Sports and Recreation Activity of Ankle

Arthritis Patients Before and After

Total Ankle Replacement
Victor Valderrabano,*†‡ MD, Geert Pagenstert,‡ MD, Monika Horisberger,‡
Markus Knupp,‡ MD, and Beat Hintermann,‡ MD
†
From the Human Performance Laboratory & Orthopaedic Department, University of Calgary,
‡
Calgary, Canada, and the Orthopaedic Department, University Hospital of Basel,
University of Basel, Basel, Switzerland

Background: Total ankle replacement is a possible treatment for ankle arthritis; however, participation in sports after this
procedure has not yet been analyzed.
Hypotheses: There is a significant increase of sports activity after total ankle replacement in patients with arthritis. There is a
significant correlation between sports activity and American Orthopaedic Foot and Ankle Society hindfoot score in patients after
total ankle replacement.
Study Design: Case series; Level of evidence, 4.
Methods: A clinical evaluation was performed preoperatively and at follow-up after total ankle replacement in 147 patients
(152 ankles) with ankle arthritis (mean age, 59.6 years; range, 28-86 years). Ankle arthritis origin, patient satisfaction, range of
motion, American Orthopaedic Foot and Ankle Society hindfoot score, radiologic assessment, and rate, level, and type of sports
activity were documented at both evaluations. The mean follow-up was 2.8 years (range, 2-4 years).
Results: Preoperative diagnosis was posttraumatic osteoarthritis in 115 cases (76%). At total ankle replacement follow-up,
excellent and good outcomes were reported in 126 cases (83%); 105 cases (69%) were pain free. The mean range of motion pre-
operatively was 21° (range, 0°-45°); after total ankle replacement, it was 35° (range, 10°-55°; P < .05). The preoperative American
Orthopaedic Foot and Ankle Society score was 36 points; after total ankle replacement, it was 84 points (P < .001). Before
surgery, 36% of the patients were active in sports; after surgery, this percentage rose to 56% (P < .001). After total ankle replace-
ment, sports-active patients showed a significantly higher hindfoot score than did patients not active in sports: 88 versus
79 points (P < .001). The 3 most frequent sports activities were hiking, biking, and swimming.
Conclusion: There was a significant increase of sports activity by treating ankle arthritis patients with total ankle replacement.
Sports-active total ankle replacement patients showed better functional results than did inactive ones.
Keywords: sports activity; ankle; arthritis; osteoarthritis; total ankle replacement (TAR)

Sports activity determines our general state of health and
represents a relevant part of our social life. This is especially
true for the aging population, which has a strong desire to
remain active in sports. The increasing life expectancy (mean
life expectancy in the United States in 2000 was 76.9 years2;
in 2002, it was 77.3 years3) and the increasing incidence and
*Address correspondence to Victor Valderrabano, MD, Human
Performance Laboratory & Orthopaedic Department, University of Calgary,
2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada (e-mail:
v.valderrabano@kin.ucalgary.ca).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 34, No. 6
DOI: 10.1177/0363546505284189
© 2006 American Orthopaedic Society for Sports Medicine
prevalence of arthritis
1,4,6,14
have led to a remarkably high
and continuously increasing number of implanted total joint
replacements yearly (541 245 hip and knee replacements in
1999 in the United States11). For sports medicine patients,
the ability to take part in sport has been shown to correlate
with satisfaction and outcome of the performed surgery.8,23 In
the past few decades, the outcomes of total joint replace-
ments have reached a high level of satisfaction and good
long-term results because of improved tribology, biomechan-
ical designs, surgical techniques, and rehabilitation. The abil-
ity to return to sports and the level of sports activity after
joint replacement also have high satisfaction results.17,19 The
improvement of pain, function, and life quality after total
joint replacement allows patients to increase their personal
physical activities and participation in sports.19,22

