Sport and Physical Activities in Total Ankle Replacement: Mobile‑ and Fix‑Bearing

Document Type: Original Article


1 IRCCS Istituto Ortopedico Galeazzi, CASCO Department, Foot and Ankle Division

2 IRCCS Istituto Ortopedico Galeazzi, CASCO Department, Foot and Ankle Division, Department of Biomedical Sciences, University of Milan, Milan, Italy,

3 Department of Orthopaedics, Medical University of South California, Charleston, SC, USA


Background: The number of total ankle replacements (TARs) is rapidly increasing in consequence of the availability of new designs
allowing to save the range of motion and to preserve against adjacent joints degeneration. This study aimed to compare participation in sports
12 months after TAR with either mobile‑bearing or fix‑bearing prosthesis. Materials and Methods: One hundred and seventeen primary
TARs were performed (77 Hintegra, 40 Zimmer Trabecular Metal Total Ankle). We retrospectively assessed pain and function using the visual
analogue scale (VAS) pain scale, American Orthopedic Foot and Ankle Society (AOFAS), Short‑Form Health Survey (SF‑12 divided into
Mental (MCS) and Physical (PCS) score) obtained preoperatively, 6 and 12 months postoperatively. Activity levels were determined using
the Halasi ankle activity scale and the University of California at Los Angeles (UCLA) score obtained preoperatively and 12 months after the
surgery. Radiographic examination included plain radiographs with full weight‑bearing taken preoperatively and 12 months postoperatively.
Results: All patients showed a significant improvement for AOFAS, VAS, and SF‑12 scores (P < 0.05). The Halasi activity scale and UCLA
score were 4.2 ± 1.2 and 6.6 ± 1.8, respectively, for the fix‑bearing group and 3.7 ± 1.5 and 6.3 ± 2.3 for the mobile‑bearing 12 months
after the surgery. In our series, jogging, dancing, and skiing represented the three most frequent sports. In the fix‑bearing group, 60% of the
patients practiced sport 1 year after surgery and 49.4% in the mobile‑bearing group. The fix‑bearing prosthesis had a quicker recovery and
better functional outcomes within the first 6 months after the operation. At 1 year, there was not a significant difference in return to sport and
physical activities between patients treated with a mobile‑bearing implant and a fix‑bearing implant. Conclusions: At 1 year, both fixed and
mobile bearing present significant improvements in functional and recreational scores, with neither prove superior.


