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Ankle osteoarthritis

101 citationsUpdated Sep 2026

Overview

Ankle osteoarthritis management is staged by disease severity. In early stages with malalignment, periarticular osteotomies are the only interventions with sufficient evidence for recommendation [2]. For end-stage disease, surgical focus shifts to ankle arthrodesis and total ankle arthroplasty (TAA) [17]. While both procedures yield satisfactory functional results when correctly indicated [2], specific indications for choosing one over the other remain debated [17]. No level I studies directly compare TAA and arthrodesis, and literature reports are contradictory [46]. Recent data favor TAA with latest-generation implants, citing better functional outcomes, fewer complications, and higher patient satisfaction [46]. Gait studies show either no difference or improved near-normal gait and uneven-surface walking after arthroplasty compared to arthrodesis [46]. Careful patient selection is mandatory for success with either procedure [46].

Arthrodesis remains a mainstay but is not optimal for all patients due to motion loss and potential adjacent joint degeneration [27]. Alternative procedures, including debridement, realignment osteotomies, distraction arthroplasty, allograft replacement, and TAA, should be discussed before arthrodesis is chosen [27]. Realignment osteotomies aim to unload arthritic joint portions and restore mechanical axis, potentially delaying arthrodesis or arthroplasty in younger patients [27]. These are best suited for chondral loss primarily in the medial or lateral gutter with minimal talar involvement, especially with supramalleolar deformity [27]. Debridement is effective for anterior impingement osteophytes or loose bodies but provides only short-term relief in advanced arthritis and requires realistic expectations [27].

TAA provides durable joint function restoration when appropriately indicated [39]. Implant designs continue to evolve as failure modes are understood [23]. Fracture posttraumatic osteoarthritis carries a markedly higher complication rate and risk of prosthesis explant compared to primary osteoarthritis [67]. Arthrodesis may be preferred in cases with preexisting subtalar or hindfoot arthritis, contralateral hindfoot or ankle arthritis, or hip or knee impairment where ankle motion benefits overall limb function [46]. Clinical results after arthrodesis are significantly worse in women, a factor to consider when determining indications [70].

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

The distal tibiofibular joint consists of the convex medial surface of the distal fibula and the concave incisura fibularis of the distal lateral tibia [91]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [91]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [91]. The talocrural angle is approximately 83 degrees and symmetrical with the contralateral ankle [100].

Radiographic Parameters: * The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [100]. * The tibiofibular clear space 10 mm above the joint line is relatively constant with rotation and has an accepted normal parameter of greater than 5 mm [100]. * The tibiofibular overlap 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 [100].

The "ball sign" is a confirmatory visual cue for fibular length, described as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length [100]. Shortening of the fibula results in lateral and valgus subluxation of the talus [100]. The size of the medial clear space more than doubles depending upon the rotational position of the limb [100]. There is a significant increase in medial clear space with ankle plantarflexion [100]. The distal tibiofibular syndesmosis morphology classification might affect biomechanical properties in total ankle arthroplasty and total knee arthroplasty in ankle osteoarthritis [62].

Ligamentous Anatomy

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

The deltoid ligament complex is the primary ankle stabilizer during stance [91]. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body and functions primarily to resist lateral talar translation and external rotation [91]. The posterior deep deltoid is the most important component of the deltoid ligament complex [91]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament, functioning primarily to resist valgus and eversion ankle forces [91].

More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the anterior talofibular ligament and calcaneofibular ligament [56]. Medial ligament injuries are usually seen in association with a fracture or joint injury [56]. The deltoid ligament consists of superficial and deep layers, with the deep portion being the primary medial stabilizer of the ankle joint [96]. The deep posterior tibiotalar ligament is the strongest component of the deltoid complex [96]. The deep deltoid ligament has a load to failure of 713.8 N ± 69.3 [96]. 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 [96]. Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid ligaments [96].

The deltoid ligament has a rich vascular supply from the medial tarsal artery, posterior tibial artery, and tibialis anterior artery [96]. It also has a component of intraosseous vascular supply from either the talus or the medial malleolus [96]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [131].

Pathophysiology

Ankle osteoarthritis is almost always secondary to an underlying disorder such as malunited fracture, recurrent instability, osteochondritis dissecans of the talus, avascular necrosis of the talus, or repeated bleeding with haemophilia [87]. Ankle osteoarthritis accounts for 4% of all osteoarthritis cases [36]. 70% to 80% of ankle arthritis is posttraumatic in origin [3], with 78% of ankle osteoarthritis specifically identified as post-traumatic [36]. Posttraumatic ankle arthritis is often seen in younger patients compared with degenerative or systemic ankle arthritis [3].

In 13% of posttraumatic osteoarthritis cases, the cause is a ligamentous lesion [3]. Lesions of the lateral ankle ligament complex are the main cause for developing ligamentous posttraumatic ankle arthritis, accounting for 85% of cases [3]. Medial ligament lesions account for 12% of ligamentous posttraumatic ankle arthritis cases, and combined medial-lateral ligament lesions account for 3% [3]. The most frequent mechanism of injury for lateral ligament lesions is the unexpected and rapid hyperinversion of the hindfoot [3]. Sports injuries were the underlying cause in 55% of ligamentous posttraumatic ankle arthritis cases [3]. Soccer injuries were the most likely sports injury to cause ligamentous posttraumatic ankle arthritis, accounting for 33% of reported sports injury cases in the cohort [3].

Ankle osteoarthritis is associated with knee osteoarthritis and joint malalignment [13]. Patients with varus knee osteoarthritis and ankle osteoarthritis demonstrate greater hindfoot inversion and larger ankle inversion loading during gait following total knee arthroplasty compared to varus knee osteoarthritis alone [30]. Ankle osteoarthritis reduces effective exchange of potential and kinetic energy, potentially increasing the muscular work required to control movements of the center of mass [64]. Patients with isolated ankle osteoarthritis show a decrease in ankle kinematics and kinetics during walking [35]. Distal foot joints do not compensate for the mechanical dysfunction of the ankle in patients with isolated ankle osteoarthritis [35].

Clinical Presentation: * Ankle osteoarthritis causes pain, stiffness, and an antalgic gait, particularly when first standing up from rest [87]. * Patients with ankle osteoarthritis often indicate the site of pain as being transversely across the front of the ankle [87]. * The ankle is usually swollen in osteoarthritis, with palpable anterior osteophytes and tenderness along the anterior joint line [87]. * The foot may be turned outwards in the stance phase to compensate for the loss of ankle movement in osteoarthritis [87].

Radiographic features of ankle osteoarthritis include joint space narrowing, subchondral sclerosis, and osteophyte formation [87]. In nearly 80% of patients with osteochondral lesions of the talus, a history of ankle trauma can be found [88]. 38% of patients with osteochondral lesions of the talus present ankle ligament laxity, while 39% of patients with ankle instability present with an osteochondral lesion of the talus [88]. Acute trauma and repetitive micro-traumata due to ankle instability and/or hindfoot malalignment are leading causes of osteochondral lesions of the talus [88].

