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Ankle arthrodesis

81 citationsUpdated Sep 2026

Overview

Ankle arthrodesis remains the gold standard for the surgical treatment of moderate to severe ankle arthritis [6]. While associated with high rates of adjacent joint arthrosis [6], the procedure is reliable for relieving functionally disabling pain, deformity, and functional limitation when good surgical technique is applied to carefully selected patients [12]. Current surgical management for end-stage ankle osteoarthritis focuses on ankle arthrodesis and total ankle arthroplasty [20], with specific indications for choosing between the two remaining a subject of debate [20]. Circumstances favoring arthrodesis include preexisting subtalar or other hindfoot arthritis, contralateral hindfoot or ankle arthritis, and hip or knee impairment where ankle motion benefits overall limb function [46]. No level I studies have directly compared the two procedures [46], and literature reports are contradictory [46]. Recent data favor total ankle arthroplasty with latest-generation implants, citing better functional outcomes, fewer complications, and higher patient satisfaction [46]. Gait studies show no difference in patterns between the two [46], though some report more nearly normal gait and better walking on uneven surfaces after arthroplasty [46]. Gait improves with either procedure [46], and careful patient selection is mandatory for success [46]. An analysis of fifty fusions emphasized the need for careful selection due to post-operative complaints [1].

Arthroscopic ankle arthrodesis is an effective operation for degenerative ankle disease [4], yielding good or excellent functional outcomes at a mean of 86 months in nearly three-quarters of patients [4]. It is reliable for end-stage arthritis in patients aged 60 years or older, providing high union rates, encouraging radiographic and functional outcomes, and low complication rates [5]. Outcomes are similarly satisfactory in ankles with severe deformity compared to mild deformity in elderly patients [5]. Arthroscopically assisted arthrodesis produces good results in patients with osteoarthritis and minimum or no deformity [14], with very short-duration immediate postoperative morbidity [14]. Compared to open arthrodesis, the arthroscopic approach offers better clinical scores, fewer complications, and shorter hospitalization [17], while union rates, reoperation rates, and operative times remain similar [17]. Compression arthrodesis produces a satisfactory fusion rate, resulting in an ankle that is functional, durable, and cosmetically superior to most ankles arthrodesed by other procedures [16].

Nonunion rates vary widely in the literature, dependent on technique, underlying diagnosis, and patient selection [42]. 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 [42]. With modern techniques, attention to detail, and management of concurrent medical conditions, fusion rates better than 90% should be expected in standard, uncomplicated cases [42]. Clinical results were significantly worse in women [29], suggesting female sex should be considered when determining indications [29], although men and women with end-stage arthritis benefited from arthrodesis with similar magnitudes of improvement [8]. Both ankle arthrodesis and tibiotalocalcaneal arthrodesis are effective for pain control, allowing return to work and improved activity participation with high patient satisfaction [22]. Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort where treatment was tailored to patient presentation [2]. However, rates of reoperation and major complications were higher after ankle replacement than after arthrodesis [2]. Clinical results were less satisfactory after total ankle replacement than after arthrodesis [7], with significantly higher surgical revision rates mainly due to periprosthetic cysts [7]. New data from patients operated on between 2005 and 2010 demonstrate increasing utilization and lower complication rates for total ankle replacement compared with ankle arthrodesis [44].

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

Radiographic parameters define normal alignment. The talocrural angle is approximately 83 degrees and should be symmetrical with the contralateral ankle [89]. The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [89]. 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 [89]. 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 AP view and less than 1 mm on the mortise view [89]. On the mortise view, the articular margins of the distal fibula and the lateral process of the talus should be parallel and equal to the tibiotalar joint space [89]. Shortening of the fibula results in lateral and valgus subluxation of the talus [89]. The "ball sign" is an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus on the AP view when the fibula is out to length [89].

The size of the medial clear space more than doubles depending upon the rotational position of the limb [89]. There is a significant increase in medial clear space with ankle plantarflexion [89]. Syndesmotic malreduction risks include overcompression in syndesmoses with a deep incisura, anterior fibular translation in anteverted incisuras, and posterior fibular translation in retroverted incisuras [88].

Ligamentous Anatomy

The lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [82]. 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 [82]. The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [82]. The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [82]. The ATFL is the weakest ankle ligament and the PTFL is the strongest [82]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [82].

The deltoid ligament complex is the primary ankle stabilizer during stance [82]. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body and functions primarily to resist lateral talar translation and external rotation [82]. The posterior deep deltoid is the most important component of the deep deltoid ligament [82]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [82]. The superficial deltoid ligament functions primarily to resist valgus and eversion ankle forces [82].

The deltoid ligament consists of superficial and deep layers, with at most six bands, of which only three are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [85]. The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [85]. The deep portion of the deltoid ligament is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [85]. The deep posterior band of the deltoid ligament comprises the largest band of the deltoid complex [85]. The deep posterior tibiotalar ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [85]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [85]. The dominant mode of failure for the superficial deltoid ligament is at its insertion on the anterior malleolus [85]. Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid ligaments [85].

The deltoid ligament has a rich vascular supply from three separate extraosseous sources: the medial tarsal artery, the posterior tibial artery, and the tibialis anterior artery [85]. The deltoid ligament also has a component of intraosseous vascular supply from either the talus or the medial malleolus [85]. More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the ATFL and CFL [86].

