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Ankle arthrodesis

74 citationsUpdated Sep 2026

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Overview

Ankle arthrodesis remains the gold standard for surgical treatment of moderate to severe ankle arthritis [6]. When performed with good technique in carefully selected patients, it is a reliable procedure for relieving functionally disabling pain, deformity, and arthritis [12]. With modern techniques and management of concurrent medical conditions, fusion rates exceeding 90% are expected in standard, uncomplicated cases [42]. Factors associated with improved results include arthroscopic or mini-incision techniques, the use of more than two screws or an adjunct plate or fibular strut, and a diagnosis of primary osteoarthritis [42]. Although the procedure is effective, it is associated with high rates of adjacent joint arthrosis [6]. Clinical outcomes are significantly worse in women, a factor that must be considered when determining indications [29].

Arthroscopic ankle arthrodesis is an effective and reliable option for degenerative ankle disease and end-stage arthritis, including in patients aged 60 years or older with severe preoperative deformity [4, 5]. This approach offers better clinical scores, fewer complications, and shorter hospitalization compared to open arthrodesis, while union rates, reoperation rates, and operative times remain similar [17]. Arthroscopic techniques produce good results in patients with minimal or no deformity and result in very short immediate postoperative morbidity [14]. Compression arthrodesis also produces a satisfactory fusion rate and yields an ankle that is functional, durable, and cosmetically superior to most other arthrodesis procedures [16].

Surgical management for end-stage ankle osteoarthritis currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other remaining a topic of debate [20]. Reports comparing the two are contradictory, and no level I studies have directly compared them [46]. Recent data favor total ankle arthroplasty with latest-generation implants, citing better functional outcomes, fewer complications, and higher patient satisfaction [46]. However, arthrodesis may be the best procedure in circumstances such as preexisting subtalar or other hindfoot arthritis, contralateral hindfoot or ankle arthritis, or hip or knee impairment where ankle motion benefits overall limb function [46]. Careful patient selection is mandatory for the success of either procedure [46].

Anatomy & Pathophysiology

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, which articulates with the dome of the talar body [82]. The talar dome is wider anteriorly and narrower posteriorly [82]. During motion from plantar flexion to dorsiflexion, the ankle mortise widens 1 to 1.5 mm, causing medial and superior clear spaces to appear wider with the foot in plantar flexion [82]. The distal fibula features a convex medial surface that articulates with the concave incisura fibularis of the distal lateral tibia [82]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation, with ankle dorsiflexion resulting in external rotation and proximal translation of the fibula [82].

Ligamentous Anatomy

The lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [82]. The anterior talofibular ligament originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [82]. The calcaneofibular ligament extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus, while the posterior talofibular ligament extends from the posterior lateral malleolus to the posterolateral talus [82]. The anterior talofibular ligament is the weakest ankle ligament, whereas the posterior talofibular ligament is the strongest [82]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [82].

The deltoid ligament complex is the primary ankle stabilizer during stance [82]. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body and functions primarily to resist lateral talar translation and external rotation [82]. The posterior deep deltoid is the most important component of the deep deltoid ligament [82]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament, functioning primarily to resist valgus and eversion ankle forces [82]. The deltoid ligament consists of superficial and deep layers, with at most six bands of which only three are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [85]. The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [85]. The deep portion of the deltoid ligament is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [85]. The deep posterior tibiotalar ligament is the strongest band of the deltoid complex [85]. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [85]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion, while the dominant mode of failure for the superficial deltoid ligament is at its insertion on the anterior malleolus [85].

Biomechanics and Motion

The ankle joint is responsible for most sagittal plane motion of the foot and ankle, contributing also to inversion, eversion, and rotation [82]. Normal ankle range of motion includes 23 to 48 degrees of plantar flexion and 10 to 23 degrees of dorsiflexion [82]. A simplified model of the ankle joint has a horizontal axis from anteromedial to posterolateral and a coronal axis from superomedial directed distally and laterally to the tip of the fibula [82]. Substantial ankle malalignment, mostly varus deformity, is common in ankles with end-stage osteoarthritis [61]. Arthrodesis of the ankle joint results in significant limitation of daily activities with reduced function of the affected limb and changes in spatial and temporal movement, weight bearing profile and contact surface [102]. While normal gait is not achieved after ankle arthrodesis, the improvement from preoperative levels is clinically significant [23]. Increasing the shoe instep by 1 cm or 2 cm shifted the ground reaction force closer to the metatarsal heads at heel-off and reduced maximal foot and tibia dorsiflexion angle in patients with tibiotalar arthrodesis [143].

Pathophysiology of Arthritis and Instability

Ankle arthrodesis remains the gold standard for symptomatic ankle arthritis but is associated with high rates of adjacent joint arthrosis [6]. There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis [19]. Surgical management for end-stage ankle osteoarthritis currently focuses on ankle arthrodesis and total ankle arthroplasty [20]. Foot and ankle arthrodesis remains the benchmark procedure for end-stage arthritis of the foot and ankle or other conditions that result in notable distortion of the normal anatomy and function of the distal lower extremity [25]. Nonunion is a potential complication of foot and ankle fusion surgery and has been associated with poor functional outcomes [25]. Patients at high risk of nonunion, such as those with medical comorbidities (diabetes, neuropathy, and osteonecrosis) and/or history of smoking or alcohol use, can have nonunion rates up to 40% [25].