Synovial fluid penetrates microfractures in damaged cartilage, and loading leads to high fluid pressure that induces osteonecrosis and later cyst formations [88]. The poor vascularization of the talus leads to a higher risk of osteonecrosis and decreased healing capacity [88]. Increased load on the cartilage in the presence of ankle instability and hindfoot malalignment can lead to cellular degeneration or death by the disruption of collagen fibril ultrastructure [88]. Cartilage damage itself does not lead to pain, but osteonecrosis of the highly innervated subchondral bone underneath the cartilage defect does [88]. An asymptomatic cartilage lesion of the ankle not involving subchondral bone plate damage may arise from a traumatic event such as an ankle sprain or fracture [89]. Microscopic cartilage lesions are considered inert and are believed not to progress into osteochondral lesions or end-stage osteoarthritis [89]. The incidence of reported osteochondral damage after ankle sprain or fracture is 45% [89].

Severe ankle instability has nearly three times the chance to develop into ankle osteoarthritis compared to moderate ankle instability in a mouse model [150]. Chronic ankle joint instability induces ankle sensorimotor dysfunction [118]. The number of mechanoreceptors is negatively correlated with ankle sensorimotor dysfunction [118]. The dynamic congruency of the joint, influenced by ligamentous integrity, is the main anatomical component in mechanical ankle instability [94]. Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery [124].

Classification

Etiology and Risk Factors

Posttraumatic ankle arthritis accounts for 70% to 80% of cases and typically presents in younger patients than degenerative or systemic forms [3]. Ligamentous posttraumatic arthritis is predominantly caused by lesions of the lateral ankle ligament complex (85%), compared with medial (12%) or combined medial-lateral lesions (3%) [3]. The primary mechanism is unexpected, rapid hyperinversion of the hindfoot, with sports injuries underlying 55% of cases, most frequently from soccer [3]. Ankle sprains are generally benign but may evolve into permanent disability and osteoarthritis if inadequately managed [14].

Fracture history significantly influences long-term outcomes. Advanced radiographic ankle osteoarthritis was present in 36.3% of patients 18 years after malleolar fractures, particularly following Weber C and associated medial malleolar fractures [19]. In unstable ankle fractures, the incidence of radiographic osteoarthritis was 20.9% at 5.5 years for operatively treated cases versus 65.5% at 6.8 years for nonoperatively treated cases [138]. Conversely, stable ankle fractures treated nonoperatively showed a radiographic osteoarthritis incidence of only 2.8% at a mean follow-up of 18 years [138]. Negative prognostic factors for general health outcome in supination-external rotation ankle fractures include medial malleolus fracture, female gender, older age, higher American Society of Anesthesiologists grade, smoking, and lower educational level [138].

Osteochondral lesions of the talus (OLT) are strongly associated with trauma, with a history of ankle trauma present in nearly 80% of patients [88]. Acute trauma and repetitive micro-traumata from ankle instability or hindfoot malalignment are leading causes of OLT [88]. The severity of ankle joint changes in Kashin–Beck disease correlates directly with the disease grade [166].

Radiographic and Imaging Classifications

Interobserver agreement among orthopaedic surgeons and residents varies significantly across systems. The van Dijk osteoarthritis scale demonstrated fair agreement (k = 0.24), while the Takakura (k = 0.19) and Kellgren (k = 0.18) classifications showed poor agreement [130]. Categorical ratings differed significantly between the van Dijk scale and the Takakura/Kellgren systems (p < 0.001) [130].

van Dijk Classification: This system grades radiographic changes as follows: Grade 0 is normal; Grade I consists of minimal degenerative changes including small osteophytes without joint space narrowing; Grade II is defined as joint space narrowing with or without osteophytes; and Grade III is defined as subtotal or total disappearance or deformation of the joint space [37]. In some patients with stage 3 varus ankle osteoarthritis, joint space obliteration is difficult to evaluate accurately using only weightbearing anteroposterior radiographs; weightbearing lateral radiographs should also be performed for accurate evaluation [21].

Takakura Classification: The modified Takakura ankle OA classification system assigns quantitative scores of 1, 2, 3, 4, and 5 to stages 1, 2, 3a, 3b, and 4, respectively, for analysis of radiographical grade changes [165]. In a study of 99 total knee arthroplasty cases, concomitant ankle OA was found in 24 ankles (24%), with 10 classified as stage I, 13 as stage II, and 1 as stage IIIa [142].

Ankle Osteoarthritis Scoring System (AOSS): The AOSS quantifies OA-related changes via MRI by assessing cartilage damage depth, subchondral bone defect, osteophytes, subchondral cysts, and bone marrow oedema [159]. Cartilage damage depth is graded 0 (no damage) to 3 (full-thickness defects), with grade 1 defined as <50% of total cartilage depth and grade 2 as ≥50% [159]. Subchondral bone defect is graded 0 (no defect) to 3 (severe ≥5 mm), with grade 1 defined as minimal (<2 mm) and grade 2 as moderate (2–5 mm) [159]. Osteophytes are graded 0 (none) to 3 (severe ≥5 mm), with grade 1 defined as minimal (<3 mm) and grade 2 as moderate (3–5 mm) [159]. Subchondral cysts are graded 0 (none) to 3 (severe ≥5 mm), with grade 1 defined as minimal (<3 mm) and grade 2 as moderate (3–5 mm) [159]. Bone marrow oedema is graded 0 (none) to 3 (severe), with grade 1 defined as minimal (<5 mm) [159].

Pathophysiology and Associated Conditions

Loss of mechanical ankle function in isolated ankle OA is not compensated by distal foot joints [35]. Patients with isolated ankle OA demonstrate decreased ankle kinematics and kinetics during walking, while no change in kinematic or kinetic functions is observed in the distal foot joints [35].

Asymptomatic cartilage lesions that do not involve subchondral bone plate damage may arise from traumatic events such as ankle sprains or fractures [89]. Microscopic cartilage lesions are generally considered inert and are believed not to progress into osteochondral lesions, end-stage osteoarthritis, or become symptomatic [89]. Although the incidence of reported osteochondral damage after ankle sprain or fracture is high (45%), the proportion resulting in poor clinical outcomes is relatively low [89].

The natural healing of osteochondral lesions (OCLs) after ankle fractures is uncommon, with an incidence of 47.5% assessed more than 1 year after surgery compared to 45.1% assessed directly after trauma [82]. The incidence of OCLs measured by CT arthrography at late evaluation was 86% in a study by Kraniotis et al. [82]. This high incidence is likely attributable to the assessment mode, which evaluates all lesions including cartilage erosions in the form of exposed subchondral bone [82].

The morphological classification of the distal tibiofibular syndesmosis (DTS) may affect biomechanical properties in total ankle replacement (TAS) and total talar arthroplasty (TTA) for ankle OA [62]. Chronic instability of the ankle joint can, in some cases, be attributed to a separate centre of ossification of the lateral malleolus [167].

