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Total ankle replacement

107 citationsUpdated Sep 2026

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Overview

Total ankle replacement is a viable treatment option for complete, end-stage ankle arthritis [3], offering a reasonable alternative to arthrodesis in carefully selected patients [13]. It is particularly indicated for rheumatoid patients with severe arthritis unresponsive to conservative treatment [19]. While intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in diverse cohorts where treatment was tailored to patient presentation [8], the design of total ankle arthroplasty systems continues to evolve as understanding of failure modes increases and surgical techniques refine [1]. The design rationale for current implants and instruments requires careful evaluation, as midterm clinical results are few, often unvalidated by independent practitioners, and no level I or II studies have been published [12]. Consequently, it is premature to make definitive comments about the in vivo performance of uncemented second-generation replacements due to limited long-term data [11].

Headline outcomes indicate that total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed [9], with high overall patient satisfaction and functional outcomes supporting its use in treating ankle arthritis [57]. However, results have not been comparable with those of replacements of other major lower extremity joints, with most implants failing to provide long-lasting pain relief or improved function over time [10]. Some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up [1], and the failure rate of total ankle arthroplasty remains 3 to 4 times that of total knee replacements [40]. Although data from patients operated on between 2005 and 2010 demonstrates increasing utilization and lower complication rates compared with ankle arthrodesis [14], rates of reoperation and major complications were higher after total ankle replacement than after arthrodesis [8]. Furthermore, total ankle replacement patients underwent a greater number of additional procedures compared to arthrodesis patients, even though revision rates were similar [17].

The currently available literature has not yet shown that total ankle arthroplasty predictably results in levels of durability and function that make it cost-effective at this time [4]. Clinical outcomes detailed in studies, generally with small numbers and short follow-up, likely say as much about patient selection and surgeon skill as they do about the performance of any particular implant system [20]. For example, primary total ankle arthroplasty with a Mayo implant yielded a good clinical result for 19 per cent, a fair result for 35 per cent, a poor result for 11 per cent, and a failure for 35 per cent of the ankles followed for at least two years [5]. The Mayo total ankle arthroplasty is not recommended, particularly in younger patients who have had a previous operative procedure on the ipsilateral ankle or foot [7]. 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 [6].

Anatomy & Pathophysiology

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, articulating with the dome of the talar body [77]. The talar dome is wider anteriorly and narrower posteriorly [77]. 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 [77]. A simplified model of the ankle joint features a horizontal axis from anteromedial to posterolateral and a coronal axis from superomedial directed distally and laterally to the tip of the fibula [77]. The distal fibula possesses a convex medial surface, while the incisura fibularis is the concave surface of the distal lateral tibia [77]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [77]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [77].

Ligamentous Anatomy

Lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [77]. 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 [77]. It is the weakest ankle ligament [77]. The calcaneofibular ligament extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [77]. The posterior talofibular ligament extends from the posterior lateral malleolus to the posterolateral talus and is the strongest ankle ligament [77]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [77].

The deltoid ligament complex is the primary ankle stabilizer during stance [77]. It consists of superficial and deep layers [88]. 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 [77]. The posterior deep deltoid is the most important component of the deep deltoid ligament [77]. The deep portion is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [88]. These bands are intra-articular but extrasynovial [88]. The anterior deep tibiotalar ligament arises from the anterior malleolus and attaches to the medial aspect of the talus, while the posterior deep tibiotalar ligament originates from the posterior malleolus and inserts on the medial body of the talus [88]. The deep posterior band comprises the largest band of the deltoid complex [88]. The deep deltoid ligament resists external rotation when the foot is dorsiflexed and is responsible for the greatest restraint against lateral translation [88].

The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [77]. It functions primarily to resist valgus and eversion ankle forces [77]. The superficial layer originates from the anterior malleolus and inserts into the navicular, neck of the talus, sustentaculum tali, and posteromedial talar tubercle [88]. The deltoid ligament consists of at most six bands, of which only three are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [88]. The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [88]. The deltoid ligament primarily prohibits eversion and abduction [88]. Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid ligaments [88].

The deep deltoid ligament has a load to failure of 713.8 N ± 69.3 [88]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion, whereas the dominant mode of failure for the superficial deltoid ligament is at its insertion on the anterior malleolus [88]. The deltoid ligament has a rich vascular supply from three extraosseous sources: the medial tarsal artery, posterior tibial artery, and tibialis anterior artery [88]. It also has a component of intraosseous vascular supply from either the talus or the medial malleolus [88].

Biomechanics and Motion

The primary functions of the foot and ankle are to provide weight-bearing support and forward ambulation [77]. The ankle joint is responsible for most sagittal plane motion of the foot and ankle [77]. Ankle plantar flexion ranges from 23 to 48 degrees, while ankle dorsiflexion ranges from 10 to 23 degrees [77]. The ankle joint contributes to inversion, eversion, and rotation [77].