Ligamentous injury-induced ankle instability causing posttraumatic osteoarthritis in a mouse model indicates that severe ankle instability has nearly three times the chance to develop into ankle osteoarthritis compared to moderate ankle instability [120]. Transected mice in the calcaneofibular ligament plus anterior talofibular ligament and calcaneofibular ligament plus deltoid ligament groups displayed mechanical instability of the ankle-subtalar joint complex, and some mice in the calcaneofibular ligament plus deltoid ligament group suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure [136]. Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging, as currently used imaging options cannot accurately predict subtalar joint instability [77].

Classification

Modified Cedell’s Classification: This system categorises ankle arthritis by severity, defining degree 1 as mild, degrees 2 and 3 as moderate, and degree 4 as severe [147]. Low tibial osteotomy is indicated for the intermediate stage of moderate ankle arthritis with a medial joint lesion within this framework [147].

Modified Takakura Ankle Osteoarthritic Stage: In a systematic review of supramalleolar osteotomy, the most commonly utilized radiographic parameter for classification was the tibial anterior surface angle (TAS) [159]. The distribution of ankles across the modified Takakura stages in that review was as follows: stage 1 comprised 74 ankles (10.1%), stage 2 comprised 200 ankles (27.4%), stage 3a comprised 302 ankles (41.4%), stage 3b comprised 137 ankles (18.8%), and stage 4 comprised 17 ankles (2.3%) [159].

Other Considerations: Patients with severe progressive collapsing foot deformity (PCFD) achieved greater radiographic correction than those with mild collapse after isolated ankle arthrodesis [15]. Functional improvements did not differ between patients with severe and mild PCFD after isolated ankle arthrodesis [15]. Arthroscopic ankle arthrodesis provides similarly satisfactory surgical outcomes in ankles with severe deformity compared with mild deformity in elderly patients [5]. Arthroscopic ankle arthrodesis is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older, resulting in a high union rate and low complication rate even in cases with severe preoperative deformity [5]. Arthroscopic ankle arthrodesis and open ankle arthrodesis resulted in comparable clinical outcomes to total ankle replacement in patients with non-deformed, COFAS Type-1 end-stage ankle arthritis [26].

Clinical Presentation

Ankle arthrodesis is indicated for the relief of functionally disabling ankle arthritis, deformity, and pain in carefully selected patients [12]. It remains the gold standard for the treatment of end-stage ankle arthritis [6]. The procedure is effective for degenerative ankle disease, resulting in good or excellent functional outcomes at a mean of 86 months post-operatively in nearly three-quarters of the patient cohort [4]. Surgical treatment significantly improves ambulatory activity, with greater change occurring at high activity levels [47]. Abnormalities of gait caused by ankle arthritis are improved by ankle arthrodesis, although normal gait is not achieved [23]. The improvement in gait from preoperative levels following ankle arthrodesis is clinically significant [23].

A careful history and physical examination, appropriate radiographs, and, when necessary, differential selective anesthetic blocks help limit fusion to only those joints that are causing pain [62]. Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint seem not to be indicative for a successful outcome of an arthrodesis of the affected joint [63]. There is no true consensus in the literature regarding whether ankle arthrodesis leads to adjacent-joint arthritis [19].

Arthroscopic vs. Open Approach

Arthroscopic ankle arthrodesis produces good results in patients who have osteoarthritis of the ankle with minimum or no deformity [14]. The immediate postoperative morbidity following arthroscopic ankle arthrodesis is of very short duration [14]. Compared to open arthrodesis, the arthroscopic approach offers better clinical scores, fewer complications, and shorter hospitalization [17]. Union rates, reoperation rates, and operative times are similar between arthroscopic and open ankle arthrodesis [17].

Comparative Outcomes and Deformity

Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation [2]. Rates of reoperation and major complications were higher after ankle replacement than after arthrodesis [2]. Patients with severe progressive collapsing foot deformity achieved greater radiographic correction than those with mild collapse after isolated ankle arthrodesis [15]. Functional improvements did not differ between patients with severe and mild progressive collapsing foot deformity after isolated ankle arthrodesis [15]. Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and severe planar deformities, providing a stable and painless foot for ambulation [64].

Risk Factors

Patients who are at high risk of nonunion, such as those with medical comorbidities (diabetes, neuropathy, and osteonecrosis) and/or history of smoking or alcohol use, can have nonunion rates up to 40% [25].

Investigations

Plain radiography: Stress radiographs confirm instability in chronic ankle instability by obtaining a lateral radiograph during the anterior drawer test and a mortise radiograph during the talar tilt test [92]. In anterior ankle impingement, lateral radiographs may not show osteophytes; an anteromedial view is often helpful [96]. For ankle arthrodesis, fusion is determined on the basis of bridging trabeculation on all three weightbearing radiographic views [66]. Alignment is assessed on the anteroposterior, mortise, and lateral views [66]. On the anteroposterior and mortise views, alignment is assessed by measuring the angle between the longitudinal tibial axis and the lateral border of the talus [66]. For patients managed with tibiotalocalcaneal arthrodesis, a lateral foot radiograph and a Broden view are evaluated to determine fusion of the subtalar joint [66].