Clinical Presentation

Etiology and Demographics

Posttraumatic ankle arthritis frequently follows lateral ligament injuries, with the most frequent mechanism being unexpected and rapid hyperinversion of the hindfoot [3]. Sports injuries underlie 55% of ligamentous posttraumatic ankle arthritis cases, with soccer injuries representing 33% of all reported sports injury cases in the cohort [3]. Ankle sprains can evolve into permanent disability and osteoarthritis if not well addressed [14]. Following malleolar fractures, advanced radiographic ankle osteoarthritis is present in 36.3% of patients 18 years later, a condition especially common following Weber C fractures and associated medial malleolar fractures [19]. The prognosis of ankle fracture-dislocation depends significantly on the damage at the time of the insult, with chondrolysis and vascular impairment leading to osteoarthritis regardless of early or late intervention [78]. Associated chondral lesions are a significant contributing factor to the late development of ankle osteoarthrosis after posteromedial ankle dislocation [42]. Additionally, harvesting of the fibula may cause long-term ankle osteoarthritis that requires ankle arthrodesis [41].

Clinical Features and Examination

A history of a twisting injury followed by pain, bruising, and swelling is typical for ankle ligament injuries [56]. Acute low ankle sprains typically manifest by a large amount of lateral ankle swelling, pain with weight bearing, and pain in the lateral ankle [134]. Swelling, ecchymosis, and pain with weight bearing are common findings in ankle sprains [161]. Physical examination for low ankle sprains characteristically shows focal tenderness to palpation over the involved lateral ankle ligamentous structures [134]. In an anterior talofibular ligament (ATFL) sprain, tenderness is maximal just distal and slightly anterior to the lateral malleolus [56]. It is essential to examine the entire leg and foot to avoid missing undisplaced fractures of the ankle, proximal fibula, tarsal bones, or peroneal tendon sheath [56].

The slightest attempt at passive inversion of the ankle is extremely painful in an ATFL sprain [56]. Stability assessment in the acute phase of an ankle ligament injury is not possible [56]. Patients with a history of numerous ankle sprains may have a positive anterior drawer test, which involves anterior translation of the slightly plantarflexed foot [134]. Excessive anterior translation in the anterior drawer test represents chronic laxity of the injured ATFL [134]. Inversion stress testing of the neutral foot may demonstrate increased laxity in the setting of an attritional calcaneofibular ligament [134]. Assessment for recurrent instability requires evaluation for hindfoot varus [161]. Patients should be questioned about symptoms of a loose body or osteochondral injury, such as mechanical symptoms like locking or catching [161].

Pain is out of proportion to findings on exam in cases of complex regional pain syndrome, which may develop after trauma or elective surgery [161]. Injury to branches of the superficial peroneal nerve can cause numbness over the dorsal midfoot following an inversion mechanism [161].

Imaging

The need for X-ray in ankle injuries is guided by the Ottawa ankle rules [56]. The Ottawa ankle rules indicate the need for x-ray if there is pain around the malleolus plus inability to take weight on the ankle immediately after injury, inability to take four steps in the Emergency Department, or bone tenderness at the posterior edge or tip of either malleolus or the base of the fifth metatarsal bone [56]. Anteroposterior, lateral, and mortise views of the ankle should be obtained for imaging [56]. Weight-bearing AP, lateral, and mortise views are recommended when radiographs are necessary for ankle sprains [134]. Weight-bearing views are useful in helping determine stability [56]. Varus stress views can be used to evaluate for excessive talar tilt in the setting of ATFL laxity [134]. External rotation stress views should be obtained to rule out a syndesmotic injury [134]. Weightbearing lateral radiographs should also be performed for patients with stage 3 varus ankle osteoarthritis [21].

Computed tomography (CT) and magnetic resonance imaging (MRI) may be needed to fully characterize an injury or in those who have persistent pain, swelling, instability, and impaired function over 6 weeks or longer [56]. MRI is rarely warranted for ankle sprains except in the setting of prolonged pain or instability [134]. MRI is performed to evaluate for associated injuries such as peroneal tendon pathology, talar osteochondral lesions, fractures of the anterior calcaneal process, or fractures of the lateral talar process [134]. MRI may demonstrate attenuation or tear of the lateral ligamentous structures [161]. CT scanning is considered for evaluation of a suspected or identified lateral process fracture [161]. As many as 42% of lateral process talar fractures are initially misdiagnosed as ankle sprains [134]. Talar body and neck fractures can occasionally be overlooked in low-energy trauma patients thought to have minor ankle injuries [134]. Bone bruising is common in severe sprains and may result in a longer time to pain-free activity and return to sports [161].

Radiographic evidence of osteoarthritis is graded according to the classification described by van Dijk et al. [37]. * Grade 0: Radiographic findings are considered normal [37]. * Grade I: Minimal degenerative changes including small osteophytes without joint space narrowing [37]. * Grade II: Joint space narrowing with or without osteophytes [37]. * Grade III: Subtotal or total disappearance or deformation of the joint space [37].

Patients eligible for platelet-rich plasma injection studies had radiographs indicating grade 2 talocrural osteoarthritis on the van Dijk classification [9].

Biomechanics and Functional Impact

Patients with isolated ankle osteoarthritis demonstrate a decrease in ankle kinematics and kinetics during walking [35]. No change in kinematic or kinetic functions were observed in the distal foot joints of patients with isolated ankle osteoarthritis [35]. Osteoarthritis in the hip, knee, or ankle reduces effective exchange of potential and kinetic energy [64]. Osteoarthritis in the hip, knee, or ankle potentially increases the muscular work required to control movements of the center of mass [64]. Patients with varus knee osteoarthritis and concurrent ankle osteoarthritis experience greater hindfoot and ankle joint inversion load during gait following total knee arthroplasty compared to varus knee osteoarthritis alone [30]. Surgical treatment of ankle arthritis significantly improves ambulatory activity [73]. Greater change in ambulatory activity occurs at high activity levels following surgical treatment of ankle arthritis [73].

Investigations

Plain radiography: Weight-bearing anteroposterior, oblique, and lateral radiographs are the standard initial assessment to evaluate joint space narrowing and alignment [160]. In patients with stage 3 varus ankle osteoarthritis, weightbearing lateral radiographs are specifically required to accurately evaluate joint space obliteration [21]. For anterior ankle impingement, lateral radiographs may fail to demonstrate osteophytes; an anteromedial view is often helpful in these cases [60]. In chronic lateral ankle instability, AP, mortise, and lateral weight-bearing radiographs are performed to evaluate the condition [104]. Instability can be confirmed using stress radiographs, which involve obtaining a lateral radiograph during the anterior drawer test and a mortise radiograph during the talar tilt test [104]. Stress inversion ankle roentgenograms should be considered in cases of talar osteochondritis dissecans [170].

Post-arthroplasty imaging presents specific limitations. The rotational position of the leg highly influences measurements in ankle radiographs after total ankle replacement [75]. Consequently, plain radiographic measurements of prosthetic migration and alignment in total ankle replacement have poor accuracy [75].