993
994 Valderrabano et al
Most of the reports in the literature on patients returning to
sports after total joint replacement are based on analysis of
patients after total hip replacement (THR) and total knee
replacement (TKR). The rate of participation in sports varies
between 29% and 56% after THR9,13,20,24 and between 34% and
77% after TKR.5,13 A few years ago, the Hip Society and Knee
Society outlined their consensus recommendations on athletic
activity after THR and TKR and classified several sports activ-
ities as follows: “recommended/allowed,” “allowed with experi-
ence,” “not recommended,” and “no conclusion.”10 Typically
allowed sports are biking, swimming, walking, golfing, and
others. Sports allowed with experience are hiking, low-impact
aerobics, horseback riding, and cross-country skiing. Sports
that are not recommended include basketball, baseball, soccer,
football, jogging, squash, volleyball, and others. No conclusion
has been published for downhill skiing, weight lifting, and oth-
ers. In general, patients with total joint replacements are
encouraged to participate in low-impact, low-demanding
sports and to avoid high-impact, high-demanding sports.11
In contrast to THR and TKR, to the knowledge of the
authors, there are no reports in the literature on precise
analysis or recommendations of participation in sports after
total ankle replacement (TAR). Therefore, the purpose
of the present prospective study was to determine the rate,
level, and type of sports activities possible with ankle
arthritis and after TAR, as well as to correlate sports level
and outcome after TAR. The hypotheses of the present
study were as follows: (1) There is a significant increase of
sports activity in patients with end-stage ankle arthritis
after TAR, and (2) there is a significant correlation between
sports activity level and the American Orthopaedic Foot and
Ankle Society (AOFAS) hindfoot score in patients with TAR.
METHODS
In this study, 147 consecutive patients (77 women and
70 men, representing 152 ankle cases; mean age, 59.6 years;
range, 28-86 years) suffering from end-stage ankle arthri-
tis and treated with a 3-component uncemented TAR
(HINTEGRA, Newdeal SA, Lyon, France) were prospec-
tively analyzed (ie, preoperatively under the condition of
ankle arthritis and at follow-up of the implanted TAR)
(Figure 1). The inclusion criterion was symptomatic end-
stage ankle arthritis with fulfillment of general TAR
indications (good bone stock, normal vascular status, no
immunosuppression, sufficient medial and lateral ankle
stability). The exclusion criteria were neuroarthropathic
degenerative disease (Charcot ankle), active or recent infec-
tion, substantial avascular necrosis of the talus, severe
benign joint hypermobility syndrome, nonreconstructable
malalignment, severe soft tissue problems around the
ankle, and sensory or motor dysfunction of the foot or leg.
The postoperative follow-up level was set at a minimum of
2 years, and follow-up was performed by an unbiased
observer (M. H.). The mean follow-up in this study was
2.8 years (range, 2-4 years).
Pain was quantified using a visual analog scale (VAS), with
0 points representing no pain and 10 points representing
maximal imaginable pain. The overall subjective satisfaction
The American Journal of Sports Medicine
was based on the following scale: excellent, good, moderate,
and none. Range of motion (ROM) was measured with a
goniometer (in degrees) with the patient in a sitting position
for plantar flexion and dorsiflexion and as a percentage
either of the uninvolved contralateral leg or of the healthy
population for inversion/eversion, as required for the
AOFAS hindfoot score.16 Hindfoot alignment was measured
with a goniometer with the patient in a standing position
and defined as follows: normal, 0° to 10°; valgus, >10°; or
varus, <0°. The AOFAS hindfoot score,16 which includes
pain, function, and alignment evaluations, was used to
assess overall clinical-functional level (minimum score of
0 points, maximum score of 100 points). As standard diag-
nostics in TAR patients, the patients were radiologically
examined preoperatively and at follow-up using standard
weightbearing radiographs in 2 planes (AP, lateral). This
study used the radiologic analysis methods of loosening and
migration as reported by Hintermann et al.12
Each patient’s sports activity level was documented pre-
operatively and at TAR follow-up using the following scale:
grade 0, none; grade 1, moderate; grade 2, normal; grade 3,
high; and grade 4, elite (Table 1). All types of sports acti-
vities reported by the patients were documented.
All subjects gave informed consent to participate in the
study. The study was carried out in accordance with the
World Medical Association Declaration of Helsinki.
Statistical analysis of the data was performed with
SPSS(r) software (version 12.0, SPSS Science Inc, Chicago,
Ill) to perform the paired Student t test, McNemar test,
and Pearson correlation analysis (r). The significance level
was set at P < .05.
RESULTS
Based on the patients’ histories, the preoperative diagnosis
was posttraumatic osteoarthritis in 115 cases (76%), pri-
mary osteoarthrosis in 21 cases (13%), and systemic arthri-
tis in 16 cases (11%).
The patients rated their satisfaction with the TAR as
excellent in 49 cases (32%), good in 77 cases (51%), moder-
ate in 17 cases (11%), and poor in 9 cases (6%). Although the
mean VAS pain score preoperatively was 6.9 points (range,
3-10 points), at follow-up after TAR, 105 ankles (69%) were
completely pain free (VAS, 0 points), and 47 (31%) suffered
TABLE 1
Sports Frequency Score
Score Definition
0 (none) No sports activity
1 (moderate) Moderate level of sports activity in
leisure time, <1 h/wk
2 (normal) Normal level of sports activity in leisure
time, 1-5 h/wk
3 (high) High level of sports activity in leisure
time, >5 h/wk
4 (elite) Professional level of sports activity,
elite athlete
Vol. 34, No. 6, 2006 Sports in Ankle Arthritis and TAR 995