MRI: MRI is useful in evaluating for associated pathology to the peroneal tendons or talar articular surface in the setting of chronic ankle instability [92]. However, MRI does not help determine functional instability in chronic ankle instability [92]. In anterior ankle impingement, MRI is not very sensitive for soft-tissue impingement [96]. MR arthrography or contrast-enhanced, fat-suppressed, three-dimensional (3D), fast-gradient recalled acquisition in the steady state with radiofrequency spoiling (CE 3D-FSPGR) MRI is more sensitive and specific for soft-tissue impingement than standard MRI [96].

Other Considerations: Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint are not indicative for a successful outcome of an arthrodesis of the affected joint [63]. Careful physical examination and diagnostic injection can help to pinpoint the diagnosis in anterior ankle impingement [96]. The use of intraarticular injections for diagnosis has been questioned because of the potential cytotoxicity to chondrocytes, although there are no studies substantiating the effects in the clinical setting [96]. In one study of anterior ankle impingement, 58% of patients had an associated diagnosis that changed the surgical plan in 33% of cases [96].

Coronal plane alignment is assessed clinically from a posterior perspective by measuring the axis of the hindfoot relative to the axis of the distal part of the leg with use of a goniometer [66]. Varus malalignment is defined radiographically as a lack of physiologic hindfoot valgus (approximately 5°) [66]. Excessive valgus malalignment is defined radiographically as ≥10° of hindfoot valgus [66]. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score is used to assess clinical and functional outcome, with a maximum score of 100 points [66]. The AOFAS ankle-hindfoot score allocates 40 points for pain, 50 points for function, and 10 points for alignment [66]. With successful ankle fusion, the maximum AOFAS score is 92 points because 8 points are forfeited in sagittal plane motion [66]. For patients with a previous subtalar or triple arthrodesis, the maximum AOFAS score is 86 points, accounting for the additional loss of inversion-eversion [66].

Treatment

Non-Operative

Ankle arthrodesis is indicated for patients with painful limited motion of the ankle who have failed conservative measures [58]. Joint-preserving and joint-sacrificing techniques are available for managing ankle arthritis, including medication, bracing, injections, osteotomies, arthrodesis, and arthroplasty [34]. Arthroscopic or open debridement of the arthritic ankle can be effective in the overall management plan but must be used judiciously and with realistic expectations of the outcome [56]. Efficacy has been shown for the removal of anterior impingement osteophytes from the tibia and/or talus [56]. Debridement of more advanced arthritic ankles provides only short-term relief and is not recommended in most cases [56].

Operative

Indications: Ankle arthrodesis is indicated for patients with painful limited motion of the ankle who have failed conservative measures and have diagnoses including posttraumatic arthritis, osteoarthritis, arthritis from chronic instability, rheumatoid or autoimmune inflammatory arthritis, gout, postinfectious arthritis, Charcot neuroarthropathy, osteonecrosis of the talus, failure of total ankle arthroplasty, or instability from neuromuscular disorders [58]. Ankle arthrodesis has long been the gold standard for the surgical treatment of moderate to severe ankle arthritis [46]. It is considered a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain when good surgical technique is used in carefully selected patients [12]. Circumstances in which arthrodesis might be the best procedure over total ankle arthroplasty include preexisting subtalar or other hindfoot arthritis, contralateral hindfoot or ankle arthritis, and hip or knee impairment where motion through the ankle joint may be beneficial to overall limb and patient function [46]. Surgical management for end-stage ankle osteoarthritis currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being a topic of debate [20].

Contraindications: Absolute contraindications to ankle fusion include vascular impairment of the limb and infection of the skin through which the surgical approach is planned [58]. Relative contraindications to ankle fusion include preexisting moderate-to-severe ipsilateral hindfoot arthritis and contralateral ankle arthritis likely to require surgical treatment in the foreseeable future [58].

Surgical Approach / Technique: Both open and arthroscopic ankle arthrodesis surgeries are safe and effective treatments for ankle arthritis [101]. Both arthroscopic and mini-open ankle arthrodesis had good clinical outcomes, with high union rates and lower rates of complications [71]. Compression arthrodesis of the ankle produces a satisfactory rate of fusion and an ankle that is functional, durable, and cosmetically superior to most ankles arthrodesed by other procedures [16]. Factors that generally improve results in ankle arthrodesis include arthroscopic or mini-incision technique, the use of more than two screws or an adjunct plate (or fibular strut), and a diagnosis of primary osteoarthritis [42].

Outcomes: Surgical treatment for end-stage ankle osteoarthritis resulted in satisfactory clinical outcomes in patients aged 75 years or older, with improvements comparable to those in younger patients [76]. Patients with severe progressive collapsing foot deformity achieved greater radiographic correction than those with mild collapse after isolated ankle arthrodesis, but functional improvements did not differ between groups [15]. Female sex is a negative predictor of outcomes in ankle arthrodesis, with clinical results significantly worse in women compared to men [29]. Men and women with end-stage ankle arthritis benefit from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement [8].

Complications and Nonunion: Nonunion rates for ankle arthrodesis vary widely in the literature, largely dependent on technique, underlying diagnosis, and patient selection [42]. Nonunion is a potential complication of foot and ankle fusion surgery associated with poor functional outcomes [25]. Nonunion after ankle arthrodesis is significantly more likely to occur with previous ipsilateral subtalar fusion and preoperative varus alignment [117]. The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union [134]. The presence of union may be difficult to establish, and physical findings of persistent swelling, pain at the fusion site, and difficulty with weight bearing should lead to careful scrutiny of plain radiographs [42]. Bridging callus across the fusion site on more than one view usually confirms successful fusion, while CT is necessary in some cases to establish fusion or evaluate nonunion [42].

