physiotherapy rehabilitation guidelines for patients … · 2018-03-27 · superseded documents...

Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement |

Date Approved 13/11/2017

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Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement

Document Type Guideline


Ratifying Body Drugs & Therapeutics Committee

Related Documents Physiotherapy rehabilitation guidelines – Lateral ligament

reconstruction of the ankle

Physiotherapy rehabilitation guidelines – Anterior ankle

arthroscopy

Physiotherapy rehabilitation guidelines – Tibialis posterior

reconstruction

Physiotherapy rehabilitation guidelines – Subtalar and

hindfoot fusion

Physiotherapy rehabilitation guidelines – Hallux valgus

deformity- Scarf Osteotomy

Physiotherapy rehabilitation guidelines – Pes Cavus

correction

Physiotherapy rehabilitation guidelines – ACI of the ankle

Author Joanna Benfield, Foot & Ankle Specialist Physiotherapist,

RNOH

Owner (Executive Director) Lucy Davies

Directorate Operations

Superseded Documents Rehab Guidelines for Ankle Replacement (2014)

Subject Clinical, Clinical Units, Communication, Inpatient &

Outpatient Services

Review Date 13/11/2022

Keywords and Phrases Rehabilitation, ankle surgery, OA, osteoarthritis, total

ankle replacement, physiotherapy, complications,

outcomes, milestones, function, treatment, exercise, pain

relief, restrictions, limitations, sport, fitness, postural

awareness, pain education, mobility, goals, precautions,



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compliance, knee pain, leg pain, foot pain

Consultation Group/Approving Bodies/Subject Matter Expert

Members of Foot and Ankle Unit Team (4 consultants, &

Clinical Nurse Specialist)

Members of Outpatient Musculoskeletal Physiotherapy

Team (Band 5, 6, 7 and 8a staff members at Stanmore

and Bolsover Street)

Members of Inpatient Orthopaedic Physiotherapy Team

(Band 7 and 8a staff members)

Readership All staff (inc. Clinical)



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Table of Contents

1. Equality Impact Assessment (EIA) Disclosure Statement ...................................... 4

2. Privacy Impact Assessment (PIA) Disclosure Statement ....................................... 5

3. Introduction and aims ............................................................................................. 6

4. Definitions .............................................................................................................. 6

5. Duties and Responsibilities .................................................................................... 6

6. Body of Policy ........................................................................................................ 6

7. Monitoring and the effectiveness of this policy ....................................................... 7

Glossary of Terms ............................................................................... 18 Appendix 1:

Other linked trust policies and guidelines ............................................ 19 Appendix 2:

Extra sources of information and support ............................................ 20 Appendix 3:



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1. Equality Impact Assessment (EIA) Disclosure Statement

Equality Impact Assessment (EIA) Disclosure Statement

This policy was assessed on the 10th day of March 2017 for its impact on equality.

The assessment determined that the policy will not have a significant negative impact

on equality in relation to each of the protected staff/patient groups below:

i.) Age; ii.) Sex (Male and Female); iii.) Disability (Learning Difficulties/Physical or

Sensory Disability); iv.) Race or Ethnicity; v.) Religion and Belief; vi) Sexual

Orientation (gay, lesbian or heterosexual); vii) Pregnancy and Maternity; vii) Gender

Reassignment (The process of transitioning from one gender to another);

viii) Marriage and Civil Partnership.



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1. Privacy Impact Assessment (PIA) Disclosure Statement

Privacy Impact Assessment (PIA) Disclosure Statement

This policy was assessed on the 10th day of March 2017 for its impact on privacy.

The assessment determined that the policy will not have a significant negative impact

on privacy of members of staff/patients.



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2. Introduction and aims

Please note that this is advisory information only. Individual / your experiences may

differ from those described. All exercises must be demonstrated to a patient by a fully

qualified physiotherapist. We cannot be held liable for the outcome of you undertaking

any of the exercises / interventions shown here independently of direct supervision

from the RNOH.