Biomechanics and Pathophysiology

The ankle joint is responsible for most sagittal plane motion of the foot and ankle [82]. Normal ankle range of motion includes 23 to 48 degrees of plantar flexion [82]. Normal ankle range of motion includes 10 to 23 degrees of dorsiflexion [82]. The ankle joint also contributes to inversion, eversion, and rotation [82].

Substantial ankle malalignment, mostly varus deformity, is common in ankles with end-stage osteoarthritis [61]. Ankle arthrodesis remains the gold standard for symptomatic ankle arthritis but is associated with high rates of adjacent joint arthrosis [6]. There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis [19]. Arthrodesis of the ankle joint results in significant limitation of daily activities with reduced function of the affected limb and changes in spatial and temporal movement, weight bearing profile, and contact surface [102]. Abnormalities of gait caused by ankle arthritis are improved by ankle arthrodesis, although normal gait is not achieved [23]. The improvement in gait from preoperative levels following ankle arthrodesis is clinically significant [23].

Severe ankle instability has nearly three times the chance to develop into ankle osteoarthritis compared to moderate ankle instability [120]. Ligament injury-induced mechanical instability of the ankle-subtalar joint complex can lead to talus dislocation due to loss of stability of the bone structure [136]. Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging [77]. Currently used imaging options cannot accurately predict subtalar joint instability [77]. The spatiotemporal parameters of hindfoot motion were not affected by the hindfoot alignment resulting from subtalar compensation [99]. The distal tibiofibular syndesmosis morphological classification might affect the biomechanics properties in tibiotalar and tibiotalocalcaneal arthrodesis in ankle osteoarthritis [98]. Loss of mechanical ankle function is not compensated by the distal foot joints in patients with ankle osteoarthritis [104]. Increasing the shoe instep by 1 cm or 2 cm shifts the ground reaction force closer to the metatarsal heads at heel-off and reduces maximal foot and tibia dorsiflexion angle in patients with tibiotalar arthrodesis [143]. The best results for pantalar arthrodesis were found when the ankle was fused in 5 to 10 degrees of plantar flexion with no pronation or supination [141].

Classification

Modified Cedell’s Classification: This system classifies ankle arthritis on weight-bearing radiographs. Degree 1 is considered mild, degrees 2 and 3 are moderate, and degree 4 is severe [147].

Takakura Ankle Osteoarthritic Stage: In a systematic review of supramalleolar osteotomy, this classification was applied to a cohort where 74 ankles (10.1%) were stage 1, 200 ankles (27.4%) were stage 2, 302 ankles (41.4%) were stage 3a, 137 ankles (18.8%) were stage 3b, and 17 ankles (2.3%) were stage 4 [159].

Other Considerations: Low tibial osteotomy is indicated for the intermediate stage of moderate ankle arthritis with a medial joint lesion [147]. In the same systematic review of supramalleolar osteotomy, the most commonly utilized radiographic parameter for classification was the tibial anterior surface angle (TAS) [159]. Regarding progressive collapsing foot deformity (PCFD), patients with severe progressive collapse achieved greater radiographic correction than those with mild collapse after isolated ankle arthrodesis, although functional improvements did not differ between the two groups [15]. Arthroscopic ankle arthrodesis is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older, resulting in a high union rate and low complication rate even in cases with severe preoperative deformity [5]. Furthermore, arthroscopic and open ankle arthrodesis resulted in comparable clinical outcomes to total ankle replacement in patients with non-deformed, COFAS Type-1 end-stage ankle arthritis [26].

Clinical Presentation

Ankle arthrodesis is indicated for the relief of functionally disabling ankle arthritis, deformity, and pain in carefully selected patients [12]. The procedure remains the gold standard for the treatment of end-stage ankle arthritis [6]. While there is no true consensus in the literature regarding whether ankle arthrodesis leads to adjacent-joint arthritis [19], surgical treatment significantly improves ambulatory activity, with greater change occurring at high activity levels [47]. Both ankle arthrodesis and tibiotalocalcaneal arthrodesis are effective procedures that result in good pain control, allow return to work, and improve activity participation with high patient satisfaction [22].

Clinical outcomes vary by patient demographics and surgical approach. Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement [8]. However, clinical results were significantly worse in women after ankle arthrodesis, which should be considered when determining the indication [29]. Arthroscopic ankle arthrodesis offers better clinical scores, fewer complications, and shorter hospitalization compared to open arthrodesis, although union rates, reoperation rates, and operative times are similar [17]. This minimally invasive approach is an effective operation for treating degenerative ankle disease, resulting in good or excellent functional outcomes at a mean of 86 months post-operatively in nearly three-quarters of the patient cohort [4]. It is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older, resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity [5]. Furthermore, arthroscopic ankle arthrodesis produces good results in patients who have osteoarthritis of the ankle with minimum or no deformity, and the immediate postoperative morbidity is of very short duration [14].

Preoperative assessment and specific pathologies influence expected outcomes. Patients with severe progressive collapsing foot deformity achieved greater radiographic correction than those with mild collapse after isolated ankle arthrodesis, but functional improvements did not differ between groups [15]. Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint seem not to be indicative for a successful outcome of an arthrodesis of the affected joint [63].