Abnormalities of gait caused by ankle arthritis are improved by ankle arthrodesis [41]. Normal gait is not achieved after ankle arthrodesis, but the improvement from preoperative levels is clinically significant [41]. Arthrodesis of the ankle joint results in significant limitation of daily activities with reduced function of the affected limb [107]. It also results in changes in spatial and temporal movement, weight bearing profile, and contact surface [107]. Total ankle replacement demonstrates superior gait mechanics compared to arthrodesis for ankle osteoarthrosis [119]. The distal tibiofibular syndesmosis morphological classification might affect biomechanics properties in tibiotalar and subtalar joints in ankle osteoarthritis [102]. There is no true consensus in the literature as to whether ankle arthrodesis leads to adjacent-joint arthritis [100]. Spatiotemporal parameters were not affected by hindfoot alignment resulting from subtalar compensation [104].

Pathophysiology and Failure Modes

Surgical management for end-stage ankle osteoarthritis currently focuses on ankle arthrodesis and total ankle arthroplasty [16]. Specific indications for choosing one procedure over the other are the topic of much debate [16]. The performance of total ankle arthroplasty in comparison to ankle fusion remains to be defined in a properly designed randomized trial [24].

Some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up [1]. Primary total ankle arthroplasty with a Mayo implant yielded a good clinical result for 19 per cent, a fair result for 35 per cent, a poor result for 11 per cent, and a failure for 35 per cent of ankles followed for at least two years [5]. The authors do not recommend the use of the Mayo total ankle arthroplasty, particularly in younger patients who have had a previous operative procedure on the ipsilateral ankle or foot [7].

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]. Satisfactory results can be achieved in patients with varus malalignment of ≥10°, which should not be considered a contraindication to total ankle replacement [60]. Preoperative coronal plane malalignment and incongruence of the ankle can be corrected and maintained for 2 years with total ankle replacement [69]. Stiff ankles seemed to be at a higher risk for subsidence in three-component total ankle arthroplasty [105]. Coronal plane malalignment in total ankle arthroplasty alters foot kinematics and plantar pressure [111]. Component malalignment in total ankle arthroplasty leads to changes in foot kinematics and plantar pressure distributions [106].

The new fixed-bearing total ankle replacement showed a safe mechanical behavior and many clinical advantages [117]. The investigated new in situ fixed-bearing ankle design achieved overall better short-term results than those reported in previous research [118]. In general, the group with a fixed-bearing implant demonstrated improvements in ankle moment and ground reaction forces [21]. In general, the mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome [21].

Polymer wear that causes aseptic loosening of the prosthesis components is the primary mechanism of intermediate and late failure of total joint replacements [126]. The average contact pressures of 5.6 MPa for the Agility total ankle system fall within the safe zone for industrial limit for contact pressures on polyethylene, which is less than 10 MPa [126]. The measured peak contact pressure of 21.2 MPa for the Agility total ankle system falls within the caution zone, which is less than the 22 MPa industrial yield point for polyethylene [126]. The compressive yield point for polyethylene has been reported to range from 13-22 MPa at room temperature [126]. After the yield point is surpassed, polyethylene undergoes plastic deformation that may lead to accelerated material failure [126].

Total ankle arthroplasties fail in a variety of ways, including: High-grade complications: due to infection or loosening or failure of a component [72]. Intermediate-grade complications: due to technical error, subsidence, or periprosthetic fracture [72]. Low-grade complications: due to wound problems and intraoperative fracture [72].

Patients with a high-grade complication were more than twice as likely to require further surgery [72]. The high-grade complication of loosening leading to subsidence and failure is frequently associated with ballooning osteolysis around a component [72]. The underlying causes of osteolysis around a total ankle arthroplasty are not fully understood and believed to be multifactorial [72]. Osteolysis in the ankle has been compared with that around the hip and thought to be due to an immune reaction related to the activation of receptor activator of nuclear factor kappa-B ligand [72]. Histological studies suggest that polyethylene particles of a certain size causing osteolysis around a total hip arthroplasty do not cause osteolysis in the ankle [72].

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 [137]. 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 [137].

Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes [108]. Supramalleolar osteotomy is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion [128]. A flexion osteotomy effectively improved the congruency of the ankle joint [125].

Third-generation total ankle arthroplasty implants feature improved bearing surfaces and fixation [45]. Fourth-generation total ankle arthroplasty systems incorporate 3D printing and patient-specific instrumentation [45]. The new design reproduces physiologic ankle mobility and maintains complete congruence at the two articulating surfaces of the meniscal bearing over the entire motion arc [103]. The prospect of minimizing wear of the meniscal bearing component is associated with maintaining complete congruence over the entire motion arc [103]. Rotational position of the leg highly influences measurements in ankle radiographs after total ankle replacement [114]. More information and data are needed to further investigate failure modes in ankle arthroplasties as the number of surgeries increases [133].

Classification

Tanaka Staging System: This system describes ankle arthritis severity in four stages, with stage I representing early, mild arthritis and stage IV representing end-stage arthritis [134].

Canadian Orthopaedic Foot and Ankle Society Classification: This classification divides ankle arthritis into four types based on the hindfoot joints involved and the presence of deformity [134].