As a specialist orthopaedic hospital we recognise that our broad and often complex

patient group needs an individualised rehabilitation approach. Our emphasis is on

patient-specific rehabilitation, which encourages recognition of those patients who

may progress slower than others. These rehabilitation guidelines are therefore

‘milestone driven’ and designed to provide an equitable rehabilitation service to all our

patients. They will also limit unnecessary visits to the outpatient clinic at RNOHT by

helping the patient and therapist to identify when specialist review is required.

3. Definitions

See section 6.

4. Duties and Responsibilities

Not applicable for this guideline.

5. Body of Policy



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Indications for Surgery

Pain and decreased function not responsive to conservative treatment. Causes include post-traumatic osteoarthritis, primary osteoarthritis, Rheumatoid Arthritis, systemic joint disease, idiopathic arthritis.

Possible Complications

Infection

Wound healing problems

Persistent swelling

Loosening / subsidence / migration of components

Impingement

Bleeding

Nerve damage

Deep Vein Thrombosis

Pulmonary Embolism

Non-union

Persistent / recurrent pain

Fracture of bone / components

Tendon injuries

Contractures

Complex Regional Pain Syndrome

If failure, may require subsequent revision ankle replacement or conversion to fusion or to below knee amputation

Surgical Techniques

The commonly used Total Ankle Replacement (TAR) prostheses at RNOH are the

BOX Ankle Replacement (MatOrtho) or the Infinity Ankle System (Wright Medical

Technology). The BOX is a three component, cementless, unconstrained, mobile-

bearing prosthesis. The Inifinity is a two component, cementless, semiconstrained

prosthesis.

The surgery may also include one or more of the following, depending on the clinical

presentation of the patient:

Tendo-Achilles lengthening

Calcaneal osteotomy

Tendon transfers

Ligament reconstruction

Other osteotomies or joint fusions



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Clinical Trials

A multi-centre randomised clinical trial is being led by the Royal National Orthopaedic

Hospital comparing ankle replacement against ankle fusion (TARVA) – further details

can be found at http://anklearthritis.co.uk

Expected Outcome

Improved function / mobility

Improved pain relief

Increased walking tolerance with decreased walking aid requirement

Return to no-impact / low-impact sports may be possible but strenuous sport inadvisable

Maintenance or improvement in range of movement (if the ankle was very stiff before surgery, range of motion may not be improved due to soft tissue constraints)

Full recovery may take up to twelve months

Pre-operatively

The patient will be seen pre-operatively where able and with consent, the following will be assessed or discussed:

Current functional levels

General Health

Social history and home set up

Ability to mobilise, plus the provision of appropriate walking aids to be used post operatively

Post-operative expectations

Post-operative management explained, including the provision of bed exercises.

Post-operatively

Always check the operation notes, and the post-operative instructions. Discuss any

deviation from routine guidelines with the team concerned. This is very important if the

patient has had any other techniques as well as the Total Ankle Replacement as

weight-bearing status and progressions may be different as well as other restrictions.

Please ensure you follow the correct protocol from the relevant consultant the patient

is under as there may be differences.

http://anklearthritis.co.uk/



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INITIAL REHABILITATION PHASE: 0-6 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, elevation

Exercises to strengthen core

Restrictions:

Ensure that weight bearing restrictions are adhered to: o Total Ankle Replacement (TAR) o Mr Singh / Mr Cullen / Mr Welck:

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 6 weeks. Into Aircast™ Boot. FWB.

o Mr Goldberg: Non weight bearing (NWB) for 2 weeks in Back Slab or Aircast™

Boot. Below Knee Plaster of Paris (BK POP) at 2 weeks or continue

with Aircast™ Boot. Progress to Full Weight Bearing (FWB) in POP / Aircast™ Boot.

POP removed at 6 weeks and into Aircast™ Boot or continue with Aircast™ Boot. FWB.

o 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 Backslab / POP / Aircast Boot

Pain-relief: Ensure adequate analgesia

Elevation

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



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On discharge from ward:

Independent and safe mobilising, including stairs if appropriate

Independent with transfers

Independent and safe with home exercise programme / monitoring

Milestones to progress to next phase:

Out of POP. Team to refer to physiotherapy at 6 weeks from clinic.

