obtain weight-bearing status and ROM protocol from the physician prior to any evaluation procedures. Generally, the patient is non weight bearing for 6 weeks with ROM restricted for the first 2 weeks postop to allow for wound healing. The patient must be continually assessed for signs of deep vein thrombosis (DVT) or infection.<ref name="Huber">Huber L. Clinical review Ankle Replacement. Cinahl Information Systems.2010</ref><br>  
== Indication for Procedure<br> ==


===== History Key Points: =====
There is no well-defined indication for a Total Ankle Arthroplasty. Surgery is considered only when conservative treatment has been attempted with no improvement. The operation is mainly being executed in patients who suffer from different types of arthrides. This cause advanced arthritic changes of disabling pain and loss of ankle motion. The ankle is most frequently affected by post-traumatic arthritis.<sup><ref>MURNAGHAN J.M., WARNOCK D.S., HENDERSON S.A.., ‘Total Ankle Replacement: Early experience with STAR prothesis’, The Ulster Medical Journal, 2005, May, vol. 74, nr. 1, p. 9-13</ref></sup>&nbsp;Total ankle joint replacement is also indicated following unsuccessful ankle arthrodesis <ref>SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306</ref>&nbsp;the ‘ideal’ patient for ankle joint replacement is an elderly person with the low physical demands who has good bone stock, normal vascular status, no immune-suppression, and excellent hind foot-ankle alignment.<ref>SALTZMAN C.L., MCLFF T.E., BUCKWALTER J.A., BROWN T.D., ‘Total Ankle Replacement revisited’, Journal of Orthopaedic &amp;amp; Sports Physical Therapy, 2000, February, vol.nr. 30(2), p. 56-67</ref><br>


*Mechanism of injury or etiology of illness
== Clinical Presentation  ==
*Date of surgery and type of implant
*Use of assistive device with weight bearing status
*Use of controlled ankle motion (CAM) walker/walking boot
*Functional deficits/assistance with ADLs/adaptive equipment
*Pain/ Symptom history: Location, duration, type, intensity (VAS), aggravating and relieving factors, 24 hour symptom behavior
*Relevant Current/Past Medical history: Other lower extremity arthritis or injuries,upper extremity issues that may limit ability to ambulate with an AD and comorbid diagnoses
*Medications for current/previous diagnoses
*Diagnostic tests
*Sleep disturbance
*Barriers to learning
*Social/occupational history
*Patient’s goals
*Vocation/avocation and associated repetitive behaviors
*Living environment<br>


===== Relevant Tests &amp; Measures:  =====
add text here relating to the clinical presentation of the condition<br>


*Observation/inspection/palpation: Skin and incision assessment, edema, muscle atrophy
== Diagnostic Tests  ==
*Circulation: Dorsal pedal pulse
*Sensory and proprioception testing
*Range of motion and Muscle length: Average postoperative arc of motion (dorsifexion and plantarfexion) is 23°<ref name="Huber" /><ref name="San Giovanni">San Giovanni T.P., Keblish D.J., Thomas W.H., Wilson M.G. Eight-year results of a minimally constrained total ankle arthroplasty. Foot Ankle Int. 2006;27(6):418-426</ref>
*Muscle strength
*Posture: Increased pronation/supination in standing, ability to maintain wait bearing status
*Assess assistive and adaptive devices for need and proper fit
*Balance: Static and dynamic standing balance, unilateral balance of the unaffected extremity (especially if patient is still non-weight bearing).<ref name="Huber" /> Patient may demonstrate dynamic postural imbalance, less reliance on ankle strategy and deficit of motor control ability<ref name="Lee" />
*Functional mobility
**American Orthopaedic Foot and Ankle Society ankle-hindfoot score<ref name="Valderrabano">Valderrabano V., Nigg B.M., von Tscharner V., Frank C.B., Hintermann B. Total ankle replacement in ankle osteoarthritis: an analysis of muscle rehabilitation. Foot Ankle Int. 2007;28(2):281-291.</ref>, Outcome measures
**Self-selected normal walking speed<ref name="Dyrby">Dyrby C., Chou L.B., Andriacchi T.P., Mann R.A. Functional evaluation of the Scandinavian Total Ankle Replacement. Foot Ankle Int.2004;25(6):377-381.</ref>
**Assess safety in mobility
*Gait Assessment<ref name="Huber" /><br>


<br>  
add text here relating to diagnostic tests for the condition<br>  


== Medical Management <br>  ==
== Medical Management <br>  ==


=== First generation:  ===
add text here <br>  
 
Early ankle prosthesis attempts involved cementing a stemmed metal ball into the tibia and a polyethylene cup cemented into the talus. Throughout the 1970’s, prosthesis evolved into using a vitallium component cemented into the talus. All designs used methylmethacrylate cement, which became the defining element of first generation prosthesis.<ref name="Cook">Cook R.A., O’Malley M.J.  Total Ankle Arthroplasty.  Orthop Nurs. 2001;20(4): 30-37.</ref>
 
