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Ankle osteoarthritis

108 citationsUpdated Sep 2026

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Overview

Ankle osteoarthritis management follows a staged algorithm based on disease severity and alignment. In early stages involving malalignment, periarticular osteotomies are the only interventions with sufficient evidence for recommendation [2]. Realignment surgery aims to unload arthritic joint portions and redistribute contact forces, potentially delaying arthrodesis or arthroplasty in younger patients [27]. For end-stage disease, surgical management focuses on ankle arthrodesis and total ankle arthroplasty [17]. While both procedures can produce satisfactory functional results when correctly indicated [2], specific indications for choosing one over the other remain debated [17]. No level I studies have directly compared these options, and literature reports are contradictory [46]. Consequently, current results do not permit absolute certainty between total ankle replacement and ankle fusion, necessitating more robust studies to definitively determine the most appropriate procedure [16].

Recent reports favor total ankle arthroplasty with latest-generation implants over arthrodesis, citing better functional outcomes, fewer complications, and higher patient satisfaction [46]. However, intermediate outcome comparisons show comparable clinical results, with higher reoperation and major complication rates after arthroplasty [46]. Arthrodesis remains a mainstay of treatment but is not optimal for all patients due to loss of motion and risk of adjacent joint degeneration [27]. Circumstances favoring arthrodesis include preexisting subtalar or hindfoot arthritis, contralateral hindfoot or ankle arthritis, and hip or knee impairment where ankle motion benefits overall limb function [46]. Gait appears improved by either procedure, though some studies report more nearly normal gait and better uneven-surface walking after arthroplasty [46].

Patient selection and demographics influence outcomes and treatment preference. Men and women with end-stage ankle arthritis benefit from both arthrodesis and total ankle replacement with similar magnitudes of improvement [49]. However, clinical results after ankle arthrodesis were significantly worse in women compared to men [70], whereas gender did not seem to affect total ankle arthroplasty outcomes [15]. Fracture posttraumatic osteoarthritis is associated with a markedly higher complication rate and risk of prosthesis explant after total ankle arthroplasty compared to primary osteoarthritis [67]. Several patient characteristics are associated with preference for one procedure over the other, which can guide counseling on treatment options [11]. The number of publications describing utilization trends for these procedures is limited and declining [132].

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 [91]. The talar dome is wider anteriorly and narrower posteriorly [91]. During motion from plantar flexion to dorsiflexion, the ankle mortise widens 1 to 1.5 mm [91]. Consequently, medial and superior clear spaces appear wider with the foot in plantar flexion [91]. The ankle joint is responsible for most sagittal plane motion of the foot and ankle, with normal motion including 23 to 48 degrees of plantar flexion and 10 to 23 degrees of dorsiflexion [91].

The distal tibiofibular joint consists of the convex medial surface of the distal fibula and the concave incisura fibularis of the distal lateral tibia [91]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [91]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [91]. Radiographic parameters include a talocrural angle of approximately 83 degrees, which should be symmetrical with the contralateral ankle [100]. The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [100]. The tibiofibular clear space, measured 10 mm above the joint line, is relatively constant with rotation and has an accepted normal parameter of greater than 5 mm [100]. The tibiofibular overlap, measured 10 mm above the joint line, is highly variable dependent on rotation, with accepted normal parameters of less than 5 mm on the AP view and less than 1 mm on the mortise view [100]. The "ball sign" is a visual cue on the AP view where an unbroken curve connects the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length [100]. Shortening of the fibula results in lateral and valgus subluxation of the talus [100]. The size of the medial clear space more than doubles depending upon the rotational position of the limb [100], with a significant increase in medial clear space observed with ankle plantarflexion [100]. On a mortise view radiograph, the condensed subchondral bone should form a continuous line around the talus [105]. The distance between the medial wall of the fibula and the incisural surface of the tibia, known as the tibiofibular clear space, should be 6 mm or less on a mortise view [105].

Ligamentous Anatomy

The lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [91]. The anterior talofibular ligament (ATFL) 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 [91]. The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [91]. The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [91]. The ATFL is the weakest ankle ligament and the PTFL is the strongest [91]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [91].

The deltoid ligament complex is the primary ankle stabilizer during stance [91]. 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 [91]. The posterior deep deltoid is the most important component of the deep deltoid ligament [91]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [91]. The superficial deltoid ligament functions primarily to resist valgus and eversion ankle forces [91]. More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the ATFL and CFL [56]. Medial ligament injuries are usually seen in association with a fracture or joint injury [56].

The deltoid ligament consists of superficial and deep layers, with the deep portion being the primary medial stabilizer of the ankle joint [96]. The deep posterior tibiotalar ligament is the strongest component of the deltoid complex [96]. The deep deltoid ligament has a load to failure of 713.8 N ± 69.3, which is higher than that of the lateral collateral ligaments [96]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [96]. The dominant mode of failure for the superficial deltoid ligament is at its insertion on the anterior malleolus [96]. Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid ligaments [96]. The deltoid ligament has a rich vascular supply from the medial tarsal artery, posterior tibial artery, and tibialis anterior artery, as well as intraosseous supply from the talus or medial malleolus [96]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [131].

Pathophysiology

Ankle osteoarthritis is almost always secondary to an underlying disorder such as malunited fracture, recurrent instability, osteochondritis dissecans of the talus, avascular necrosis of the talus, or repeated bleeding with haemophilia [87]. 70% to 80% of ankle arthritis is posttraumatic in origin and is often seen in younger patients compared with degenerative or systemic ankle arthritis [3]. Ankle osteoarthritis accounts for 4% of all osteoarthritis cases, compared to 41% for the knee and 19% for the hip [36]. 78% of ankle osteoarthritis is post-traumatic, compared to 9% of primary osteoarthritis [36]. In 13% of posttraumatic osteoarthritis cases, the cause is a ligamentous lesion [3]. Lesions of the lateral ankle ligament complex are the main cause for developing ligamentous posttraumatic ankle arthritis, accounting for 85% of cases [3]. Medial ligament lesions account for 12% of ligamentous posttraumatic ankle arthritis cases and combined medial-lateral ligament lesions account for 3% [3]. The most frequent mechanism of injury for lateral ligament lesions leading to posttraumatic ankle arthritis is the unexpected and rapid hyperinversion of the hindfoot [3]. Sports injuries were the underlying cause in 55% of cases of ligamentous posttraumatic ankle arthritis [3]. Soccer injuries were the most likely sports injury to cause ligamentous posttraumatic ankle arthritis, representing 33% of all reported sports injury cases in the arthritis cohort [3].