Progression from NWB to FWB phase. Team to refer to physiotherapy if required to review safety of mobility / use of walking aids

Adequate analgesia



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RECOVERY REHABILITATION PHASE: 6 weeks- 12 weeks

Goals:

Mr Singh / Mr Cullen / Mr Welck:

Once advised by team bone healing is sufficient to come out of Aircast Boot: o To be independently mobile out of Aircast™ boot with walking aid as

appropriate o To achieve optimal range of movement (as described in operation note)

To address core stability and strength and control throughout kinetic chain within any restrictions

Mr Goldberg:

To remain independently and safely mobile in Aircast Boot with appropriate walking aid

To address core stability and strength and control throughout kinetic chain within any restrictions

Restrictions:

Weight Bearing and POP / Aircast Boot progressions are dependent upon the bone healing of the individual patient. The surgical team will advise when to progress weight bearing and when to start to wean from / work out of Aircast Boot.

Ensure that any weight bearing restrictions are adhered to

Ensure that any post-operative instructions and advice from the team are adhered to as to when to progress from Aircast Boot and when it is ok to start work around the foot and ankle and out of the Aircast Boot.


FWB in Aircast Boot from 6 weeks until advised by consultant can wean from this

Mr Goldberg:

FWB in Aircast Boot until 12 weeks or until advised by consultant. Into PUSH ankle brace at 12 weeks (FWB) or when advised by consultant

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 appropriate once reaches FWB stage.

Gait Re-education

Wean out of Aircast™ boot once advised to do so and into normal footwear.

Exercises: o Core stability work



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o Review lower limb biomechanics and kinetic chain within any restrictions. Address issues as appropriate.

o Range Of Movement (ROM) exercises of foot and ankle only when team advises can start these – Passive (PROM) / Active assisted (AAROM) / Active ROM (AROM)

o ROM exercises of other joints throughout kinetic chain as appropriate o Strengthening exercises of foot and ankle only when team advises can

start these o Strengthening exercises of other muscles / muscle groups throughout

kinetic chain as appropriate o Balance / proprioception work once appropriate o Stretches of tight structures as appropriate (e.g. Achilles Tendon) once

team advises can start to work on these

Swelling Management

Manual Therapy: only when team advises can start to work out of boot / around foot and ankle:

o Soft tissue techniques as appropriate o Joint mobilisations as appropriate

Monitor sensation, swelling, colour, temperature, circulation

Orthotics if required via surgical team

Hydrotherapy if appropriate within restrictions once team advises can start this

Pacing advice as appropriate


Independently mobilising in Aircast™ boot +/- walking aid as appropriate

Independent and safe with monitoring / self-management

Adequate analgesia

Failure to meet milestones:

Refer back to team / Discuss with team

Continue with outpatient physiotherapy if still progressing



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INTERMEDIATE REHABILITATION PHASE: 12 weeks – 6 months

Goals:

Once advised by team bone healing is sufficient to come out of Aircast Boot: o To be independently mobile out of Aircast™ boot with ankle brace /

walking aid as appropriate o To achieve optimal range of movement (as described in operation note) o To optimise normal ankle and foot movement & restore gait o To be wearing normal footwear o Grade 4 or 5 muscle strength around ankle

Optimise core stability and strength and control throughout kinetic chain within any restrictions

Restrictions:

Weight Bearing and POP / Aircast Boot progressions are dependent upon the bone healing of the individual patient. The surgical team will advise when to progress weight bearing and when to start to wean from / work out of Aircast Boot.

Ensure that any weight bearing restrictions are adhered to

Ensure that any post-operative instructions and advice from the team are adhered to as to when to progress from Aircast Boot and when it is ok to start work around the foot and ankle and out of the Aircast Boot.

Mr Goldberg:

Out of Aircast™ boot and into PUSH ankle brace FWB at 12 weeks, or when advised by consultant


Team will advise when to wean from Aircast boot. No ankle brace

Treatment:

Further progression of the above treatment:

Pain relief

Advice / Education

Posture advice / education

Mobility: ensure safely and independently mobile adhering to restrictions. Progress off walking aids as appropriate.

