Postoperative Physical Therapy

Physical therapy may include patient education and self-management strategies, progressive therapeutic exercise (strength, power, endurance, and task-specific functional training), neuromuscular and motor control interventions (balance, proprioception, and movement coordination training), manual therapy (joint mobilization, manipulation, and soft tissue techniques); gait retraining, and development and progression of a home exercise program. While no evidence met our full inclusion criteria for this question, Uselli et.al. provided relevant information on fast-track protocols, which may be of use to clinicians. Enhanced recovery after TAR surgery programs, also called fast-track protocols, in patients with ankle osteoarthritis, is also a viable option. There is no convincing evidence to suggest that immediate postoperative weight bearing without a cast is not a viable option in well selected patients.

Usuelli et al developed a selection score for proper patient selection with a low risk for perioperative complications who were appropriate for a fast-track protocol which included cast removal on post op day 1 and immediate protected weightbearing (Fast-Track Protocol) compared to the standard post op protocol of non-weight bearing and application of cast for a period of three weeks prior to weight bearing activity.i Stratification was based on the presence or absence of eight validated predictive variables (including body mass index >30, the state of anxiety or depression, functional preoperative status, fixed ankle equinus, the coronal malalignment, operative time, the surgical accessory procedures, and the bone quality) that may affect the outcome of TAR. Using this selection criteria, no significant differences were found in both clinical and radiologic date between the “standard protocol” versus the “Fast-track protocol” patients at different time points after surgery.

Benefits & Harms: 

Potential Benefits 

• Earlier mobilization and weightbearing may accelerate functional recovery and reduce deconditioning.

• Early removal of the cast could allow for advanced cryotherapy (Game Ready) and low-intensity electromagnetic field (Limfa) therapy with a potential benefit on postoperative edema and inflammation.ii
• Potential for improved patient satisfaction and faster return to activities for appropriately selected patients.

Potential Harm / Risks 

• If misapplied to patients who do not meet the strict selection criteria (poor bone quality, high BMI, significant deformity, psychiatric comorbidity, prolonged surgery or multiple accessory procedures), there may be increased risk of wound problems, implant early loosening, or other complications (not proven in the paper but a plausible risk). Usuelli’s study avoided such high-risk patients by selection.

• The results of the case-controlled study by Usuelli et al are not generalizable. Application of this fast-track protocol to most patients who present for TAR for OA will lead to significant complications because a lot of these patients have associated severe comorbidities which will preclude them based on the strict criteria presented by Usuelli et al.
• Evidence base is limited (nonrandomized; smaller fast-track group) so rare adverse outcomes or late implant survivorship differences may not yet be apparent.

Outcome Importance: 

TAR for OA is steadily gaining popularity with significant advancement in implant technology and improved perioperative care of these patient populations. Usuelli et al. reported comparable short-term clinical and radiographic outcomes and no increase in complications using their Fast-Track protocol, but long-term implant survivorship differences remain unknown. Demonstrating enhanced recovery protocols for rehabilitation for TAR which have been used effectively in the hip and knee patients will greatly enhance the delivery of care to this fast-evolving patient population. With future randomized controlled studies, this protocol can be extended to many high-volume practices and demanding patients without the fear of increased complications.

Cost Effectiveness/Resource Utilization: 

Direct evidence in TAR fast-track is not provided in the Usuelli paper. However, ERAS / fast-track programs in hip and knee arthroplasty have consistently shown reduced length of stay and lower early resource utilization and sometimes reduced complications — suggesting likely cost savings if similar reductions occur for TAR.

Acceptability: 

Likely acceptable to many patients (quicker mobilization) and to multidisciplinary teams familiar with ERAS for large-joint arthroplasty, but acceptability depends on clear patient selection, preop counseling, and local practice cultures. Some surgeons may be cautious until further TAR-specific evidence accumulates. 

Feasibility: 

Feasible in centers that have: 

• Multidisciplinary ERAS infrastructure (anesthesia protocols for multimodal analgesia / nerve blocks, perioperative nursing, physiotherapy for immediate mobilization).
• Surgeon experience with TAR and ability to limit operative time and accessory procedures in selected patients.  
• Pathways for early follow-up, wound checks, and clear patient education materials. In less-resourced settings or with less TAR experience, implementation should be cautious and limited to well-selected patients.

 Future Research: 

• Randomized controlled trials comparing fast-track vs standard protocols in TAR with stratification by the selection score used by Usuelli et al. (or validation of that score).
• Multicenter prospective cohorts to increase sample size, test generalizability across different implants/approaches and surgical volumes.
• Long-term follow-up (≥5–10 years) on implant survival and late complications to ensure early mobilization does not adversely affect longevity.
• Cost-effectiveness analyses specifically in TAR (hospital costs, readmissions, rehabilitation costs).
• Patient-reported outcome studies (PROMs, return to activity, satisfaction) and qualitative work on acceptability.
• Validation and refinement of the 8-variable selection scoring system in independent datasets.

Additional Citations Not Meeting Inclusion Criteria

1. Usuelli FG, Paoli T, Indino C, Maccario C, Di Silvestri CA. Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients. Foot Ankle Int. 2023;44(2):148-158. doi:10.1177/10711007221140841  
2. Brigido SA, Wobst GM, Galli MM, Bleazey ST, Protzman NM. Evaluating component migration after modular stem fixed-bearing total ankle replacement. J Foot Ankle Surg. 2015;54(3):326-331