An asymptomatic cartilage lesion of the ankle that does not involve damage to the subchondral bone plate may arise from a traumatic event such as an ankle sprain or fracture [89]. Superficial lacerations of articular cartilage that are limited in size and depth neither heal nor progress to more serious disorders [89]. The incidence of reported osteochondral damage after ankle sprain or fracture is 45% [89]. In nearly 80% of patients with osteochondral lesions of the talus (OLT), a history of ankle trauma can be found [88]. 38% of patients with OLT present with ankle ligament laxity and 39% of patients with ankle instability present with an OLT [88]. Acute trauma and repetitive micro-traumata due to ankle instability and/or hindfoot malalignment are leading causes of OLT [88]. In an ankle with chondral damage, synovial fluid penetrates microfractures, and loading leads to high fluid pressure that induces osteonecrosis and later cyst formations [88]. The poor vascularization of the talus leads to a higher risk of osteonecrosis and decreased healing capacity [88]. Cartilage damage itself does not lead to pain, but the osteonecrosis of the highly innervated subchondral bone underneath the cartilage defect does [88].

Severe ankle instability has nearly three times the chance to develop into ankle osteoarthritis compared to moderate ankle instability [150]. The dynamic congruency of the joint, influenced by ligamentous integrity, is the main anatomical component in mechanical ankle instability [94]. Abnormal internal rotation of the talus in patients with mechanical ankle instability is decreased after ankle lateral stabilization surgery [124]. The number of mechanoreceptors is negatively correlated with ankle sensorimotor dysfunction in chronic ankle joint instability [118]. OA in the hip, knee, or ankle reduces effective exchange of potential and kinetic energy, potentially increasing the muscular work required to control movements of the center of mass [64]. Patients with isolated ankle osteoarthritis demonstrate a decrease in ankle kinematics and kinetics during walking [35]. No change in kinematic or kinetic functions is observed in the distal foot joints of patients with isolated ankle osteoarthritis, demonstrating that these joints do not compensate for the mechanical dysfunction of the ankle [35]. Ankle osteoarthritis is associated with knee osteoarthritis and joint malalignment [13]. Patients with varus knee osteoarthritis and ankle osteoarthritis experience greater hindfoot and ankle joint inversion load during gait following total knee arthroplasty compared to those with varus knee osteoarthritis alone [30]. The distal tibiofibular syndesmosis morphological classification might affect the biomechanics properties in tibiotalar and subtalar joints in ankle osteoarthritis [62]. Ankle symptoms are affected by coronal alignment changes of the ankle after high tibial osteotomy [139]. Most osteotomies around the knee seem to require no particular concern for the ipsilateral ankle function [7].

Classification

Etiology and Risk Factors

Posttraumatic injury is the dominant etiology of ankle arthritis, accounting for 70% to 80% of cases [3]. This posttraumatic form typically presents in younger patients compared with degenerative or systemic variants [3]. Within ligamentous posttraumatic ankle arthritis, sports injuries were the underlying cause in 55% of cases [3], with soccer injuries specifically accounting for 33% of reported sports injury cases [3]. Ligamentous damage patterns include medial ligament lesions, which account for 12% of cases, and combined medial-lateral ligament lesions, which account for 3% [3].

Malleolar fractures carry a significant risk for subsequent joint degeneration. Advanced radiographic ankle osteoarthritis was present in 36.3% of patients 18 years after malleolar fractures [19]. This progression was especially common following Weber C fractures and associated medial malleolar fractures [19]. Ankle sprains can evolve into permanent disability and osteoarthritis if not well addressed [14].

Osteochondral lesions of the talus are frequently linked to trauma. In nearly 80% of patients with these lesions, a history of ankle trauma can be found [88]. Acute trauma and repetitive micro-traumata due to ankle instability and/or hindfoot malalignment are leading causes [88]. The incidence of osteochondral lesions assessed more than 1 year after surgery for ankle fractures is 47.5% [82], while the incidence assessed directly after trauma or during primary surgery is 45.1% [82].

Joint malalignment is associated with both knee and ankle osteoarthritis [13]. Concomitant ankle osteoarthritis is related to increased ankle pain and a worse clinical outcome following total knee arthroplasty [142].

Radiographic Staging and Reliability

The modified Takakura ankle OA classification system is used to assess the presence and severity of ankle OA on radiographs [142]. Stages 1, 2, 3a, 3b, and 4 of this system are assigned quantitative scores of 1, 2, 3, 4, and 5 respectively for radiological evaluation [165].

Interobserver reliability varies significantly among classification systems. The van Dijk osteoarthritis scale demonstrates fair interobserver agreement with a kappa value of 0.24 [130]. In contrast, the Takakura classification system shows poor agreement with a kappa value of 0.19 [130], and the Kellgren classification system shows poor agreement with a kappa value of 0.18 [130]. The difference in categorical rating reliability between the van Dijk scale and the Takakura and Kellgren systems is statistically significant (p < 0.001) [130].

In some patients with stage 3 varus ankle osteoarthritis, the obliteration of the joint space is difficult to evaluate accurately using only weightbearing anteroposterior radiographs [21]. Weightbearing lateral radiographs should be performed in addition to anteroposterior views to accurately evaluate stage 3 varus ankle osteoarthritis [21].

MRI Scoring

The Ankle Osteoarthritis Scoring System (AOSS) quantifies OA-related changes in the ankle by MRI [159]. The system grades multiple parameters on a scale from 0 to 3: * Cartilage damage depth: Graded from 0 (no damage) to 3 (full-thickness cartilage defects) [159]. * Subchondral bone defect depth: Graded from 0 (no defect) to 3 (severe, ≥5 mm) [159]. * Osteophyte size: Graded from 0 (no osteophytes) to 3 (severe, ≥5 mm) [159]. * Subchondral cysts: Graded by largest diameter from 0 (no cysts) to 3 (severe, ≥5 mm) [159]. * Bone marrow oedema: Graded by largest diameter from 0 (no oedema) to 3 (severe) [159].

Pathophysiology and Progression

An asymptomatic cartilage lesion of the ankle not involving damage to the subchondral bone plate may arise from a traumatic event such as an ankle sprain or fracture [89]. Microscopic cartilage lesions are considered inert and are believed not to progress into osteochondral lesions or end-stage osteoarthritis [89]. Consequently, the proportion of osteochondral damage after ankle trauma that results in poor clinical outcomes is relatively low [89].

In patients with isolated ankle osteoarthritis, loss of mechanical ankle function is not compensated by the distal foot joints [35]. No change in kinematic or kinetic functions is observed in the distal foot joints of these patients [35]. The higher the grade of Kashin–Beck disease, the more serious the change of the ankle joint [166].

Clinical Presentation

Epidemiology and Etiology

Ankle osteoarthritis accounts for 4% of all osteoarthritis cases, with 78% of cases being post-traumatic [36]. The most frequent mechanism for ligamentous posttraumatic ankle arthritis is the unexpected and rapid hyperinversion of the hindfoot [3]. Among sports injuries, soccer was the most likely cause, representing 33% of reported cases in the arthritis cohort [3]. Advanced radiographic ankle osteoarthritis is common, occurring in 36.3% of patients 18 years after malleolar fractures [19]. This progression is especially prevalent following Weber C fractures and associated medial malleolar fractures [19]. Associated chondral lesions significantly contribute to the late development of ankle osteoarthrosis after posteromedial ankle dislocation [42]. Furthermore, chondrolysis and vascular impairment lead to osteoarthritis after ankle fracture-dislocation regardless of early or late intervention [78]. Harvesting of the fibula may also cause long-term ankle osteoarthritis that requires ankle arthrodesis [41].