Nonunion Risk: Nonunion is a potential complication of foot and ankle fusion surgery and has been associated with poor functional outcomes [25]. Patients who are at high risk of nonunion, such as those with medical comorbidities (diabetes, neuropathy, and osteonecrosis) and/or history of smoking or alcohol use, can have nonunion rates up to 40% [25].

Investigations

Plain radiography: Radiographic analysis for ankle arthrodesis requires three weightbearing radiographs of the ankle [66]. Fusion is determined by the presence of bridging trabeculation on all three views [66]. In patients managed with tibiotalocalcaneal arthrodesis, a lateral foot radiograph and a Broden view are evaluated to determine fusion of the subtalar joint [66]. Alignment is assessed on the anteroposterior, mortise, and lateral views [66]. On the anteroposterior and mortise views, alignment is assessed by the angle between the longitudinal tibial axis and the lateral border of the talus [66]. Sagittal plane alignment is determined radiographically [66]. Coronal plane alignment is assessed clinically from a posterior perspective by measuring the axis of the hindfoot relative to the axis of the distal part of the leg with use of a goniometer [66]. Varus malalignment is defined as a lack of physiologic hindfoot valgus (approximately 5°) [66]. Excessive valgus malalignment is defined as ≥10° of hindfoot valgus [66].

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

Other Considerations: Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint are not indicative for a successful outcome of an arthrodesis of the affected joint [63]. Stress radiographs can be used to confirm instability in patients with chronic lateral ankle instability [92]. Lateral radiographs may not show osteophytes in anterior ankle impingement, and an anteromedial view is often helpful [96]. Careful physical examination and diagnostic injection can help to pinpoint the diagnosis of anterior ankle impingement [96]. The use of intraarticular injections for anterior ankle impingement has been questioned because of the potential cytotoxicity to chondrocytes, although there are no studies substantiating the effects in the clinical setting [96]. In one study, 58% of patients with anterior ankle impingement had an associated diagnosis that changed the surgical plan in 33% of cases [96].

Treatment

Non-Operative

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

Operative

Indications: Ankle arthrodesis has long been the gold standard for the surgical treatment of moderate to severe ankle arthritis [46]. It is considered a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain when good surgical technique is used in carefully selected patients [12]. Specific diagnoses 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, or instability from neuromuscular disorders [58]. Arthrodesis may be the best procedure for patients with preexisting subtalar or other hindfoot arthritis, contralateral hindfoot or ankle arthritis, or hip or knee impairment where motion through the ankle joint may be beneficial to overall limb and patient function [46]. Surgical management for end-stage ankle osteoarthritis currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being a topic of debate [20].

Contraindications: Absolute contraindications to ankle fusion include vascular impairment of the limb and infection of the skin through which the surgical approach is planned [58]. Relative contraindications include preexisting moderate-to-severe ipsilateral hindfoot arthritis and contralateral ankle arthritis likely to require surgical treatment in the foreseeable future [58]. Female sex is a negative predictor of outcomes in ankle arthrodesis, with clinical results significantly worse in women compared to men [29]. However, men and women with end-stage ankle arthritis benefit from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement [8].

Surgical Approach / Technique: Both open and arthroscopic ankle arthrodesis surgeries are safe and effective treatments for ankle arthritis [101]. Arthroscopic arthrodesis provides surgeons with an alternative to traditional open techniques for the management of severe ankle arthritis [32]. Arthroscopically assisted arthrodesis of the ankle produces good results in patients who have osteoarthritis of the ankle with minimum or no deformity, and the immediate postoperative morbidity is of very short duration [14]. Both arthroscopic and mini-open ankle arthrodesis have good clinical outcomes, with high union rates and lower rates of complications [71]. Compression arthrodesis of the ankle produces a satisfactory rate of fusion and an ankle that is functional, durable, and cosmetically superior to most ankles arthrodesed by other procedures [16]. Factors that improve results in ankle arthrodesis include arthroscopic or mini-incision technique, the use of more than two screws or an adjunct plate (or fibular strut), and a diagnosis of primary osteoarthritis [42]. Surgical treatment for end-stage ankle osteoarthritis resulted in satisfactory clinical outcomes in patients aged 75 years or older, with improvements comparable to those in younger patients [76].

Complications and Management: Nonunion is significantly more likely to occur in ankle arthrodesis patients with previous ipsilateral subtalar fusion and preoperative varus alignment [117]. Nonunion rates in foot and ankle arthrodesis can reach up to 40% in patients at high risk due to medical comorbidities such as diabetes, neuropathy, and osteonecrosis, or history of smoking or alcohol use [25]. Assessment of a patient with a delayed union or nonunion after ankle arthrodesis includes drawing 25-hydroxyvitamin D levels, albumin, prealbumin, parathyroid hormone, thyroid stimulating hormone, calcium, C-reactive protein, erythrocyte sedimentation rate, and hemoglobin A1c levels [42]. Satisfactory immobilization of a delayed union in a protected weight-bearing boot or cast is necessary for management [42]. Pulsed electronic magnetic field devices used with immobilization and limited weight bearing were successful in only five of 19 delayed unions of foot and ankle arthrodeses [42]. Some patients with nonunion after ankle arthrodesis will require reoperation with bone grafting and more stable fixation [42]. Revision arthrodesis for nonunion has reported successful fusion rates of 75% to 94% [42]. Recombinant human BMP-2 increased the incidence and rate of healing in complex ankle arthrodesis, with 93% fusion in patients receiving rhBMP-2 compared to 53% in those without [42].