Figure 1. Treatment of ankle arthritis by total ankle replacement. Patient with severe posttraumatic ankle osteoarthritis (A, B) and
implanted total ankle replacement at follow-up (C, D).
996 Valderrabano et al The American Journal of Sports Medicine

TABLE 2
Diagnosis-Dependent Analysis of AOFAS Score and Sports Activitya

AOFAS Score Sports Activity Rate Sports Activity Levelb

PRE TAR PRE TAR PRE TAR

Absolute Absolute Mean Mean

Etiology Mean Range Mean Range % No. % No. Grade Range Grade Range
c d c
Posttraumatic 38 0-74 83 28-100 40 46 58 67 0.6 0-3 1.0 0-3
osteoarthritis (n = 115)
Primary 36 0-62 86c 52-100 19 4 62d 13 0.1 0-1 0.9d 0-2
osteoarthrosis (n = 21)
Systemic 25 10-52 89c 45-100 31 5 31 5 0.2 0-1 0.3 0-2
arthritis (n = 16)
Total (N = 152) 36 10-74 84c 28-100 36 55 56c 85 0.5 0-3 0.9c 0-3
a
AOFAS score, hindfoot score of the American Orthopaedic Foot and Ankle Society; PRE, preoperative arthritic condition; TAR, total ankle
replacement condition.
b
See Table 1.
c
Statistically significantly different from preoperative condition, P < .001.
d
Statistically significantly different from preoperative condition, P < .05.

TABLE 3 TABLE 4
Sports Activity Level and Rate List of Reported Sports Activities

Preoperative Total Ankle Preoperative Total Ankle

Arthritic Conditionb Replacementc Arthritic Conditiona Replacementb

Sports Activity Absolute No. Absolute No. Type of Sports Absolute No. Absolute No.
Level Gradea % of Patients % of Patients Activity % of Patients % of Patients

