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Total ankle arthroplasty (TAA) is a surgical procedure designed to replace a damaged ankle joint with prosthetic components, aiming to relieve pain and restore function in patients with severe ankle arthritis. This procedure involves precise bone cuts and implant placements, requiring careful attention to soft tissue balancing and implant alignment to ensure optimal outcomes. TAA offers an alternative to ankle fusion, preserving joint mobility and providing significant pain relief, making it a preferred option for patients seeking to maintain an active lifestyle. Clinicians participating in this course gain comprehensive knowledge and skills related to the latest techniques in TAA, including preoperative assessment, surgical procedures, and postoperative care. They learn strategies for minimizing complications and enhancing patient-centered care by improving interprofessional communication and coordination. The course emphasizes the importance of a multidisciplinary approach, highlighting the roles of various healthcare professionals in delivering high-quality care in TAA. Objectives: Identify the indications and contraindications for total ankle arthroplasty in patients with severe ankle arthritis. Differentiate between total ankle arthroplasty and ankle fusion, understanding the benefits and limitations of each procedure. Apply evidence-based protocols for preoperative assessment and postoperative care to optimize patient recovery and outcomes for patients undergoing total ankle arthroplasty. Communicate the importance of collaboration within the interprofessional healthcare team to foster a comprehensive understanding of the total ankle arthroplasty procedure on a level that allows for improved care for patients undergoing this procedure. Access free multiple choice questions on this topic.

Total ankle arthroplasty (TAA), or total ankle replacement, is a surgical procedure involving replacing an arthritic ankle joint with an artificial implant. TAA aims to relieve pain, improve function, and maintain or restore mobility in individuals with end-stage ankle arthritis. While ankle arthrodesis has historically been the mainstay treatment for end-stage ankle arthritis, studies have shown that the rates of TAA have been steadily increasing.[1][2] TAA was developed in the 1970s as a concerted effort to preserve ankle mobility in treating end-stage ankle osteoarthritis.[3] Before the development of TAA, the mainstay treatment with arthrodesis greatly limited joint mobility.[4] Retaining the motion of the ankle joint through arthroplasty, as opposed to arthrodesis, allows for the preservation of other joints by normalizing gait and, thus, the joint reactive forces throughout the lower extremity.

Wound Healing In TAA, postoperative wound complications can range from superficial to deep. Superficial dehiscence, stitch abscesses, cellulitis, and delayed wound healing are known complications. Ensuring delicate soft tissue handling using tension-reducing closing sutures during the case can decrease wound complications. A compressive dressing has been shown to reduce wound complications.[12][13] Prosthetic Joint Infection The incidence of infection in primary TAA noted in the literature ranges from 0% to 13% and is more frequently seen in revision TAA compared to primary.[14][15] Prosthetic joint infections (PJIs) can be quite severe and require much more aggressive intervention for treatment. Surgical treatment of acute (within 3 weeks postoperative) PJIs is typically managed with debridement, antibiotics, polyethylene insert exchange, and retention of the prosthesis components. Surgical treatment of chronic PJIs in the setting of TAA typically includes an explant of the prosthesis and an aggressive and comprehensive debridement of the ankle and surrounding tissues with the insertion of an antibiotic-impregnated spacer. Supplementing an aggressive antibiotic regimen, either oral or intravenous, for an extended time is typically warranted; they may require serial debridements and complex revision surgery after clearing the infection. As of 2023, there is a lack of diagnostic criteria specific for PJI after TAA, and instead, clinical and laboratory tests frequently used in hip and knee arthroplasty are generally used in the setting of TAA.[16] Intraoperative Fracture Iatrogenic medial malleolus fracture is the most common intraoperative fracture during TAA. They usually occur due to fracture propagation through the narrow bone bridge formed after the tibial cuts are made, especially if the cuts are more medial.[17] Prevention of this potentially detrimental complication is accomplished through prophylactic screw fixation of the medial malleolus with retention of the screws postoperatively versus Kirschner wire fixation until the final implants are in.[18] Other Common Postoperative Complications Other complications include: Sensory deficits or nerve injury [19] Component loosening or subsidence [20] Talus component fails more commonly than the tibial component due to loosening [20] Osteolysis [21] Iatrogenic tendon injury or postoperative tendinitis [21][22]

Iatrogenic medial malleolus fracture is the most common intraoperative fracture during TAA. They usually occur due to fracture propagation through the narrow bone bridge formed after the tibial cuts are made, especially if the cuts are more medial.[17] Prevention of this potentially detrimental complication is accomplished through prophylactic screw fixation of the medial malleolus with retention of the screws postoperatively versus Kirschner wire fixation until the final implants are in.[18] Other Common Postoperative Complications Other complications include: Sensory deficits or nerve injury [19] Component loosening or subsidence [20] Talus component fails more commonly than the tibial component due to loosening [20] Osteolysis [21] Iatrogenic tendon injury or postoperative tendinitis [21][22] Polyethylene displacement or subluxation [20] Gutter impingement [21][22] Arthrofibrosis [21][22]

Healthcare professionals responsible for supervising patients with end-stage ankle arthritis must thoroughly understand the total ankle arthroplasty procedure and the specific indications and contraindications associated with it to correctly identify suitable candidates for this form of treatment. Effective TAA relies heavily on a multidisciplinary team approach to ensure optimal patient outcomes and safety. Foot and ankle surgeons and podiatrists should provide transparent guidance on expectations and postoperative care. Educating patients on weight-bearing ability, pain management, perioperative medical management, wound care, and postoperative rehabilitation is imperative to promote rapid recovery and minimize complications. Perioperative nurses are responsible for coordinating and monitoring patients before, during, and after surgery, promptly informing clinicians of any changes in vital signs or mental status. Additionally, nurses and advanced practitioners should support clinicians in educating patients and their families about expectations regarding the procedure. The hospital pharmacist should assess the patient for potential drug interactions and allergic reactions and assist with proper dosing for pain management during the patient's hospital stay. Postoperative rehabilitation is typically facilitated by a physical therapist, with rehabilitation protocols put in place. Regular follow-up office visits, clinical evaluations, and sequential postoperative imaging are essential to quickly identify and address potential postoperative complications. Interprofessional communication and care coordination are critical for seamless patient-centered care in TAA. Achieving the best outcomes requires a coordinated effort from the entire healthcare team. This integrated approach improves clinical outcomes, enhances patient satisfaction, and improves team performance.