Controlling Edema in Total Ankle Arthroplasty
Postoperative edema following total ankle arthroplasty is more than a temporary inconvenience—it is a critical determinant of wound healing and long-term outcomes. Emerging evidence suggests that both preoperative soft-tissue characteristics and persistent postoperative swelling may predict wound complications and revision risk. Strategic edema control beginning in the operating room and extending through rehabilitation is essential to optimize recovery and protect the surgical incision.
Key Takeaways
1. Preoperative soft-tissue thickness may predict postoperative complications. Emerging data suggest that decreased anterior ankle soft-tissue thickness is associated with wound dehiscence, while greater radiographic soft-tissue thickness may correlate with revision risk—highlighting the importance of preoperative radiographic assessment.
2. Edema control begins intraoperatively and requires a multimodal approach. Evidence supports the use of tranexamic acid (TXA), compression dressings, elevation, cryotherapy, and structured rehabilitation protocols to reduce swelling and protect incision integrity. Adjunctive therapies such as mannitol may represent a novel strategy but require further study.
3. Persistent edema is a red flag. Postoperative swelling should progressively resolve and return to baseline by one year. Radiographic increases greater than 10 mm on lateral view or edema persisting beyond six months may signal increased risk for wound complications or revision and warrant closer monitoring.
Total ankle arthroplasty (TAA) is a reliable treatment for end-stage osteoarthritis, with continued advancements in implant components and surgical techniques.1 Nevertheless, postoperative edema is critically important to wound healing and overall postoperative outcomes, as increased interstitial pressure can place tension on the incision site, increasing the risk of wound dehiscence, delayed wound healing, or the need for revision surgery.2–7 Effective management of postoperative TAA edema is therefore essential for recovery and complication prevention through both immediate postoperative care and longitudinal rehabilitation efforts.
Despite these advancements, the role of ankle edema in the preoperative and postoperative periods—and its effect on outcomes—remains incompletely understood. Recent studies have evaluated preoperative radiographic soft-tissue measurements as predictors of postoperative wound complications.8,9 A 2022 study evaluated 197 TAAs performed at a single institution and assessed the ankle soft-tissue thickness ratio (ASTR), dividing patients into 2 groups (>1.38 and <1.38). The researcher did not identify a statistically significant difference in complications, although complications occurred more frequently in the low ASTR group.8 Subsequently, a 2025 study evaluated the risk of wound dehiscence following TAA in relation to anterior soft-tissue depth (ASTD). Among 100 TAAs, postoperative wound dehiscence was significantly increased in patients with a preoperative ASTD of <16 mm.9
Additionally, a retrospective review of 323 patients that underwent TAA evaluated the effect of preoperative soft-tissue thickness on revision surgery. Tibial and talar soft tissue thickness were measured preoperatively, and greater soft tissue thickness was significantly associated with the need for revision surgery, while body mass index was not predictive.10 Collectively, these studies demonstrate an association between decreased preoperative anterior ankle soft tissue thickness and wound complications, as well as between prolonged postoperative edema and wound-healing difficulties and revision surgery. The natural progression of postoperative edema in the foot and ankle is well documented, with early swelling typically resolving to baseline within a year.
Control of postoperative TAA edema begins in the operating room. Investigations of tranexamic acid (TXA) and its effects in total ankle replacement surgery demonstrate reductions in blood loss and postoperative edema.11,12 In a study by Nodzo and colleagues, perioperative blood loss and hemarthrosis were reduced following TAA with TXA use. Use of postoperative drains also aided in edema reduction, with a significant decrease in drain output observed in the TXA-treated TAA group.13
In patients with inherited bleeding disorders undergoing TAA, intravenous mannitol has been used in the immediate postoperative period to reduce edema. Although not well-studied in the literature this intervention may represent a novel approach to postoperative edema control. A 2017 study reported the postoperative use of mannitol in TAA patients without associated complications.14 Mannitol is an osmotic diuretic commonly used to rapidly reduce intracranial and intraocular pressure. A 2023 study examining postoperative rehabilitation following multiple metacarpal fractures evaluated a combined steroid and mannitol regimen. Early range of motion is critical for postoperative recovery, and soft-tissue edema and pain can limit early mobilization. The researchers compared 2 groups: the first treated with both medications over a 5-day inpatient course and the second without. Both groups followed the same rehabilitation protocol. The treatment group demonstrated significantly improved visual analog scale (VAS) pain scores at postoperative day 6, as well as significantly reduced edema at weeks 2–5. Rehabilitation began 3 days earlier, and full active grip strength returned approximately 10 days sooner in the treatment group.15
In the immediate postoperative period, compression dressings are recommended over casting, as compression wraps have been associated with decreased wound complications.6 Standard postoperative edema management protocols include immobilization, elevation of the operative limb, and cryotherapy.
Notes on the Authors’ Technique
When performing TAA, we place significant emphasis on postoperative edema management, as uncontrolled swelling can lead to early wound dehiscence and later wound complications requiring revision surgery. Our standard protocol includes intraoperative administration of TXA, followed by application of a compression dressing and posterior splint. Patients are instructed to rest, ice, and elevate the operative limb during the postoperative period to minimize edema.