0 64 97 44 67 Hiking 26 14 53 45c
1 24 37 27 41 Biking 44 24 46 39d
2 9 14 22 34 Swimming 40 22 34 29
3 3 4 7 10 Aerobics 18 10 12 10
4 0 0 0 0 Downhill 11 6 8 7
skiing
Sports activity 36 55 56 85d Golfing 4 2 6 5
rate Horseback 4 2 2 2
riding
a
See Table 1. Tennis 4 2 1 1
b
Sports activity level with ankle arthritis preoperatively Bowling 0 0 1 1
(N = 152). Jogging 0 0 1 1
c
Sports activity level with total ankle replacement at follow-up Waterskiing 0 0 1 1
(N = 152).
d a
Paired Student t test for all levels shows statistically significant Sports activities reported with ankle arthritis preoperatively.
b
difference, P < .001. Sports activities reported with total ankle replacement at
follow-up.
c
Statistically significantly different from ankle arthritis condition,
P < .001.
moderate pain (mean VAS, 2.4 points; range, 1-5 points; d
Statistically significantly different from ankle arthritis condition,
P < .001). The mean dorsiflexion/plantar flexion ROM pre- P < .05.
operatively was 21° (range, 0°-45°) and at final follow-up
was 35° (range, 10°-55°; P = .04). The mean preoperative
AOFAS hindfoot score was 36 points (range, 10-74 points) 20 percentage points; P < .001) (Tables 2 and 3). A significant
and at follow-up was 84 points (range, 28-100 points), rate increase was seen in the posttraumatic osteoarthritis
which was significantly higher (P < .001) (Table 2). The sys- and primary osteoarthrosis group (P < .003 and P < .012,
temic ankle arthritis group after TAR averaged 89 points respectively) (Table 2). The systemic arthritis group did
(range, 45-100 points), which was the highest AOFAS hind- not contribute to the sports activity rate increase (differ-
foot score (Table 2). ence before and after TAR, 31%; P = 1). The overall sports
Preoperatively, the sports activity rate was 36% (55 activity level distribution after TAR was significantly dif-
cases); after TAR, it was 56% (85 cases; overall increase of ferent from the one at the preoperative arthritic condition
Vol. 34, No. 6, 2006
Ankle Arthritis
Sports-Active
n = 55 (36%)
AOFAS Hindfoot Score: 39 (16-74)
Sports-Inactive
n = 97 (64%)
AOFAS Hindfoot Score: 34 (10-72)a
Figure 2. Sports activity flowchart. aNo statistically significant difference to sports-active ankle arthritis patients (P = .12).
*Statistically significant difference to sports-active total ankle replacement patients (from group of sports-active ankle arthritis
patients; P < .05). **Statistically significant difference to sports-active total ankle replacement patients (from group of sports-
inactive ankle arthritis patients; P < .001). AOFAS, American Orthopaedic Foot and Ankle Society.
(P < .001) (Table 3). After TAR, there was a significant
increase of sports-active cases in grades 1 to 3 (P < .001).
None of the patients reported sports activity grade 4/elite
either before or after TAR.
Among patients who were active in sports preoperatively,
76% of the cases (n = 42) maintained their sports activity
after TAR implantation (P = .01) (Figure 2). Twenty-four per-
cent of the sports-active arthritis patients lost their sports
activity after TAR implantation because of continued pain
(VAS, 4; range, 3-5) and had decreased AOFAS hindfoot
scores (81 points; range, 37-92 points). In the group that was
not active in sports preoperatively, 44% of the cases (n = 43)
regained a sports activity (such as swimming, biking, hiking)
after TAR implantation (P < .001) (Figure 2). The new
regained sports activity levels were grade 1/moderate in 23
cases, grade 2/normal in 18 cases, and grade 3/high in 2 cases.
The most frequently reported sports activities preopera-
tively were, in descending order, biking (43.6%), swimming
(40.0%), hiking (25.5%), aerobics (18.2%), and downhill ski-
ing (10.9%). Golfing, horseback riding, and tennis were
performed equally (3.6%) (Table 4). The most frequently
reported sports activities after TAR were, in descending
order, hiking (52.8%), biking (45.9%), swimming (34.1%),
aerobics (11.8%), downhill skiing (8.2%), golfing (5.9%),
and horseback riding (2.4%). Tennis, bowling, jogging, and
waterskiing were performed equally (1.2%) (Table 4).
Statistical analysis between preoperative and postopera-
tive situations showed a significant difference for only hik-
ing (P < .001) and biking (P = .02).
Comparing sports activity and AOFAS hindfoot score,
there was no significant correlation between sports activ-
ity level and AOFAS hindfoot score preoperatively (r = .1,
P = .13), but a significant correlation was seen after TAR
(r = .4, P < .001). Overall, sports-active TAR patients
showed a significantly higher AOFAS hindfoot score than
did patients who were not active in sports: 88 points versus
79 points (P < .001).
Thirteen ankles (9%) required a revision of the TAR at the
time of follow-up. Twelve of these 13 ankles had an origin of
posttraumatic ankle osteoarthritis, and 1 patient suffered
Sports in Ankle Arthritis and TAR 997
Total Ankle Replacement
Sports-Active
n = 42 (76%)
AOFAS Hindfoot Score: 92 (66-100)
Sports-Inactive
n = 13 (24%)
AOFAS Hindfoot Score: 81 (37-92)*
Sports-Active
n = 43 (44%)
AOFAS Hindfoot Score: 84 (56-100)
Sports-Inactive
n = 54 (56%)
AOFAS Hindfoot Score: 78 (28-100)**
from hemophilic arthritis. Nine of these 13 ankles had a
primary loosening of the components that had to be conse-
quently exchanged. One patient suffered from a fibulotalar
impingement, 2 patients from ankle joint stiffness, and
1 patient from an inlay dislocation due to a varus malalign-
ment. In all revision cases, the sports activity level had
been 0 after primary TAR implantation. All 13 cases under-
went successful revision surgery, and none had to be con-
verted to an ankle arthrodesis. Of these 13 revised cases,
at follow-up, 7 patients did not perform sports (grade 0),
5 patients performed grade 1/moderate sports, and 1 patient
performed grade 2/normal sports.
On radiographs at recent follow-up, the tibial component
was stable in all cases, showing no progressive tilting or
migration of the component since primary or revision surgery.
As the bone-component interface of the talar component can-
not be seen radiologically, loosening can only be assumed from
migration of the component. This was observed in 3 ankles;
these patients reported no sports activity and only moderate
pain. Eleven ankles (7%) had evidence of heterotopic
periarticular bone formation that did not correlate with
the sports activity level after TAR (r = .2, P = .62).
DISCUSSION
The principal findings of this study were that TAR
increased the sports activity rate in ankle arthritis patients
and that patients active in sports after TAR showed a
higher functional AOFAS hindfoot score than did patients
who were not active in sports.
The increased success with arthroplasty of joints such as
the knee or hip,5,10 along with concerns about the long-term
outcomes after ankle arthrodesis,7,21 has created renewed
interest in total ankle arthroplasty during the past
decade.12,18,25,26 New 2- and 3-component TAR systems have
been designed with attention to the reproduction of normal
ankle function, normal joint biomechanics, physiologic liga-
ment stability, and correct mechanical alignment. Recent
total ankle prostheses also include porous-coating and
998 Valderrabano et al The American Journal of Sports Medicine