Management of Nonunion: Assessment of a patient with a delayed union or nonunion begins with an overall assessment for medical issues, including drawing 25-hydroxyvitamin D levels, albumin, prealbumin, parathyroid hormone, thyroid stimulating hormone, calcium, C-reactive protein, erythrocyte sedimentation rate, and hemoglobin A1c levels [42]. Satisfactory immobilization of a delayed union in a protected weight-bearing boot or cast is necessary for management [42]. The use of pulsed electronic magnetic field devices with immobilization and limited weight bearing was successful in only five of 19 delayed unions of foot and ankle arthrodeses [42]. Revision arthrodesis for nonunion has reported successful fusion rates of 75% to 94% [42]. Bone autograft or allograft tissue with or without biologic augmentation can be used to facilitate fusion in patients with foot and ankle arthrodesis [25]. In a study of 82 patients with comorbidities requiring complex ankle arthrodesis, more patients with rhBMP-2 had fusion (93%) than those without rhBMP-2 (53%) [42]. There are no randomized level 1 studies that compare autograft to any commercially available product for use in ankle arthrodesis [42].

Adjacent Joint Effects: Progression of adjacent joint (subtalar and/or talonavicular) disease following ankle arthrodesis is one reason ankle arthroplasty may be more favorable [117]. In a study of 66 ankle fusions, significant radiologic progression of arthritis was reported in all adjacent joints [117]. In a study with a mean follow-up of 22 years, 91% and 57% of subtalar and talonavicular joints, respectively, developed moderate to severe arthritis after ankle arthrodesis [117]. The clinical significance of adjacent joint disease progression following ankle arthrodesis is unknown [117]. In a mid- to long-term outcome study, a moderate radiographic increase in adjacent subtalar and talonavicular arthritis was reported at a minimum of 5 years after arthrodesis [60]. In 140 ankles averaging 6.5 years’ follow-up, 40% and 34% of adjacent subtalar and talonavicular joints, respectively, showed progression of arthritic changes using the modified Kellgren Lawrence scale after arthrodesis [60].

Total Ankle Arthroplasty Comparison: Total ankle arthroplasty offers a reasonable alternative to ankle arthrodesis in carefully selected patients [39]. Overall patient satisfaction was high as were functional outcomes, supporting ankle arthroplasty as an option in the treatment of ankle arthritis [41]. The share of ankle replacement performed compared to arthrodesis increased markedly from 14% in 2007 to 45% in 2013, with arthrodesis patients continuing to have more comorbidities [60]. Arthrodesis has the advantage of predictable pain relief and the disadvantage of limited motion, whereas arthroplasty has the advantage of motion preservation and the disadvantage of more frequent complications [60]. A study involving 114 ankle arthroplasties and 47 ankle arthrodeses reported no significant difference in the mean improvement in pain and function between the two groups at a minimum of 2 years postoperatively, but complication rates were 54% after arthroplasty and 26% after arthrodesis [60]. In a systematic review including 1262 arthrodeses and 852 arthroplasties, revision rates were less than 10% and infection rates were less than 5% after both procedures [60]. In a multicenter study involving 321 patients, intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable, although reoperation and major complications were more frequent after ankle replacement [60]. In a multisite prospective cohort study of 517 patients, no statistically significant difference in adverse events was found at 1 year after either arthrodesis or arthroplasty [60]. Failure rates for total ankle arthroplasty ranged from 1% to 32%, with an overall mean failure rate of 12% [60]. Total ankle arthroplasty was determined to be a cost-effective alternative to ankle arthrodesis in a 60-year-old cohort with end-stage ankle arthritis [60].

Functional Outcomes and Patient Selection: Patients with total ankle replacement have higher expectations before surgery than do patients with arthrodesis and are more likely to have their expectations met [60]. Patients with total ankle replacement had higher scores than ankle arthrodesis patients in walking on uneven surfaces, upstairs, downstairs, and uphill [60]. In a study comparing 59 patients with total ankle arthroplasty to 46 with arthrodesis, functional results were significantly better in those with arthroplasty; however, there was no difference in terms of quality of life [60]. Gait analysis has shown that patients with total ankle replacement have a more normal gait pattern than those with arthrodesis [60]. Sports participation has been reported to be similar after both total ankle replacement and arthrodesis, with approximately 76% in both groups active in sports after surgery [60]. Total ankle replacement is possibly a better choice with respect to arthrodesis for highly active individuals, as it allows patients to increase participation in sports and recreation activities [119]. Satisfactory results can be achieved in patients with varus malalignment of 10 degrees or greater, which should not be considered a contraindication to total ankle replacement [69]. Total ankle replacement is likely to be successful in carefully selected rheumatoid patients with severe arthritis of the ankle that is unresponsive to conservative treatment [152].

Implant-Specific Outcomes: Early results of INBONE intramedullary-fixation total ankle arthroplasty demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of two years [49]. Primary total ankle arthroplasty with a Mayo implant yielded a good clinical result for 19%, a fair result for 35%, a poor result for 11%, and a failure for 35% of the ankles followed for at least two years [48].