Adjacent Joint Disease: Progression of adjacent joint (subtalar and/or talonavicular) disease following ankle arthrodesis is a potential complication [117]. In a study of 66 ankle fusions, significant radiologic progression of arthritis was reported in all adjacent joints [117]. In a study with a mean follow-up of 22 years, 91% of subtalar joints and 57% of talonavicular joints developed moderate to severe arthritis after ankle arthrodesis [117]. The clinical significance of adjacent joint disease progression following ankle arthrodesis is unknown [117].

Total Ankle Arthroplasty Comparison: Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort, but rates of reoperation and major complications were higher after ankle replacement [2]. Clinical results were less satisfactory after total ankle replacement than after arthrodesis, with significantly higher surgical revision rates mainly due to periprosthetic cysts [7]. Total ankle arthroplasty offers a reasonable alternative to ankle arthrodesis in carefully selected patients [39]. Overall patient satisfaction was high as were functional outcomes, supporting ankle arthroplasty as an option in the treatment of ankle arthritis [41]. In a study involving 114 ankle arthroplasties and 47 ankle arthrodeses, there was no significant difference in the mean improvement in pain and function between the two groups at a minimum of 2 years postoperatively, but complication rates were 54% after arthroplasty and 26% after arthrodesis [60]. A systematic review of 1262 arthrodeses and 852 arthroplasties identified revision rates of less than 10% and infection rates of less than 5% after both procedures [60]. In a multisite prospective cohort study of 517 patients, there was no statistically significant difference in adverse events at 1 year after either ankle arthrodesis or arthroplasty [60]. Failure rates for total ankle arthroplasty ranged from 1% to 32%, with an overall mean failure rate of 12% [60]. Total ankle arthroplasty was determined to be a cost-effective alternative to ankle arthrodesis in a 60-year-old cohort with end-stage ankle arthritis [60]. Patients with total ankle replacement had higher scores than ankle arthrodesis patients in walking on uneven surfaces, upstairs, downstairs, and uphill [60]. In a study comparing 59 patients with total ankle arthroplasty to 46 with arthrodesis, functional results were significantly better in those with arthroplasty, but there was no difference in terms of quality of life [60]. Gait analysis has shown that patients with total ankle replacement have a more normal gait pattern than those with arthrodesis [60]. Sports participation has been reported to be similar after both total ankle replacement and arthrodesis, with approximately 76% in both groups active in sports after surgery [60]. Total ankle replacement is possibly a better choice than arthrodesis for highly active individuals, as it allows patients to increase participation in sports and recreation activities [119]. Satisfactory results can be achieved in patients with varus malalignment of 10 degrees or greater, which should not be considered a contraindication to total ankle replacement [69]. Early results of INBONE intramedullary-fixation total ankle arthroplasty demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of two years [49]. Primary total ankle arthroplasty with a Mayo implant yielded a good clinical result for 19%, a fair result for 35%, a poor result for 11%, and a failure for 35% of the ankles followed for at least two years [48]. Total ankle replacement is likely to be successful in carefully selected rheumatoid patients with severe arthritis of the ankle that is unresponsive to conservative treatment [152].

Salvage and Conversion Procedures: An analysis of fifty ankle fusions revealed sufficient post-operative complaints to emphasize the need for careful patient selection when considering conversion to total ankle arthroplasty [1]. Salvage fusion after a failed total ankle arthroplasty shows moderate rates of failure and reoperations, with nearly 25% of patients requiring revision within three years [9]. Treatment of patients with a painful total ankle arthroplasty is complex and requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options [11]. Custom-made total ankle arthroplasty components can be used as an alternative to arthrodesis of the ankle in patients with a failed TAA and major talar bone loss [72]. Poor outcomes have been reported for fusion with Trabecular Metal implants after failed total ankle replacement in early results of 11 patients [75].

Joint-Preserving and Alternative Procedures: Periarticular osteotomies of the tibia, fibula, or hindfoot are reasonable approaches to the management of localized arthritis of the ankle [56]. The goal of realignment osteotomies is to unload the more arthritic portion of the joint and provide a more anatomic mechanical axis to redistribute joint contact forces and loads [56]. Realignment surgery can delay the need for arthrodesis or arthroplasty in younger patients [56]. Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes [55]. Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques [33]. Joint distraction arthroplasty is based on the concept that mechanical unloading of the joint and the intermittent flow of intraarticular synovial fluid encourage cartilage healing [43]. In a randomized controlled trial, motion distraction resulted in earlier and consistently better outcomes compared to fixed distraction in patients with ankle osteoarthritis [43]. Adverse events associated with distraction arthroplasty included 43 pin-track infections and eight neurapraxias [43]. The ideal candidate for distraction arthroplasty is a young motivated patient whose symptoms are not relieved with conservative measures and who is unwilling to have an arthrodesis [43]. Contraindications for distraction arthroplasty include active infection, advanced coronal plane deformity, significant loss of bone stock, and patients who are poor frame candidates [43]. Uncontrolled diabetes, tobacco use, chronic edema of the lower limb, severe ankle deformity, and severe ankle ankylosis are relative contraindications for distraction arthroplasty [43]. Debridement and hinged motion distraction is superior to debridement alone in patients with ankle osteoarthritis [40]. Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and severe planar deformities, providing a stable and painless foot for ambulation [64]. Both ankle arthrodesis and tibiotalocalcaneal arthrodesis are effective procedures that resulted in good pain control, allowed return to work, and improved activity participation with high patient satisfaction [22]. Tibiotalocalcaneal arthrodesis with headless compression screws for the treatment of severe arthropathy of the ankle and subtalar joint is an effective treatment that is minimally invasive and is associated with a short operation time, high fusion rate, low incidence of complications and good postoperative recovery [116].