Modified Cedell’s Classification: This system classifies ankle arthritis on weight-bearing radiographs into four degrees, with degree 1 considered mild, degrees 2 and 3 considered moderate, and degree 4 considered severe [138].

Takakura Ankle Osteoarthritic Stage: This radiographic classification system is utilized in studies of supramalleolar osteotomy for ankle osteoarthritis [42]. In a systematic review of supramalleolar osteotomy studies, the distribution of ankles by Takakura stage was 10.1% stage 1, 27.4% stage 2, 41.4% stage 3a, 18.8% stage 3b, and 2.3% stage 4 [42].

Glazebrook Complication Grading: Glazebrook et al. divided complications in total ankle arthroplasty into three grades based on the likelihood of revision surgery [72]. High grade includes infection, loosening, or component failure; intermediate grade includes technical error, subsidence, or periprosthetic fracture; and low grade includes wound problems and intraoperative fracture [72]. Patients with a high-grade complication were more than twice as likely to require further surgery compared to other grades [72].

Other Considerations: Neither the Tanaka staging system nor the Canadian Orthopaedic Foot and Ankle Society classification is reliable to aid in surgical decision making for the arthritic ankle [134]. The Gadd et al. assessment of a three-grade classification of complications in total ankle replacement is cited as a reference for risk stratification [68].

Clinical Presentation

Osteoarthritis of the ankle is a disabling condition that affects a patient’s quality of life as much as arthritis of the hip and congestive heart failure [61]. The most common aetiological factor in the development of osteoarthritis of the ankle is post-traumatic, often following fractures and severe sprains of the ankle [61]. The demand incidence of symptomatic ankle osteoarthritis has recently been estimated to be 47.7 per 100,000 in the United Kingdom [61].

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 the topic of much debate [16]. Total ankle arthroplasty offers a reasonable alternative to ankle arthrodesis in carefully selected patients [13]. Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement [29]. Clinical outcomes, complication rates, and survivorship of total ankle arthroplasty were comparable between men and women [56]. While the observation that favorable midterm outcomes were achieved in both younger and older patients supports the possibility that transfibular total ankle arthroplasty may be considered across a broader age spectrum, the current data do not establish equivalence between the age groups [55].

Total ankle replacement in patients with rheumatoid arthritis, using a second-generation prosthesis, can provide reliable relief of pain and good functional results at intermediate-term followup, although the incidence of osteolysis warrants close followup [18]. Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients [33]. 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 [34].

While most patients had reduced pain following total ankle replacement, persistent pain is not infrequent even in otherwise uncomplicated cases, often caused by soft-tissue impingement [52]. In general, the group with a fixed-bearing implant demonstrated improvements in ankle moment and ground reaction forces, while the mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome [21]. The authors present a diagnostic and treatment algorithm to assist surgeons in managing painful total ankle arthroplasty, emphasizing that fusion should be considered for complex cases such as those with extensive heterotopic ossification or recurrent stiffness following revision [25].

Periprosthetic joint infection after total ankle arthroplasty is a dreaded complication with devastating consequences; surgeons must be prepared to diagnose and manage potential infections to improve outcomes [53]. Endoscopic posterior ankle decompression and release after total ankle arthroplasty is technically demanding and should be reserved for the experienced foot and ankle arthroscopists [51].

Investigations

Plain radiography: AP, mortise, and lateral weight-bearing ankle x-rays may not demonstrate subtle osteochondral lesions [93].

CT: CT scan is helpful for bony lesions, determining integrity of subchondral bone, identifying cysts, and preoperative planning for osteochondral lesions [93].

MRI: MRI is sensitive for all osteochondral lesions, but the edema pattern frequently overestimates the severity of injury [93]. Linear fluid signal deep to subchondral bone on MRI indicates an unstable osteochondral injury [93]. MRI has a sensitivity of 92% for predicting stable versus unstable osteochondral lesions [93].

Other Considerations: Treatment of patients with a painful total ankle arthroplasty requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options [6]. A diagnostic and treatment algorithm exists to assist surgeons in managing painful total ankle arthroplasty [25]. Fusion should be considered for complex cases of painful total ankle arthroplasty such as those with extensive heterotopic ossification or recurrent stiffness following revision [25].

Total ankle arthroplasty for moderate and severe varus arthritic deformity showed similar satisfactory clinical and radiographic outcomes as those obtained by patients in the neutral group when postoperative neutral alignment was achieved [73]. Total ankle arthroplasty may be considered in ankles with deformity of >20° [47]. Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques [39].

Rates of reoperation and major complications were higher after ankle replacement than after arthrodesis [8]. Clinical results were less satisfactory after total ankle replacement than after arthrodesis, with significantly higher surgical revision rates mainly due to periprosthetic cysts [74]. 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 [14]. Improvement in step activity may occur more quickly following arthroplasty than arthrodesis, but at 3 years, there is no significant difference between the 2 procedures [148].