===== Types:  =====
 
*<u>Constrained</u> - Increased stability due to only allowing dorsiflexion and plantarflexion. Loosening of the prosthesis was common from increased torque at the joint.<ref name="Cook" />
*<u>Nonconstrained</u> - Allows full ROM, resulting in decreased stability that commonly caused impingement against the medial and/or lateral malleoli.
*<u>Semiconstrained</u> - A combination of contrained and nonconstrained models, allowing greater ROM and medial-lateral stability. The Imperial College, London Hospital prosthesis uses a concave polyethylene in the tibia and a stainless steel component on the talus.<ref name="Cook" />
 
Unfortunately, by the early 1980’s, first generation ankle arthroplasties were not recommended by the majority of orthaepedic surgeons. Numerous studies showed loosening of the cement fixation, wound issues, and low patient satisfaction <ref name="Saltzman, CL">Saltzman, C.L., McIff, T.E., Buckwalter, J.A., Brown, T.D. Total Ankle Replacement Revisited.  JOSPT. 2000;30: 56-67.</ref><ref name="Cook" />. As a result of the poor outcomes and high complication rate, surgeons began to recommended ankle arthrodesis.
 
=== Second generation:  ===
 
Second generation arthroplasties are cementless, using bony ingrowth to stabilize the implant. Compared to cement, bony ingrowth prosthesis have less bone resection, damage to soft tissue and complications of the cement such as cement displacement<ref name="Saltzman, CL">Saltzman, C.L., McIff, T.E., Buckwalter, J.A., Brown, T.D. Total Ankle Replacement Revisited.  JOSPT. 200;30: 56-67.</ref>.
 
===== Surgical Factors:  =====
 
*<u>Fixation</u>: Ingrowth implants tend to have either a beaded surface along the bony interface, hydroxyapatite layer or a combination of both. Current surgical designs tend to use the combination fixation technique.<ref name="Cook" /><ref name="Saltzman, CL" />&nbsp;Between types of prosthesis the number of articulating surfaces and components both need to be considered.<ref name="Saltzman, CL" /><ref name="Cook" /><ref name="Gill">Gill. LH. Challenges in Total Ankle Arthroplasty.  Foot Ankle Int. 2004;25(4):195-207.</ref>.
*<u>Components</u>:
**<u>Articulating surfaces</u>: Current designs vary on the articulations that need to be resurfaced. Resurfacing may occur at the superior tibiotalar joint, superior and medial articulations, or medial, lateral, and superior joints.<ref name="Cook" /> Determining which patients would benefit the most from each type of surgery is ongoing.<ref name="Saltzman, CL" />
 
===== Design components:  =====
 
*2 component implants include a tibial and talar articulating component. Implants may also incorporate syndesmosis fusion to resurface the medial and lateral recesses of ankle and converting the ankle from a 3-bone joint to a 2-bone joint. Known designs: Agility, Salto Talaris, Eclipse, INBONE
**<u>Advantages</u>: decreased shear and torsion on prosthesis<ref name="Guyer">Guyer, A.J., Richardson, E.G. Current Concepts Review: Total Ankle Arthroplasty.  Foot Ankle Int. 2008;29(2): 256-264.</ref>, syndesmosis decreases shear force and increase the bony support for the tibial component<ref name="Saltzman, CL" />
**<u>Disadvantages</u>: increased bony resection, likelihood of soft tissue compromise, accelerated polyethylene wear, and possibility of syndesmosis fusion failure.<ref name="Saltzman, CL" />
 
{| width="400" border="0" cellpadding="1" cellspacing="1" align="center"
|+ '''2 Component Ankle Replacement Examples'''
|-
| [[Image:SaltoTalaris ankle.jpg|200px|SaltoTalaris ankle.jpg]]
| [[Image:AGILITY ankle.jpg|200px|AGILITY ankle.jpg]]
|-
| <sup>Salto Talaris</sup>
| <sup>Agility</sup>
|}
 
*3 component implants include a “mobile bearing” of polyethylene between the tibial plate and talar component. Known designs: Buechel-Pappas, Scandinavian Total Ankle Replacement (STAR), Mobility, HINTEGRA
**<u>Advantages</u>: low polyethylene wear rates, allow multiplanar motion<ref name="Cook" />, increased congruency, minimal bony resection<ref name="Saltzman, CL" /><ref name="Guyer" />
**<u>Disadvantages</u>: mobile bearing segment may dislocate, more involved surgery, abnormal ligamentous stress due to malalignment of axis of rotation<ref name="Saltzman, CL" /><ref name="Cook" />
 