Complications

Ankle Arthrodesis Complications

Nonunion: Nonunion is a potential complication of foot and ankle fusion surgery associated with poor functional outcomes [25]. Patients at high risk, including those with medical comorbidities such as diabetes, neuropathy, or osteonecrosis, and/or a history of smoking or alcohol use, can experience nonunion rates up to 40% [25]. The use of a posterior blade plate for hindfoot arthrodesis is associated with a higher proportion of delayed union and nonunion compared to other approaches, along with a high proportion of complications [79]. In a matched cohort study, overall complication rates were 26% after ankle arthrodesis [60].

Adjacent Joint Arthritis: In a study of 140 ankles with a mean follow-up of 6.5 years, 40% of adjacent subtalar joints and 34% of adjacent talonavicular joints showed progression of arthritic changes after ankle arthrodesis [60].

Surgical Approach: Arthroscopic ankle arthrodesis offers fewer complications compared to open arthrodesis [17] and is associated with a low complication rate, even in cases with severe preoperative deformity in patients 60 years of age or older [5]. Both arthroscopic and mini-open ankle arthrodesis are associated with lower rates of complications [71, 74].

Septic Arthritis: Ankle arthrodesis performed with an Ilizarov external fixator for septic ankle arthritis is associated with high surgical and psychologic morbidity [144].

Total Ankle Arthroplasty Complications

Reoperation and Major Complications: Rates of reoperation and major complications are higher after total ankle replacement than after ankle arthrodesis [2]. In a multicenter study, reoperation and major complications were more frequent after total ankle replacement than after ankle arthrodesis [60]. In a study of 114 ankle arthroplasties and 47 ankle arthrodeses, the complication rate was 54% after arthroplasty [60]. Total ankle arthroplasty failure rates range from 1% to 32%, with an overall mean failure rate of 12% [60].

Age-Related Outcomes: Younger patients (<55 years) undergoing total ankle arthroplasty have higher rates of any reoperation (19.9%) compared to patients aged 55–70 years (11.7%) and >70 years (6.5%) [142]. This age group also has higher rates of implant failure (5.6%) compared to patients aged 55–70 years (2.9%) and >70 years (1.1%) [142], and higher rates of polyethylene exchange (7.7%) compared to patients aged 55–70 years (4.3%) and >70 years (2.3%) [142].

Salvage Procedures: Salvage fusion after a failed total ankle arthroplasty is associated with moderate rates of failure and reoperations, with nearly 25% of patients requiring revision within three years [9]. Fusion with Trabecular Metal implants after failed total ankle replacement has shown poor outcomes in early results [75].

Periprosthetic Cysts: Periprosthetic cysts are a primary cause of higher surgical revision rates after total ankle replacement compared to arthrodesis [7].

Infection (PJI): Periprosthetic joint infection is a reported complication following total ankle arthroplasty [28]. In a systematic review of 1262 arthrodeses and 852 arthroplasties, infection rates were less than 5% after both procedures [60]. In a study of 1105 ankles with mobile and fixed bearing implants, deep infections ranged from 0% to 5% [121].

Thromboembolism: Deep vein thrombosis is a reported risk following total ankle replacement, even with routine chemical thromboprophylaxis [28].

Wound Complications: Wound complications are a reported issue following total ankle arthroplasty [28]. Blood transfusion during total ankle arthroplasty is associated with increased in-hospital complications and cost [28].

Other Considerations:

Heterotopic Ossification: Heterotopic ossification is a reported complication following total ankle arthroplasty [28].

Risk Factors: Cigarette use is associated with complication rates and outcomes following total ankle arthroplasty [28]. A history of bariatric surgery is not an important predictor of joint infection, instrumentation removal, or ORIF within 5 years after primary total ankle arthroplasty or arthrodesis [70].

General Revision Rates: In a systematic review of 1262 arthrodeses and 852 arthroplasties, revision rates were less than 10% after both procedures [60]. In a multisite prospective cohort study of 517 patients, there was no statistically significant difference in adverse events at 1 year between ankle arthrodesis and total ankle arthroplasty [60].

Implant-Specific Complications and Survival:

In a study of 2340 ankles across 95 academic centers, the overall complication rate for total ankle arthroplasty was 1.4%, with rates <0.5% after 2007 [121]. In a study of 67 ankles with Salto Talaris implants, 15 patients (22%) experienced 23 complications [121]. In a study of 106 ankles with Mobility implants, the complication rate was 12% [121]. In a study of 54 ankles with HINTEGRA and MOBILITY implants, ankle impingement syndrome was significantly more common with HINTEGRA, and intraoperative malleolar fracture occurred only with MOBILITY [121]. In a study of 50 ankles with HINTEGRA implants, osteolysis was identified in 24 ankles (48%) [121].