The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the Agility arthroplasty are encouraging [48]. The clinical and radiographic data suggest that transbular TAA is an effective and durable treatment option for end-stage ankle arthritis, with excellent mid-term implant survivorship [62]. Prosthetic talar replacement is a useful procedure for patients with osteonecrosis of the talus as it maintains ankle function [64]. Custom-made total ankle arthroplasty components should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA [70]. While normal gait is not achieved after ankle arthrodesis, the improvement from preoperative levels is clinically significant [41].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions. Total ankle replacement is indicated for end-stage ankle arthritis, implying the failure of prior non-operative measures, though specific conservative prerequisites are not enumerated in this dataset.

Operative

Indications: Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle when proper indications are used [58]. Patients with rheumatoid arthritis benefit from total ankle arthroplasty and achieve outcomes similar to those with noninflammatory arthritis [135]. For highly active individuals, total ankle replacement may be a better choice than arthrodesis because it allows increased participation in sports and recreation activities [140]. The principle of nonmaleficence should not be used to exclude obese patients from total ankle arthroplasty; instead, these patients should be counseled through shared decision-making regarding increased risks [127]. Pain and disability are significantly reduced in overweight and obese patients after successful ankle replacement or fusion [130].

Implant Selection: 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 [1]. While there is consensus that the procedure will continue to be implanted in carefully selected patients, it is premature to make definitive comments about the in vivo performance of uncemented second-generation replacements due to limited long-term data [11]. Third-generation implants feature improved bearing surfaces and fixation, while fourth-generation systems incorporate 3D printing and patient-specific instrumentation [45]. Modern fixed-bearing total ankle arthroplasty has demonstrated excellent implant survival, improved plantar flexion and total range of motion, and good-to-excellent functional outcomes at a mean follow-up of 5.2 years [112]. Patients undergoing total ankle arthroplasty with a fixed-bearing implant with a modular intramedullary stem for end-stage ankle arthritis experience significant improvement in alignment, pain scores, quality-of-life measures, and subjective function [65].

Outcomes and Efficacy: Total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed [9]. In a diverse cohort where treatment was tailored to patient presentation, intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable, although rates of reoperation and major complications were higher after ankle replacement [8]. When both procedures are performed by the same group of surgeons, patients undergoing total ankle arthroplasty or arthrodesis for end-stage ankle arthritis show significant improvement in overall function, ankle-specific function, and pain at 48 months, with better functional improvement in the total ankle arthroplasty group [145]. Although revision rates were similar between groups, total ankle replacement patients underwent a greater number of additional procedures compared to arthrodesis groups [17]. The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after arthroplasty are encouraging [48]. The trend of improved outcomes indicates that modern ankle replacement designs are performing well provided the surgery is done well, though additional procedures such as the Strayer procedure may be required [81]. Based on data from 1888 patients, patient satisfaction rates typically exceeded 90%, ranging from 80% to 97% [26]. Functional outcome assessment using commonly applied scoring systems suggested uniform improvement in all studies, with follow-up scores generally ranging from 70 to 90 points (maximum, 100 points) [26]. Tobacco cessation appears to reverse the effects of smoking, allowing total ankle arthroplasty to be an effective and safe procedure for former smokers, who have perioperative complication rates and outcomes similar to nonsmokers [71].

Complications and Management: Peroperative complications affected 12% (n =71) of operations in a French cohort, including malleolar fracture in 53 cases (35 medial, 18 lateral) [28]. Postoperative X-ray found 90% (n =535) satisfactory positioning in this French cohort, with 31 of 57 defective implantations concerning imprecise positioning [28]. The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation [67]. Arthroscopic treatment is an effective and potentially advantageous alternative to open treatment of impingement after total ankle replacement [90].

Conversion and Salvage Procedures: The use of specific components is encouraged as an alternative to arthrodesis of the ankle in patients with a failed total ankle arthroplasty [70]. The combination of a total ankle arthroplasty and a custom-built talar prosthesis secured to both the calcaneus and the navicular may be useful in the treatment of rare cases of large, trauma-induced bone defects [63].

Other Considerations: Published studies of total ankle arthroplasty have overwhelmingly carried a Grade-C recommendation (fair evidence or conflicting, or poor-quality, evidence, i.e., level III, IV, or V) for mobile or fixed-bearing designs [26]. Without uniform outcome measures being applied to all studies, comparison of the results from different case series is challenging [26]. Debate remains over which outcome measures are most appropriate in the assessment of total ankle arthroplasty, and there are few comparative studies [26]. There are too few studies with good and fair-quality evidence or longer-term follow-up to improve the recommendation for total ankle arthroplasty in the management of end-stage ankle arthritis from a Grade C to a Grade B or A [26]. Its performance in comparison to the current reference standard (that is, ankle fusion) remains to be defined in a properly designed randomized trial [24]. Modern uncemented ankle replacements are stable enough to allow weight-bearing within the first week after bilateral surgical procedures, warranting a large-scale randomized controlled trial of weight-bearing following ankle replacement [139].