MRI: Magnetic resonance imaging is useful for evaluating associated pathology to the peroneal tendons or talar articular surface in chronic lateral ankle instability [104]. While MRI confirms the abnormal appearance of affected ligaments, it does not help determine functional instability [104]. In anterior ankle impingement, MRI can show osteophytes but is not very sensitive for soft-tissue impingement [60]. MR arthrography or contrast-enhanced, fat-suppressed, three-dimensional fast-gradient recalled acquisition in the steady state with radiofrequency spoiling MRI is more sensitive and specific than standard MRI for soft-tissue impingement in the ankle [60]. In one study of anterior ankle impingement, 58% of patients had an associated diagnosis on MRI, which changed the surgical plan in 33% of cases [60].

CT: Simulated weightbearing computed tomography is used for verification of radiographic staging of varus ankle osteoarthritis [21]. The bone mineral density of the talus in end-stage ankle osteoarthritis was significantly lower than that of a healthy talus [168].

Arthroscopy: Preoperative ankle arthroscopy revealed an essential amount of information that would otherwise have been undetected in patients with chronic ankle instability [77]. Arthroscopic findings demonstrate that abnormalities of different structures are involved in chronic ankle instability, with no single causal entity [77].

Other Considerations: The measurement properties of the Dutch patient-reported American Orthopaedic Foot and Ankle Society score were sufficient in patients with ankle osteoarthritis [50]. In patients with ankle osteoarthritis, platelet-rich plasma injections did not improve pain and function at 52 weeks [18].

Treatment

Non-Operative

Conservative management for painful exacerbations of ankle osteoarthritis includes analgesics or NSAIDs [87]. Offloading the joint with a walking stick and weight loss are supported adjuncts [87]. Intra-articular hyaluronate injections at 3-weekly intervals in patients with moderate to severe unilateral ankle arthritis provide significant improvement in outcome and balance, and reduce NSAID use at 6 months [143]. However, a single hyaluronic acid injection shows no difference in pain or patient outcomes compared with saline [143]. Platelet-rich plasma (PRP) does not improve pain or function at 52 weeks [18, 115]. While three PRP injections at 2-week intervals in varus ankle OA resulted in significant improvement in pain and patient-reported outcomes out to 24 weeks without adverse effects [143], standardized PRP preparation appears to provide safe, sustained benefits particularly in younger, athletic patients with early-stage disease [149]. Viscosupplementation potential is suggested, but no dosing studies have been published [135]. No evidence supports that any treatment other than surgery changes the course of ankle arthritis [143].

Operative

Indications: Surgical intervention is indicated when conservative measures fail. Joint-preserving surgery is appropriate for early-stage ankle OA with malalignment [2]. Realignment surgery is an alternative to fusion or total ankle replacement in selected cases of asymmetric (varus or valgus) ankle osteoarthritis [24]. Ankle arthrodesis is indicated for patients with painful limited motion where conservative measures have failed [44]. Specific indications for arthrodesis include posttraumatic arthritis, osteoarthritis, arthritis from chronic instability, rheumatoid or autoimmune inflammatory arthritis, gout, postinfectious arthritis, Charcot neuroarthropathy, osteonecrosis of the talus, failure of total ankle arthroplasty, and instability from neuromuscular disorders [44]. Total ankle arthroplasty is indicated for end-stage ankle OA [2].

Surgical Approach / Technique: In early stages with malalignment, periarticular osteotomies are the only procedure with sufficient evidence for recommendation [2]. Supramalleolar osteotomy (SMO) demonstrates good clinical and radiological outcomes with a low failure rate at mid-term follow-up [6]. SMO alone and SMO with fibular osteotomy effectively alleviate pain and improve function in varus ankle osteoarthritis [122]. SMO for varus ankle osteoarthritis shows improved clinical outcomes compared to preoperative assessments [123]. Periarticular osteotomies of the tibia, fibula, or hindfoot are reasonable approaches for localized arthritis [27]. Low tibial osteotomy is an effective alternative for moderate ankle arthritis, improving pain, function, and motion, potentially saving the ankle from fusion or postponing it [133]. The dual approach of SMO and proximal fibular osteotomy shows promise as a joint-preserving alternative for patients with moderate to severe ipsilateral ankle and knee osteoarthritis [80].

Arthroscopic debridement for anterior ankle impingement has reported success rates ranging from 73% to 96% in level II to IV studies [60]. Efficacy is shown for the removal of anterior impingement osteophytes from the tibia and/or talus [27]. Patients with mechanical locking from a demonstrable loose body may benefit from arthroscopic management [27]. However, increased motion following osteophyte removal in a joint with irregular arthritic surfaces may lead to different or increased postoperative pain [27]. Aggressive removal of osteophytes may lead to anterior extrusion of the talus postoperatively [27]. In a 2015 systematic review, patient satisfaction for ankle arthroscopy was good or excellent in 74% to 100%, with a complication rate of 5.1% [60]. There is a grade B recommendation (fair evidence) to support the use of ankle arthroscopy for ankle impingement [60].

Joint distraction arthroplasty is based on the concept that mechanical unloading and intermittent flow of intraarticular synovial fluid encourage cartilage healing [81]. Hinges should be placed along the axis of the ankle joint (Inman axis) to prevent uneven distraction and preserve motion [81]. A circular fixator is superior to monolateral fixation because a monolateral frame delivers uneven distraction through cantilever mechanics [81]. Use of a forefoot wire should be avoided as it is uncomfortable and discourages weight bearing [81]. No more than 5 to 6 mm of acute distraction should be applied in the operating room [81]. Range-of-motion exercises should be started early to preserve mobility [81]. The ideal candidate is a young motivated patient whose symptoms are not relieved with conservative measures and who is unwilling to have an arthrodesis [81]. Contraindications include active infection, advanced coronal plane deformity, significant loss of bone stock, and poor frame candidacy [81]. Relative contraindications include uncontrolled diabetes, tobacco use, chronic edema of the lower limb, severe ankle deformity, and severe ankle ankylosis [81].

Ligament stabilization with arthroscopic procedures for individuals with chronic ankle instability and medial ankle OA yielded significant functional outcomes with high patient satisfaction, even without radiographic improvement [129]. Bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis showed to be safe and to provide a satisfactory outcome at 10 years [33]. However, patients with end-stage OA treated with this method presented a high revision rate at 10 years [33].

Implant Selection: For ankle arthrodesis, there is fair evidence (grade B) to advocate the use of internal fixation [32]. Factors that improve results include arthroscopic or mini-incision technique, the use of more than two screws or an adjunct plate (or fibular strut), and a diagnosis of primary osteoarthritis [32]. There is evolving grade B evidence suggesting that minimally invasive techniques may be equivalent to open procedures in selected patients [32]. Arthroscopically assisted arthrodesis produces good results in patients with osteoarthritis and minimum or no deformity [12]. The immediate postoperative morbidity of arthroscopically assisted arthrodesis is of very short duration [12]. Arthroscopic ankle arthrodesis is considered the new gold standard for patients with isolated ankle osteoarthritis and no/minimal deformity [26]. The posterior arthroscopic ankle fusion is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up [72].

