| Ankle arthroplasty is a procedure performed to reconstruct or replace a damaged ankle joint. Total ankle arthroplasty (TAA) replaces a damaged or diseased ankle with a prosthetic ankle composed of metal and plastic components. Different types of prostheses can be used. Older designs, such as the Agility ankle, use a two-component system that is cemented in place. Newer designs, such as the STAR and Buechel-Pappas Meniscal Bearing total ankle replacement, use a three-component uncemented system.
Ankle replacement is still not as commonly performed as fusion of the ankle joint (ankle arthrodesis), which has been the standard procedure. Although TAA results are considered to be comparable to fusion results, an important difference is that development of progressive degenerative arthritis in adjacent joints occurs less often following replacement than it does after fusion. Outcomes for TAA continue to improve as new prostheses are designed. |
Source: Medical Disability Advisor
| Arthroplasty is used to treat degeneration of the ankle joint and resulting immobility, stiffness, swelling, and pain that occur as a result of severe osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, infectious arthritis, or loss of blood supply to the ankle joint (avascular necrosis). Arthroplasty repair may also be performed to treat degenerative joint diseases, such as osteochondritis dissecans.
A person over age 50 who is less physically active and whose job or recreational activities do not put heavy stress on the ankle (e.g., avoid heavy lifting and high impact sports) is likely to be a good candidate for this procedure. |
Source: Medical Disability Advisor
| Ankle arthroplasty is performed through an open incision made at the top of the ankle. Vital structures are pushed aside so that the joint capsule can be opened (incised). When the joint space is exposed, the ends of the lower leg bones (tibia and fibula) and ankle bone (talus) are resurfaced to prepare them for the prosthesis. After artificial parts are properly placed, screws are inserted into the ankle bones to secure the joint. Bone grafting may be done to ensure that no movement of the tibia and fibula will occur. The graft involves placing a piece of bone removed from the talus during resurfacing between the tibia and fibula so that they fuse. Casts or splints must be worn after the procedure to aid healing. Antibiotics are given to prevent post-operative infection. Medication may be given for pain. |
Source: Medical Disability Advisor
| Outcomes of ankle arthroplasty are still not as successful as outcomes of hip and knee replacements, largely due to complications with the design of ankle prostheses; however, ankle replacement can improve mobility and relieve pain and other symptoms in most individuals undergoing the procedure. A review study compared outcomes in 1230 patients who underwent TAA to outcomes in 1262 patients who had ankle arthrodesis. Thirty percent of arthroplasty patients had excellent results, 32% had good results, and 14% had fair results.
Subsequent surgeries (revisions) were necessary in 6% of patients who underwent TAA, and 1% of these patients eventually required below-knee amputations. Arthrodesis results were comparable except that more patients (5%) required below-knee amputations (Haddad).
The length of time an ankle replacement will last without complications appears to depend on the type of prosthetic ankle used. The ankle joint is small compared to its weight-bearing capacity, and because of the stress of supporting the whole body, design of prosthetic ankles has been challenging. Efforts to repair an ankle replacement many years later can fail because of bony growth. Several studies have followed patient outcomes over time. After 5 years, about 97% of individuals were without significant complications following replacement with the Agility ankle, a two-component prosthesis (Kopp 97). Researchers found uncemented STAR replacements, a three-component prosthesis, to have good outcomes 3.5 years following the procedure (Salzman 58). One study found that 70% of STAR replacements were functional after 5 years (Anderson 1327). Another study reported that patients receiving Buechel-Pappas Meniscal Bearing total ankle replacement had 93.5% functionality after 10 years (Buechel 462). |
Source: Medical Disability Advisor
| Note on research and authorship The main goal of rehabilitation after ankle arthroplasty is to restore function by controlling pain, improving range of motion, and strengthening the ankle. Rehabilitation will progress based on the protocol of the treating physician throughout the treatment period.
Physical therapy begins in the hospital and continues on an outpatient basis. Initially, modalities such as application of cold may be beneficial for controlling pain and edema. Gait training is indicated (Roos), with an assistive device and weight bearing as directed by the surgeon. Preoperative gait instruction might facilitate early postoperative ambulation. Upper extremity strengthening exercises may be necessary for effective use of an assistive device for independent ambulation. Some individuals may require occupational therapy for transfer training and assessment for needed devices for the home including an elevated commode or tub chair.
The second goal of physical therapy emphasizes full ankle range of motion as permitted by the prosthetic joint. This includes active, active assisted, and passive range of motion as directed by the surgeon. Simultaneously, individuals should be instructed in active exercises of the adjacent joints to prevent loss of motion and strength. The final goal of physical therapy is to increase strength of the involved lower extremity and normalize gait.