Complications

Operative and Perioperative: Peroperative complications affected 12% of total ankle arthroplasty operations in a French cohort [28]. Malleolar fractures occurred in 53 cases (35 medial, 18 lateral), secondary to component oversizing or faulty surgical movement [28]. These fractures required longer immobilization but did not significantly impact the final clinical result compared to the series as a whole [28]. Six cracked pilons occurred due to tibial component impaction [28], and one talar neck fracture was reported [28]. Five cases of peroperative bearing instability were noted [28], alongside three defective implant fixations (two talar, one tibial) [28]. Two cases of tendon sectioning occurred [28], while no vascular lesions were reported in the French cohort [28]. Blood transfusion during total ankle arthroplasty is associated with increased in-hospital complications and cost [31]. The median length of hospital stay for patients undergoing total ankle replacement was 77 hours [85].

Infection (PJI): Periprosthetic joint infection after total ankle arthroplasty is a complication with devastating consequences [53]. One patient with rheumatoid arthritis undergoing total ankle arthroplasty developed a deep local infection requiring revision surgery [86]. A history of bariatric surgery is not an important predictor of joint infection within 5 years after primary total ankle arthroplasty [156].

Mechanical and Structural Failures: Primary total ankle arthroplasty with a Mayo implant resulted in failure for 35% of ankles followed for at least two years [5]. Most total ankle arthroplasty implants have failed to provide long-lasting pain relief or improved function over time [10]. A relatively high rate of reoperation was noted after total ankle arthroplasty with a second-generation device [46]. Revision arthroplasty for a failed Agility total ankle implant carries a high complication rate and substantial technical demands [153]. Total ankle replacement patients underwent a greater number of additional procedures compared to arthrodesis patients, although revision rates were similar [17]. Rates of reoperation and major complications were higher after ankle replacement than after ankle arthrodesis in a diverse cohort [8]. Pooled data analysis demonstrated a higher reoperation rate for revision after total ankle arthroplasty compared to ankle arthrodesis [79]. Fracture posttraumatic osteoarthritis was associated with a markedly higher complication rate after total ankle arthroplasty and a higher risk of failure requiring prosthesis explant compared with primary osteoarthritis [66].

Periprosthetic Osteolysis: The prevalence of periprosthetic osteolysis after total ankle arthroplasty is considerable and negatively affects clinical outcomes [151]. In a cohort of 144 ankles, 22 cases (15.3%) of periprosthetic osteolysis were identified, with 8 ankles revised for aseptic loosening or component subsidence and 14 cases treated with curettage, bone graft, and polyethylene liner exchange [132].

Implant Positioning and Stability: In a French cohort, 31 of 57 defective implantations concerned imprecise positioning, including 16 cases of frontal malalignment, 10 of sagittal malalignment, and five of poor talar positioning [28]. Bearing stability issues concerned 14 ankles in a French cohort, comprising four cases of frontal instability and 10 of sagittal centering [28]. Nine implants showed immediate tibial radiolucency and three talar components were oversized in a French cohort [28].

Thromboembolic Events: Readmissions after total ankle arthroplasty were dominated by evaluation of wound compromise as well as deep vein thrombosis (DVT) and pulmonary embolism (PE) [152]. The incidence of symptomatic thromboembolic events after total ankle arthroplasty without routine use of chemoprophylaxis is low [31].

Wound and Soft Tissue Complications: Tobacco cessation reverses the effects of smoking, allowing total ankle arthroplasty to be an effective and safe procedure for former smokers with perioperative complication rates and outcomes similar to nonsmokers [71]. Arthroscopic debridement after total ankle arthroplasty is contraindicated in the presence of prosthesis loosening, subsidence, incorrect implant sizing, inadequate polyethylene insert size, or bone infection requiring open procedures [136]. Arthroscopic debridement after total ankle arthroplasty is contraindicated in the presence of complications such as deep periprosthetic infection requiring revision [136].

Adjacent Joint and Long-term Issues: Secondary development of subtalar arthrosis was not seen radiographically in patients with normal subtalar joints at the time of total ankle replacement [43]. Only one patient with significant pre-existing changes of the subtalar joint developed symptomatic subtalar arthrosis after total ankle replacement [43]. The incidence of osteolysis in patients with rheumatoid arthritis undergoing total ankle replacement warrants close followup [18].

Other Considerations: One case of deep infection in a total ankle arthroplasty cohort was successfully treated by revision total ankle arthroplasty through 2-stage reconstruction [132]. One case of technical error in a total ankle arthroplasty cohort involved recurrent instability with polyethylene dislocation, treated with lateral ligament reconstruction and polyethylene liner exchange [132].

Recovery

Light activity (weeks): Driving safety requires caution in the early postoperative period. Nearly 10% of patients did not pass a brake reaction time test 6 weeks after undergoing right-sided total ankle arthroplasty [97].

Full activity (months): Return to recreational and occupational demands is common. Two-thirds of patients were active in sports after total ankle arthroplasty [110]. The majority of patients met current health-enhancing physical activity recommendations after total ankle arthroplasty [110].

Other Considerations: Anatomical restoration of the joint is a key early milestone. 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]. Clinical benefits are consistent across demographics; men and women with end-stage ankle arthritis benefited from total ankle replacement with similar magnitudes of improvement [29].