{| width="400" border="0" cellpadding="1" cellspacing="1" align="center"
|+ '''3 Component Ankle Replacement Examples'''
|-
| [[Image:STAR ankle.jpg|200px|STAR ankle.jpg]]
| [[Image:BuechelPappas ankle.gif|BuechelPappas ankle.gif]]
|-
| <sup>STAR</sup>
| <sup>Buechel Pappas</sup>
|}
 
<br> Both component designs permit semiconstrained motion, specifically allowing some inversion and eversion during sagittal plane ankle movement. The four 2 component designs have been approved by the U.S. Food and Drug Administration (FDA). The STAR was recommended for approval by the FDA in 2008.<ref name="Cracchiolo">Cracchiolo  A. III, Deorio, J.K. Design features of current total ankle replacements: implants and instrumentation. J Am Acad Orthop Surg. 2008;16(9):530-540.</ref><ref name="Guyer" />&nbsp;There is insufficient evidence determining the life expectancy of current prosthesis designs.<ref name="Guyer" />
 
=== Alternate Option:  ===
 
'''Ankle Arthrodesis'''
 
Ankle arthrodesis or fusion was the recommended surgical option after the failure of the first generation ankle arthroplasty. The procedure includes resecting the articular surfaces of the joint, realignment the talus and tibia and fusing the bones together. As a result, the ankle joint doesn’t allow any motion. The goal of ankle arthrodesis is pain relief.<ref name="Pfeiff">Pfeiff C. The Scandinavian Total Ankle Replacement (STAR). Orthop Nurs. 2006; 25(1): 30-33.</ref><ref name="Gill">Gill. LH. Challenges in Total Ankle Arthroplasty.  Foot Ankle Int. 2004;25(4):195-207.</ref> Unfortunately, the lack of ankle motion can cause elevated stress on the knee and hindfoot and in addition, increases motion at the hindfoot that may become arthritic.<ref name="Cook" /> Other complications of fusion include accelerated degeneration of adjacent joint and limitations in activity.<ref name="Guyer">Guyer, A.J., Richardson, E.G. Current Concepts Review: Total Ankle Arthroplasty.  Foot Ankle Int. 2008;29(2): 256-264.</ref><br>
 
{| width="300" cellspacing="1" cellpadding="1" border="0" align="center"
|-
| {{#ev:youtube|8GJl4BD-xzM|300}}
|-
| <sup>Used with permission by Susan Barber Lindquist, Media Relations Coordinator, Mayo Clinic Health System<ref name="Herr">Herr, Mark. otal Ankle Replacement with Dr. Mark Herr [Video]. YouTube. http://www.youtube.com/watch?v=8GJl4BD-xzM. Published Jan 19, 2010. Accessed July 11, 2011.</ref></sup>
|}
 
<br>  


== Physical Therapy Management <br>  ==
== Physical Therapy Management <br>  ==


As can be expected after any type of surgery, pain and inflammation must be controlled. This is the case especially after ankle replacement because pain and inflammation can last up to 12 months after surgery.<ref name="Lagaay">Lagaay PM, Schuberth JM. Analysis of Ankle Range of Motion and Functional Outcome Following Total Ankle Arthoplasty. The Journal of Foot and Ankle Surgery. 2010: Iss. 49, 147-151.</ref> Surrounding muscles can be damaged during surgery and can result in decreased range of motion and strength.<ref name="Gougoulias">Gougoulias N, Khanna A, Maffulli N. How Successful are Current Ankle Replacements?: A Systematic Review of the Literature. Clinical Orthopaedics and Related Research. Clin Orthop Relat Res. Jan 2010: 199-208.</ref><ref name="Buechel">Buechel FF Sr, Buechel FF Jr, Pappas MJ. Twenty- year evaluation of cementless mobile-bearing total ankle replacements. Department of Orthopaedic Surgery New Jersey Medical School. Jul 2004: 19-26.</ref><ref name="Bonnin">Bonnin M, Judet T, Colombier JA, Buscayret JA, Graveleau N, Piriou P. Midterm results of the Salto Total Ankle Prosthesis. Clin Orthop Relat Res. Jul 2004: 6-18.</ref> Damage to joint proprioceptors during excision of the capsule may cause deficits in both static and dynamic balance.<ref name="Lee">Lee KB, Park YH, Song EK, Yoon TR, Jung KI. Static and dynamic postural balance after successful mobile-bearing total ankle arthroplasty. Arch Phys Med Rehabil. Apr 2010: 519-522.</ref><ref name="Culham">Culham EG, Westlake KP, Wu Y. Sensory-specific balance training in older adults: effect on position, movement, and velocity sense at the ankle. Phys Ther. May 2007: 560-568.</ref>&nbsp;These components can lead to gait disability and decreased efficiency of locomotion.<ref name="Detrembleur">Detrembleur C. Leemrijse T. The effects of total ankle replacement on gait disability: analysis of energetic and mechanical variables. Gait Posture. Feb 2009. 270-274.</ref> Correction of gait posture and ambulation deficiencies will be a target of therapy once the patient is ambulating independently.<br>  
As it will be explained in the Pre-Op and Post-Op the physician has a big role in making the arrangements before and after the surgery. Before the surgery the main job for the physician is to educate the patient about what will happen before, during and after the surgery. The physician will evaluate: the ROM from the patient, muscle strength, gait and deviations. For ergonomic reasons it is important that the patient learns how to walk with crutches so he still can perform ADL’s. After the surgery it is important that the patient keeps moving and performing his daily activities. However there is still discussion between physicians about when the patient should start again with exercising. There are some that allow exercise immediately after surgery. But some say it is considered best to wait until there is a satisfactory bony in growth as shown radio graphically. However it’s the job of the physician to try to improve:<span style="mso-spacerun:yes">&nbsp; </span>the patient’s ROM of the ankle, maintain the ROM in the hip and knee, increase the muscle strength with exercise for the Gluteus Maximus, Quadriceps femoris muscles and the muscles that are responsible for dorsal flexion and the plantar flexion of the ankle. Postoperative mobilization begins early, with rapid progression to resumption of normal activities.<ref>SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306.</ref><sup>&nbsp;</sup>The goal is to obtain 10° of dorsal flexion and 30° of plantar flexion. For patients who have almost no motion in their ankle is any motion an improvement.<ref>SALTZMAN C.L., MCLFF T.E., BUCKWALTER J.A., BROWN T.D., ‘Total Ankle Replacement revisited’, Journal of Orthopaedic &amp;amp; Sports Physical Therapy, 2000, February, vol.nr. 30(2), p. 56-67</ref>&nbsp;<br>  