Clinical Features and Examination

A history of a twisting injury followed by pain, bruising, and swelling is typical for ankle ligament injuries [56]. In an ATFL sprain, tenderness is maximal just distal and slightly anterior to the lateral malleolus, and the slightest attempt at passive inversion is extremely painful [56]. Acute low ankle sprains typically manifest with significant lateral ankle swelling, pain with weight bearing, and focal tenderness over the involved lateral ligamentous structures [134]. Swelling, ecchymosis, and pain with weight bearing are common findings in ankle sprains [161]. It is essential to examine the entire leg and foot to avoid missing undisplaced fractures of the ankle, proximal fibula, tarsal bones, or peroneal tendon sheath [56]. Injury to branches of the superficial peroneal nerve can cause numbness over the dorsal midfoot following an inversion mechanism [161].

Stability assessment in the acute phase of an ankle ligament injury is not possible [56]. Patients with a history of numerous ankle sprains may have a positive anterior drawer test, which involves anterior translation of the slightly plantarflexed foot; excessive anterior translation represents chronic laxity of the injured ATFL [134]. Inversion stress testing of the neutral foot may demonstrate increased laxity, such as in the setting of an attritional calcaneofibular ligament [134]. Assessment for recurrent instability requires evaluation for hindfoot varus [161]. Patients should be questioned about symptoms of a loose body or osteochondral injury, such as mechanical symptoms like locking or catching [161]. Pain out of proportion to findings on exam indicates complex regional pain syndrome, which may develop after trauma or elective surgery [161].

Imaging

The need for X-ray in ankle injuries is guided by the Ottawa ankle rules [56]. Anteroposterior, lateral, and mortise views of the ankle should be obtained [56]. Weight-bearing views are useful in helping determine stability [56]. For ankle sprains, weight-bearing AP, lateral, and mortise views are recommended [134]. Varus stress views can be used to evaluate for excessive talar tilt in the setting of ATFL laxity, while external rotation stress views should be obtained to rule out a syndesmotic injury [134]. Radiographs should be evaluated for lateral process of the talus fracture, anterior process fracture, osteochondral defects, and mortise or syndesmosis instability [161]. Foot x-rays should be obtained for any pain on examination, especially at the base of the fifth metatarsal or anterior process of the calcaneus, to rule out fracture [161].

CT and MRI may be needed to fully characterize an injury or in those who have persistent pain, swelling, instability, and impaired function over 6 weeks or longer [56]. MRI is rarely warranted for ankle sprains except in the setting of prolonged pain or instability [134]. MRI is performed to evaluate for associated injuries such as peroneal tendon pathology, talar osteochondral lesions, fractures of the anterior calcaneal process, or fractures of the lateral talar process [134]. As many as 42% of lateral process talar fractures are initially misdiagnosed as ankle sprains [134]. Talar body and neck fractures can occasionally be overlooked in low-energy trauma patients thought to have minor ankle injuries [134]. CT scanning is considered for evaluation of a suspected or identified lateral process fracture [161]. MRI is typically reserved for patients with continued pain despite weeks of conservative treatment or concern about a loose body or osteochondral defect [161]. MRI may demonstrate attenuation or tear of the lateral ligamentous structures [161]. Bone bruising is common in severe sprains and may result in a longer time to pain-free activity and return to sports [161]. Weightbearing lateral radiographs should also be performed for stage 3 varus ankle osteoarthritis [21]. Preoperative ankle arthroscopy reveals abnormalities of different structures involved in chronic ankle instability that would otherwise have been undetected [77].

Biomechanics and Functional Impact

Patients with isolated ankle OA demonstrate a decrease in ankle kinematics and kinetics during walking [35]. No change in kinematic or kinetic functions were observed in the distal foot joints of patients with isolated ankle OA, indicating that distal foot joints do not compensate for the mechanical dysfunction of the ankle [35]. OA in the hip, knee, or ankle reduces effective exchange of potential and kinetic energy and potentially increases the muscular work required to control movements of the center of mass [64]. Patients with varus knee osteoarthritis and ankle osteoarthritis experience greater hindfoot and ankle joint inversion load during gait following total knee arthroplasty compared to varus knee osteoarthritis alone [30]. Ankle pain worsened after medial opening-wedge high tibial osteotomy in patients with concurrent ankle OA [71]. Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels [73].

Investigations

Plain radiography: Weight-bearing anteroposterior, oblique, and lateral radiographs of the ankle are required to assess joint space narrowing and alignment [160]. Standard weight-bearing radiographs of the foot should also be obtained to evaluate foot alignment [160]. In stage 3 varus ankle osteoarthritis, weightbearing lateral radiographs are specifically indicated [21]. For anterior ankle impingement, lateral radiographs may fail to demonstrate osteophytes; an anteromedial view is often helpful in these cases [60]. Associated chondral lesions are a significant contributing factor to the late development of ankle osteoarthrosis [42]. Advanced radiographic ankle osteoarthritis is common, occurring in 36.3% of patients 18 years after malleolar fractures, particularly following Weber C fractures and associated medial malleolar fractures [19]. Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients, despite substantial radiographic evidence of osteoarthritis in one-half of the patients [43]. The bone mineral density of the talus in end-stage ankle osteoarthritis is significantly lower than that of a healthy talus [168].

MRI: MRI can identify osteophytes but lacks sensitivity for soft-tissue impingement [60]. 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 offers greater sensitivity and specificity for soft-tissue impingement, though it is less practical [60]. In one study, 58% of patients with anterior ankle impingement had an associated diagnosis, which changed the surgical plan in 33% of cases [60]. MRI is useful for evaluating associated pathology to the peroneal tendons or talar articular surface in chronic lateral ankle instability [104]. However, MRI does not help determine functional instability in chronic lateral ankle instability [104]. Stress inversion ankle roentgenograms should be considered in cases of talar osteochondritis dissecans [170].

CT: Simulated weightbearing computed tomography can be used for verification of radiographic staging of varus ankle osteoarthritis [21]. In the majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty [22].

Arthroscopy: Preoperative ankle arthroscopy reveals essential information that would otherwise be undetected, demonstrating that abnormalities of different structures are involved in chronic ankle instability with no single causal entity [77]. Arthroscopic findings in patients with chronic ankle instability indicate that abnormalities of different structures are involved [77].