Key Evidence

• [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. [1] (10.5435/jaaos-d-16-00715)
• [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. [2] (10.5435/jaaos-d-25-00638)
• [L4] Total ankle replacement is a good treatment option for complete, end-stage ankle arthritis. [3] (10.3238/arztebl.2015.0177)
• [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. [6] (10.5435/jaaos-d-14-00017)
• [L3] The authors do not recommend the use of the Mayo total ankle arthroplasty, particularly in younger patients who have had a previous operative procedure on the ipsilateral ankle or foot. [7] (10.2106/00004623-199407000-00003)
• [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. [8] (10.2106/jbjs.l.01597)
• [L5] The findings suggest that total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed. [9] (10.2106/jbjs.26.00501)
• [L4] The results of total ankle arthroplasty have not been comparable with those of replacements of other major joints of the lower extremity, with most implants failing to provide long-lasting pain relief or improved function over time. [10] (10.2106/00004623-199810000-00002)
• [L4] The total ankle replacement design is still evolving, and while there is consensus that it will continue to be implanted in carefully selected patients, it is premature to make definitive comments about the in vivo performance of uncemented second-generation replacements due to limited long-term data. [11] (10.1097/01.blo.0000132244.18548.40)
• [L5] The design rationale for current total ankle replacement implants and instruments should be carefully evaluated as midterm clinical results are few, often unvalidated by independent practitioners, and no level I or II studies have been published. [12] (10.5435/00124635-200809000-00005)
• [L4] Total ankle arthroplasty offers a reasonable alternative to ankle arthroplasty in carefully selected patients. [13] (10.1302/2058-5241.3.170029)
• [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. [14] (10.2106/jbjs.15.01341)
• [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. [15] (10.2106/jbjs.i.01301)
• [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. [16] (10.5435/jaaos-d-23-00743)
• [L3] Although revision rates were similar, total ankle replacement patients underwent a greater number of additional procedures. [17] (10.2106/jbjs.18.01012)
• [L4] Total ankle replacement in patients with rheumatoid arthritis, using a second-generation prosthesis, can provide reliable relief of pain and good functional results at intermediate-term followup, although the incidence of osteolysis warrants close followup. [18] (10.1097/01.blo.0000132181.46593.82)
• [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. [19] (10.2106/00004623-198466030-00004)
• [L5] The clinical outcomes detailed in studies regarding total ankle arthroplasty, generally with small numbers and short follow-up, likely say as much about patient selection and surgeon skill as they do about the performance of any particular implant system. [20] (10.2106/jbjs.n.01084)
• [L2] In general, the group with a fixed-bearing implant demonstrated improvements in ankle moment and ground reaction forces, while the mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome. [21] (10.2106/jbjs.m.00971)
• [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)
• [L1] Its performance in comparison to the current reference standard (that is, ankle fusion) remains to be defined in a properly designed randomized trial. [24] (10.1007/s00402-004-0765-3)
• [L5] The authors present a diagnostic and treatment algorithm to assist surgeons in managing painful total ankle arthroplasty, emphasizing that fusion should be considered for complex cases such as those with extensive heterotopic ossification or recurrent stiffness following revision. [25] (10.1302/0301-620x.99b1.37536)
• [L4] [26] (10.2106/jbjs.j.00126)
• [L4] [28] (10.1016/j.otsr.2010.03.002)
• [L4] Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. [29] (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. [30] (10.1302/0301-620x.105b10.bjj-2023-0010.r1)
• [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. [33] (10.2106/jbjs.o.00396)
• [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. [34] (10.1097/01.blo.0000132460.27102.d6)
• [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. [39] (10.1302/2058-5241.2.160021)
• [L5] Revision total ankle arthroplasty can be safe and durable and can produce excellent patient outcomes, though the failure rate of total ankle arthroplasty remains 3 to 4 times that of total knee replacements. [40] (10.2106/jbjs.22.00764)
• [L3] While normal gait is not achieved, the improvement from preoperative levels is clinically significant. [41] (10.1302/0301-620x.98b10.37614)
• [L4] [42] (10.1007/s00167-022-07144-7)
• [L3] [43] (10.1097/01.blo.0000132245.18548.09)
• [L4] The article summarizes design rationales and clinical outcomes for evolving total ankle arthroplasty systems, noting that third-generation implants feature improved bearing surfaces and fixation, while fourth-generation systems incorporate 3D printing and patient-specific instrumentation. [45] (10.5435/jaaos-d-23-00559)
• [L4] We noted a relatively high rate of reoperation after total ankle arthroplasty with this second-generation device. [46] (10.2106/00004623-200406000-00008)
• [L3] Our results suggested that total ankle arthroplasty may be considered in ankles with deformity of >20°. [47] (10.2106/jbjs.19.00416)