TABLE 5
Guidelines for Sports Activity After Total Ankle Replacement (TAR)

General Guidelinesa

1. In general and on a long-term basis, after TAR, patients must be aware of the possibility of accelerated polyethylene wear,
loosening, or revision surgery due to inappropriate sports activity.
2. Before sports activity, patients with a TAR should be free of any complications and have undergone a physical therapy
rehabilitation program.
3. The TAR must show a radiologically concluded osteointegration and no signs of loosening or migration.
4. Before sports activity, patients with a TAR must consult their treating surgeon to discuss the individually allowed/recommended
sport and possibly required supporting orthoses.
5. In general, high-impact and stop-and-go sports should be avoided.
6. Patients with pain during sports activity must consult their treating surgeon.

Allowed With Experience/Caution

Allowed and Appropriate Equipment Not Recommended

Stationary biking; ballroom dancing; Low-impact aerobics; road biking; bowling; High-impact aerobics; baseball; basketball;
bowling; golfing; swimming; walking low-impact gymnastics; hiking; rowing; cross-country skiing; football; gymnastics; handball;
downhill skiing; doubles tennis hockey/ice skating; horseback riding; inline skating;
jogging; lacrosse; squash; rock climbing; soccer;
singles tennis; volleyball; waterskiing; and others
a
Guidelines are based on Healy et al,10 Vertullo and Nunley,27 the results of the present study, and the authors’ experience.