Gait Re-education

Wean out of Aircast™ boot once advised to do so and into normal footwear. If patient unable to get into normal footwear advise to try Crocs™ or other wide fitting shoes.

Exercises: o Core stability work o Review lower limb biomechanics and kinetic chain within any

restrictions. Address issues as appropriate.



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o Range Of Movement (ROM) exercises of foot and ankle only when team advises can start these – PROM / AAROM / AROM

o ROM exercises of other joints throughout kinetic chain as appropriate o Strengthening exercises of foot and ankle only when team advises can

start these o Strengthening exercises of other muscles / muscle groups throughout

kinetic chain as appropriate o Balance / proprioception work once appropriate o Stretches of tight structures as appropriate (e.g. Achilles Tendon) once

team advises can start to work on these

Swelling Management

Manual Therapy: only when team advises can start to work out of boot / around foot and ankle:

o Soft tissue techniques as appropriate o Joint mobilisations as appropriate

Monitor sensation, swelling, colour, temperature, circulation

Orthotics if required via surgical team

Hydrotherapy if appropriate within restrictions once team advises can start this

Pacing advice as appropriate


Full range of movement

Independently mobilising out of Aircast™ boot with ankle brace / walking aid as appropriate

Wearing normal footwear

Neutral foot position when weight bearing / mobilising

Grade 4 or 5 muscle strength around ankle

Failure to meet milestones:

Refer back to team / Discuss with team

Continue with outpatient physiotherapy if still progressing



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FINAL REHABILITATION PHASE: 6 months – 1 year

Goals:

Independently mobile unaided / with walking aid if required long term

Return to gentle no-impact / low-impact sports

Establish long term maintenance programme

Grade 5 muscle strength around ankle

Treatment:

Mobility / function: Progression of mobility and function, increasing dynamic control with specific training to functional goals

Gait Re-education

Exercises: o Progression of exercises including range of movement, strengthening,

transfer activation, balance and proprioception, core stability

Swelling Management

Manual Therapy: o Soft tissue techniques as appropriate o Joint mobilisations as appropriate

Pacing advice

Milestones for discharge:

Independently mobile unaided / with walking aid if required long term

Appropriate patient-specific functional goals achieved, eg. return to low/no impact sport

Independent with long term maintenance programme

Grade 5 muscle strength around ankle



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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

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



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6. Monitoring and the effectiveness of this policy

This guideline will be reviewed 5 yearly.



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Glossary of Terms Appendix 1:

Not applicable.



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Other linked trust policies and guidelines Appendix 2:

Physiotherapy rehabilitation guidelines – Lateral ligament reconstruction of the ankle

Physiotherapy rehabilitation guidelines – Anterior ankle arthroscopy

Physiotherapy rehabilitation guidelines – Tibialis posterior reconstruction

Physiotherapy rehabilitation guidelines – Subtalar and hindfoot fusion

Physiotherapy rehabilitation guidelines – Hallux valgus deformity- Scarf Osteotomy

Physiotherapy rehabilitation guidelines – Pes Cavus correction

Physiotherapy rehabilitation guidelines – ACI of the ankle

All other RNOH Physiotherapy Rehabilitation Orthopaedic Post-operative Guidelines

(Knee, Sarcoma Unit, Peripheral Nerve Injuries, Shoulder & Upper Limb, Spinal

Surgery Unit)



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Extra sources of information and support Appendix 3:

Summary of evidence for physiotherapy guidelines

A comprehensive literature search was carried out to identify research relating to total

ankle replacement and subsequent rehabilitation. After reviewing the articles and

information, the physiotherapy guidelines were produced on the best available

evidence.

Assal, M., Ahmad, A., Lacraz, A., Courvoisier, D., Stern, R. and Crevoisier, X. (2011). Step activity monitoring to assess ambulation before and after total ankle arthroplasty. Foot and Ankle Surgery, 17(3), pp.136-139.

Bloch, B., Srinivasan, S. and Mangwani, J. (2015). Current Concepts in the Management of Ankle Osteoarthritis: A Systematic Review. The Journal of Foot and Ankle Surgery, 54(5), pp.932-939.