Salvage and Conversion Procedures: Treatment of patients with a painful total ankle arthroplasty is complex and requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options [11]. Custom-made total ankle arthroplasty components should be encouraged as an alternative to arthrodesis of the ankle in patients with a failed TAA [72]. Poor outcomes were observed in fusion with Trabecular Metal implants after failed total ankle replacement in early results of 11 patients [75].

Joint-Preserving and Alternative Procedures: Periarticular osteotomies of the tibia, fibula, or hindfoot are reasonable approaches to the management of localized arthritis of the ankle [56]. The goal of realignment osteotomies is to unload the more arthritic portion of the joint and provide a more anatomic mechanical axis to the ankle to redistribute joint contact forces and loads [56]. Realignment surgery can delay the need for arthrodesis or arthroplasty in younger patients [56]. Chondral loss primarily in the medial or lateral gutter of the ankle with minimal involvement of the superior surface of the talus, especially with supramalleolar deformity, seems best suited for realignment osteotomy [56]. Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes [55]. Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques [33].

Distraction Arthroplasty: Joint distraction arthroplasty is based on the concept that mechanical unloading of the joint and the intermittent flow of intraarticular synovial fluid encourage cartilage healing [43]. Twenty-one (98%) of 23 patients reported by Tellisi et al. reported decreased pain after distraction arthroplasty; other series have reported good results in approximately 75% [43]. In a randomized controlled trial, patients with motion distraction had earlier and consistently better outcomes than those with fixed distraction [43]. Adverse events associated with distraction arthroplasty included 43 pin-track infections and eight neurapraxias [43]. The beneficial effects of distraction are not immediate and tend to occur over a long period of time, ranging from 6 months to 2 years [43]. The ideal candidate for distraction arthroplasty is a young motivated patient whose symptoms are not relieved with conservative measures and who is unwilling to have an arthrodesis [43]. Contraindications for distraction arthroplasty include active infection, advanced coronal plane deformity, significant loss of bone stock, and patients who are poor frame candidates [43]. Uncontrolled diabetes, tobacco use, chronic edema of the lower limb, severe ankle deformity, and severe ankle ankylosis are relative contraindications for distraction arthroplasty [43]. In a randomized study, functional outcomes and quality of life were similar with debridement and a hinged distraction compared to debridement alone, although the rate of post-operative revision surgery was higher if distraction was not used [43]. Currently, there is not enough high-level evidence to support ankle joint distraction for generally accepted indications [43]. Hinges for distraction arthroplasty should be placed along the axis of the ankle joint (Inman axis) to prevent uneven joint distraction and preserve joint motion [43]. Use of a forefoot wire should be avoided in distraction arthroplasty because it is very uncomfortable and discourages weight bearing [43]. No more than 5 to 6 mm of acute distraction should be applied in the operating room for distraction arthroplasty [43]. Range-of-motion exercises should be started early to preserve ankle mobility during distraction arthroplasty [43]. A circular fixator is superior

Complications

Ankle Arthrodesis

Surgical Approach: Arthroscopic and mini-open ankle arthrodesis are associated with lower rates of complications compared to open arthrodesis [17, 71, 74]. Arthroscopic techniques maintain a low complication rate even in patients aged 60 years or older with severe preoperative deformity [5]. The use of a posterior blade-plate for hindfoot arthrodesis is associated with a higher proportion of patients experiencing delayed union and nonunion compared to other approaches [79]. The overall proportion of patients with complications following posterior blade-plate hindfoot fusion is high [79].

Infection: In a systematic review including 1262 arthrodeses, infection rates after ankle arthrodesis were less than 5% [60]. Ankle arthrodesis with an Ilizarov external fixator for septic ankle arthritis is associated with disappointingly high morbidity [144].

Union and Revision: In a systematic review including 1262 arthrodeses, revision rates after ankle arthrodesis were less than 10% [60]. In a study of 114 ankle arthroplasties and 47 ankle arthrodeses, the complication rate was 26% after arthrodesis [60]. In a German-wide retrospective study of 1,525 patients undergoing ankle arthrodesis, the average unplanned reoperation-free time was estimated at 17.41 years [138].

Adjacent Joint Arthritis: In a study of 140 ankles with ankle arthrodesis, 40% of adjacent subtalar joints showed progression of arthritic changes at a minimum of 5 years follow-up [60]. In the same study, 34% of adjacent talonavicular joints showed progression of arthritic changes at a minimum of 5 years follow-up [60].

Other Considerations: In a multicenter study of 321 patients, major complications were more frequent after ankle replacement than after ankle arthrodesis [60]. In the same multicenter study, reoperation rates were higher after ankle replacement than after ankle arthrodesis [60]. In a multisite prospective cohort study of 517 patients, there was no statistically significant difference in adverse events at 1 year between ankle arthrodesis and arthroplasty [60]. In a German-wide retrospective study, no significant difference in reoperation-free survival was found between the ankle arthrodesis group and the total ankle replacement group [138]. In a study of 50 ankle fusions, sufficient post-operative complaints were observed to emphasize the need for careful patient selection [1]. In a study of 25 ankle arthrodeses and 25 replacements, clinical results were less satisfactory after total ankle replacement than after arthrodesis [7]. In the same study, surgical revision rates were significantly higher after total ankle replacement, mainly due to periprosthetic cysts [7]. In a study of 36 patients undergoing distraction arthroplasty, adverse events included 43 pin-track infections and eight neurapraxias [43].