===== Physical Therapy Goals: =====
== Pre-Op ==


*Decrease pain
Before the surgery, the most important role is intended for the physical therapist and the doctor. It is important that they orient the patient to the procedure and explain what they want to achieve with the treatment. The patient will be evaluated on his range of motion, muscle strength, ability to perform ADL, gait pattern and deviations. The patient will be given deep-breathing and coughing exercises. The physician will also give bilateral isometric contraction exercises for the Gluteus Maximus and the Quadriceps femoris muscles but also isotonic ankle exercise for planter flexion and dorsal flexion for not affected leg. For ergonomic reasons the patient needs to learn how to transfer from the bed to a chair without weight bearing on the affected ankle. He also needs to walk with Lofstrand crutches.<ref>SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306</ref>  
*Decrease inflammation
*Increase strength
*Increase range of motion  
*Improve dynamic and static balance
*Improve proprioception
*Proper independent ambulation<br>


===== Medical Precautions:<ref name="DePuy">DePuy Orthopaedic Inc. My ankle replacement. http://www.myanklereplacement.com/DePuy/docs/Ankle/Replacement/Rehabilitation/following_ars.html. Updated 2011. Accessed July 14, 2011.</ref> =====
In early postoperative period it is important that the incision heals and the implant becomes solidly fixed to the bony bed to do this they will use a below knee non-weight bearing immobilization. This is maintained until there is satisfactory bony in growth.<sup>&nbsp;</sup><ref>SALTZMAN C.L., MCLFF T.E., BUCKWALTER J.A., BROWN T.D., ‘Total Ankle Replacement revisited’, Journal of Orthopaedic &amp;amp;amp;amp;amp; Sports Physical Therapy, 2000, February, vol.nr. 30(2), p. 56-67</ref><sup>. </sup>The first 2 weeks the physician’s most important job is to help the patient maintain doing ADL activities, with crutches on a safe way. The second goal is to control the swelling and pain. It’s important that the patient rests and keeps his affected limb elevated above the heart.


*Immobilization
<span lang="EN-US">After 2 weeks the cast will be replaced by a short leg boot. At this moment the patient goes back to the hospital for a first post-operative visit to the doctor.</span>
**0-2 weeks: short leg cast
**2-6 weeks: splint, can be removed during therapy
*Mobilization
**0-6 weeks: non-weight bearing&nbsp;
**&gt;6 weeks: weight bearing as tolerated with assistive device


<br>  
<span lang="EN-US">The main goal for the physician is to increase the ROM of the ankle and maintain the hip and the knee ROM.</span>  


=== Treatment  ===
<span lang="EN-US">However there is still discussion between physicians about when the patient should start again with exercising. There are some that allow exercise immediately after surgery. But some say it is considered best to wait until there is a satisfactory bony in growth as shown radio graphically.</span>