Brigido, S., Mulhern, J., Wobst, G. and Protzman, N. (2015). Preoperative and Postoperative Range of Motion: A Retrospective Comparison of Two Total Ankle Replacement Systems. The Journal of Foot and Ankle Surgery, 54(5), pp.809-814.

Buechel et al (2004) Twenty-year evaluation of cementless mobile-bearing Total Ankle Replacements. Clinical Orthopaedics and Related Research 424, 19-26

Casartelli, N., Item-Glatthorn, J., Bizzini, M., Leunig, M. and Maffiuletti, N. (2013). Differences in gait characteristics between total hip, knee, and ankle arthroplasty patients: a six-month postoperative comparison. BMC Musculoskeletal Disorders, 14(1).

Chopra, S., Rouhani, H., Assal, M., Aminian, K. and Crevoisier, X. (2013). Outcome of unilateral ankle arthrodesis and total ankle replacement in terms of bilateral gait mechanics. Journal of Orthopaedic Research, 32(3), pp.377-384.

Coetzee, J. and Castro, M. (2004). Accurate Measurement of Ankle Range of Motion after Total Ankle Arthroplasty. Clinical Orthopaedics and Related Research, 424, pp.27-31.

Coetzee, J., Petersen, D. and Stone, R. (2016). Comparison of Three Total Ankle Replacement Systems Done at a Single Facility. Foot & Ankle Specialist, 10(1), pp.20-25.

Conti S & Wong YS (2001) Complications of Total Ankle Replacement. Clinical Orthopaedics and Related Research 391, 105-114

Conti, S., Dazen, D., Stewart, G., Green, A., Martin, R., Kuxhaus, L. and Miller, M. (2008). Proprioception after Total Ankle Arthroplasty. Foot & Ankle International, 29(11), pp.1069-1073.

Flavin, R., Coleman, S., Tenenbaum, S. and Brodsky, J. (2013). Comparison of Gait After Total Ankle Arthroplasty and Ankle Arthrodesis. Foot & Ankle International, 34(10), pp.1340-1348.



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Goldberg, A., Zaidi, R., Thomson, C., Doré, C., Skene, S., Cro, S., Round, J., Molloy, A., Davies, M., Karski, M., Kim, L. and Cooke, P. (2016). Total ankle replacement versus arthrodesis (TARVA): protocol for a multicentre randomised controlled trial: Table 1. BMJ Open, 6(9), p.e012716.

Goldberg A. (2016). Total ankle joint replacement. Drug and Therapeutics Bulletin, 54(2), pp.22-24.

Griesberg J & Hansen S (2003) Total Ankle Arthroplasty in the advanced flatfoot. Techniques in Foot and Ankle Surgery 2, (3): 152-161

Gross, C., Hamid, K., Green, C., Easley, M., DeOrio, J. and Nunley, J. (2016). Operative Wound Complications Following Total Ankle Arthroplasty. Foot & Ankle International, 38(4), pp.360-366.

Gross, C., Lampley, A., Green, C., DeOrio, J., Easley, M., Adams, S. and Nunley, J. (2015). The Effect of Obesity on Functional Outcomes and Complications in Total Ankle Arthroplasty. Foot & Ankle International, 37(2), pp.137-141.

Hintermann, B., Knupp, M., Zwicky, L. and Barg, A. (2012). Total Ankle Replacement for Treatment of End-Stage Osteoarthritis in Elderly Patients. Journal of Aging Research, 2012, pp.1-8.

Jones, C., Rush, S., Berlet, G., Regina, J., Penner, M., Brigido, S., Smith, W. and Brigido, S. (2015). Understanding the Postoperative Course and Rehabilitation Protocol for Total Ankle Arthroplasty. Foot & Ankle Specialist, 8(3), pp.203-208.

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

Lawton, C., Butler, B., Dekker, R., Prescott, A. and Kadakia, A. (2017). Total ankle arthroplasty versus ankle arthrodesis—a comparison of outcomes over the last decade. Journal of Orthopaedic Surgery and Research, 12(1).