• [L4] The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging. [48] (10.2106/00004623-200406000-00007)
• [L4] This is technically demanding and should be reserved for the experienced foot and ankle arthroscopists. [51] (10.1016/j.eats.2022.01.001)
• [L4] While most patients had reduced pain following total ankle replacement, persistent pain is not infrequent even in otherwise uncomplicated cases, often caused by soft-tissue impingement. [52] (10.1302/0301-620x.95b3.31219)
• [L5] Periprosthetic joint infection after total ankle arthroplasty is a dreaded complication with devastating consequences; surgeons must be prepared to diagnose and manage potential infections to improve outcomes. [53] (10.5435/jaaos-d-23-01266)
• [L5] While the observation that favorable midterm outcomes were achieved in both younger and older patients supports the possibility that transfibular total ankle arthroplasty may be considered across a broader age spectrum, the current data do not establish equivalence between the age groups. [55] (10.2106/jbjs.26.00460)
• [L3] Clinical outcomes, complication rates, and survivorship of total ankle arthroplasty were comparable between men and women. [56] (10.1186/s13018-020-01731-5)
• [L4] Overall patient satisfaction was high as were functional outcomes, supporting ankle arthroplasty as an option in the treatment of ankle arthritis. [57] (10.1302/0301-620x.103b4.bjj-2020-0758.r1)
• [L4] Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used. [58] (10.2106/jbjs.e.00414)
• [L2] Satisfactory results can be achieved in patients with varus malalignment of ≥10°, which should not be considered a contraindication to total ankle replacement. [60] (10.2106/jbjs.l.00797)
• [L1] [61] (10.1302/0301-620x.95b11.31633)
• [L3] The clinical and radiographic data in this study suggest that transbular TAA is an effective and durable treatment option for end-stage ankle arthritis, with excellent mid-term implant survivorship. [62] (10.2106/jbjs.24.00983)
• [L4] The combination of a total ankle arthroplasty and a custom-built talar prosthesis secured to both the calcaneus and the navicular may be useful in the treatment of rare cases of large, trauma-induced bone defects. [63] (10.2106/00004623-200408000-00024)
• [L4] Prosthetic talar replacement is a useful procedure for patients with osteonecrosis of the talus as it maintains ankle function. [64] (10.2106/jbjs.n.01272)
• [L3] Patients who undergo total ankle arthroplasty with a fixed-bearing implant with a modular intramedullary stem for end-stage ankle arthritis have significant improvement in alignment, pain scores, quality-of-life measures, and subjective function. [65] (10.2106/jbjs.m.01386)
• [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. [66] (10.5435/jaaos-d-22-01192)
• [L4] The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation. [67] (10.1016/j.otsr.2016.03.015)
• [L4] [68] (10.1302/0301-620x.100b10.bjj-2018-0180.r1)
• [L4] Preoperative coronal plane malalignment and incongruence of the ankle can be corrected and maintained for 2 years with total ankle replacement. [69] (10.1097/01.blo.0000132248.64290.52)
• [L4] This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA. [70] (10.1302/0301-620x.99b2.bjj-2016-0504.r2)
• [L3] Furthermore, tobacco cessation appeared to reverse the effects of smoking, which allowed total ankle arthroplasty to be an effective and safe procedure for providing pain relief and improving function in former smokers as they had perioperative complication rates and outcomes similar to nonsmokers. [71] (10.1177/1071100716655435)
• [L4] [72] (10.1302/0301-620x.100b4.bjj-2017-0963)
• [L3] Total ankle arthroplasty for moderate and severe varus arthritic deformity showed similar satisfactory clinical and radiographic outcomes as those obtained by patients in the neutral group when postoperative neutral alignment was achieved. [73] (10.1302/0301-620x.99b10.bjj-2016-1275.r1)
• [L3] Clinical results were less satisfactory after total ankle replacement than after arthrodesis, with significantly higher surgical revision rates mainly due to periprosthetic cysts. [74] (10.1016/j.otsr.2018.10.014)
• [L1] Pooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. [79] (10.1186/s13018-017-0576-1)
• [L4] The article documents the trend of improved outcomes of ankle replacement surgery, indicating that modern ankle replacement designs are performing well provided the surgery is done well, and that additional procedures such as the Strayer procedure may be required. [81] (10.2106/jbjs.18.00555)
• [L4] [85] (10.2106/jbjs.k.00834)
• [L4] [86] (10.1097/01.blo.0000131246.79993.ec)
• [Paper] This case shows that arthroscopic treatment is an effective and potentially advantageous alternative to open treatment of impingement after total ankle replacement. [90] (10.1016/j.eats.2015.12.001)
• [L5] Nearly 10% of patients did not pass a brake reaction time test 6 weeks after undergoing right-sided total ankle arthroplasty, reinforcing concerns that patients driving within a few weeks of major lower-limb surgery are taking a big risk. [97] (10.1097/corr.0000000000001069)
• [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. [100] (10.2106/jbjs.n.00426)
• [L3] DTS morphological classification might affect the biomechanics properties in TAS and TTA in ankle OA. [102] (10.1186/s13018-023-03985-1)