In a study of 98 ankles with STAR implants, 32 ankles (29%) required metal component revision and/or polyethylene bearing exchange [121]. In a study of 72 ankles with STAR implants, 29 patients (38%) required revision of at least one metallic component [121]. In a study of 96 ankles with Salto implants, the reoperation rate was 35% [121]. In a study of 45 patients (52 ankles) with STAR implants, the revision rate was 17% [121]. In a study of 76 patients (78 ankles) with STAR implants, additional surgeries were required in 17% of cases [121]. In a study of 82 ankles with STAR implants, additional surgeries were required in 17% of cases [121]. In a study of 684 patients (722 ankles) with HINTEGRA implants, 61 ankles (8%) had revision arthroplasties [121]. In a study of 85 patients (88 ankles) with MOBILITY implants, 8 ankles (9%) required revision [121]. In a study of 194 ankles with INBONE implants, the revision rate was 6% [121]. In a study of 59 ankles with INBONE implants, 14 patients (2%) required reoperation because of complication [121]. In a study of 18 ankles with STAR implants, additional surgery was required in 39% of cases [121].

In a study of 1107 ankles with mobile bearing implants, complication rates ranged from 2% to 15% [121]. In a study of 852 ankles with mobile and fixed bearing implants, the revision rate was 7% [121].

In a study of 2088 ankles with STAR mobile bearing implants, the 5-year survival rate was 86% and the 10-year survival rate was 71% [121]. In a study of 2312 ankles with Agility mobile bearing implants, the revision rate was approximately 10% [121]. In a study of 7942 ankles with STAR, Hintegra, and TNK implants, the overall survivorship was 89% at 10 years [121]. In a study of 1421 ankles with Salto mobile and fixed bearing implants, the revision rate was 4% with mobile bearings and 2.4% with fixed bearings [121]. In a study of 645 ankles from the Finnish Arthroplasty Register, prosthesis survival was 83% at 5 years and 78% at 7 years [121].

In a study of 45 patients (52 ankles) with STAR implants, prosthesis survival was 90% at 5 years and 84% at 8 years [121]. In a study of 96 patients (100 ankles) with Mobility implants, prosthesis survival was 97% at 3 years and 94% at 4 years [121]. In a study of 76 patients (78 ankles) with STAR implants, the probability of prosthesis survival was 96% at 5 years and at least 90% at 10 years [121]. In a study of 96 patients (98 ankles) with Salto implants, prosthesis survival was 65% at 10 years, or 85% when fusion or revision of any component was used as the criterion for failure [121]. In a study of 82 ankles with STAR implants, prosthesis survival was 94% at 5 years, with a projected 9-year survival of 88% [121]. In a study of 684 patients (722 ankles) with HINTEGRA implants, prosthesis survival was 94% at 5 years, with a projected 10-year survival of 84% [121]. In a study of 72 patients (77 ankles) with STAR implants, the probability of implant survival was 71% at 10 years and 46% at 14 years [121]. In a study of 67 ankles with Salto Talaris implants, implant survival was 96% at 3 years [121]. In a study of 85 patients (88 ankles) with MOBILITY implants, cumulative survival was 90% at 3 years and 88% at 4 years [121]. In a study of 194 ankles with INBONE implants, the overall implant survival was 89% [121]. In a study of 59 ankles with INBONE implants, the estimated survival rate was 97% at 2 years [121]. In a study of 18 ankles with STAR implants, the overall implant survival was 94% [121].

Functional Outcomes: In a study of 50 ankles with HINTEGRA implants, AOFAS scores and ROM were significantly improved [121]. In a study of 106 ankles with MOBILITY implants, there was a 53-point improvement in AOFAS scores [121]. In a study of 85 patients (88 ankles) with MOBILITY implants, good pain relief and improved function were reported in 82% of cases [121].

Additional Reoperation Data: In a study of 67 ankles with Salto Talaris implants, 8 patients (12%) had additional surgery after the index procedure [121]. In a study of 72 patients (77 ankles) with STAR implants, 29 patients (38%) required revision of at least one metallic component [121]. In a study of 96 patients (98 ankles) with Salto implants, the reoperation rate was 35% [121]. In a study of 2340 ankles across 95 academic centers, the overall complication rate was 1.4%, with rates <0.5% after 2007 [121]. In a study of 72 patients (77 ankles) with STAR implants, the probability of implant survival was 71% at 10 years and 46% at 14 years [121].

Recovery

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

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

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for when pain, strength, and final functional outcomes stabilise.

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

Functional milestones: While normal gait is not achieved following ankle arthrodesis, the improvement from preoperative levels is clinically significant [23]. Compression arthrodesis of the ankle produces a satisfactory rate of ankle arthrodesis and an ankle that is functional, durable, and cosmetically superior to most of those that are arthrodesed by other procedures [16].