Lee, K., Park, Y., Song, E., Yoon, T. and Jung, K. (2010). Static and Dynamic Postural Balance After Successful Mobile-Bearing Total Ankle Arthroplasty. Archives of Physical Medicine and Rehabilitation, 91(4), pp.519-522.

Macaulay, A., VanValkenburg, S. and DiGiovanni, C. (2015). Sport and activity restrictions following total ankle replacement: A survey of orthopaedic foot and ankle specialists. Foot and Ankle Surgery, 21(4), pp.260-265.

Martin, R., Stewart, G. and Conti, S. (2007). Posttraumatic Ankle Arthritis: An Update on Conservative and Surgical Management. Journal of Orthopaedic & Sports Physical Therapy, 37(5), pp.253-259.

Pagenstert, G., Horisberger, M., Leumann, A., Wiewiorski, M., Hintermann, B. and Valderrabano, V. (2011). Distinctive Pain Course during First Year after



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Total Ankle Arthroplasty: A Prospective, Observational Study. Foot & Ankle International, 32(2), pp.113-119.

Prusinowska, A., Krogulec, Z., Turski, P., Przepiórski, E., Małdyk, P. and Księżopolska-Orłowska, K. (2015). Total ankle replacement – surgical treatment and rehabilitation. Reumatologia/Rheumatology, 1, pp.34-39.

Rodrigues-Pinto, R., Muras, J., Martín Oliva, X. and Amado, P. (2013). Functional results and complication analysis after total ankle replacement. Foot and Ankle Surgery, 19(4), pp.222-228.

Roselló Añón, A., Martinez Garrido, I., Cervera Deval, J., Herrero Mediavilla, D., Sánchez González, M. and Vicent Carsí, V. (2014). Total ankle replacement in patients with end-stage ankle osteoarthritis: Clinical results and kinetic gait analysis. Foot and Ankle Surgery, 20(3), pp.195-200.

Schipper, O., Denduluri, S., Zhou, Y. and Haddad, S. (2015). Effect of Obesity on Total Ankle Arthroplasty Outcomes. Foot & Ankle International, 37(1), pp.1-7.

Schuh, R., Hofstaetter, J., Krismer, M., Bevoni, R., Windhager, R. and Trnka, H. (2011). Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome. International Orthopaedics, 36(6), pp.1207-1214.

Spirt et al (2004) Complications and failure after Total Ankle Arthroplasty. The Journal of Bone and Joint Surgery 86-A, (6): 1172-1178

Stavrakis, A. and SooHoo, N. (2016). Trends in Complication Rates Following Ankle Arthrodesis and Total Ankle Replacement. The Journal of Bone and Joint Surgery, 98(17), pp.1453-1458.

Tenenbaum, S., Bariteau, J., Coleman, S. and Brodsky, J. (2017). Functional and clinical outcomes of total ankle arthroplasty in elderly compared to younger patients. Foot and Ankle Surgery, 23(2), pp.102-107.

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

Valderrabano, V., Nigg, B., Tscharner, V., Frank, C. and Hintermann, B. (2007). J. Leonard Goldner Award 2006: Total Ankle Replacement in Ankle Osteoarthritis: An Analysis of Muscle Rehabilitation. Foot & Ankle International, 28(2), pp.281-291.

Valderrabano, V., Nigg, B., von Tscharner, V., Stefanyshyn, D., Goepfert, B. and Hintermann, B. (2007). Gait analysis in ankle osteoarthritis and total ankle replacement. Clinical Biomechanics, 22(8), pp.894-904.

Valderrabano, V., Tscharner, V., Nigg, B., Göpfert, B., Hintermann, B., Dick, W. and Frank, C. (2006). Muscle atrophy in ankle osteoarthritis and its rehabilitation with total ankle arthroplasty. Journal of Biomechanics, 39, p.S199.



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Zaidi et al (2013). How do patients with end-stage ankle arthritis decide between two surgical treatments? A qualitative study. BMJ Open, 3 (7).

Zaidi et al (2013). The outcome of total ankle replacement: a systematic review and meta-analysis. The Bone & Joint Journal, 95-B (11), 1500-1507



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