Patients remain non-weight-bearing for 2 weeks with evaluation for incisional healing at the first postoperative visit. At that time, we transition them to a multilayer compression dressing and a pneumatic walking boot, with crutch-assisted weight-bearing as tolerated at home and use of a knee scooter or wheelchair for longer distances. We provide a prescription for physical therapy to assist with progressive weight-bearing in the boot. Patients return at postoperative week 6 for weight-bearing reassessment and transition to stable shoe gear, with continued physical therapy involvement. Ongoing compression therapy with socks or stockings is recommended. Serial radiographs take place throughout the postoperative period.
In our practice, a critical indicator of increased complication risk is postoperative ankle edema on lateral radiographs compared with preoperative measurements. A change greater than 10 mm, or edema persisting beyond 6 months without improvement, raises concern. Postoperative ankle edema following TAA should return to preoperative measurements by one year.
Conclusion
Postoperative edema increases interstitial pressure and may predispose surgical incisions to wound complications and delayed healing. Edema management following TAA begins intraoperatively with pharmacologic interventions and postoperative dressings and continues through immobilization, elevation, cryotherapy, and compression protocols. Serial postoperative radiographic assessment may serve as an objective tool to identify patients at increased risk for complications when edema fails to resolve by 6 months.
Dr. Crenshaw is a Fellow at the Phoenix Foot and Ankle Institute Fellowship in Scottsdale, AZ.
Dr. McAlister is the Fellowship Director at the Phoenix Foot and Ankle Institute Fellowship in Scottsdale, AZ. He discloses that he is a Speaker/Consultant for Smith and Nephew, Medline, and Treace.
References
1. Goldberg AJ, Chowdhury K, Bordea E, et al. Total ankle replacement versus arthrodesis for end-stage ankle osteoarthritis: a randomized controlled trial. Ann Intern Med. 2022;175(12):1648-1657.
2. Cottom JM, Douthett SM, McConnell KK, Plemmons BS. The effect of tobacco use on incision healing in total ankle arthroplasty: a review of 114 patients. Foot Ankle Spec. 2020.
3. Reb CW, Watson B, Fidler C, et al. Anterior ankle incision wound complications between total ankle replacement and ankle arthrodesis: a matched cohort study. J Foot Ankle Surg. 2020.
4. McAlister JE, Hyer CF, et al. Postoperative edema and wound complications following total ankle arthroplasty. J Foot Ankle Surg. 2019;58(4):734-739.
5. Elliott AD, Roukis TS. Anterior incision offloading for primary and revision total ankle replacement: a comparative analysis of two techniques. Open Orthop J. 2017;11:678-686.
6. Schipper ON, Hsu AR, Haddad SL. Reduction in wound complications after total ankle arthroplasty using a compression wrap protocol. Foot Ankle Int. 2015;36(12):1448-1454.
7. Sakkab R, Radcliffe MJ, Paramasivam D, McAlister JE. Total ankle arthroplasty incision management: what matters? A systematic review. Foot & Ankle Surgery: Techniques, Reports & Cases. 2024;4(4):100433.
8. Kalma J, El-Zein Z, Koueiter D, Fortin P. Soft tissue thickness as a predictor of wound complications after total ankle arthroplasty: a retrospective study. Foot & Ankle Orthopaedics. 2022;7:2473011421S0027.
9. Christie LM, Thomson A, Korba C, Kaikis AC, Wolfe WM, Malay DS. The association of anterior soft tissue depth (ASTD) with wound dehiscence following total ankle arthroplasty. J Foot Ankle Surg. 2025;64(5):559-565.
10. Wu KA, Anastasio AT, Krez AN, et al. Association of radiographic soft tissue thickness with revision total ankle arthroplasty following primary total ankle arthroplasty: a minimum of 5-year follow-up. Foot & Ankle Orthopaedics. 2024;9(2):24730114241255351.
11. Ali M, Hassan A, Shah S, Rashid A, Naguib A. The effect of tranexamic acid on the outcome of total ankle replacement. Cureus. 2022;14(7):e26706. Published 2022 Jul 9. doi:10.7759/cureus.26706
12. Butler JJ, Rajivan R, Konar K, et al. Tranexamic acid reduces perioperative blood loss and postoperative hemoglobin loss during total ankle arthroplasty: A systematic review and meta-analysis of clinical comparative studies. J ISAKOS. 2024;9(4):682-688. doi:10.1016/j.jisako.2024.03.009
13. Nodzo SR, Pavlesen S, Ritter C, Boyle KK. Tranexamic acid reduces perioperative blood loss and hemarthrosis in total ankle arthroplasty. Am J Orthop (Belle Mead NJ). 2018;47(8):10.12788/ajo.2018.0063. doi:10.12788/ajo.2018.0063
14. Kotela A, Wilk-Frańczuk M, Jaczewska J, Żbikowski P, Łęgosz P, Ambroziak P, Kotela I. Perioperative physiotherapy for total ankle replacement in patients with inherited bleeding disorders: outline of an algorithm. Med Sci Monit. 2017 Jan 27;23:498-504. doi: 10.12659/msm.898075. PMID: 28129322; PMCID: PMC5292987.
15. Choi J, Seo HJ, Shin J, Byun JH, Jung SN. The effect of steroid and mannitol combination treatment on postoperative rehabilitation of multiple metacarpal bone fractures. Medicina (Kaunas). 2023 Apr 17;59(4):783. doi: 10.3390/medicina59040783. PMID: 37109741; PMCID: PMC10146106.
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