===== Pain and inflammation:<ref name="Lagaay">Lagaay PM, Schuberth JM. Analysis of Ankle Range of Motion and Functional Outcome Following Total Ankle Arthoplasty. The Journal of Foot and Ankle Surgery. 2010: Iss. 49, 147-151.</ref><ref name="DePuy" /> =====
<span lang="EN-US">From here on it is important that the patient maintain his ROM from his ankle, knee and hip. He will be giving exercise to improve the strength of the Gluteus Maximus, Quadriceps and the muscles that are responsible for dorsal flexion and plantar flexion of the ankle.<ref>SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306.</ref></span>  


*Pain relievers<br>  
After a few months the patient needs to make an appointment with the doctor. Here they will take X-ray scans to see if there are no complications like: joint debridement for osseous impingement; the next most common procedures were extra-articular procedures for axial misalignments and component replacements.<ref>ADRIENNE A. SPIRT, MATHIEU ASSAL, SIGVARD T. HANSEN Jr., ‘Complications and Failure After Total Ankle Arthroplasty’, The Journal of Bone and Joint Surgery, 2004, June, vol. 86-A, nr. 6, p.1172-1178</ref>&nbsp;
*Anti-inflammatory drugs<br>
*RICE<br>


===== Mobility: =====
== Key Research ==


*Education on weight-bearing status
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
*Education on proper ambulatory technique using assistive device <br>


===== Range of Motion:<ref name="Gougoulias">Gougoulias N, Khanna A, Maffulli N. How Successful are Current Ankle Replacements?: A Systematic Review of the Literature. Clinical Orthopaedics and Related Research. Clin Orthop Relat Res. Jan 2010: 199-208.</ref><ref name="Buechel" /><ref name="Bonnin" />  =====
== Resources <br>  ==
 
*2-6 weeks: Active and passive ankle dorsiflexion, plantar flexion, inversion, eversion, toe flexion and extension&nbsp;
*&gt;6 weeks: Aggressive stretching emphasizing dorsiflexion
 
===== Strength:  =====
 
*2-6 weeks: Light Thera-band resistive exercises into dorsiflexion, plantar flexion, inversion and eversion
*&gt;6 weeks: Increase Thera-band resistance. Resisted adduction with inversion and resisted abduction with eversion. Begin weight-bearing activities such as toe and heel raises
 
===== Proprioception and balance:<ref name="Lee" /><ref name="Culham" />  =====
 
*Seated rocker board exercise (dorsiflexion to plantarflesion and inversion to eversion. May progress to standing as indicated
*Fallproof Program:
**Focuses on strength, balance, endurance and flexibility during functional activities such as single-limb stance on stable and unstable surface, standing on toes, standing on toes and reaching and bending forward to reach objects on ground.
**[http://www.exrx.net/Store/HK/Fallproof.html http://www.exrx.net/Store/HK/Fallproof.html]
 
===== Independent ambulation:<ref name="Detrembleur">Detrembleur C. Leemrijse T. The effects of total ankle replacement on gait disability: analysis of energetic and mechanical variables. Gait Posture. Feb 2009. 270-274.</ref>  =====
 
*Gait training with direction toward normalization
 
<br>  
 
=== Sample Exercises ===


{| width="500" border="0" cellpadding="1" cellspacing="1" align="center"
{| width="100%" cellspacing="1" cellpadding="1"
|-
| [[Image:Balance perturbation.JPG|115x130px|Balance against perturbation]]
| [[Image:Ball toss.JPG|115x130px|Ball toss.JPG]]
| [[Image:Standing reach.JPG|115x130px|Standing reach.JPG]]
|-
|-
| <sup>Balance c perturbation</sup>  
| {{#ev:youtube|83DmBuP2S20|300}}<ref>Dr Selene Parekh Ankle Replacement Surgery https://www.youtube.com/channel/UCxqRUzmxviIRrz3MBt6Xxew [Accessed 24/05/2014]</ref>  
| <sup>Ball toss</sup>
| {{#ev:youtube|HA_KYQMCYd8|300}}<ref>Dr Selene Parekh Ankle Replacement Surgery https://www.youtube.com/channel/UCxqRUzmxviIRrz3MBt6Xxew [Accessed 24/05/2014]</ref>
| <sup>Standing reach</sup>
|}
|}