• [L5] The new design reproduces physiologic ankle mobility and maintains complete congruence at the two articulating surfaces of the meniscal bearing over the entire motion arc, with the prospect of minimizing wear of this component. [103] (10.1097/01.blo.0000132246.26172.b7)
• [L3] The spatiotemporal parameters were not affected by the hindfoot alignment resulting from subtalar compensation. [104] (10.1186/s13018-024-04615-0)
• [L4] Stiff ankles seemed to be at a higher risk for subsidence. [105] (10.1016/j.otsr.2012.04.005)
• [L5] This CORR Insights commentary notes that the referenced cadaveric study by Buckner et al. demonstrated that component malalignment in total ankle arthroplasty leads to changes in foot kinematics and plantar pressure distributions, improving biomechanical understanding of the procedure. [106] (10.1097/corr.0000000000001316)
• [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. [107] (10.1186/s13018-026-06842-z)
• [L5] Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes. [108] (10.5435/jaaos-d-12-00124)
• [L4] Two-thirds of the patients were active in sports after total ankle arthroplasty, and the majority of the patients met current health-enhancing physical activity recommendations. [110] (10.1177/0363546508323253)
• [L5] In this cadaver study, coronal plane malalignment in TAA altered foot kinematics and plantar pressure. [111] (10.1097/corr.0000000000001294)
• [L4] Modern fixed-bearing total ankle arthroplasty had excellent implant survival, improved plantar flexion and total range of motion, and had good-to-excellent functional outcome at a mean follow-up of 5.2 years. [112] (10.2106/jbjs.16.00090)
• [L4] The findings suggest that rotational position of the leg highly influences measurements in ankle radiographs after TAR. [114] (10.1186/s13018-015-0220-x)
• [L5] The new fixed-bearing total ankle replacement showed a safe mechanical behavior and many clinical advantages. [117] (10.1186/s12891-017-1848-y)
• [L4] The investigated new in situ fixed-bearing ankle design achieved overall better short-term results than those reported in previous research. [118] (10.1097/corr.0000000000002515)
• [L5] For ankle osteoarthrosis, total ankle replacement demonstrates superior gait mechanics compared to arthrodesis, while adult acquired flatfoot deformity treatment depends on the stage of posterior tibial tendon dysfunction. [119] (10.1302/2058-5241.1.000015)
• [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] A flexion osteotomy effectively improved the congruency of the ankle joint. [125] (10.1302/0301-620x.101b6.bjj-2018-0932.r2)
• [L5] [126] (10.1097/01.blo.0000132461.34725.a7)
• [L5] The principle of nonmaleficence should not be used to exclude obese patients from total ankle arthroplasty, and patients should be counseled through shared decision-making regarding increased risks. [127] (10.2106/jbjs.24.01142)
• [L3] SMOT is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion. [128] (10.1186/s13018-021-02732-8)
• [L4] Pain and disability are significantly reduced in overweight and obese patients after successful ankle replacement or fusion. [130] (10.2106/jbjs.k.00513)
• [L3] [132] (10.2106/jbjs.17.00703)
• [L4] More information and data are needed to further investigate failure modes in ankle arthroplasties as the number of surgeries increases. [133] (10.1007/s00402-014-2067-8)
• [L4] [134] (10.5435/jaaos-d-24-00955)
• [L3] Patients with rheumatoid arthritis benefit from total ankle arthroplasty and have similar outcomes to patients with noninflammatory arthritis. [135] (10.2106/jbjs.m.01164)
• [Paper] [136] (10.1016/j.eats.2021.02.001)
• [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. [137] (10.1186/s13018-021-02683-0)
• [L4] [138] (10.1007/s004020000243)
• [L5] The commentary suggests that modern uncemented ankle replacements are stable enough to allow weight-bearing within the first week after bilateral surgical procedures, warranting a large-scale randomized controlled trial of weight-bearing following ankle replacement. [139] (10.2106/jbjs.22.00826)
• [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. [140] (10.1055/s-0037-1601408)
• [L2] When both procedures are performed by the same group of surgeons, patients who undergo TAA or AA for end-stage ankle arthritis have significant improvement in overall function, ankle-specific function, and pain at 48 months after surgery, with better functional improvement in the TAA group. [145] (10.2106/jbjs.20.01357)
• [L2] Improvement may occur more quickly following arthroplasty than arthrodesis, but at 3 years, we detected no significant difference between the 2 procedures. [148] (10.2106/jbjs.18.00511)
• [L4] The study demonstrated that the prevalence of periprosthetic osteolysis after total ankle arthroplasty was considerable and that the development of osteolysis negatively affected clinical outcomes. [151] (10.2106/jbjs.21.01093)
• [L4] Readmissions were dominated by evaluation of wound compromise as well as DVT and PE. [152] (10.2106/jbjs.17.01149)
• [L4] Revision arthroplasty may be considered as an alternative to arthrodesis when treating patients with a failed Agility total ankle implant, although the complication rate remains high and technical demands are substantial. [153] (10.2106/jbjs.k.00920)
• [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. [156] (10.5435/jaaos-d-24-01267)

See Also

• Ankle arthrodesis
• Ankle osteoarthritis
• Lateral ligament reconstruction

References

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