Other Considerations: Fusion rates of 76% to 100% are reported for tibiotalocalcaneal arthrodesis using intramedullary nails, with time to fusion of approximately 16 weeks [165]. A history of bariatric surgery is not an important predictor of joint infection, instrumentation removal, or open reduction and internal fixation within 5 years after primary ankle arthrodesis [70]. The proportion of patients treated with a posterior blade-plate hindfoot fusion who had delayed union and nonunion was greater than that reported for patients in other series who underwent primary hindfoot arthrodesis with other approaches [79]. Additionally, the proportion of patients with complications following posterior blade-plate hindfoot fusion was high [79].

Key Evidence

• [L2] Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation; rates of reoperation and major complications were higher after ankle replacement. [2] (10.2106/jbjs.l.01597)
• [L4] Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients. [3] (10.2106/jbjs.o.00396)
• [L4] Arthroscopic ankle arthrodesis is an effective operation for treating degenerative ankle disease, resulting in good/excellent functional outcomes at a mean of 86 months post-operatively in nearly three-quarters of the patient cohort. [4] (10.1016/j.arthro.2016.03.077)
• [L3] Arthroscopic ankle arthrodesis is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older, resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity. [5] (10.1016/j.arthro.2020.05.036)
• [L4] Ankle arthrodesis remains the gold standard but is associated with high rates of adjacent joint arthrosis. [6] (10.5435/jaaos-d-25-00638)
• [L3] Clinical results were less satisfactory after total ankle replacement than after arthrodesis, with significantly higher surgical revision rates mainly due to periprosthetic cysts. [7] (10.1016/j.otsr.2018.10.014)
• [L4] Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. [8] (10.2106/jbjs.21.00287)
• [L3] Salvage fusion after a failed total ankle arthroplasty shows moderate rates of failure and reoperations, with nearly 25% of patients requiring revision within three years. [9] (10.1302/0301-620x.105b10.bjj-2023-0010.r1)
• [L4] Treatment of patients with a painful total ankle arthroplasty is complex and requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options. [11] (10.5435/jaaos-d-14-00017)
• [L5] When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain. [12] (10.5435/00124635-200005000-00007)
• [L4] For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation. [13] (10.1097/01.blo.0000132460.27102.d6)
• [L4] Arthroscopically assisted arthrodesis of the ankle produces good results in patients who have osteoarthritis of the ankle with minimum or no deformity, and the immediate postoperative morbidity is of very short duration. [14] (10.2106/00004623-199407000-00023)
• [L2] Patients with severe PCFD achieved greater radiographic correction than those with mild collapse after isolated ankle arthrodesis, but functional improvements did not differ between groups. [15] (10.1097/corr.0000000000003756)
• [L4] This procedure produces a satisfactory rate of ankle arthrodesis and an ankle that is functional, durable, and cosmetically superior to most of those that are arthrodesed by other procedures. [16] (10.2106/00004623-198365020-00011)
• [L5] Arthroscopic ankle arthrodesis offers better clinical scores, fewer complications, and shorter hospitalization compared to open arthrodesis, although union rates, reoperation rates, and operative times are similar. [17] (10.1016/j.arthro.2018.01.006)
• [L1] There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. [19] (10.2106/jbjs.n.00426)
• [L5] Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being the topic of much debate. [20] (10.5435/jaaos-d-23-00743)
• [L4] For patients with pain at the site of a failed ankle arthrodesis, conversion to total ankle arthroplasty with the use of a three-component ankle implant is a viable treatment option that provides reliable intermediate-term results. [21] (10.2106/jbjs.i.01301)
• [L3] Both ankle arthrodesis and tibiotalocalcaneal arthrodesis are effective procedures that resulted in good pain control, allowed return to work, and improved activity participation with high patient satisfaction. [22] (10.1177/1071100713478929)
• [L3] While normal gait is not achieved, the improvement from preoperative levels is clinically significant. [23] (10.1302/0301-620x.98b10.37614)
• [L4] [25] (10.5435/jaaosglobal-d-23-00216)
• [L3] Arthroscopic ankle arthrodesis and open ankle arthrodesis resulted in comparable clinical outcomes to total ankle replacement in patients with non-deformed, COFAS Type-1 end-stage ankle arthritis. [26] (10.2106/jbjs.18.01012)
• [L3] The clinical results were significantly worse in women after ankle arthrodesis, which should be considered when determining the indication. [29] (10.1186/s13018-024-05045-8)
• [L4] Arthroscopic arthrodesis provides surgeons with an alternative to traditional open techniques for the management of severe ankle arthritis. [32] (10.1186/s13018-016-0490-y)
• [L4] Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques. [33] (10.1302/2058-5241.2.160021)
• [L4] This review discusses both joint-preserving and joint-sacrificing techniques for managing ankle arthritis, noting that while joint-sacrificing procedures dominated historic management, various options including medication, bracing, injections, osteotomies, arthrodesis, and arthroplasty are available. [34] (10.5435/jaaos-d-24-00955)
• [L4] Total ankle arthroplasty offers a reasonable alternative to ankle arthroplasty in carefully selected patients. [39] (10.1302/2058-5241.3.170029)
• [L1] [40] (10.1007/s00167-018-5156-3)