Other Considerations: The assumption that associations may exist between knee and ankle osteoarthritis and joint malalignment was confirmed [13]. Ankle osteoarthritis is associated with knee osteoarthritis [13]. Ankle sprains are mainly benign lesions but can evolve into permanent disability and osteoarthritis if not well addressed [14]. 70% to 80% of ankle arthritis is posttraumatic in origin and is often seen in younger patients compared with the age of patients with degenerative or systemic ankle arthritis [3]. Lesions of the lateral ankle ligament complex are the main cause for developing ligamentous posttraumatic ankle arthritis, with 85% lateral ligament lesions, 12% medial ligament lesions, and 3% combined medial-lateral ligament lesions [3]. Sports injuries were the underlying cause in 55% of cases of ligamentous posttraumatic ankle arthritis, with soccer injuries being the most likely to cause this entity [3]. In patients with ankle osteoarthritis, platelet-rich plasma (PRP) did not improve pain and function at 52 weeks [18]. Patients eligible for PRP injection trials for ankle osteoarthritis were required to have ankle pain severity on a visual analog scale (VAS) of 40 mm (0-100 mm) during daily activities and radiographs indicating grade 2 talocrural osteoarthritis on the van Dijk classification [9]. In adults with end-stage osteoarthritis, total ankle replacement and arthrodesis did not differ with respect to change in MOXFQ scores at 1 year [28]. Surgical treatment for end-stage ankle osteoarthritis resulted in satisfactory clinical outcomes in patients aged ≥75 years, with improvements comparable to those in younger patients [5]. Although patient-reported outcome measures for the knee joint improved irrespective of the presence of ankle osteoarthritis, ankle pain worsened after medial opening-wedge high tibial osteotomy in patients with ankle osteoarthritis [71]. Despite achieving proper coronal knee alignment postoperatively, patients with varus knee osteoarthritis and ankle osteoarthritis experienced greater hindfoot and ankle joint inversion load during gait compared to those with varus knee osteoarthritis alone [30]. Although ankle osteoarthritis did not directly affect clinical outcomes after total knee arthroplasty, residual valgus alignment and older age were independently associated with worse postoperative WOMAC scores [48].

Treatment

Non-Operative Management

Conservative management remains the first-line approach for ankle osteoarthritis, though no evidence supports that any non-surgical treatment alters the natural course of the disease [143]. Intra-articular hyaluronic acid injections administered at 3-weekly intervals provide significant improvements in patient outcome and balance while reducing NSAID use at 6 months in patients with moderate to severe unilateral ankle arthritis [143]. However, a single hyaluronic acid injection is not superior to saline solution injection in randomized, double-blind, placebo-controlled settings [143]. The potential for viscosupplementation has been suggested in the literature, but no dosing studies have been published to date [135]. Platelet-rich plasma (PRP) injections have shown mixed results; they did not improve pain and function at 52 weeks in patients with ankle osteoarthritis [18], nor did intra-articular PRP significantly improve symptoms and function over 52 weeks compared with placebo [115]. Conversely, three PRP injections at 2-week intervals in patients with varus ankle OA resulted in significant pain and patient-reported outcome improvements out to 24 weeks without adverse side effects [143]. Standardized intra-articular PRP provides safe, sustained clinical benefits, particularly in younger and athletic patients with early-stage disease [149].

Operative

Indications: Surgical intervention is indicated when conservative measures fail to relieve pain and limited motion [44]. Ankle arthrodesis is a reliable procedure for functionally disabling ankle arthritis, deformity, and pain in carefully selected patients [79]. Indications for arthrodesis include 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, and instability from neuromuscular disorders [44]. Total ankle arthroplasty (TAR) is contraindicated in patients with infectious ankle osteoarthritis or severe deformities (≥15° varus and valgus deformity of the ankle joint) [155]. TAR is also not appropriate for patients with a high level of physical activity, including sports and farming, even if they are ≥60 years of age [155]. 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 [81]. Contraindications for distraction arthroplasty include active infection, advanced coronal plane deformity, significant loss of bone stock, and patients who are poor frame candidates [81]. Relative contraindications for distraction arthroplasty include uncontrolled diabetes, tobacco use, chronic edema of the lower limb, severe ankle deformity, and severe ankle ankylosis [81]. Absolute contraindications to ankle fusion include vascular impairment of the limb and infection of the skin through which the approach is planned [44]. 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 [44].

Surgical Approach / Technique: In the early stages of ankle OA with malalignment, only periarticular osteotomies have sufficient evidence to recommend [2]. Realignment surgery is an alternative to fusion or total ankle replacement in selected cases of asymmetric (varus or valgus) ankle osteoarthritis [24]. Low tibial osteotomy is an effective alternative for moderate ankle arthritis that can improve pain, function, and motion, potentially saving the ankle from fusion or postponing it [133]. Both supramalleolar osteotomy (SMO) alone and SMO with fibular osteotomy (FO) effectively alleviate pain and improve ankle function in patients with varus ankle osteoarthritis [122]. Supramalleolar osteotomy for varus ankle osteoarthritis shows improved clinical outcomes compared to preoperative assessments [123]. The dual approach of supramalleolar osteotomy and proximal fibular osteotomy shows promise as a joint-preserving alternative for patients with moderate to severe ipsilateral ankle and knee osteoarthritis [80]. Arthroscopic debridement for anterior ankle impingement has reported success rates ranging from 73% to 96% in level II to IV studies [60]. Ankle arthroscopy is successful for anteromedial impingement, anterolateral impingement, and anterior bony impingement according to level IV studies [60]. Patients with a poorer prognosis for ankle arthroscopy include those without a clear diagnosis and those with higher grades of arthritic changes of the ankle [60]. Joint distraction arthroplasty is based on the concept that mechanical unloading of the joint and intermittent flow of intraarticular synovial fluid encourage cartilage healing [81]. 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 [81]. Use of a forefoot wire in distraction arthroplasty should be avoided because it is uncomfortable and discourages weight bearing [81]. No more than 5 to 6 mm of acute distraction should be applied in the operating room for distraction arthroplasty [81]. Range-of-motion exercises should be started early to preserve ankle mobility during distraction arthroplasty [81]. A circular fixator is superior to monolateral fixation for distraction arthroplasty because a monolateral frame delivers uneven distraction through cantilever mechanics [81]. Arthroscopically assisted arthrodesis of the ankle produces good results in patients who have osteoarthritis of the ankle with minimum or no deformity [12]. The immediate postoperative morbidity of arthroscopically assisted arthrodesis is of very short duration [12]. Arthroscopic ankle arthrodesis is considered the new gold standard for patients with isolated ankle osteoarthritis and no or minimal deformity [26]. The posterior arthroscopic ankle fusion is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up [72]. Ligament stabilization with arthroscopic procedures for individuals with chronic ankle instability and medial ankle OA yielded significant functional outcomes with high patient satisfaction, even without radiographic improvement [129]. Bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis showed a safe and satisfactory outcome at 10 years, although patients with end-stage OA presented a high revision rate [33].

Implant Selection: 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 [17]. Factors that improve results of 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 [32]. Triple arthrodesis is rarely appropriate and should be performed only according to specific indications [116].

