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Total ankle replacement

106 citationsUpdated Sep 2026

Overview

Total ankle replacement serves as a viable treatment option for complete, end-stage ankle arthritis [3] and offers a reasonable alternative to ankle arthrodesis in carefully selected patients [13]. While surgical management for end-stage ankle osteoarthritis currently focuses on both arthrodesis and arthroplasty, specific indications for one procedure over the other remain a subject of debate [16]. The procedure is likely to be successful in carefully selected rheumatoid patients with severe arthritis unresponsive to conservative treatment [19]. Although utilization has increased and complication rates are lower compared with ankle arthrodesis for patients operated between 2005 and 2010 [14], the currently available literature has not yet demonstrated that total ankle arthroplasty predictably results in levels of durability and function that make it cost-effective at this time [4].

Clinical outcomes have historically been inconsistent, with most implants failing to provide long-lasting pain relief or improved function comparable to replacements of other major lower extremity joints [10]. Some implants with acceptable intermediate results showed much poorer outcomes at 7- to 10-year follow-up [1], and the failure rate of total ankle arthroplasty remains 3 to 4 times that of total knee replacements [40]. Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort where treatment was tailored to patient presentation [8]; however, rates of reoperation and major complications were higher after total ankle replacement than after arthrodesis [8]. Additionally, total ankle replacement patients underwent a greater number of additional procedures compared to arthrodesis patients, even though revision rates were similar [17].

The design of total ankle arthroplasty systems is evolving as understanding of failure modes increases and surgical techniques refine [1]. It is premature to make definitive comments about the in vivo performance of uncemented second-generation replacements due to limited long-term data [11], and the design rationale for current implants should be carefully evaluated as midterm clinical results are few and often unvalidated by independent practitioners [12]. Clinical outcomes detailed in studies, generally with small numbers and short follow-up, likely say as much about patient selection and surgeon skill as they do about the performance of any particular implant system [20]. Despite these challenges, total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed [9], with overall patient satisfaction and functional outcomes supporting ankle arthroplasty as an option in the treatment of ankle arthritis [57].

Anatomy & Pathophysiology

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, articulating with the dome of the talar body [77]. The talar dome is wider anteriorly and narrower posteriorly [77]. During motion from plantar flexion to dorsiflexion, the ankle mortise widens 1 to 1.5 mm, causing medial and superior clear spaces to appear wider with the foot in plantar flexion [77]. A simplified model of the ankle joint features a horizontal axis from anteromedial to posterolateral and a coronal axis from superomedial directed distally and laterally to the tip of the fibula [77]. The distal fibula possesses a convex medial surface, while the incisura fibularis is the concave surface of the distal lateral tibia [77]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation, with dorsiflexion resulting in external rotation and proximal translation of the fibula [77].

Ligamentous Anatomy

Lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [77]. The anterior talofibular ligament originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [77]. The calcaneofibular ligament extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus, while the posterior talofibular ligament extends from the posterior lateral malleolus to the posterolateral talus [77]. The anterior talofibular ligament is the weakest ankle ligament, whereas the posterior talofibular ligament is the strongest [77]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [77].

The deltoid ligament complex is the primary ankle stabilizer during stance and consists of superficial and deep layers [77, 88]. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body, functioning primarily to resist lateral talar translation and external rotation [77]. The posterior deep deltoid is the most important component of the deep deltoid ligament [77]. Structurally, the deep portion is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [88]. The deep posterior tibiotalar ligament comprises the largest band of the deltoid complex [88]. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments, with a dominant mode of failure being an intrasubstance rupture near its talar insertion [88].

The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [77]. It functions primarily to resist valgus and eversion ankle forces [77]. The superficial layer originates from the anterior malleolus and inserts into the navicular, neck of the talus, sustentaculum tali, and posteromedial talar tubercle [88]. The tibiocalcaneal portion is the strongest component of the superficial deltoid layer, which fails dominantly at its insertion on the anterior malleolus [88].