Total Ankle Arthroplasty

General Complication Rates: Total ankle arthroplasty is associated with more frequent complications than ankle arthrodesis [60]. In a study of 114 ankle arthroplasties, the complication rate was 54% [60]. In a study of 2340 ankles across 95 academic centers, the overall complication rate for total ankle arthroplasty was 1.4% [121]. In the same study, the complication rate for total ankle arthroplasty was less than 0.5% after 2007 [121]. In the same study, the readmission rate for total ankle arthroplasty was 3% [121].

Infection: In a systematic review including 852 arthroplasties, infection rates after total ankle arthroplasty were less than 5% [60]. In a study of 1105 ankles with mobile and fixed bearing implants, deep infections occurred in 0% to 5% of cases [121]. A history of bariatric surgery is not an important predictor of joint infection, instrumentation removal, or ORIF within 5 years after primary total ankle arthroplasty [70].

Revision and Failure: In a systematic review including 852 arthroplasties, revision rates after total ankle arthroplasty were less than 10% [60]. Failure rates for total ankle arthroplasty range from 1% to 32%, with an overall mean failure rate of 12% [60]. In a study of 644 patients undergoing total ankle replacement, the proportion of patients without an unplanned reoperation at 5 years was 75% [138]. In the same study, the average unplanned reoperation-free time was estimated at 17.09 years [138].

Implant-Specific Complications: Salto Talaris: In a study of 67 ankles with Salto Talaris implants, 15 patients (22%) experienced 23 complications [121]. In a study of 96 patients (98 ankles) with Salto implants, the reoperation rate was 35% [121]. In a study of 1421 ankles with Salto implants, the revision rate was 4% for mobile bearing and 2.4% for fixed bearing [121]. HINTEGRA: In a study of 50 ankles with HINTEGRA implants, osteolysis was identified in 24 ankles (48%) [121]. In a study of 54 ankles with HINTEGRA and MOBILITY implants, ankle impingement syndrome was significantly more common with HINTEGRA [121]. In a study of 684 patients (722 ankles) with HINTEGRA implants, 61 ankles (8%) had revision arthroplasties [121]. MOBILITY: In a study of 54 ankles with HINTEGRA and MOBILITY implants, intraoperative malleolar fracture occurred only with the MOBILITY implant [121]. In a study of 106 ankles with MOBILITY implants, the complication rate was 12% [121]. In a study of 85 patients (88 ankles) with MOBILITY implants, 8 ankles (9%) required revision [121]. INBONE: In a study of 59 ankles with INBONE implants, 14 patients (2%) required reoperation because of a complication [121]. In a study of 194 patients (194 ankles) with INBONE implants, the revision rate was 6% [121]. STAR: In a study of 98 ankles with STAR implants, 32 ankles (29%) required metal component revision and/or polyethylene bearing exchange [121]. In a study of 45 patients (52 ankles) with STAR implants, the revision rate was 17% [121]. In a study of 76 patients (78 ankles) with STAR implants, additional surgeries were performed in 17% of cases [121]. In a study of 82 patients (82 ankles) with STAR implants, additional surgeries were performed in 17% of cases [121]. In a study of 72 patients (77 ankles) with STAR implants, 29 patients (38%) required revision of at least one metallic component [121]. In a study of 18 patients (18 ankles) with STAR implants, additional surgery was required in 39% of cases [121]. In a study of 2088 ankles with STAR implants, the 5-year survival rate was 86% [121]. In the same study, the 10-year survival rate was 71% [121]. Agility: In a study of 2312 ankles with Agility implants, the revision rate was approximately 10% [121]. Mayo: Primary total ankle arthroplasty with a Mayo implant yielded a failure rate of 35% in ankles followed for at least two years [48].

Bearing Type Outcomes: In a study of 1107 ankles with mobile bearing implants, complication rates ranged from 2% to 15% [121]. In the same study, secondary surgery was performed in 12% of cases [121]. In the same study, arthrodesis was performed in 6% of cases [121]. In a study of 852 ankles with mobile and fixed bearing implants, the revision rate was 7% [121]. In a study of 7942 ankles with STAR, Hintegra, and TNK implants, the overall survivorship at 10 years was 89% [121].

Patient Age Factors: Younger patients (<55 years) undergoing total ankle arthroplasty have higher rates of any reoperation compared to patients aged 55 to 70 years and >70 years [142]. Younger patients (<55 years) undergoing total ankle arthroplasty have higher rates of implant failure compared to patients aged 55 to 70 years and >70 years [142]. Younger patients (<55 years) undergoing total ankle arthroplasty have higher rates of polyethylene exchange compared to patients aged 55 to 70 years and >70 years [142]. In a study of 1,115 patients, the rate of any reoperation for total ankle arthroplasty was 19.9% in patients <55 years, 11.7% in patients 55 to 70 years, and 6.5% in patients >70 years [142]. In the same study, the rate of implant failure for total ankle arthroplasty was 5.6% in patients <55 years, 2.9% in patients 55 to 70 years, and 1.1% in patients >70 years [142]. In the same study, the rate of polyethylene exchange for total ankle arthroplasty was 7.7% in patients <55 years, 4.3% in patients 55 to 70 years, and 2.3% in patients >70 years [142].