Alignment / Balancing Strategy: In 35 consecutive patients with posttraumatic ankle osteoarthritis treated with lower leg and hindfoot realignment surgery, pain decreased by an average of 4 points on a visual analog scale and range of ankle motion increased by an average of 5° at a mean follow-up of 5 years [24]. Revision surgery was performed in 10 ankles (29%) following realignment surgery for asymmetric ankle osteoarthritis, with three ankles (9%) converted to total ankle replacement [24].

Pain Management: Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels [73].

Adjuncts: There is no specific evidence in the provided text regarding adjuncts such as tourniquets, tranexamic acid, or navigation systems.

Setting of Care: There is no specific evidence in the provided text regarding outpatient versus inpatient settings.

Revision: The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation [169].

Other Considerations: Clinical results were significantly worse in women after ankle arthrodesis, which should be considered when determining the indication [70]. Patient satisfaction for arthroscopic debridement of ankle impingement was good or excellent in 74% to 100% of cases, with a complication rate of 5.1% [60]. Twenty-one (98%) of 23 patients reported by Tellisi et al. reported decreased pain after distraction arthroplasty [81]. Other series have reported good results in approximately 75% of patients following distraction arthroplasty [81]. In a randomized controlled trial, patients with motion distraction had earlier and consistently better outcomes than those with fixed distraction [81]. Adverse events associated with distraction arthroplasty included 43 pin-track infections and eight neurapraxias [81]. The beneficial effects of distraction arthroplasty are not immediate and tend to occur over a period ranging from 6 months to 2 years [81]. In a randomized study, functional outcomes and quality of life were similar with debridement and hinged distraction compared to debridement alone, although the rate of post-operative revision surgery was higher if distraction was not used [81]. There is not enough high-level evidence to support ankle joint distraction for generally accepted indications [81]. Ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of ankle OA [2]. Ankle arthrodesis can produce satisfactory functional results if correctly indicated in the final stages of ankle OA [2]. 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 [5]. Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement [49]. There have been improvements in the clinical safety of total ankle replacement over time [40]. Daniels et al. found comparable clinical outcomes between arthrodesis and arthroplasty at a mean 5.5-year follow-up, but rates of reoperation and major complications were higher after ankle arthroplasty [46]. Norvell et al. found that ankle-specific adverse events were infrequent and only weakly associated with operative procedure [46]. 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 [86]. Complication rates were 54% after arthroplasty and 26% after arthrodesis in a study involving 114 ankle arthroplasties and 47 ankle arthrodeses [86]. Haddad et al. identified revision rates of less than 10% and infection rates of less than 5% after both arthrodesis and arthroplasty in a systematic review including 1262 arthrodeses and 852 arthroplasties [86]. Daniels et al. reported that intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable, although reoperation and major complications were more frequent after ankle replacement [86]. Norvell et al. found no statistically significant difference in adverse events at 1 year after either arthrodesis or arthroplasty in a multisite prospective cohort study of 517 patients [86]. Glazebrook et al. found that failure rates for total ankle arthroplasty ranged from 1% to 32%, with an overall mean failure rate of 12% [86]. 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 [86]. Patients with total ankle replacement have higher expectations before surgery than do patients with arthrodesis and are more likely to have their expectations met [86]. Patients with total ankle replacement had higher scores than ankle arthrodesis patients in walking on uneven surfaces, upstairs, downstairs, and uphill [86]. Functional results were significantly better in patients with total ankle arthroplasty compared to arthrodesis, but there was no difference in terms of quality of life [86]. Gait analysis has shown that patients with total ankle replacement have a more normal gait pattern than those with arthrodesis [86]. Sports participation has been reported to be similar after both arthroplasty and arthrodesis, with approximately 76% in both groups active in sports after surgery [86]. Dekker et al. reported a moderate radiographic increase in adjacent subtalar and talonavicular arthritis at a minimum of 5 years after arthrodesis [86]. In 140 ankles averaging 6.5 years’ follow-up, 40% and 34% of adjacent subtalar and talonavicular joints, respectively, showed progression of arthritic changes after arthrodesis [86]. Dekker et al. demonstrated that 30% of the clinical motion observed after ankle arthroplasty occurs through the subtalar and talonavicular joints [86]. Sealey et al. reported 9.3 degrees of compensatory subtalar motion and 16.4 degrees of midfoot motion after ankle arthrodesis [86]. Dekker et al. reported 6.7 degrees and 16.5 degrees for subtalar and midfoot compensatory motion after arthroplasty [86]. Pinsker et al. reported that only 15% of patients with arthroplasty or arthrodesis experienced resolution of all symptoms and limitations [86]. To definitively determine which procedure is more appropriate in advanced ankle OA, more and better-designed studies are required, given that the results reported thus far do not permit to determine with absolute certainty which of the two procedures, TAR or AF, is more adequate [16]. The share of ankle replacement performed compared to arthrodesis increased markedly from 14% in 2007 to 45% in 2013 [86].

Complications

Ankle Arthrodesis

Nonunion and Revision: Clinical evidence is insufficient to definitively implicate most risk factors for nonunion after ankle arthrodesis [32]. Persistent swelling, pain at the fusion site, and difficulty with weight bearing necessitate careful scrutiny of plain radiographs to establish union, with CT imaging sometimes required to confirm fusion or evaluate nonunion [32]. Revision arthrodesis for nonunion reports successful fusion rates of 75% to 94% [32]. Pulsed electronic magnetic field devices for stimulation of bone growth after failed arthrodesis were successful in only five of 19 delayed unions of foot and ankle arthrodeses when used with immobilization and limited weight bearing [32].

Surgical Technique and Outcomes: Factors improving results 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 [32]. There is fair evidence (grade B) to advocate internal fixation for ankle arthrodesis [32]. Evolving grade B evidence suggests minimally invasive techniques may be equivalent to open procedures in selected patients [32]. Arthroscopically assisted arthrodesis produces good results in patients with osteoarthritis and minimum or no deformity, with very short-duration immediate postoperative morbidity [12]. In a retrospective case series of 101 ankles undergoing arthroscopic ankle arthrodesis, 94% achieved fusion and 75% reported "good/excellent" results, with no cases of deep infection or serious adverse events [45].

Adjacent Joint Arthritis: Arthritis found in adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change rather than directly caused by the tibiotalar fusion [90]. In a mid- to long-term outcome study, 40% of adjacent subtalar joints and 34% of adjacent talonavicular joints showed progression of arthritic changes at a minimum of 5 years after ankle arthrodesis [86]. In a retrospective case series of 101 ankles undergoing arthroscopic ankle arthrodesis, 85% of ankles had no changes in the talonavicular joint and 69% had no changes in the subtalar joint regarding progression of arthritis at a mean follow-up of 86 months [45].

Hardware Augmentation: In a retrospective cohort study comparing ankle arthrodesis with and without anterior plate augmentation, there was no statistically significant difference in nonunion rate or revision rate, although numbers trended toward improvement with anterior plate augmentation [45]. A trend toward higher numbers of deep wound infection with anterior plate use was observed but was not supported statistically [45].