anatomical surfaces that allow for biological fixation and
reduced amount of bone resection necessary for implanta-
tion.12 Similar to THR and TKR, the positive results and
increased survivorship after TAR12,18,25,26 have encouraged
patients to take this treatment into consideration for their
painful end-stage ankle arthritis, allowing them to reach a
better functional level or even to take part in sports.
To our knowledge, at the present time there are no
studies in the literature specifically addressing the rate
of sports activity in a large series of end-stage ankle arthri-
tis patients. Not surprisingly, in the present study, 64% of
the patients did not perform any sports preoperatively. The
sports activity rate of 36% in our patients with ankle arthri-
tis was mainly represented by the moderate sports level
grade 1 (Table 3). Driven by their subjective symptoms
(such as pain, depression, and others) and their joint patho-
biomechanics (such as reduced ROM, limp, reduced walking
distance, and others), ankle arthritis patients tended to
perform mainly low-impact sport activities, such as biking
and swimming (Table 4), to avoid possible abnormal ground
reaction forces and, therefore, pain-inducing joint reaction
forces.
Patients’ return to sports has been reported for
THR9,13,20,24 and TKR,5,13 but no reports exist on how many
patients can return to sports after TAR. In the literature,
the sports activity rate after THR and TKR varies between
29% and 77%, of which an overall THR-TKR mean rate of
49% can be calculated.5,9,13,20,24 The rate of sports activity
after TAR in the present study was 56% and is therefore
within the reported rate range and close to the calculated
overall mean rate for THR and TKR. Compared with the
preoperative arthritic state,TAR significantly increased the
overall sports activity rate in our cohort by 20%. The high-
est absolute increase was seen in the sports levels grade
2/normal and grade 3/high (Table 3). Remarkably, hiking
was the most reported sports activity after TAR (Table 4),
with a 53% higher rate than the one described by Dubs et al9
in their study on THR (41%). When discussing the steady
state of the downhill skiing rate in the arthritic and TAR
condition, one has to take into account the degree of popu-
larity of this sport in our country. Patients who performed
downhill skiing after TAR often reported that they felt quite
stable and supported in their hard ski boots while skiing.
After TAR, patients who returned to sports had a signifi-
cantly higher clinical-functional AOFAS hindfoot score
than did patients who did not engage in sports. However,
the exact relationship between sports activity level and
AOFAS hindfoot score is still unclear. The patients could
be returning to sports because they have higher AOFAS
hindfoot scores, or they could have higher AOFAS scores
because they are active in sports. Whether sports activity
has a protective or harmful effect on long-term outcome
after TAR was not answered in the present study. However,
we did show that patients who reported sports activity in
the preoperative arthritic state had a tendency to be active
in sports after the TAR procedure (Figure 2). Furthermore,
this study showed that at this length of follow-up, there is
not a negative relationship between revision rate and
sports activity. As do others, we believe that low-impact
sports activity might be beneficial for the bone-implant
interface by encouraging bone ingrowth as long as the
forces are below an as yet unidentified threshold.5,9 Sports
activity might also help to reduce muscle atrophy, which is
often seen preoperatively in patients with ankle arthritis,
and help to enhance the lower leg muscular performance.
Thus, it might reduce the dangerous peaks of the resulting
joint reaction forces during locomotion.
Guidelines for return to sports after TAR are not available
in the literature; therefore, the authors came up with a recom-
mendation for sports activity after TAR (Table 5) based on
Vol. 34, No. 6, 2006
the recommendations of the Hip Society and Knee Society for
sports activity after THR/TKR as reported by Healy et al,10
on the guidelines of sports activity after foot and ankle
arthrodeses reported by Vertullo and Nunley,27 and on the
results of the present study and our own long-standing expe-
rience in the TAR field. In general, we recommend patients
perform no- or low-impact sports activities and recreation
after arthroplasty. High-impact, contact, or stop-and-go
sports should be avoided because they might be higher than
the force threshold at the bone-implant interface and cause
loosening, migration, accelerated polyethylene wear, or even
component breakage.5,15,19 Despite the herewith-improved
knowledge of sports activity after TAR, a broader consensus
recommendation based on a wide interrogation survey of foot
and ankle surgeons might be necessary in the future.
A potential flaw of this study is the preliminary follow-up
time of the cohort. This cohort would need to be evaluated at
5- to 10-year follow-up for valid conclusions to be drawn on
the effect of sports activity level and different sports activity
types on TAR.15 Furthermore, the sports activity score
(Table 1) represents a sports frequency score and does not
take into consideration the variable physical activity
requirements between the different sports activities. To
eliminate possible psychological and social effects on the
sports activity, a SF-36 score would have been useful in this
prospective cohort series.
CONCLUSION
This study provides information on sports activity in
patients with ankle arthritis and after TAR. This informa-
tion might serve as a guide for clinicians and surgeons who
want to give recommendations for sports activity to patients
with ankle arthritis and TAR. Treatment by TAR signifi-
cantly increased the overall sports activity rate and, there-
fore, the life quality of these patients. This increase was
seen mostly in sports level grades 2 and 3. Furthermore,
this study supports the fact that patients who are active in
sports before TAR are most likely to be active after TAR.
Finally, patients who performed sports after TAR showed a
higher functional AOFAS hindfoot score than did patients
who did not engage in sports activities. In accordance with
studies reporting on sports activity after THR and TKR,
we support the notion of recommending low-impact and
discouraging high-impact sports after TAR.
ACKNOWLEDGMENT
The Swiss Orthopaedic Surgery Society is acknowledged
for the support of the first author, Dr Victor Valderrabano.
The authors thank all staff members of the Orthopaedic
Department of the University Hospital of Basel for their
help in the ongoing prospective data collection.
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