Enhanced recovery (fast-track surgery) after total ankle replacement: The state of the art

Total ankle replacement: Implant Manufacturer's guidelines for post-operative rehabilitation: A review of literature

Introduction

Total ankle replacements (TARs) is emerging as a successful alternate treatment option to arthrodesis for surgical treatment of end stage ankle arthritis. This has led to manufacturers producing a selection of implants. There is wide variations in post-operative rehab protocols being adopted for treatment following TAR surgery. This depends on choice of implants and manufacturer recommendations too. Following the author's investigation, a lack of standardisation between manufacturer post-operative protocols was identified. The aim of this project was to analyse similarities and differences in guidelines for: choice of immobilisation, weight-bearing (WB) status, of range of movement (ROM) exercises and Physiotherapy.

Method

Current commonly used TAR implants in the UK were identified using National Joint Registry's 2020 Annual Report. Additional implants were included after accessing data regarding the TAR market. Individual company websites were researched for information available on public domain for post op management guidelines and the results were summarised.

Results

Only 7 implants were reviewed as 6 companies either did not provide post-operative protocols or recommended a surgeon guided rehabilitation process. Different manufacturers allow partial WB by week 2, week 3 and week 7. One protocol suggested full WB from week 4 whereas two others suggested it from week 6. Choices of immobilisation varied as one company suggested casting alone for 6 weeks, two suggest casting followed by a period in a boot, one suggests splinting and a boot and one uses all 3 types of immobilisations. ROM exercises were mentioned by three manufacturers and were encouraged from week 2 and 3. Physiotherapy was mentioned in four protocols, two of which suggest intervention from week 6, one from week 7 and the other mentions the importance of therapy rather than specific timelines.

Conclusion

There are differences between post op TAR guidelines from the implant manufacturers regarding the categories analysed. The variation in the data collected makes it challenging to suggest a singular protocol to be followed after TAR surgery.

Home and Outpatient Physical Therapy Utilization Following Total Ankle Replacement

Background

Physical therapy (PT) following total ankle replacement (TAR) is often considered, but guidelines for its use are not standardized. Although patient factors may dictate recommendations, this retrospective cohort study aims to characterize baseline utilization practices to set the stage for establishing generalizable recommendations.

Methods

TAR patients were identified from the 2010-2019 M91 Ortho PearlDiver data set based on administrative coding. Patient factors were extracted, including age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients' surgery was performed (Midwest, Northeast, South, West), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of home or outpatient PT utilization in the 90 days following TAR were identified. Inpatient PT was not captured. Univariate and multivariate logistic regression analyses allowed identification of predictive factors for PT utilization.

Results

Of 5412 TAR patients identified, postoperative PT services were used by 2453 (45.3%). Most PT was outpatient (38.3% of the study population) compared to home (4.1% of the study population). Weekly utilization of PT was greatest in the first week following surgery (17.7% of PT visits) and thereafter followed a roughly bell-shaped curve, with utilization greatest at 7 weeks following surgery (14.9% of PT visits).Independent predictors of PT utilization following TAR included having surgery performed in the Midwest (relative to the South, OR 1.37, P < .0001), Northeast (OR 1.20, P = .0217), or West (OR 1.26, P < .0021) and having commercial (relative to Medicare, OR 1.87, P < .0001) or Medicaid insurance (OR 1.46, P = .0239).

Conclusion

Of 5412 TAR patients, 42.5% used PT within 90 days of surgery. PT utilization was highest in the first and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAR, PT care pathways may be better defined.

Level of Evidence

Level III, retrospective cohort study.