Total Ankle Arthroplasty

Complication and Failure Rates: Complication rates were 54% after total ankle arthroplasty and 26% after ankle arthrodesis in a study involving 114 ankle arthroplasties and 47 ankle arthrodeses [86]. Failure rates for total ankle arthroplasty ranged from 1% to 32%, with an overall mean failure rate of 12% [86]. 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 [86]. 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 [86]. In a multisite prospective cohort study of 517 patients, there was no statistically significant difference in adverse events at 1 year after either total ankle arthroplasty or ankle arthrodesis [86].

Long-term Outcomes and Implant Specificity: Results for total ankle arthroplasty may deteriorate over time, and long-term outcomes require a minimum follow-up of 5 years [61]. Some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up [23]. Findings suggest that there have been improvements in the clinical safety of total ankle replacement over time [40]. Early clinical outcomes and survivorship of the TARIC total ankle arthroplasty were comparable to previous reports on other total ankle systems [76]. Intermediate results for second-generation total ankle arthroplasty are promising but should be interpreted with care due to the poor history of earlier prostheses and technical difficulties [52]. Due to relatively high rates of complications and reoperations, the authors do not recommend ankle arthroplasty with the constrained Mayo implant for rheumatoid arthritis or osteoarthritis of the ankle [25].

Risk Factors and Comparative Data: Fracture posttraumatic osteoarthritis was associated with a markedly higher complication rate after total ankle arthroplasty and higher risk of failure requiring prosthesis explant compared with primary osteoarthritis [67]. Total ankle replacement patients had lower rates of readmission and periprosthetic joint infection/wound infections compared to ankle arthrodesis patients in a large state-wide database study [45]. Total ankle arthroplasty in ankles with preoperative severe coronal plane deformity (>20°) showed satisfactory and comparable clinical outcomes without increasing complication rates relative to those with moderate deformity in the intermediate-term follow-up [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 [164].

Realignment Osteotomy

Outcomes and Revision: Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques [4]. Supramalleolar osteotomy in patients with ankle osteoarthritis demonstrates good clinical and radiological outcomes, together with a low failure rate at mid-term follow-up [6]. Revision surgery was performed in 10 ankles (29%) following realignment surgery for asymmetric ankle osteoarthritis, of which three ankles (9%) were converted to total ankle replacement [24].

Specific Deformity Correction: In nine patients treated with one-stage opening-wedge valgus osteotomy for post-traumatic progressive varus deformity of the ankle, the osteotomy site united within two months in eight patients and at six months in one patient [141]. Postoperatively, the range of motion of the ankle was decreased in six patients and remained unchanged in three patients following opening-wedge valgus osteotomy for post-traumatic varus deformity [141].

Distraction Arthroplasty

Adverse Events and Contraindications: Adverse events in a randomized controlled trial comparing fixed distraction to motion distraction included 43 pin-track infections and eight neurapraxias [81]. Relative contraindications for distraction arthroplasty include uncontrolled diabetes, tobacco use, chronic edema of the lower limb, severe ankle deformity, and severe ankle ankylosis [81]. Currently there is not enough high-level evidence to support ankle joint distraction for generally accepted indications [81].

Posttraumatic Ankle Osteoarthritis

Etiology and Prevalence: Sports injuries were the underlying cause in 55% of cases of ligamentous posttraumatic ankle arthritis, with soccer injuries being the most likely cause [3]. Despite ankle osteoarthritis only accounting for 4% of all osteoarthritis cases, 78% of ankle osteoarthritis is post-traumatic [36]. Associated chondral lesion is a significant contributing factor to late development of ankle osteoarthrosis following posteromedial ankle dislocation without malleolar fracture [42].

Fracture Complications and OA Risk: Wound infection/dehiscence occurs in 1%–10% of ankle fractures, with superficial infections often treated with antibiotics and dressings, while deep infections may require surgery to debride the wound and obtain bacteriologic specimens [68]. Loss of reduction occurs in 0%–2% of ankle fractures, most commonly in conservatively treated unstable fractures, and malunion increases the risk of osteoarthritis [68]. Deep vein thrombosis occurs in 3% and pulmonary embolism in 0.3% of ankle fracture patients [68]. Symptomatic hardware removal is effective in 50% of patients following ankle fracture [68]. Osteoarthritis is rare in low-energy ankle fractures but occurs in up to 30% of unstable patterns, may take several decades to become evident, and is higher when anatomical reduction of the mortise is not achieved [68]. Nonunion is most commonly encountered after nonoperative treatment of ankle fractures and may require revision fixation and possibly bone grafting if painful [68]. Compartment syndrome is rare and associated with high-energy ankle fractures [68]. Neuroma can result from injury to the superficial peroneal, sural, and saphenous nerves in the subcutaneous layer during ankle fracture surgery, resulting in anesthetic or dysesthetic skin [68].

Prognosis and Predictors: Postoperative complications have been shown to result in significantly worse patient-reported outcomes following ankle fracture [68]. There is a correlation between complications and development of osteoarthritis following ankle fracture [68]. Cartilage damage was a predictor of posttraumatic osteoarthritis at a mean of almost 13 years follow-up, with worse outcomes found with deeper lesions and those on the anterior or lateral talus or the medial malleolus [68]. The mean time from ankle fracture to end-stage osteoarthritis was 21 years [68].

Other Considerations

Biomechanical Loading: Despite achieving proper coronal knee alignment postoperatively, patients with varus knee osteoarthritis and ankle osteoarthritis experienced greater hindfoot and ankle joint inversion load during gait compared to varus knee osteoarthritis alone [30].

Injectable Therapies: In a study of twenty ankles with varus osteoarthritis, pain and functional outcomes significantly decreased at 4, 12, and 24 weeks after three injections of PRP at 2-week intervals, with no adverse effects reported [45].

Recovery

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

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

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

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

Functional milestones: In adults with end-stage ankle osteoarthritis, total ankle replacement and ankle arthrodesis did not differ with respect to change in MOXFQ scores at 1 year [28].

Other Considerations: Non-operative interventions include platelet-rich plasma (PRP) injections, which did not improve pain and function at 52 weeks in patients with ankle osteoarthritis [18]. Eligibility for PRP studies required a visual analog scale pain severity of 40 mm (0-100 mm) during daily activities and grade 2 talocrural osteoarthritis on the van Dijk classification [9].

Osteotomy options include supramalleolar osteotomy, which demonstrates good clinical and radiological outcomes and a low failure rate at mid-term follow-up [6]. Good outcomes in asymmetrical ankle osteoarthritis are achieved by understanding specific deformities and appropriate indications for peri-talar re-alignment osteotomy [4]. In the early stages of ankle osteoarthritis with malalignment, only periarticular osteotomies have enough evidence to be recommended [2]. Most osteotomies around the knee do not require particular concern for ipsilateral ankle function [7].

Arthrodesis is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up, including via posterior arthroscopic ankle fusion [72]. Arthritis found in adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change rather than being directly caused by the tibiotalar fusion [90]. Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients [65].

