Guideline. Drugs & Therapeutics Committee

Transcription

1 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Document Type Date Approved Ratifying Body Related Documents Guideline 13/11/2017 Drugs & Therapeutics Committee 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Cavus correction Physiotherapy rehabilitation guidelines ACI of the ankle Author Owner (Executive Director) Directorate Superseded Documents Subject Joanna Benfield, Foot & Ankle Specialist Physiotherapist, RNOH Lucy Davies Operations Rehab Guidelines for Ankle Replacement (2014) Clinical, Clinical Units, Communication, Inpatient & Outpatient Services Review Date Keywords and Phrases 13/11/2022 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, Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 1

2 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) Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 2

3 Table of Contents 1. Equality Impact Assessment (EIA) Disclosure Statement Privacy Impact Assessment (PIA) Disclosure Statement Introduction and aims Definitions Duties and Responsibilities Body of Policy Monitoring and the effectiveness of this policy... 7 Appendix 1: Appendix 2: Appendix 3: Glossary of Terms Other linked trust policies and guidelines Extra sources of information and support Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 3

4 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. Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 4

5 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. Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 5

6 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 Duties and Responsibilities Not applicable for this guideline. 5. Body of Policy Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 6

7 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, mobilebearing 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 7

8 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 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. Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 8

9 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 postoperatively, 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 9

10 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 10

11 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. Mr Singh / Mr Cullen / Mr Welck: 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 11

12 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 Milestones to progress to next phase: 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 12

13 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 Mr Singh / Mr Cullen / Mr Welck: 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. Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 13

14 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 Milestones to progress to next phase: 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 14

15 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 15

16 FAILURE TO PROGRESS If a patient is failing to progress, then consider the following: POSSIBLE PROBLEM Swelling Pain Breakdown of Wound e.g inflammation, bleeding, infection Numbness / altered sensation ACTION 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 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 Refer to surgical team or to GP 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 16

17 6. Monitoring and the effectiveness of this policy This guideline will be reviewed 5 yearly. Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 17

18 Appendix 1: Glossary of Terms Not applicable. Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 18

19 Appendix 2: Other linked trust policies and guidelines 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) Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 19

20 Appendix 3: Extra sources of information and support 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 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 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 Buechel et al (2004) Twenty-year evaluation of cementless mobile-bearing Total Ankle Replacements. Clinical Orthopaedics and Related Research 424, 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 Coetzee, J. and Castro, M. (2004). Accurate Measurement of Ankle Range of Motion after Total Ankle Arthroplasty. Clinical Orthopaedics and Related Research, 424, pp 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 Conti S & Wong YS (2001) Complications of Total Ankle Replacement. Clinical Orthopaedics and Related Research 391, 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 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 Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 20

21 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.e Goldberg A. (2016). Total ankle joint replacement. Drug and Therapeutics Bulletin, 54(2), pp Griesberg J & Hansen S (2003) Total Ankle Arthroplasty in the advanced flatfoot. Techniques in Foot and Ankle Surgery 2, (3): 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 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 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 Kobayashi et al (2004) Ankle arthroplasties generate wear particles similar to knee arthroplasties. Clinical Orthopaedics and Related Research 424, Kotnis et al (2006) The management of failed ankle replacement. The Journal of Bone and Joint Surgery 88-B, (8): Lalonde K & Conti S (2006) Ankle arthritis: current status of ankle replacement versus fusion and other treatment modalities Current Opinion in Orthopaedics 17, (2): 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 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 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 Pagenstert, G., Horisberger, M., Leumann, A., Wiewiorski, M., Hintermann, B. and Valderrabano, V. (2011). Distinctive Pain Course during First Year after Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 21

22 Total Ankle Arthroplasty: A Prospective, Observational Study. Foot & Ankle International, 32(2), pp 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 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 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 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 Spirt et al (2004) Complications and failure after Total Ankle Arthroplasty. The Journal of Bone and Joint Surgery 86-A, (6): 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 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 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): 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): 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 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 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. Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 22

23 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), Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 23

24 This policy is available on request in large print and alternative languages. It is a manager s responsibility to ensure employees are aware of these options. * The following policies must be sent for review to the Local Counter Fraud Specialist: Fraud and Bribery Standard Financial Instructions Declaration of Interests Gifts and Hospitality Whistleblowing Disciplinary IT Anti-Money Laundering Managing Sickness Absence Secondary Employment Expenses Overpayment Financial Redress TOIL (Time off in Lieu) Code of Conduct/Standards of Business Conduct Data Protection Lone Worker Patient Transport Commercial Sponsorship Overseas Visitors Disclosure Physiotherapy Rehabilitation Guidelines for patients undergoing Total Ankle Replacement Page 24