Salvage Procedures: In a study of 11 patients, fusion with Trabecular Metal implants after failed total ankle replacement resulted in poor outcomes [75]. Salvage fusion after a failed total ankle arthroplasty shows moderate rates of failure and reoperations [9]. Nearly 25% of patients requiring salvage fusion after a failed total ankle arthroplasty require revision within three years [9].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for manual work, sport, or full range-of-motion and strength return.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The evidence provided does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression, or sling and brace removal timing.

Functional milestones: Arthroscopic ankle arthrodesis results in good or excellent functional outcomes at a mean of 86 months post-operatively in nearly three-quarters of the patient cohort [4]. While normal gait is not achieved following ankle arthrodesis, the improvement from preoperative levels is clinically significant [23].

Other Considerations: Ankle arthrodesis remains the gold standard but is associated with high rates of adjacent joint arthrosis [6]. Fusion rates of 76% to 100% are reported for tibiotalocalcaneal arthrodesis using intramedullary nails, with time to fusion of approximately 16 weeks [165]. The proportion of patients treated with a posterior blade-plate hindfoot fusion who had delayed union and nonunion was greater than that reported for patients in other series who underwent primary hindfoot arthrodesis with other approaches [79]. The proportion of patients with complications following posterior blade-plate hindfoot fusion was high [79].