Additional information may provide some insight into the rehabilitation needs of these individuals (Brander, Saltzman). |
| FREQUENCY OF REHABILITATION VISITS | | Surgical | |
| Physical or Occupational Therapist | | Inpatient: daily | | | | | | | | Physical or Occupational Therapist | | Outpatient: up to 15 visits in 6 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Complications vary according to the procedure and prosthesis used. For example, cemented prostheses can be complicated by extrusion of cement at the time of implantation, which can physically block ankle motion post-operatively.
Concerning prostheses, the Agility ankle was shown in a study that retrospectively reviewed the results of total ankle arthroplasty to have a 5% rate of moderate complications (Kopp 97). In another study, the tibial and talar ankle parts moved (migrated) in 67% of individuals because of poor or incomplete bone healing, which is a frequent problem with the Agility prosthesis (Ishikawa 238). An independent review of all Agility total ankle replacements performed by a single surgeon within a ten year period reported that 90% of patients had pain reduction; some individuals in this study developed subtalar joint arthritis and improper bone healing (Knecht). Studies of patients receiving the Buechel-Pappas Meniscal Bearing total ankle replacement reported that after 4.5 years individuals had problems with wound healing, subtalar arthritis, osteonecrosis, and malleolar nonunion (Ishikawa 239). Developers of the Buechel-Pappas prosthesis reported that, from a review of 49 patients, a few individuals developed a pain syndrome (complex regional pain syndrome or CRPS) at the surgical site (Buechel 467); this was due to the trauma of surgery, not the type of prosthesis. A study of the STAR uncemented replacement revealed problems with loosened parts (Anderson). Infection and or nerve damage was reported to occur in 2% to 4% of individuals post-operatively ("A Patient's Guide"). |
Source: Medical Disability Advisor
| Individuals may need to use walkers or crutches and wear a cast or splint for 3 months postoperatively. Individuals whose work requires standing, walking or running will need reassignment to more sedentary duties. Individuals may need time off from work to see their doctor for follow-up appointments. |
Source: Medical Disability Advisor
| "A Patient's Guide to Artificial Joint Replacement of the Ankle." Center for Hip & Knee Surgery. 3 Dec. 2004 <http://www.hipandkneesurgery.com.sg/PatientEdu/Ankle/jointrep.htm>.Anderson, Thomas, et al. "Uncemented STAR Total Ankle Prosthesis." Journal of Bone and Joint Surgery 85-A 7 (2003): 1321-1329. Brander, V. A., et al. "Rehabilitation in Joint and Connective Tissue Disease. 3. Limb Disorders." Archives of Physical and Medical Rehabilitation 76 5 Spec No (1995): S47-S56. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <PMID: 7741630>. Buechel, Frederick F., et al. "Ten Year Evaluation of Cementless Buechel-Pappas Meniscal Bearing Total Ankle Replacement." Foot & Ankle International 24 6 (2003): 462-472. Crockarell, John R., James L. Guyton, and . "Arthroplasty of Ankle and Knee." Campbell's Operative Orthopaedics. 10th ed. St. Louis: Mosby, Inc., 2003. 243-245. MD Consult. Elsevier, Inc. 3 Dec. 2004 <http://home.mdconsult.com/das/book/body/295779927/1111/62.html?printing=true>. Haddad, S. L., et al. "Intermediate and Long-term Outcomes of Total Ankle Arthroplasty and ankle Arthrodesis. A Systematic Review of the Literature." Journal of Bone and Joint Surgery 89 9 (2007): 1899-1905. Knecht, S. I., et al. "The Agility Total Ankle Arthroplasty. Seven to Sixteen-Year Follow-Up." Journal of Bone and Joint Surgery 86-A 6 (2004): 1161-1171. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <http://www.ncbi.nlm.nih.gov/>. Kopp, F. J., et al. "Total Ankle Arthroplasty with the Agility Prosthesis: Clinical and Radiographic Evaluation." Foot & Ankle International 27 (2006): 97. Roos, E. M. "Effectiveness and Practice Variation of Rehabilitation after Joint Replacement." Current Opinion in Rheumatology 15 2 (2003): 160-162. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <PMID: 12598806>. Saltzman, C. L., et al. "Total Ankle Replacement Revisited." Orthopedic and Sports Physical Therapy 30 2 (2000): 56-67. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <PMID: 10693083>. |
Source: Medical Disability Advisor
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