Rehabilitation Guidelines for Total Ankle Replacement

Initial rehabilitation phase

0-4 weeks

Goals:

To be safely and independently mobile with appropriate walking aid, adhering to weight bearing status
To be independent with home exercise programme as appropriate
To understand self management / monitoring, e.g. skin sensation, colour, swelling, temperature, circulation

Restrictions:

Ensure that weight bearing restrictions are adhered to:

Total Ankle Replacement (TAR):

Non Weight Bearing (NWB) for 2 weeks in Back Slab
Below Knee Plaster of Paris (BK POP) at 2 weeks. Progress to Full Weight Bearing (FWB) in POP.
POP removed at 4 weeks. May require aircast boot. FWB.

If any other surgical technique used ensure you check any restrictions with team as these may differ from TAR alone

Elevation
If sedentary employment, may be able to return to work from 4 weeks post-operatively, as long as provisions to elevate leg, and no complications

Treatment:

Likely to be in POP
Pain-relief: Ensure adequate analgesia
Elevation: ensure elevating leg with foot higher than waist
Exercises: teach circulatory exercises
Education: teach how to monitor sensation, colour, circulation, temperature, swelling, and advise what to do if concerned
Mobility: ensure patient independent with transfers and mobility, including stairs if necessary

Recovery rehabilitation phase

4 weeks – 3 months

Goals:

To be independently mobile out of aircast boot
To achieve full range of movement
To optimise normal movement

Restrictions:

Ensure adherence to weight bearing status.
No strengthening against resistance until at least 3 months post-operatively of any tendon transfers if performed.
Do not stretch any tendon transfers / ligament reconstructions if performed. They will naturally lengthen over a 6 month period

Treatment:

Pain relief
Advice / Education
Posture advice / education
Mobility: ensure safely and independently mobile adhering to appropriate weight bearing restrictions. Progress off walking aids as able once reaches FWB stage.
Gait Re-education
Wean out of aircast boot once advised to do so, and provision of plaster shoe as appropriate, if patient unable to get into normal footwear
Exercises:

Passive range of movement (PROM)
Active assisted range of movement (AAROM)
Active range of movement (AROM)
Strengthening exercises as appropriate
Core stability work
Balance / proprioception work once appropriate
Stretches of tight structures as appropriate (e.g. Achilles Tendon), not of tendon transfers / ligament reconstructions if performed.
Review lower limb biomechanics. Address issues as appropriate.
If tendon transfer performed, encourage isolation of transfer activation without overuse of other muscles. Biofeedback likely to be useful.

Swelling Management
Manual Therapy:

Soft tissue techniques as appropriate
Joint mobilisations as appropriate ensuring awareness of osteotomy sites and those joints which may be fused, and therefore not appropriate to mobilise

Monitor sensation, swelling, colour, temperature, circulation
Orthotics if required via surgical team
Hydrotherapy if appropriate
Pacing advice as appropriate

Intermediate rehabilitation phase

12 weeks – 6 months

Goals:

Independently mobile unaided
Wearing normal footwear
Optimise normal movement
Grade 5 muscle strength around ankle
Grade 4 muscle strength of tendon transfers if performed

Treatment:

Further progression of the above treatment:

Pain relief
Advice / Education
Posture advice / education
Mobility: Progression of mobility and function
Gait Re-education
Exercises:

Range of movement
Strengthening exercises as appropriate
Core stability work
Balance / proprioception work
Stretches of tight structures as appropriate (e.g. Achilles Tendon), not of transfers / ligament reconstructions if performed.
Review lower limb biomechanics. Address issues as appropriate.
If tendon transfer performed progress isolation of transfer activation without overuse of other muscles. Biofeedback likely to be useful.

