Rehabilitation after total ankle replacement: boot, weight-bearing and physiotherapy

A total ankle replacement resurfaces the worn ankle joint with metal and plastic components. The British Orthopaedic Foot and Ankle Society says the post-operative plan varies between surgeons and hospitals. A review of implant manufacturers' rehabilitation guidance found the same thing: only seven implants had usable public protocols, six companies gave none or deferred to the surgeon, and the published timetables disagreed on immobilisation, weight-bearing, range-of-movement exercises and physiotherapy.

The UK TARVA trial, comparing replacement with ankle fusion, takes the same pragmatic line. Its protocol states that each surgeon's usual post-operative protocol is followed for immobilisation, in plaster or a walking boot, and for weight-bearing status, and that the details are recorded for each patient.

After the operation the leg is commonly in a plaster cast and you mobilise on crutches with little or no weight through the ankle for at least two weeks. The society says the operation is usually done under general anaesthetic with a nerve block to numb the ankle. Stitches are taken out at a two-week review, which in the TARVA protocol is also when the plaster is assessed.

During this period the aim is wound healing, swelling control and avoiding stiffness in neighbouring joints. A UK interview study of people who had ankle replacement or fusion found that some felt they were discharged too soon, with too little information, which is a good reason to ask before you leave the ward how the first weeks will run and who to call.

The society describes the usual pattern after replacement: a weight-bearing walking boot is fitted at about two weeks and patients are allowed to wean out of it from about six weeks, though this depends on whether additional surgery was performed. After ankle fusion, by contrast, patients commonly spend up to six weeks in plaster and then a further six in a boot, which shows how the plans for the two operations differ.

These are general figures from a patient leaflet, and the manufacturer review shows that real protocols range around them. Partial weight-bearing starts at week 2 in some, week 3 in others and week 7 in one, and full weight-bearing is permitted from week 4 in one protocol and week 6 in two others.

Because manufacturers differ, physiotherapy tends to follow the surgeon's plan. The review found physiotherapy mentioned in four of the seven protocols, with one stressing the importance of therapy rather than timings. In practice the goals are to restore ankle movement in the directions the implant allows, rebuild calf and foot strength, retrain balance, and normalise the way you walk.

The interview study found pre-operative physiotherapy was uncommon among its participants, and several relied on family support and self-motivation for exercises. If a pre-operative physiotherapy visit is offered, it may be a chance to learn crutch technique and the exercises before surgery.

The society says ankle replacement can give excellent pain relief and good function, but that the components can wear out or loosen, and that wear is a little more rapid than in hip and knee replacements. That is why regular long-term X-rays are arranged, and why replacement may be less favourable than fusion in younger patients, for example under about 50.

Risks listed in the same leaflet include stiffness or persistent pain, nerve damage, blood clots, infection and the need for further surgery if the replacement is unstable. Being overweight, smoking or having diabetes or other major illness increases the risk of complications and can lengthen recovery.

In a qualitative study from northern England, participants who had ankle replacement or fusion were generally pleased with the surgery, but many felt education from the care team was inadequate, and some had substantial ongoing difficulty walking or chronic pain. One participant who had a fusion described severe heel pain after leaving the boot and worry that the operation had not worked.

Useful questions to ask your own team include how long you will be in plaster and in a boot, when weight-bearing starts, who will supervise physiotherapy, when you can drive, and how often X-rays will be needed.