Alignment / Balancing Strategy: In 35 consecutive patients with posttraumatic ankle osteoarthritis treated with lower leg and hindfoot realignment surgery, pain decreased by an average of 4 points on a visual analog scale at mean followup of 5 years [24]. Range of ankle motion increased by an average of 5° at mean followup of 5 years [24]. Walking ability and the functional parts of the American Foot and Ankle Society score increased by an average of 10 and 21 points, respectively, at mean followup of 5 years [24].

Pain Management: Ankle arthrodesis has the advantage of predictable pain relief and the disadvantage of limited motion [86]. 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 [86]. In a randomized controlled trial, Saltzman et al. compared fixed distraction to motion distraction in 36 patients and found that those with motion distraction had earlier and consistently better outcomes [81]. Twenty-one (98%) of 23 patients reported by Tellisi et al. reported decreased pain after distraction arthroplasty [81]. Other series have reported good results in approximately 75% of patients after distraction arthroplasty [81]. In a randomized study, Herrera-Perez et al. showed similar functional outcomes and quality of life with debridement and a hinged distraction compared to debridement alone, although the rate of post-operative revision surgery was higher if distraction was not used [81].

Adjuncts: The beneficial effects of distraction are not immediate and tend to occur over a long period of time, ranging from 6 months to 2 years [81]. Adverse events in a distraction arthroplasty series included 43 pin-track infections and eight neurapraxias [81]. Currently there is not enough high-level evidence to support ankle joint distraction for generally accepted indications [81].

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

Revision: Revision surgery was performed in 10 ankles (29%) following realignment surgery for asymmetric ankle osteoarthritis, of which three ankles (9%) were converted to total ankle replacement [24]. Revision arthrodesis has reported successful fusion rates of 75% to 94% [32]. In a systematic review of the literature that included 1262 arthrodeses and 852 arthroplasties, Haddad et al. identified revision rates of less than 10% and infection rates of less than 5% after arthrodesis [86]. In a systematic review of the literature that included 1262 arthrodeses and 852 arthroplasties, Haddad et al. identified revision rates of less than 10% and infection rates of less than 5% after arthroplasty [86].

Other Considerations: Ankle arthrodesis can produce satisfactory functional results if correctly indicated in the final stages of ankle OA [2]. When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain [79]. Nonunion rates after ankle arthrodesis vary widely in the literature, largely dependent on technique, underlying diagnosis, and patient selection [32]. Physical findings of persistent swelling, pain at the fusion site, and difficulty with weight bearing should lead to careful scrutiny of the plain radiographs to assess for nonunion [32]. CT is necessary in some cases to establish that fusion has occurred or to evaluate the nonunion [32]. Satisfactory immobilization of a delayed union in a protected weight-bearing boot or cast is necessary for treatment [32]. The use of pulsed electronic magnetic field devices with immobilization and limited weight bearing was successful in only five of 19 delayed unions of foot and ankle arthrodeses [32]. The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation [169].

Absolute contraindications to ankle fusion include vascular impairment of the limb and infection of the skin through which the approach is planned [44]. Relative contraindications to ankle fusion include preexisting moderate-to-severe ipsilateral hindfoot arthritis and contralateral ankle arthritis likely to require surgical treatment in the foreseeable future [44].

In a study involving 114 ankle arthroplasties and 47 ankle arthrodeses, complication rates were 26% after arthrodesis [86]. In a study involving 114 ankle arthroplasties and 47 ankle arthrodeses, complication rates were 54% after arthroplasty [86]. In a multicenter study involving 321 patients, Daniels et al. reported that intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable [86]. In a multicenter study involving 321 patients, Daniels et al. reported that reoperation and major complications were more frequent after ankle replacement than arthrodesis [86]. In a multisite prospective cohort study of 517 patients, Norvell et al. found no statistically significant difference in adverse events at 1 year after either arthrodesis or arthroplasty [86].

Gait analysis has shown that patients with total ankle replacement have a more normal gait pattern than those with arthrodesis [86]. Some gait studies have noted no difference in gait patterns after arthroplasty and arthrodesis [46]. Other gait studies report more nearly normal gait and better walking on uneven surfaces after arthroplasty [46]. Gait appears to be improved by either arthroplasty or arthrodesis [46]. Sports participation has been reported to be similar after both arthroplasty and arthrodesis, with approximately 76% in both groups active in sports after surgery [86].

In the first mid- to long-term outcome study of its kind, Dekker et al. reported a moderate radiographic increase in adjacent subtalar and talonavicular arthritis at a minimum of 5 years after arthrodesis [86]. In 140 ankles averaging 6.5 years’ follow-up after arthrodesis, 40% and 34% of adjacent subtalar and talonavicular joints, respectively, showed progression of arthritic changes using the modified Kellgren Lawrence scale [86]. Sealey et al. reported 9.3 degrees of compensatory subtalar motion and 16.4 degrees of midfoot motion after ankle arthrodesis [86]. Pinsker et al. reported that only 15% of patients with arthroplasty or arthrodesis experienced resolution of all symptoms and limitations [86].

Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being the topic of much debate [17]. To definitively determine which procedure is more appropriate in advanced ankle OA, more and better-designed studies are required, given that the results reported thus far do not permit to determine with absolute certainty which of the two procedures, TAR or AF, is more adequate [16]. No level I studies have directly compared total ankle arthroplasty and ankle arthrodesis [46].

Complications

Ankle Arthrodesis

Nonunion: Nonunion rates after ankle arthrodesis vary widely in the literature, dependent on technique, underlying diagnosis, and patient selection [32]. Clinical evidence is insufficient to definitively implicate most risk factors for nonunion [32]. Factors that improve results include arthroscopic or mini-incision technique, the use of more than two screws or an adjunct plate (or fibular strut), and a diagnosis of primary osteoarthritis [32]. Persistent swelling, pain at the fusion site, and difficulty with weight bearing should lead to careful scrutiny of plain radiographs to establish union [32]. CT is sometimes necessary to establish that fusion has occurred or to evaluate nonunion [32]. 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 [32]. Revision arthrodesis for delayed union or nonunion has reported successful fusion rates of 75% to 94% [32].

Infection: In a systematic review including 1262 arthrodeses, infection rates were less than 5% after ankle arthrodesis [86]. In a retrospective cohort study comparing screw-only versus screw-and-plate constructs, there was a trend toward higher numbers of deep wound infection with anterior plate use, which was not statistically significant [45]. In a retrospective case series of 101 ankles undergoing arthroscopic ankle arthrodesis, no cases of deep infection or serious adverse events were reported [45].