{| width="500" border="0" cellpadding="1" cellspacing="1" align="center"
{| width="100%" cellspacing="1" cellpadding="1"
|-
| [[Image:Standing reach 2.JPG|115x130px|Standing reach 2.JPG]]
| [[Image:Seated rocker board.JPG|115x130px|Seated rocker board.JPG]]
| [[Image:DF theraband.JPG|115x130px|DF theraband.JPG]]
|-
| <sup>Standing reach</sup>
| <sup>Seated rocker board</sup>
| <sup>DF theraband</sup>
|-
| [[Image:Eversion.JPG|115x130px|Eversion.JPG]]
| [[Image:DF stretch.JPG|115x130px|DF stretch.JPG]]
| [[Image:PF theraband.JPG|115x130px|stuff]]
|-
|-
| <sup>Ankle eversion</sup>  
| {{#ev:youtube|wmihPwctFSQ|300}}<ref>Dr Selene Parekh Ankle Replacement Surgery https://www.youtube.com/channel/UCxqRUzmxviIRrz3MBt6Xxew {Accessed 24/05/2014]</ref>  
| <sup>DF stretch</sup>
| {{#ev:youtube|JGjyRJNWAbA|300}}<ref>Total Ankle Replacement Surgery educational video. Available from https://www.youtube.com/watch?v=JGjyRJNWAbA [Accessed 24/05/2014]fckLR|}</ref>
| <sup>Ankle PF</sup>
|}
|}
<br>
== Key Research  ==
*Saltzman, C.L., McIff, T.E., Buckwalter, J.A., Brown, T.D. Total Ankle Replacement Revisited. JOSPT. 2000;30: 56-67.<br>
*Cook R.A., O’Malley M.J. Total Ankle Arthroplasty. Orthop Nurs. 2001;20(4): 30-37.
*Guyer, A.J., Richardson, E.G. Current Concepts Review: Total Ankle Arthroplasty. Foot Ankle Int. 2008;29(2): 256-264.
*Detrembleur C. Leemrijse T. The effects of total ankle replacement on gait disability: analysis of energetic and mechanical variables. Gait Posture. Feb 2009. 270-274.
<br>
== Resources <br>  ==
[http://www.mayoclinic.com The Mayo Clinic]
[http://www.myanklereplacement.com My Ankle Replacement (.com)]


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


Once an ankle has reached the point where total arthroplasty is warranted, there is not much the Physical Therapist can do pre-surgery other than general strengthening for better post-op recovery. After the surgery the PT will need to focus on joint stability &amp; strength, pain &amp; edema, general medical management, ROM, and balance/gait control. As the ankle is the most inferior joint in direct weight-bearing of the torso and limbs, utmost concern should be noted when working within the gait &amp; locomotion arena.<br>  
add text here <br>  


<br>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])<br>  ==
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1lg0RU4SkRVBqMFj5d-bSyy2dkWVinKpajNeDAG9Bmj8Xqj5o|charset=UTF-8|short|max=10</rss> &lt;/div&gt;<br>  
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1VwHIhVo4vdyrtaEe-clEgaFBaRMj3ptrl0HYJ5qSaXRFbmg-8|charset=UTF-8|short|max=10</rss>  


<br>
== References  ==
</div>
== References<br> ==


<references />  
<references /><br>  


[[Category:Ankle]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]   [[Category:Texas_State_University_EBP_Project]]
[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]] [[Category:Ankle]]  [[Category:EIM_Residency_Project]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Procedures]]

Revision as of 12:00, 24 May 2014

Original Editor - Sharon Schumacher, Carlos De Coster

Top Contributors - Jeremy Brady, Jorge Solorzano, Admin, Scott Buxton, Kim Jackson, Dana Williams, Shaimaa Eldib, Carlos De Coster, 127.0.0.1, Neha Palsule, Mariam Hashem, Simisola Ajeyalemi, Uchechukwu Chukwuemeka, Tony Lowe, Ryan De Laet, Rachael Lowe, Rucha Gadgil, Sharon Schumacher, Lucinda hampton, Jess Bell, Michael Kauffmann and George Prudden  

Search Strategy[edit | edit source]

PubMed (http://www.ncbi.nlm.nih.gov/pubmed)

MeSH terms:

  • Complications
  • Diagnosis
  • Drug therapy
  • Epidemiology
  • Etiology
  • Pathology
  • Rehabilitation
  • Surgery
  • Therapy

Medline Plus

Used keyword:

  • Ankle replacement

Definition/Description[edit | edit source]

Ankle replacement surgery has been available for over two decades however it is a far less common procedure than hip or knee arthroplasty owing to the less frequent incidence of osteoarthritis ankle pathology. The majority of ankle osteoarthritis is secondary to trauma.[1]

Until relatively recently, ankle joint arthrodesis (fusion) was the gold standard of treatment, but this was not without its complications, e.g. non-union,Osteoarthritis in the other mid/hind foot joints and stiffness and loss of proprioception[2]

     Total ankle replacement was developed in the 1970's but initially was plagued with high long term failure rates. The older prosthesis loosened or malfunctioned and frequently needed to be removed[3].  In the late 70's Dr. Frank G. Alvine an orthopedic surgeon from Sioux Falls, SD developed the Agility Ankle which was the first FDA approved total ankle implant in use in the United States[4]. Since its introduction the Agility Ankle System has gone through several modifications. Currently the Agility Ankle System is the most widely used ankle prosthesis. With more than 20 years of experience it has the longest followup of any fixed bearing device[5].