1. Agel J, Coetzee JC, Sangeorzan BJ, Roberts MM, Hansen ST Jr.
Functional limitations of patients with end‑stage ankle arthrosis. Foot
Ankle Int 2005;26:537‑9.
2. Deleu PA, Devos Bevernage B, Gombault V, Maldague P, Leemrijse T.
Intermediate‑term results of mobile‑bearing total ankle replacement.
Foot Ankle Int 2015;36:518‑30.
3. Saltzman CL, Zimmerman MB, O’Rourke M, Brown TD,
Buckwalter JA, Johnston R, et al. Impact of comorbidities on the
measurement of health in patients with ankle osteoarthritis. J Bone Joint
Surg Am 2006;88:2366‑72.
4. Valderrabano V, Hintermann B, Nigg BM, Stefanyshyn D, Stergiou P.
Kinematic changes after fusion and total replacement of the ankle:
Part 2: Movement transfer. Foot Ankle Int 2003;24:888‑96.
5. Bonnin MP, Laurent JR, Casillas M. Ankle function and sports activity
after total ankle arthroplasty. Foot Ankle Int 2009;30:933‑44.
6. Horterer H, Miltner O, Muller‑Rath R, Phisitkul P, Barg A. Sports
activity in patients with total ankle replacement. Sports Orthop
Traumatol 2015;31:34‑40.
7. Macaulay AA, VanValkenburg SM, DiGiovanni CW. Sport and activity
restrictions following total ankle replacement: A survey of orthopaedic
foot and ankle specialists. Foot Ankle Surg 2015;21:260‑5.
8. Naal FD, Impellizzeri FM, Loibl M, Huber M, Rippstein PF. Habitual
physical activity and sports participation after total ankle arthroplasty.
Am J Sports Med 2009;37:95‑102.
9. Valderrabano V, Pagenstert G, Horisberger M, Knupp M, Hintermann B.
Sports and recreation activity of ankle arthritis patients before and after
total ankle replacement. Am J Sports Med 2006;34:993‑9.
10. Usuelli FG, Indino C, Maccario C, Manzi L, Salini V. Total ankle
replacement through a lateral approach: Surgical tips. SICOT J 2016;2:38.
11. Barg A, Knupp M, Henninger HB, Zwicky L, Hintermann B. Total ankle
replacement using HINTEGRA, an unconstrained, three‑component
system: Surgical technique and pitfalls. Foot Ankle Clin 2012;17:607‑35.
12. Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot
and Ankle. 9th ed. Philadelphia: Elsevier; 2014. p. 1127‑8.
13. Usuelli FG, Maccario C, Manzi L, Tan EW. Posterior talar shifting in
mobile‑bearing total ankle replacement. Foot Ankle Int 2016;37:281‑7.
14. Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability
and validity of the visual analogue scale. Pain 1983;16:87‑101.
15. Chen CY, Huang PJ, Kao KF, Chen JC, Cheng YM, Chiang HC, et al.
Surgical reconstruction for chronic lateral instability of the ankle. Injury
16. Guyton GP. Theoretical limitations of the AOFAS scoring systems: An
analysis using Monte Carlo Modeling. Foot Ankle Int 2001;22:779‑87.
17. Jenkinson C, Layte R, Jenkinson D, Lawrence K, Petersen S, Paice C,
et al. A shorter form health survey: Can the SF‑12 replicate results from
the SF‑36 in longitudinal studies? J Public Health Med 1997;19:179‑86.
18. Madeley NJ, Wing KJ, Topliss C, Penner MJ, Glazebrook MA,
Younger AS, et al. Responsiveness and validity of the SF‑36, Ankle
Osteoarthritis Scale, AOFAS Ankle Hindfoot Score, and Foot Function
Index in end stage ankle arthritis. Foot Ankle Int 2012;33:57‑63.
19. Halasi T, Kynsburg A, Tállay A, Berkes I. Development of a new
activity score for the evaluation of ankle instability. Am J Sports Med
20. Zahiri CA, Schmalzried TP, Szuszczewicz ES, Amstutz HC. Assessing
activity in joint replacement patients. J Arthroplasty 1998;13:890‑5.
21. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol
Meas 1960;20:37‑46.
22. Hogg RV, Ledolter J. Engineering Statistics. New York: MacMillan;
23. Valderrabano V, Pagenstert GI, Müller AM, Paul J, Henninger HB,
Barg A, et al. Mobile‑ and fixed‑bearing total ankle prostheses: Is there
really a difference? Foot Ankle Clin 2012;17:565‑85.
24. Abdo RV, Wasilewski SA. Ankle arthrodesis: A long‑term study. Foot
Ankle 1992;13:307‑12.
25. Gougoulias N, Khanna A, Maffulli N. How successful are current ankle
replacements?: A systematic review of the literature. Clin Orthop Relat
Res 2010;468:199‑208.
26. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L,
et al. Intermediate and long‑term outcomes of total ankle arthroplasty
and ankle arthrodesis. A systematic review of the literature. J Bone Joint
Surg Am 2007;89:1899‑905.
27. Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes
following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg
Am 2006;88:526‑35.
28. Valderrabano V, Hintermann B, Nigg BM, Stefanyshyn D, Stergiou P.
Kinematic changes after fusion and total replacement of the ankle:
Part 1: Range of motion. Foot Ankle Int 2003;24:881‑7.
29. Valderrabano V, Hintermann B, Nigg BM, Stefanyshyn D, Stergiou P.
Kinematic changes after fusion and total replacement of the ankle:
Part 3: Talar movement. Foot Ankle Int 2003;24:897‑900.
30. Chou LB, Mann RA, Yaszay B, Graves SC, McPeake WT 3rd,
Dreeben SM, et al. Tibiotalocalcaneal arthrodesis. Foot Ankle Int
31. Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for
post‑traumatic osteoarthrosis of the ankle and hindfoot. J Bone Joint
Surg Am 1992;74:1042‑9.
32. Hahn ME, Wright ES, Segal AD, Orendurff MS, Ledoux WR,
Sangeorzan BJ, et al. Comparative gait analysis of ankle arthrodesis
and arthroplasty: Initial findings of a prospective study. Foot Ankle Int
33. Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A,
Buckwalter JA, et al. Epidemiology of ankle arthritis: Report of a
consecutive series of 639 patients from a tertiary orthopaedic center.
Iowa Orthop J 2005;25:44‑6.
34. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B.
Etiology of ankle osteoarthritis. Clin Orthop Relat Res
35. Schuh R, Hofstaetter J, Krismer M, Bevoni R, Windhager R, Trnka HJ,
et al. Total ankle arthroplasty versus ankle arthrodesis. Comparison
of sports, recreational activities and functional outcome. Int Orthop
36. Tan EW, Maccario C, Talusan PG, Schon LC. Early Complications and
Secondary Procedures in Transfibular Total Ankle Replacement. Foot
Ankle Int 2016;37:835‑41.
37. Femino JE, Vaseenon T. The direct lateral approach to the distal tibia and
fibula: A single incision technique for distal tibial and pilon fractures.
Iowa Orthop J 2009;29:143‑8.
38. Lamothe J, Deland J, Schon LC, Saltzman C, Herbst S, Ellis S.
Total ankle replacement through a lateral approach. Tech Foot Ankle
39. Barg A, Zwicky L, Knupp M, Henninger HB, Hintermann B. HINTEGRA
total ankle replacement: Survivorship analysis in 684 patients. J Bone
Joint Surg Am 2013;95:1175‑83.