• [L4] Overall patient satisfaction was high as were functional outcomes, supporting ankle arthroplasty as an option in the treatment of ankle arthritis. [41] (10.1302/0301-620x.103b4.bjj-2020-0758.r1)
• [L3] The inclusion of new data on patients who underwent surgery between 2005 and 2010 demonstrates increasing utilization and lower complication rates for total ankle replacement compared with ankle arthrodesis. [44] (10.2106/jbjs.15.01341)
• [L2] Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. [47] (10.2106/jbjs.18.00511)
• [L4] Early results of INBONE intramedullary-fixation total ankle arthroplasty demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of two years. [49] (10.2106/jbjs.n.00227)
• [L5] Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes. [55] (10.5435/jaaos-d-12-00124)
• [L3] Substantial ankle malalignment, mostly varus deformity, is common in ankles with end-stage osteoarthritis. [61] (10.1007/s11999-014-3960-8)
• [L3] Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint seem not to be indicative for a successful outcome of an arthrodesis of the affected joint. [63] (10.1186/1471-2474-15-11)
• [L5] Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and severe planar deformities, providing a stable and painless foot for ambulation. [64] (10.5435/jaaos-d-14-00102)
• [L4] [66] (10.2106/jbjs.g.00506)
• [L2] Satisfactory results can be achieved in patients with varus malalignment of ≥10°, which should not be considered a contraindication to total ankle replacement. [69] (10.2106/jbjs.l.00797)
• [L3] A history of bariatric surgery is not an important predictor of joint infection, instrumentation removal, or ORIF within 5 years after primary total ankle arthroplasty or arthrodesis. [70] (10.5435/jaaos-d-24-01267)
• [L3] Both arthroscopic and mini-open ankle arthrodesis had good clinical outcomes, with high union rates and lower rates of complications. [71] (10.1016/j.arthro.2017.08.160)
• [L4] This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA. [72] (10.1302/0301-620x.99b2.bjj-2016-0504.r2)
• [L4] Both arthroscopic and mini-open ankle arthrodesis had a good clinical outcomes, with high union rate and lower rate of complications. [74] (10.1016/j.arthro.2013.07.055)
• [L4] [75] (10.1016/j.otsr.2017.11.022)
• [L3] Surgical treatment for end-stage ankle OA resulted in satisfactory clinical outcomes in patients aged ≥75 years, with improvements comparable to those in younger patients. [76] (10.1186/s13018-023-03734-4)
• [L4] Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging. [77] (10.1007/s00167-018-5232-8)
• [L4] [79] (10.1007/s11999-016-4955-4)
• [L3] DTS morphological classification might affect the biomechanics properties in TAS and TTA in ankle OA. [98] (10.1186/s13018-023-03985-1)
• [L3] The spatiotemporal parameters were not affected by the hindfoot alignment resulting from subtalar compensation. [99] (10.1186/s13018-024-04615-0)
• [L2] Both open and arthroscopic ankle arthrodesis surgeries are safe and effective treatments for ankle arthritis. [101] (10.5435/jaaos-d-25-00590)
• [L4] Arthrodesis of the ankle joint results in significant limitation of daily activities with reduced function of the affected limb and changes in spatial and temporal movement, weight bearing profile and contact surface. [102] (10.1186/s13018-026-06842-z)
• [L5] This CORR Insights commentary notes that while multisegment foot models provide biomechanical insights, there is inadequate evidence to support their clinical use, and future studies must verify reproducibility and accuracy by comparing different models and measurement systems. [104] (10.1097/corr.0000000000001519)
• [L4] Tibiotalocalcaneal arthrodesis with headless compression screws for the treatment of severe arthropathy of the ankle and subtalar joint is an effective treatment that is minimally invasive and is associated with a short operation time, high fusion rate, low incidence of complications and good postoperative recovery. [116] (10.1186/s13018-016-0425-7)
• [L4] Total ankle replacement is possibly a better choice with respect to arthrodesis for highly active individuals, as it allows patients to increase participation in sports and recreation activities. [119] (10.1055/s-0037-1601408)
• [L5] Based on the mouse model, the findings indicate that severe ankle instability has nearly three times the chance to develop into ankle OA compared to moderate ankle instability. [120] (10.1186/s12891-022-05164-5)
• [L5] Transected mice in the CL+ATFL and CL+DL groups displayed mechanical instability of the ankle-subtalar joint complex, and some mice in the CL+DL group also suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure. [136] (10.1186/s13018-021-02683-0)
• [L3] [142] (10.2106/jbjs.23.00122)
• [L4] Increasing the shoe instep by 1 cm or 2 cm shifted the ground reaction force closer to the metatarsal heads at heel-off and reduced maximal foot and tibia dorsiflexion angle. [143] (10.1097/01.blo.0000180892.10666.43)
• [L5] The author states that while the success of ankle arthrodesis with an Ilizarov external fixator is impressive, the morbidity is disappointingly high, and future efforts should focus on reducing surgical and psychologic complications. [144] (10.1097/corr.0000000000002505)
• [L4] [147] (10.1007/s004020000243)
• [L4] Total ankle replacement is likely to be successful in carefully selected rheumatoid patients with severe arthritis of the ankle that is unresponsive to conservative treatment. [152] (10.2106/00004623-198466030-00004)
• [L4] [159] (10.1007/s00167-022-07144-7)
• [L5] Fusion rates of 76% to 100% are reported, with time to fusion of approximately 16 weeks. [165] (10.5435/00124635-201201000-00001)

See Also

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

References

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