On May 29, 2009 the medical news today announced the FDA approved the first mobile bearing device called the Scandinavian Total Ankle Replacement System (STAR). As a condition of FDA approval the company (Small Bone Innovations Inc.) must evaluate the safety and effectiveness of the device during the next eight years[6].

     In a systematic review of the literature published in the Journal of Bone and Joint Surgery in 2007, the intermediate outcome of total ankle arthroplasty appears to be similiar to that of ankle arthrodesis however data was sparse[7].  In a study comparing reoperation rates following ankle arthrodesis and total ankle arthroplasty SooHoo, Zingmond and Ko confirmed that ankle replacement is associated with a higher risk of complications as compared with ankle fusion, but also has potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion[8].  In a seven to sixteen year follow up on the Agility Total Ankle Arthroplasty, Knecht, Estin, Callagham et al concluded that the relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging[9].

     Although interest in total ankle replacements is increasing, midterm clinical results to date are few and often have not been validated by independent pratitioners. In addition no level I or II studies have been published[10].

Clinically Relevant Anatomy[edit | edit source]

Indication for Procedure
[edit | edit source]

There is no well-defined indication for a Total Ankle Arthroplasty. Surgery is considered only when conservative treatment has been attempted with no improvement. The operation is mainly being executed in patients who suffer from different types of arthrides. This cause advanced arthritic changes of disabling pain and loss of ankle motion. The ankle is most frequently affected by post-traumatic arthritis.[11] Total ankle joint replacement is also indicated following unsuccessful ankle arthrodesis [12] the ‘ideal’ patient for ankle joint replacement is an elderly person with the low physical demands who has good bone stock, normal vascular status, no immune-suppression, and excellent hind foot-ankle alignment.[13]

Clinical Presentation[edit | edit source]

add text here relating to the clinical presentation of the condition

Diagnostic Tests[edit | edit source]

add text here relating to diagnostic tests for the condition

Medical Management
[edit | edit source]

add text here

Physical Therapy Management
[edit | edit source]

As it will be explained in the Pre-Op and Post-Op the physician has a big role in making the arrangements before and after the surgery. Before the surgery the main job for the physician is to educate the patient about what will happen before, during and after the surgery. The physician will evaluate: the ROM from the patient, muscle strength, gait and deviations. For ergonomic reasons it is important that the patient learns how to walk with crutches so he still can perform ADL’s. After the surgery it is important that the patient keeps moving and performing his daily activities. However there is still discussion between physicians about when the patient should start again with exercising. There are some that allow exercise immediately after surgery. But some say it is considered best to wait until there is a satisfactory bony in growth as shown radio graphically. However it’s the job of the physician to try to improve:  the patient’s ROM of the ankle, maintain the ROM in the hip and knee, increase the muscle strength with exercise for the Gluteus Maximus, Quadriceps femoris muscles and the muscles that are responsible for dorsal flexion and the plantar flexion of the ankle. Postoperative mobilization begins early, with rapid progression to resumption of normal activities.[14] The goal is to obtain 10° of dorsal flexion and 30° of plantar flexion. For patients who have almost no motion in their ankle is any motion an improvement.[15] 

Pre-Op[edit | edit source]

Before the surgery, the most important role is intended for the physical therapist and the doctor. It is important that they orient the patient to the procedure and explain what they want to achieve with the treatment. The patient will be evaluated on his range of motion, muscle strength, ability to perform ADL, gait pattern and deviations. The patient will be given deep-breathing and coughing exercises. The physician will also give bilateral isometric contraction exercises for the Gluteus Maximus and the Quadriceps femoris muscles but also isotonic ankle exercise for planter flexion and dorsal flexion for not affected leg. For ergonomic reasons the patient needs to learn how to transfer from the bed to a chair without weight bearing on the affected ankle. He also needs to walk with Lofstrand crutches.[16]

In early postoperative period it is important that the incision heals and the implant becomes solidly fixed to the bony bed to do this they will use a below knee non-weight bearing immobilization. This is maintained until there is satisfactory bony in growth. [17]. The first 2 weeks the physician’s most important job is to help the patient maintain doing ADL activities, with crutches on a safe way. The second goal is to control the swelling and pain. It’s important that the patient rests and keeps his affected limb elevated above the heart.

After 2 weeks the cast will be replaced by a short leg boot. At this moment the patient goes back to the hospital for a first post-operative visit to the doctor.

The main goal for the physician is to increase the ROM of the ankle and maintain the hip and the knee ROM.

However there is still discussion between physicians about when the patient should start again with exercising. There are some that allow exercise immediately after surgery. But some say it is considered best to wait until there is a satisfactory bony in growth as shown radio graphically.