Swelling Management
Manual Therapy:

Soft tissue techniques as appropriate
Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise

Monitor sensation, swelling, colour, temperature, circulation
Orthotics if required via surgical team
Hydrotherapy if appropriate
Pacing advice as appropriate

Final rehabilitation phase

6 months – 1 year

Goals:

Return to gentle no-impact / low-impact sports
Establish long term maintenance programme
Grade 4 or 5 muscle strength of tendon transfers if performed

Treatment:

Mobility / function: Progression of mobility and function, increasing dynamic control with specific training to functional goals
Gait Re-education
Exercises:

Progression of exercises including range of movement, strengthening, transfer activation, balance and proprioception, core stability

Swelling Management
Manual Therapy:

Soft tissue techniques as appropriate
Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise

Pacing advice

Failure to progress

If a patient is failing to progress, then consider the following:

POSSIBLE PROBLEM	ACTION
Swelling	Ensure elevating leg regularly Use ice as appropriate if normal skin sensation and no contraindications Decrease amount of time on feet Pacing Use walking aids Circulatory exercises If decreases overnight, monitor closely If does not decrease overnight, refer back to surgical team or to GP
Pain	Decrease activity Ensure adequate analgesia Elevate regularly Decrease weight bearing and use walking aids as appropriate Pacing Modify exercise programme as appropriate If persists, refer back to surgical team or to GP
Breakdown of Wound e.g inflammation, bleeding, infection	Refer to surgical team or to GP
Transfer not activating	Start working in NWB gravity eliminated position with AAROM and then build up as able Biofeedback Ensure adequate analgesia as appropriate Ensure swelling under control as appropriate Ensure foot neutral when mobilising to avoid excessive shear. Consider orthotics referral via surgical team if unable to keep neutral Refer back to surgical team if no improvement
Numbness / altered sensation	Review immediate post-operative status if possible Ensure swelling under control If new onset or increasing refer back to surgical team or GP If static, monitor closely, but inform surgical team and refer back if deteriorates or if concerned

Summary of evidence for physiotherapy guidelines

A comprehensive literature search was carried out to identify research relating to surgery for tibialis posterior tendon dysfunction and subsequent rehabilitation. After reviewing the articles and information, the physiotherapy guidelines were produced on the best available evidence.

Ali et al (2007) “Intermediate results of Buechel Pappas unconstrained uncemented Total Ankle Replacement for osteoarthritis” The Journal of Foot and Ankle Surgery 46, (1): 16-20
Buechel et al (2004) “Twenty-year evaluation of cementless mobile-bearing Total Ankle Replacements” Clinical Orthopaedics and Related Research 424, 19-26
Coetzee J & Castro M (2004) “Accurate measurement of ankle range of motion after Total Ankle Arthroplasty” Clinical Orthopaedics and Related Research 424, 27-31
Conti S & Wong YS (2001) “Complications of Total Ankle Replacement” Clinical Orthopaedics and Related Research 391, 105-114
Griesberg J & Hansen S (2003) “Total Ankle Arthroplasty in the advanced flatfoot” Techniques in Foot and Ankle Surgery 2, (3): 152-161
Knecht et al (2004) “The Agility Total Ankle Arthroplasty” The Journal of Bone and joint Surgery 86-A, (6): 1161-1171
Kobayashi et al (2004) “Ankle arthroplasties generate wear particles similar to knee arthroplasties” Clinical Orthopaedics and Related Research 424, 69-72
Kotnis et al (2006) “The management of failed ankle replacement” The Journal of Bone and Joint Surgery 88-B, (8): 1039-1047
Lalonde K & Conti S (2006) “Ankle arthritis: current status of ankle replacement versus fusion and other treatment modalities” Current Opinion in Orthopaedics 17, (2): 117-123
Mendolia et al (1005) “Lond term (10-14 years) results of the Ramses Total Ankle Arthroplasty” Techniques in Foot and Ankle Surgery 4, (3): 160-173
Spirt et al (2004) “Complications and failure after Total Ankle Arthroplasty” The Journal of Bone and Joint Surgery 86-A, (6): 1172-1178
Tochigi et al (2005) “The effect of accuracy of implantation on range of movement of the Scandinavian Total Ankle Replacement” The Journal of Bone and Joint Surgery 87-B, (5): 736-740
Valderrabano et al (2006) “Sports and recreation activity of ankle arthritis patients before and after Total Ankle Replacement” The American Journal of Sports Medicine 34, (6): 993-999