Key Evidence

• [L2] Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation; rates of reoperation and major complications were higher after ankle replacement. [2] (10.2106/jbjs.l.01597)
• [L4] Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients. [3] (10.2106/jbjs.o.00396)
• [L4] Arthroscopic ankle arthrodesis is an effective operation for treating degenerative ankle disease, resulting in good/excellent functional outcomes at a mean of 86 months post-operatively in nearly three-quarters of the patient cohort. [4] (10.1016/j.arthro.2016.03.077)
• [L3] Arthroscopic ankle arthrodesis is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older, resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity. [5] (10.1016/j.arthro.2020.05.036)
• [L4] Ankle arthrodesis remains the gold standard but is associated with high rates of adjacent joint arthrosis. [6] (10.5435/jaaos-d-25-00638)
• [L3] Clinical results were less satisfactory after total ankle replacement than after arthrodesis, with significantly higher surgical revision rates mainly due to periprosthetic cysts. [7] (10.1016/j.otsr.2018.10.014)
• [L4] Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. [8] (10.2106/jbjs.21.00287)
• [L3] Salvage fusion after a failed total ankle arthroplasty shows moderate rates of failure and reoperations, with nearly 25% of patients requiring revision within three years. [9] (10.1302/0301-620x.105b10.bjj-2023-0010.r1)
• [L4] Treatment of patients with a painful total ankle arthroplasty is complex and requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options. [11] (10.5435/jaaos-d-14-00017)
• [L5] When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain. [12] (10.5435/00124635-200005000-00007)
• [L4] For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation. [13] (10.1097/01.blo.0000132460.27102.d6)
• [L4] Arthroscopically assisted arthrodesis of the ankle produces good results in patients who have osteoarthritis of the ankle with minimum or no deformity, and the immediate postoperative morbidity is of very short duration. [14] (10.2106/00004623-199407000-00023)
• [L2] Patients with severe PCFD achieved greater radiographic correction than those with mild collapse after isolated ankle arthrodesis, but functional improvements did not differ between groups. [15] (10.1097/corr.0000000000003756)
• [L4] This procedure produces a satisfactory rate of ankle arthrodesis and an ankle that is functional, durable, and cosmetically superior to most of those that are arthrodesed by other procedures. [16] (10.2106/00004623-198365020-00011)
• [L5] Arthroscopic ankle arthrodesis offers better clinical scores, fewer complications, and shorter hospitalization compared to open arthrodesis, although union rates, reoperation rates, and operative times are similar. [17] (10.1016/j.arthro.2018.01.006)
• [L1] There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. [19] (10.2106/jbjs.n.00426)
• [L5] Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being the topic of much debate. [20] (10.5435/jaaos-d-23-00743)
• [L4] For patients with pain at the site of a failed ankle arthrodesis, conversion to total ankle arthroplasty with the use of a three-component ankle implant is a viable treatment option that provides reliable intermediate-term results. [21] (10.2106/jbjs.i.01301)
• [L3] Both ankle arthrodesis and tibiotalocalcaneal arthrodesis are effective procedures that resulted in good pain control, allowed return to work, and improved activity participation with high patient satisfaction. [22] (10.1177/1071100713478929)
• [L3] While normal gait is not achieved, the improvement from preoperative levels is clinically significant. [23] (10.1302/0301-620x.98b10.37614)
• [L4] [25] (10.5435/jaaosglobal-d-23-00216)
• [L3] Arthroscopic ankle arthrodesis and open ankle arthrodesis resulted in comparable clinical outcomes to total ankle replacement in patients with non-deformed, COFAS Type-1 end-stage ankle arthritis. [26] (10.2106/jbjs.18.01012)
• [L3] The clinical results were significantly worse in women after ankle arthrodesis, which should be considered when determining the indication. [29] (10.1186/s13018-024-05045-8)
• [L4] Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques. [33] (10.1302/2058-5241.2.160021)
• [L4] This review discusses both joint-preserving and joint-sacrificing techniques for managing ankle arthritis, noting that while joint-sacrificing procedures dominated historic management, various options including medication, bracing, injections, osteotomies, arthrodesis, and arthroplasty are available. [34] (10.5435/jaaos-d-24-00955)
• [L4] Total ankle arthroplasty offers a reasonable alternative to ankle arthroplasty in carefully selected patients. [39] (10.1302/2058-5241.3.170029)
• [L4] Overall patient satisfaction was high as were functional outcomes, supporting ankle arthroplasty as an option in the treatment of ankle arthritis. [41] (10.1302/0301-620x.103b4.bjj-2020-0758.r1)
• [L3] The inclusion of new data on patients who underwent surgery between 2005 and 2010 demonstrates increasing utilization and lower complication rates for total ankle replacement compared with ankle arthrodesis. [44] (10.2106/jbjs.15.01341)
• [L2] Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. [47] (10.2106/jbjs.18.00511)
• [L4] Early results of INBONE intramedullary-fixation total ankle arthroplasty demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of two years. [49] (10.2106/jbjs.n.00227)
• [L5] Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes. [55] (10.5435/jaaos-d-12-00124)
• [L3] Substantial ankle malalignment, mostly varus deformity, is common in ankles with end-stage osteoarthritis. [61] (10.1007/s11999-014-3960-8)
• [L5] [62] (10.5435/00124635-200409000-00007)
• [L3] Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint seem not to be indicative for a successful outcome of an arthrodesis of the affected joint. [63] (10.1186/1471-2474-15-11)
• [L5] Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and severe planar deformities, providing a stable and painless foot for ambulation. [64] (10.5435/jaaos-d-14-00102)
• [L4] [66] (10.2106/jbjs.g.00506)
• [L2] Satisfactory results can be achieved in patients with varus malalignment of ≥10°, which should not be considered a contraindication to total ankle replacement. [69] (10.2106/jbjs.l.00797)
• [L3] A history of bariatric surgery is not an important predictor of joint infection, instrumentation removal, or ORIF within 5 years after primary total ankle arthroplasty or arthrodesis. [70] (10.5435/jaaos-d-24-01267)
• [L3] Both arthroscopic and mini-open ankle arthrodesis had good clinical outcomes, with high union rates and lower rates of complications. [71] (10.1016/j.arthro.2017.08.160)
• [L4] This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA. [72] (10.1302/0301-620x.99b2.bjj-2016-0504.r2)
• [L4] Both arthroscopic and mini-open ankle arthrodesis had a good clinical outcomes, with high union rate and lower rate of complications. [74] (10.1016/j.arthro.2013.07.055)
• [L4] [75] (10.1016/j.otsr.2017.11.022)
• [L3] Surgical treatment for end-stage ankle OA resulted in satisfactory clinical outcomes in patients aged ≥75 years, with improvements comparable to those in younger patients. [76] (10.1186/s13018-023-03734-4)
• [L4] Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging. [77] (10.1007/s00167-018-5232-8)
• [L4] [79] (10.1007/s11999-016-4955-4)
• [L2] Both open and arthroscopic ankle arthrodesis surgeries are safe and effective treatments for ankle arthritis. [101] (10.5435/jaaos-d-25-00590)
• [L4] Arthrodesis of the ankle joint results in significant limitation of daily activities with reduced function of the affected limb and changes in spatial and temporal movement, weight bearing profile and contact surface. [102] (10.1186/s13018-026-06842-z)
• [L4] Total ankle replacement is possibly a better choice with respect to arthrodesis for highly active individuals, as it allows patients to increase participation in sports and recreation activities. [119] (10.1055/s-0037-1601408)
• [L5] Based on the mouse model, the findings indicate that severe ankle instability has nearly three times the chance to develop into ankle OA compared to moderate ankle instability. [120] (10.1186/s12891-022-05164-5)
• [L4] The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation. [134] (10.1016/j.otsr.2016.03.015)
• [L5] Transected mice in the CL+ATFL and CL+DL groups displayed mechanical instability of the ankle-subtalar joint complex, and some mice in the CL+DL group also suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure. [136] (10.1186/s13018-021-02683-0)
• [L3] [138] (10.1186/s12891-024-07612-w)
• [L3] [142] (10.2106/jbjs.23.00122)
• [L4] Increasing the shoe instep by 1 cm or 2 cm shifted the ground reaction force closer to the metatarsal heads at heel-off and reduced maximal foot and tibia dorsiflexion angle. [143] (10.1097/01.blo.0000180892.10666.43)
• [L5] The author states that while the success of ankle arthrodesis with an Ilizarov external fixator is impressive, the morbidity is disappointingly high, and future efforts should focus on reducing surgical and psychologic complications. [144] (10.1097/corr.0000000000002505)
• [L4] [147] (10.1007/s004020000243)
• [L4] Total ankle replacement is likely to be successful in carefully selected rheumatoid patients with severe arthritis of the ankle that is unresponsive to conservative treatment. [152] (10.2106/00004623-198466030-00004)
• [L4] [159] (10.1007/s00167-022-07144-7)
• [L5] Fusion rates of 76% to 100% are reported, with time to fusion of approximately 16 weeks. [165] (10.5435/00124635-201201000-00001)

See Also

• Ankle osteoarthritis
• Total ankle replacement
• Chronic ankle instability
• Ankle impingement
• Charcot neuroarthropathy

References

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