Adjacent Joint Arthritis: Arthritis found in adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change and not directly caused by the tibiotalar fusion [90]. In a mid- to long-term outcome study, 40% of adjacent subtalar and 34% of adjacent talonavicular joints showed progression of arthritic changes at a minimum of 5 years after ankle arthrodesis [86]. In a retrospective case series of 101 ankles undergoing arthroscopic ankle arthrodesis, 85% of ankles had no changes in the talonavicular joint and 69% had no changes in the subtalar joint regarding progression of arthritis at a mean follow-up of 86 months [45].

Other Considerations: Arthroscopically assisted arthrodesis of the ankle produces good results in patients with osteoarthritis and minimum or no deformity, with immediate postoperative morbidity of very short duration [12]. In a retrospective case series of 101 ankles undergoing arthroscopic ankle arthrodesis, 94% achieved fusion and 75% reported "good/excellent" results [45]. In a retrospective cohort study comparing ankle arthrodesis with screw-only versus screw-and-plate constructs, there was no statistically significant difference in nonunion rate or revision rate, though numbers trended toward improvement with anterior plate augmentation [45]. In a study of 114 ankle arthroplasties and 47 ankle arthrodeses, the complication rate was 26% after arthrodesis [86]. In a systematic review including 1262 arthrodeses, revision rates were less than 10% after ankle arthrodesis [86]. In a multicenter study involving 321 patients, reoperation and major complications were more frequent after ankle replacement than after ankle arthrodesis [86]. In a multisite prospective cohort study of 517 patients, there was no statistically significant difference in adverse events at 1 year after ankle arthrodesis or arthroplasty [86]. In a retrospective cohort study using a large state-wide database, total ankle replacement patients had lower rates of readmission and periprosthetic joint infection/wound infections compared to ankle arthrodesis patients [45]. Over a 15-year period, total ankle replacement complication rates improved relative to ankle arthrodesis [40].

Total Ankle Arthroplasty

Infection: In a systematic review including 852 arthroplasties, infection rates were less than 5% after total ankle arthroplasty [86]. In a retrospective cohort study of 8,491 ankle arthrodesis and 1,290 ankle replacements, total ankle replacement patients had lower rates of readmission and periprosthetic joint infection/wound infections [45].

Failure and Revision: Failure rates for total ankle arthroplasty range from 1% to 32%, with an overall mean failure rate of 12% [86]. In a systematic review including 852 arthroplasties, revision rates were less than 10% after total ankle arthroplasty [86]. Compared with primary osteoarthritis, fracture posttraumatic osteoarthritis was associated with a markedly higher complication rate after total ankle arthroplasty and higher risk of failure requiring prosthesis explant [67].

Other Considerations: In a study of 114 ankle arthroplasties and 47 ankle arthrodeses, the complication rate was 54% after arthroplasty [86]. Results for total ankle arthroplasty may deteriorate over time, and long-term outcomes require a minimum follow-up of 5 years [61]. In a retrospective cohort study of 8,491 ankle arthrodesis and 1,290 ankle replacements, there have been improvements in the clinical safety of total ankle replacement over time [40].

Recovery

The provided evidence base for ankle osteoarthritis focuses on long-term clinical outcomes, implant survivorship, and prognostic factors rather than specific post-operative rehabilitation timelines. Consequently, there is no evidence in this document to define specific week or month ranges for Light activity, Full activity, or Complete recovery / outcome plateau. Similarly, no data regarding Rehabilitation protocol (such as immobilisation duration, weight-bearing progression, or brace removal timing) or specific Functional milestones (validated PROM trajectories over time) are present. The following sections detail the available evidence regarding treatment outcomes and prognostic considerations.

Non-Operative Interventions

Platelet-rich plasma (PRP) injections did not improve pain and function at 52 weeks in patients with ankle osteoarthritis [18]. Eligibility for PRP injection studies in this population required a visual analog scale (VAS) pain severity of 40 mm (0-100 mm) during daily activities and radiographic grade 2 talocrural osteoarthritis on the van Dijk classification [9].

Joint Preservation and Osteotomy

Supramalleolar osteotomy for ankle osteoarthritis demonstrates good clinical and radiological outcomes and a low failure rate at mid-term follow-up [6]. Peri-talar re-alignment osteotomy can achieve good clinical and radiological outcomes in asymmetrical ankle osteoarthritis when specific deformities and appropriate indications are understood [4]. In the early stages of ankle osteoarthritis with malalignment, only periarticular osteotomies have sufficient evidence to be recommended [2]. Most osteotomies around the knee do not require particular concern for ipsilateral ankle function [7].

Arthrodesis

Ankle arthrodesis can produce satisfactory functional results when correctly indicated in the final stages of ankle osteoarthritis [2]. Arthroscopically assisted arthrodesis of the ankle produces good results in patients with osteoarthritis and minimum or no deformity, with very short duration of immediate postoperative morbidity [12]. Posterior arthroscopic ankle fusion is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up [72]. Arthritis found in adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change rather than being directly caused by the tibiotalar fusion [90]. Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients [65].

Total Ankle Arthroplasty (TAA)

Total ankle replacement can produce satisfactory functional results when correctly indicated in the final stages of ankle osteoarthritis [2]. In adults with end-stage ankle osteoarthritis, total ankle replacement and arthrodesis did not differ with respect to change in MOXFQ scores at 1 year [28]. Surgical treatment for end-stage ankle osteoarthritis resulted in satisfactory clinical outcomes in patients aged ≥75 years, with improvements comparable to those in younger patients [5]. Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement [49]. There have been improvements in the clinical safety of total ankle replacement over time [40]. The early experience and small rate of adverse events reported for the Infinity fixed-bearing implant continue to support its use for the treatment of end-stage ankle arthritis [172]. The outcome of the Mobility total ankle replacement at a mean of four years is satisfactory in > 85% of patients [173]. Early clinical outcomes and survivorship of the TARIC mobile-bearing total ankle arthroplasty were comparable to previous reports on other total ankle systems [76]. In the majority of cases, an anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty [22]. The design of total ankle arthroplasty systems is evolving as understanding of failure modes increases and surgical techniques refine, with some implants showing acceptable intermediate results but much poorer outcomes at 7- to 10-year follow-up [23]. Surgeons and patients should be cautioned against enthusiasm for total ankle arthroplasty based on short-term follow-up, as results may deteriorate over time and long-term outcomes require a minimum follow-up of 5 years [61]. Several characteristics are associated with consumer preference for total ankle arthroplasty over ankle arthrodesis and vice versa, which can be useful when counseling patients on treatment options for end-stage ankle osteoarthritis [11].

Osteochondral Lesions and Other Procedures

A one-step technique using bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis showed to be safe and provided a satisfactory outcome, although patients with end-stage osteoarthritis presented a high revision rate at 10 years [33]. Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients, despite substantial radiographic evidence of osteoarthritis in one-half of the patients [43].