Total ankle arthroplasty (TAR) outcomes vary by implant. The early experience and small rate of adverse events reported for the Infinity fixed-bearing implant continue to support its use for the treatment of end-stage ankle arthritis [172]. The outcome of the Mobility total ankle replacement at a mean of four years is satisfactory in > 85% of patients [173]. Early clinical outcomes and survivorship of the TARIC mobile-bearing total ankle arthroplasty were comparable to previous reports on other total ankle systems [76]. In the majority of cases, an anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty [22]. Surgeons and patients should be cautious about enthusiasm for total ankle arthroplasty based on short-term follow-up, as results may deteriorate over time and long-term outcomes require a minimum follow-up of 5 years [61].

For osteochondral lesions, a one-step technique using bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in osteoarthritic ankles showed to be safe and provided a satisfactory outcome, although patients with end-stage osteoarthritis presented a high revision rate at 10 years [33].

In the post-traumatic context, while prompt reduction is important, the prognosis of ankle fracture-dislocation depends significantly on the damage at the time of the insult, with chondrolysis and vascular impairment leading to osteoarthritis regardless of early or late intervention [78].

Key Evidence

• [L5] In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment, while both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease. [2] (10.1530/eor-21-0117)
• [L4] [3] (10.1177/0363546505281813)
• [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. [4] (10.1302/2058-5241.2.160021)
• [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. [5] (10.1186/s13018-023-03734-4)
• [L4] This systematic review demonstrates good clinical and radiological outcomes, together with a low failure rate at mid-term follow-up following supramalleolar osteotomy in patients with ankle osteoarthritis. [6] (10.1007/s00167-022-07144-7)
• [L3] Most osteotomies around the knee seem to require no particular concern for the ipsilateral ankle function. [7] (10.1007/s00167-021-06699-1)
• [L1] [9] (10.1177/03635465231182438)
• [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. [10] (10.5435/jaaos-d-14-00017)
• [L4] Several characteristics were associated with preference for TAA over AA and vice versa, which can be useful when counseling patients on treatment options for end-stage ankle osteoarthritis. [11] (10.5435/jaaos-d-25-00236)
• [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. [12] (10.2106/00004623-199407000-00023)
• [L3] The assumption that associations may exist between knee and ankle osteoarthritis and joint malalignment was confirmed. [13] (10.1007/s00402-007-0502-9)
• [L4] Ankle sprains are mainly benign lesions but can evolve into permanent disability and osteoarthritis if not well addressed. [14] (10.1302/2058-5241.6.210017)
• [L3] These results suggest that gender did not seem to affect outcomes of total ankle arthroplasty in patients with ankle osteoarthritis. [15] (10.1186/s13018-020-01731-5)
• [Paper] To definitively determine which procedure is more appropriate in advanced ankle OA, more and better-designed studies are required, given that the results reported thus far do not permit to determine with absolute certainty which of the two procedures, TAR or AF, is more adequate. [16] (10.1530/eor-2025-0106)
• [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. [17] (10.5435/jaaos-d-23-00743)
• [L1] In patients with ankle osteoarthritis, PRP did not improve pain and function at 52 weeks. [18] (10.2106/jbjs.23.01338)
• [L3] Advanced radiographic ankle OA was common (36.3%) 18 years after malleolar fractures, especially following Weber C fractures and associated medial malleolar fractures. [19] (10.1007/s00264-011-1472-7)
• [L2] Surgeons can consider isolated ankle arthrodesis for end-stage ankle osteoarthritis with concomitant PCFD, even in severe cases, expecting substantial deformity correction without additional procedures. [20] (10.1097/corr.0000000000003756)
• [L4] In some patients with stage 3 varus ankle osteoarthritis, the obliteration of the joint space is difficult to evaluate accurately using only weightbearing anteroposterior radiographs; weightbearing lateral radiographs should also be performed. [21] (10.1186/s12891-021-04618-6)
• [L3] In the majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty. [22] (10.1186/1471-2474-14-260)
• [L4] The design of total ankle arthroplasty systems is evolving as understanding of failure modes increases and surgical techniques refine; some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up. [23] (10.5435/jaaos-d-16-00715)
• [L4] [24] (10.1097/blo.0b013e318124a462)
• [L4] It is considered the new gold standard for patients with isolated ankle osteoarthritis and no/minimal deformity. [26] (10.1530/eor-2023-0100)
• [L1] In adults with end-stage ankle osteoarthritis, TAR and AA did not differ with respect to change in MOXFQ scores at 1 year. [28] (10.2106/jbjs.23.00497)
• [L3] Despite achieving proper coronal knee alignment postoperatively, these patients experienced greater hindfoot and ankle joint inversion load during gait. [30] (10.1002/ksa.12249)
• [L4] This one-step technique for the treatment of OLT in OA ankles showed to be safe and to provide a satisfactory outcome, even if patients with end stage OA presented a high revision rate at 10 years. [33] (10.1007/s00167-021-06494-y)
• [L3] The findings showed a decrease in ankle kinematics and kinetics of patients with isolated ankle OA during walking, whereas no change in kinematic or kinetic functions were observed in the distal foot joints, demonstrating that these do not compensate for the mechanical dysfunction of the ankle. [35] (10.1097/corr.0000000000001443)
• [L3] [36] (10.1186/s12891-021-04230-8)
• [L5] The findings suggest that total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed. [39] (10.2106/jbjs.26.00501)
• [L3] These findings suggest that there have been improvements in the clinical safety of total ankle replacement over time. [40] (10.2106/jbjs.15.01341)
• [Case_report] Harvesting of the fibula may cause long-term ankle osteoarthritis that requires ankle arthrodesis. [41] (10.1007/s00402-007-0378-8)
• [L4] Associated chondral lesion is a significant contributing factor to late development of ankle osteoarthrosis. [42] (10.1016/j.injury.2012.07.002)
• [L4] Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients despite substantial radiographic evidence of osteoarthritis in one-half of the patients. [43] (10.2106/jbjs.l.00426)
• [L3] Although ankle OA did not directly affect clinical outcomes, residual valgus alignment and older age were independently associated with worse postoperative WOMAC scores. [48] (10.1016/j.arth.2025.08.067)
• [L4] Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. [49] (10.2106/jbjs.21.00287)
• [L1] The measurement properties of the Dutch PR-AOFAS were sufficient in patients with ankle osteoarthritis who are willing to participate in a trial on injection therapy. [50] (10.1016/j.jisako.2023.07.003)
• [L4] Intermediate results for second-generation total ankle arthroplasty are promising but should be interpreted with care due to the poor history of earlier prostheses and technical difficulties. [52] (10.5435/jaaos-d-25-00638)
• [L2] Patients with tibiotalar osteoarthritis were more likely to receive a total ankle replacement procedure if they had Medicare or private insurance compared with patients who had Medicaid. [58] (10.1177/1071100716674311)