From here on it is important that the patient maintain his ROM from his ankle, knee and hip. He will be giving exercise to improve the strength of the Gluteus Maximus, Quadriceps and the muscles that are responsible for dorsal flexion and plantar flexion of the ankle.[18]

After a few months the patient needs to make an appointment with the doctor. Here they will take X-ray scans to see if there are no complications like: joint debridement for osseous impingement; the next most common procedures were extra-articular procedures for axial misalignments and component replacements.[19] 

Key Research[edit | edit source]

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources
[edit | edit source]

[20]
[21]
[22]
[23]

Clinical Bottom Line[edit | edit source]

add text here

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ Ankle Replacement Surgery. Annals of the Royal College of Surgeons of England. 2006 July;88(4):417-418
  2. ↑ Ankle Replacement Surgery. Annals of the Royal College of Surgeons of England. 2006 July;88(4):417-418
  3. ↑ http://www.medicalnewstoday.com/articles/11222.php
  4. ↑ http://www.medicalnewstoday.com/articles/11222.php
  5. ↑ Cerrato R, Myerson MS. Total Ankle Replacement:the Agility LP prosthesis. Foot and Ankle Clin. 2008 Sept; 13(3): 485-94.
  6. ↑ http://medicalnewstoday.com/printerfriendlynews.php?newsid=151776
  7. ↑ Haddad SL, Coetzee JC, Estok R. et al. Intermediate and Long-Term Outcomes of Total Ankle Arthroplasy and Ankle Arthrodesis. The Journal of Bone and Joint Surgery (American). 2007;89:1899-1905.
  8. ↑ SooHoo NF, Zingmond DS, Ko CY. Comparison of Reoperation Rates Following Ankle Arthrodesis and Total Ankle Arthroplasty. The Journal of Bone and Joint Surgery (American). 2007;89:2143-2149.
  9. ↑ Knecht SI, Estin M, Callaghan JJ et al. The Agility Total Ankle Arthroplasty: Seven to Sixteen-Year Follow-up. The Journal of Bone and Joint Surgery (American). 2004;86:1161-1171.
  10. ↑ Cracchiolo A 3rd, Deorio JK. Design features of current total ankle replacements: implants and instrumentation. Journal of the American Academy of Orthopedic Surgeons. 2008 Sept:16(9):530-40.
  11. ↑ MURNAGHAN J.M., WARNOCK D.S., HENDERSON S.A.., ‘Total Ankle Replacement: Early experience with STAR prothesis’, The Ulster Medical Journal, 2005, May, vol. 74, nr. 1, p. 9-13
  12. ↑ SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306
  13. ↑ SALTZMAN C.L., MCLFF T.E., BUCKWALTER J.A., BROWN T.D., ‘Total Ankle Replacement revisited’, Journal of Orthopaedic &amp; Sports Physical Therapy, 2000, February, vol.nr. 30(2), p. 56-67
  14. ↑ SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306.
  15. ↑ SALTZMAN C.L., MCLFF T.E., BUCKWALTER J.A., BROWN T.D., ‘Total Ankle Replacement revisited’, Journal of Orthopaedic &amp; Sports Physical Therapy, 2000, February, vol.nr. 30(2), p. 56-67
  16. ↑ SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306
  17. ↑ SALTZMAN C.L., MCLFF T.E., BUCKWALTER J.A., BROWN T.D., ‘Total Ankle Replacement revisited’, Journal of Orthopaedic &amp;amp;amp;amp; Sports Physical Therapy, 2000, February, vol.nr. 30(2), p. 56-67
  18. ↑ SMITH C.L., L.T., M.S.C., U.S.N., ‘Physical therapy management of patients with total ankle replacement’, Physical Therapy, 1980, March, vol. 60, nr. 8, p. 303-306.
  19. ↑ ADRIENNE A. SPIRT, MATHIEU ASSAL, SIGVARD T. HANSEN Jr., ‘Complications and Failure After Total Ankle Arthroplasty’, The Journal of Bone and Joint Surgery, 2004, June, vol. 86-A, nr. 6, p.1172-1178
  20. ↑ Dr Selene Parekh Ankle Replacement Surgery https://www.youtube.com/channel/UCxqRUzmxviIRrz3MBt6Xxew [Accessed 24/05/2014]
  21. ↑ Dr Selene Parekh Ankle Replacement Surgery https://www.youtube.com/channel/UCxqRUzmxviIRrz3MBt6Xxew [Accessed 24/05/2014]
  22. ↑ Dr Selene Parekh Ankle Replacement Surgery https://www.youtube.com/channel/UCxqRUzmxviIRrz3MBt6Xxew {Accessed 24/05/2014]
  23. ↑ Total Ankle Replacement Surgery educational video. Available from https://www.youtube.com/watch?v=JGjyRJNWAbA [Accessed 24/05/2014]fckLR|}


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