Prognosis and Risk Factors

Advanced radiographic ankle osteoarthritis was common (36.3%) 18 years after malleolar fractures, especially following Weber C fractures and associated medial malleolar fractures [19]. In some patients with stage 3 varus ankle osteoarthritis, the obliteration of the joint space is difficult to evaluate accurately using only weightbearing anteroposterior radiographs; weightbearing lateral radiographs should also be performed [21]. Patients with ankle varus were older and had prolonged symptom duration compared to those with chronic lateral ankle instability alone [171]. Although ankle osteoarthritis did not directly affect clinical outcomes after total knee arthroplasty, residual valgus alignment and older age were independently associated with worse postoperative WOMAC scores [48].

Key Evidence

• [L5] In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment, while both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease. [2] (10.1530/eor-21-0117)
• [L4] [3] (10.1177/0363546505281813)
• [L4] Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques. [4] (10.1302/2058-5241.2.160021)
• [L3] Surgical treatment for end-stage ankle OA resulted in satisfactory clinical outcomes in patients aged ≥75 years, with improvements comparable to those in younger patients. [5] (10.1186/s13018-023-03734-4)
• [L4] This systematic review demonstrates good clinical and radiological outcomes, together with a low failure rate at mid-term follow-up following supramalleolar osteotomy in patients with ankle osteoarthritis. [6] (10.1007/s00167-022-07144-7)
• [L3] Most osteotomies around the knee seem to require no particular concern for the ipsilateral ankle function. [7] (10.1007/s00167-021-06699-1)
• [L1] [9] (10.1177/03635465231182438)
• [L4] Treatment of patients with a painful total ankle arthroplasty is complex and requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options. [10] (10.5435/jaaos-d-14-00017)
• [L4] Several characteristics were associated with preference for TAA over AA and vice versa, which can be useful when counseling patients on treatment options for end-stage ankle osteoarthritis. [11] (10.5435/jaaos-d-25-00236)
• [L4] Arthroscopically assisted arthrodesis of the ankle produces good results in patients who have osteoarthritis of the ankle with minimum or no deformity, and the immediate postoperative morbidity is of very short duration. [12] (10.2106/00004623-199407000-00023)
• [L3] The assumption that associations may exist between knee and ankle osteoarthritis and joint malalignment was confirmed. [13] (10.1007/s00402-007-0502-9)
• [L4] Ankle sprains are mainly benign lesions but can evolve into permanent disability and osteoarthritis if not well addressed. [14] (10.1302/2058-5241.6.210017)
• [L3] These results suggest that gender did not seem to affect outcomes of total ankle arthroplasty in patients with ankle osteoarthritis. [15] (10.1186/s13018-020-01731-5)
• [Paper] To definitively determine which procedure is more appropriate in advanced ankle OA, more and better-designed studies are required, given that the results reported thus far do not permit to determine with absolute certainty which of the two procedures, TAR or AF, is more adequate. [16] (10.1530/eor-2025-0106)
• [L5] Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being the topic of much debate. [17] (10.5435/jaaos-d-23-00743)
• [L1] In patients with ankle osteoarthritis, PRP did not improve pain and function at 52 weeks. [18] (10.2106/jbjs.23.01338)
• [L3] Advanced radiographic ankle OA was common (36.3%) 18 years after malleolar fractures, especially following Weber C fractures and associated medial malleolar fractures. [19] (10.1007/s00264-011-1472-7)
• [L2] Surgeons can consider isolated ankle arthrodesis for end-stage ankle osteoarthritis with concomitant PCFD, even in severe cases, expecting substantial deformity correction without additional procedures. [20] (10.1097/corr.0000000000003756)
• [L4] In some patients with stage 3 varus ankle osteoarthritis, the obliteration of the joint space is difficult to evaluate accurately using only weightbearing anteroposterior radiographs; weightbearing lateral radiographs should also be performed. [21] (10.1186/s12891-021-04618-6)
• [L3] In the majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty. [22] (10.1186/1471-2474-14-260)
• [L4] The design of total ankle arthroplasty systems is evolving as understanding of failure modes increases and surgical techniques refine; some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up. [23] (10.5435/jaaos-d-16-00715)
• [L4] [24] (10.1097/blo.0b013e318124a462)
• [L4] It is considered the new gold standard for patients with isolated ankle osteoarthritis and no/minimal deformity. [26] (10.1530/eor-2023-0100)
• [L1] In adults with end-stage ankle osteoarthritis, TAR and AA did not differ with respect to change in MOXFQ scores at 1 year. [28] (10.2106/jbjs.23.00497)
• [L3] Despite achieving proper coronal knee alignment postoperatively, these patients experienced greater hindfoot and ankle joint inversion load during gait. [30] (10.1002/ksa.12249)
• [L4] This one-step technique for the treatment of OLT in OA ankles showed to be safe and to provide a satisfactory outcome, even if patients with end stage OA presented a high revision rate at 10 years. [33] (10.1007/s00167-021-06494-y)
• [L3] The findings showed a decrease in ankle kinematics and kinetics of patients with isolated ankle OA during walking, whereas no change in kinematic or kinetic functions were observed in the distal foot joints, demonstrating that these do not compensate for the mechanical dysfunction of the ankle. [35] (10.1097/corr.0000000000001443)
• [L3] [36] (10.1186/s12891-021-04230-8)
• [L4] [37] (10.1177/0363546509351556)
• [L5] The findings suggest that total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed. [39] (10.2106/jbjs.26.00501)
• [L3] These findings suggest that there have been improvements in the clinical safety of total ankle replacement over time. [40] (10.2106/jbjs.15.01341)
• [Case_report] Harvesting of the fibula may cause long-term ankle osteoarthritis that requires ankle arthrodesis. [41] (10.1007/s00402-007-0378-8)
• [L4] Associated chondral lesion is a significant contributing factor to late development of ankle osteoarthrosis. [42] (10.1016/j.injury.2012.07.002)
• [L4] Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients despite substantial radiographic evidence of osteoarthritis in one-half of the patients. [43] (10.2106/jbjs.l.00426)
• [L3] Although ankle OA did not directly affect clinical outcomes, residual valgus alignment and older age were independently associated with worse postoperative WOMAC scores. [48] (10.1016/j.arth.2025.08.067)
• [L4] Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. [49] (10.2106/jbjs.21.00287)
• [L1] The measurement properties of the Dutch PR-AOFAS were sufficient in patients with ankle osteoarthritis who are willing to participate in a trial on injection therapy. [50] (10.1016/j.jisako.2023.07.003)
• [L2] Patients with tibiotalar osteoarthritis were more likely to receive a total ankle replacement procedure if they had Medicare or private insurance compared with patients who had Medicaid. [58] (10.1177/1071100716674311)
• [L5] The commentary cautions surgeons and patients about enthusiasm for total ankle arthroplasty based on short-term follow-up, noting that results may deteriorate over time and that long-term outcomes require a minimum follow-up of 5 years. [61] (10.2106/jbjs.19.00700)
• [L3] DTS morphological classification might affect the biomechanics properties in TAS and TTA in ankle OA. [62] (10.1186/s13018-023-03985-1)