• [L5] The commentary cautions surgeons and patients about enthusiasm for total ankle arthroplasty based on short-term follow-up, noting that results may deteriorate over time and that long-term outcomes require a minimum follow-up of 5 years. [61] (10.2106/jbjs.19.00700)
• [L3] DTS morphological classification might affect the biomechanics properties in TAS and TTA in ankle OA. [62] (10.1186/s13018-023-03985-1)
• [L3] OA in the hip, knee, or ankle reduces effective exchange of potential and kinetic energy, potentially increasing the muscular work required to control movements of the center of mass. [64] (10.1007/s11999-016-4921-1)
• [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. [65] (10.2106/jbjs.o.00396)
• [L3] The authors advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis. [66] (10.2106/jbjs.22.00072)
• [L3] Compared with primary osteoarthritis, fracture posttraumatic osteoarthritis was associated with a markedly higher complication rate after total ankle arthroplasty and was at higher risk of failure requiring prosthesis explant. [67] (10.5435/jaaos-d-22-01192)
• [L3] The clinical results were significantly worse in women after ankle arthrodesis, which should be considered when determining the indication. [70] (10.1186/s13018-024-05045-8)
• [L3] Although patient-reported outcome measures for the knee joint improved irrespective of the presence of ankle OA, ankle pain worsened after MOWHTO in patients with ankle OA. [71] (10.1177/03635465221143999)
• [L4] The posterior arthroscopic ankle fusion is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up. [72] (10.1007/s00167-015-3975-z)
• [L2] Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. [73] (10.2106/jbjs.18.00511)
• [L4] The findings suggest that rotational position of the leg highly influences measurements in ankle radiographs after TAR. [75] (10.1186/s13018-015-0220-x)
• [L4] Early clinical outcomes and survivorship of TARIC TAA were comparable to previous reports on other total ankle systems. [76] (10.1302/0301-620x.108b1.bjj-2025-0096.r2)
• [L4] Preoperative ankle arthroscopy revealed an essential amount of information that would otherwise have been undetected, showing that abnormalities of different structures are involved in chronic ankle instability with no single causal entity. [77] (10.1177/03635465020300031601)
• [L5] While prompt reduction is important, the prognosis of ankle fracture-dislocation depends significantly on the damage at the time of the insult, with chondrolysis and vascular impairment leading to osteoarthritis regardless of early or late intervention. [78] (10.1007/s00402-008-0578-x)
• [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. [79] (10.5435/00124635-200005000-00007)
• [L5] The dual approach of SMO and PFO shows promise as a joint-preserving alternative for patients with moderate to severe ipsilateral ankle and knee osteoarthritis, demonstrating improved alignment, pain relief, and functionality. [80] (10.1016/j.jisako.2025.100895)
• [L4] [82] (10.1007/s00167-020-06187-y)
• [L5] [88] (10.1530/eor-22-0024)
• [L5] [89] (10.1007/s00167-021-06755-w)
• [L4] Arthritis found in the adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change and not directly caused by the tibiotalar fusion. [90] (10.1016/j.arthro.2017.11.031)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. [94] (10.1186/s12891-025-09458-2)
• [Paper] Intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 52 weeks in patients with ankle OA. [115] (10.1177/03635465231213856)
• [L4] Triple arthrodesis is rarely appropriate and should be performed only according to specific indications. [116] (10.2106/00004623-199303000-00004)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [118] (10.1177/03635465231217490)
• [L3] Total ankle arthroplasty in ankles with preoperative severe coronal plane deformity showed satisfactory and comparable clinical outcomes without increasing complication rates relative to those with moderate deformity in the intermediate-term follow-up. [121] (10.2106/jbjs.19.00416)
• [L4] Both SMO alone and SMO + FO can effectively alleviate pain and improve ankle function in patients with varus ankle osteoarthritis. [122] (10.1186/s12891-026-09762-5)
• [L4] This study showed improved clinical outcomes after SMO for varus ankle osteoarthritis in comparison to the preoperative assessments. [123] (10.1177/0363546514530669)
• [L3] Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery. [124] (10.1177/23259671211023447)
• [L4] Ligament stabilization with arthroscopic procedures for individuals with chronic ankle instability and medial ankle OA yielded significant functional outcomes with high patient satisfaction, even without radiographic improvement. [129] (10.1007/s00167-020-05845-5)
• [L2] [130] (10.1007/s00167-015-3871-6)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [131] (10.2106/00004623-199607000-00006)
• [L4] There is limited and declining number of publications describing the utilization trends of TAA and AA procedures for end-stage ankle OA. [132] (10.5435/jaaosglobal-d-24-00181)
• [L4] Low tibial osteotomy is an effective alternative treatment for moderate ankle arthritis that can improve pain, function, and motion, potentially saving the ankle from fusion or postponing it. [133] (10.1007/s004020000243)
• [L2] The potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date, and dosing in the ankle joint remains an area for discussion. [135] (10.1007/s00402-010-1165-5)
• [L3] Ankle symptoms were affected by coronal alignment changes of the ankle after HTO. [139] (10.1007/s00167-015-3890-3)
• [L4] [141] (10.2106/00004623-199802000-00008)
• [L3] [142] (10.2106/jbjs.17.00883)
• [L4] Intra-articular PRP prepared with a standardized method appeared to provide safe, sustained clinical benefits in ankle OA, particularly in younger and athletic patients with early-stage disease. [149] (10.1186/s12891-026-09790-1)
• [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. [150] (10.1186/s12891-022-05164-5)
• [L4] [155] (10.1186/s12891-020-3061-7)
• [L2] [159] (10.1007/s00167-013-2719-1)
• [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. [164] (10.5435/jaaos-d-24-01267)
• [L3] [165] (10.1186/s13018-019-1168-z)
• [L3] The higher the grade of Kashin–Beck disease, the more serious the change of the ankle joint. [166] (10.1186/s13018-023-03633-8)
• [L4] The bone mineral density of the talus in end-stage ankle osteoarthritis was significantly lower than that of a healthy talus. [168] (10.1186/s12891-025-08798-3)
• [L4] The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation. [169] (10.1016/j.otsr.2016.03.015)
• [L4] The case demonstrates that repeated inversion stress in ankles with lax lateral ligaments can result in osteochondral lesions of the medial part of the talus, and stress inversion ankle roentgenograms should be considered in cases of talar osteochondritis dissecans. [170] (10.2106/00004623-197052010-00018)
• [L2] The early experience and small rate of adverse events reported in this study continue to support the use of the Infinity TAA implant for the treatment of end-stage ankle arthritis. [172] (10.2106/jbjs.22.01294)
• [L4] The outcome of the Mobility TAR at a mean of four years is satisfactory in > 85% of patients. [173] (10.1302/0301-620x.95b10.30204)

See Also

• Ankle arthrodesis
• Total ankle replacement
• Ankle fracture
• Syndesmotic injury
• Talus fracture
• Ankle arthroscopy
• Chronic ankle instability
• Ankle impingement
• Charcot neuroarthropathy

References

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