• [L3] OA in the hip, knee, or ankle reduces effective exchange of potential and kinetic energy, potentially increasing the muscular work required to control movements of the center of mass. [64] (10.1007/s11999-016-4921-1)
• [L4] Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients. [65] (10.2106/jbjs.o.00396)
• [L3] The authors advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis. [66] (10.2106/jbjs.22.00072)
• [L3] Compared with primary osteoarthritis, fracture posttraumatic osteoarthritis was associated with a markedly higher complication rate after total ankle arthroplasty and was at higher risk of failure requiring prosthesis explant. [67] (10.5435/jaaos-d-22-01192)
• [L3] The clinical results were significantly worse in women after ankle arthrodesis, which should be considered when determining the indication. [70] (10.1186/s13018-024-05045-8)
• [L4] The posterior arthroscopic ankle fusion is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up. [72] (10.1007/s00167-015-3975-z)
• [L2] Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. [73] (10.2106/jbjs.18.00511)
• [L4] The findings suggest that rotational position of the leg highly influences measurements in ankle radiographs after TAR. [75] (10.1186/s13018-015-0220-x)
• [L4] Early clinical outcomes and survivorship of TARIC TAA were comparable to previous reports on other total ankle systems. [76] (10.1302/0301-620x.108b1.bjj-2025-0096.r2)
• [L4] Preoperative ankle arthroscopy revealed an essential amount of information that would otherwise have been undetected, showing that abnormalities of different structures are involved in chronic ankle instability with no single causal entity. [77] (10.1177/03635465020300031601)
• [L5] While prompt reduction is important, the prognosis of ankle fracture-dislocation depends significantly on the damage at the time of the insult, with chondrolysis and vascular impairment leading to osteoarthritis regardless of early or late intervention. [78] (10.1007/s00402-008-0578-x)
• [L5] When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain. [79] (10.5435/00124635-200005000-00007)
• [L5] The dual approach of SMO and PFO shows promise as a joint-preserving alternative for patients with moderate to severe ipsilateral ankle and knee osteoarthritis, demonstrating improved alignment, pain relief, and functionality. [80] (10.1016/j.jisako.2025.100895)
• [L4] [82] (10.1007/s00167-020-06187-y)
• [L5] [88] (10.1530/eor-22-0024)
• [L5] [89] (10.1007/s00167-021-06755-w)
• [L4] Arthritis found in the adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change and not directly caused by the tibiotalar fusion. [90] (10.1016/j.arthro.2017.11.031)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. [94] (10.1186/s12891-025-09458-2)
• [Paper] Intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 52 weeks in patients with ankle OA. [115] (10.1177/03635465231213856)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [118] (10.1177/03635465231217490)
• [L4] Both SMO alone and SMO + FO can effectively alleviate pain and improve ankle function in patients with varus ankle osteoarthritis. [122] (10.1186/s12891-026-09762-5)
• [L4] This study showed improved clinical outcomes after SMO for varus ankle osteoarthritis in comparison to the preoperative assessments. [123] (10.1177/0363546514530669)
• [L3] Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery. [124] (10.1177/23259671211023447)
• [L4] Ligament stabilization with arthroscopic procedures for individuals with chronic ankle instability and medial ankle OA yielded significant functional outcomes with high patient satisfaction, even without radiographic improvement. [129] (10.1007/s00167-020-05845-5)
• [L2] [130] (10.1007/s00167-015-3871-6)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [131] (10.2106/00004623-199607000-00006)
• [L4] There is limited and declining number of publications describing the utilization trends of TAA and AA procedures for end-stage ankle OA. [132] (10.5435/jaaosglobal-d-24-00181)
• [L4] Low tibial osteotomy is an effective alternative treatment for moderate ankle arthritis that can improve pain, function, and motion, potentially saving the ankle from fusion or postponing it. [133] (10.1007/s004020000243)
• [L2] The potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date, and dosing in the ankle joint remains an area for discussion. [135] (10.1007/s00402-010-1165-5)
• [L4] [138] (10.1007/s11999-009-0988-2)
• [L3] [142] (10.2106/jbjs.17.00883)
• [L4] Intra-articular PRP prepared with a standardized method appeared to provide safe, sustained clinical benefits in ankle OA, particularly in younger and athletic patients with early-stage disease. [149] (10.1186/s12891-026-09790-1)
• [L5] Based on the mouse model, the findings indicate that severe ankle instability has nearly three times the chance to develop into ankle OA compared to moderate ankle instability. [150] (10.1186/s12891-022-05164-5)
• [L2] [159] (10.1007/s00167-013-2719-1)
• [L3] [165] (10.1186/s13018-019-1168-z)
• [L3] The higher the grade of Kashin–Beck disease, the more serious the change of the ankle joint. [166] (10.1186/s13018-023-03633-8)
• [L4] The treatment of this condition should be surgical, and chronic instability of the ankle joint in some cases can be attributed to a separate centre of ossification of the lateral malleolus. [167] (10.1007/bf00419948)
• [L4] The bone mineral density of the talus in end-stage ankle osteoarthritis was significantly lower than that of a healthy talus. [168] (10.1186/s12891-025-08798-3)
• [L4] The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation. [169] (10.1016/j.otsr.2016.03.015)
• [L4] The case demonstrates that repeated inversion stress in ankles with lax lateral ligaments can result in osteochondral lesions of the medial part of the talus, and stress inversion ankle roentgenograms should be considered in cases of talar osteochondritis dissecans. [170] (10.2106/00004623-197052010-00018)
• [L3] Patients with ankle varus were older and had prolonged symptom duration compared to those with CLAI alone. [171] (10.1186/s13018-025-06232-x)
• [L2] The early experience and small rate of adverse events reported in this study continue to support the use of the Infinity TAA implant for the treatment of end-stage ankle arthritis. [172] (10.2106/jbjs.22.01294)
• [L4] The outcome of the Mobility TAR at a mean of four years is satisfactory in > 85% of patients. [173] (10.1302/0301-620x.95b10.30204)

See Also

• Ankle arthrodesis
• Osteochondral lesion of the talus
• Total ankle replacement
• Ankle fracture
• Syndesmotic injury
• Ankle impingement
• Ankle arthroscopy
• Chronic ankle instability
• Charcot neuroarthropathy

References

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[3] Ligamentous Posttraumatic Ankle Osteoarthritis. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546505281813

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[6] Supramalleolar osteotomy for the treatment of ankle osteoarthritis leads to favourable outcomes and low complication rates at mid‐term follow‐up: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07144-7

[7] Osteotomies around the knee are not correlated to substantial post‐operative ankle pain. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06699-1

[9] Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231182438

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[11] Consumer Preferences for Total Ankle Arthroplasty Versus Ankle Arthrodesis: A Conjoint Analysis of 1,410 US Healthcare Consumers. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00236

[12] Arthroscopically assisted arthrodesis for osteoarthrotic ankles.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199407000-00023

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