Biomechanics and Motion

The ankle is responsible for most sagittal plane motion of the foot and ankle, contributing to inversion, eversion, and rotation [77]. Ankle plantar flexion ranges from 23 to 48 degrees, while dorsiflexion ranges from 10 to 23 degrees [77]. Abnormalities of gait caused by ankle arthritis are improved by ankle arthrodesis, although normal gait is not achieved; however, the improvement from preoperative levels is clinically significant [41]. Arthrodesis results in significant limitation of daily activities with reduced function of the affected limb, along with changes in spatial and temporal movement, weight bearing profile, and contact surface [107]. In contrast, total ankle replacement demonstrates superior gait mechanics compared to arthrodesis for ankle osteoarthrosis [119]. There is no true consensus in the literature as to whether ankle arthrodesis leads to adjacent-joint arthritis [100].

The distal tibiofibular syndesmosis morphological classification might affect the biomechanics properties in tibiotalar and subtalar joints in ankle osteoarthritis [102]. Spatiotemporal parameters were not affected by the hindfoot alignment resulting from subtalar compensation [104]. Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes [108]. A flexion osteotomy effectively improved the congruency of the ankle joint [125]. Supramalleolar osteotomy is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion [128].

Pathophysiology and Failure Modes

Surgical management for end-stage ankle osteoarthritis currently focuses on ankle arthrodesis and total ankle arthroplasty [16]. Severe ankle instability has nearly three times the chance to develop into ankle osteoarthritis compared to moderate ankle instability based on a mouse model [120]. Transected mice in the calcaneofibular ligament plus anterior talofibular ligament and calcaneofibular ligament plus deltoid ligament groups displayed mechanical instability of the ankle-subtalar joint complex [137]. Some mice in the calcaneofibular ligament plus deltoid ligament group suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure [137].

Third-generation total ankle arthroplasty implants feature improved bearing surfaces and fixation, while fourth-generation systems incorporate 3D printing and patient-specific instrumentation [45]. In general, the group with a fixed-bearing implant demonstrated improvements in ankle moment and ground reaction forces, whereas the mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome [21]. The new fixed-bearing total ankle replacement showed a safe mechanical behavior and many clinical advantages [117]. The investigated new in situ fixed-bearing ankle design achieved overall better short-term results than those reported in previous research [118]. The new design reproduces physiologic ankle mobility and maintains complete congruence at the two articulating surfaces of the meniscal bearing over the entire motion arc, with the prospect of minimizing wear of this component [103].

In the majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty [22]. Satisfactory results can be achieved in patients with varus malalignment of ≥10°, which should not be considered a contraindication to total ankle replacement [60]. Preoperative coronal plane malalignment and incongruence of the ankle can be corrected and maintained for 2 years with total ankle replacement [69]. However, stiff ankles seemed to be at a higher risk for subsidence [105]. Coronal plane malalignment in total ankle arthroplasty altered foot kinematics and plantar pressure [111]. Component malalignment in total ankle arthroplasty leads to changes in foot kinematics and plantar pressure distributions [106].

Some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up [1]. The authors do not recommend the use of the Mayo total ankle arthroplasty, particularly in younger patients who have had a previous operative procedure on the ipsilateral ankle or foot [7]. Its performance in comparison to the current reference standard (that is, ankle fusion) remains to be defined in a properly designed randomized trial [24]. More information and data are needed to further investigate failure modes in ankle arthroplasties as the number of surgeries increases [133]. The findings suggest that rotational position of the leg highly influences measurements in ankle radiographs after total ankle replacement [114].

Polymer wear that causes aseptic loosening of the prosthesis components is the primary mechanism of intermediate and late failure of total joint replacements [126]. The average contact pressures of 5.6 MPa for the Agility total ankle system fall within the safe zone for industrial limit for contact pressures on polyethylene, which is less than 10 MPa [126]. The measured peak contact pressure of 21.2 MPa for the Agility total ankle system falls within the caution zone, which is less than the 22 MPa industrial yield point for polyethylene [126]. Contact pressures decreased dramatically with larger components in the Agility total ankle system [126]. The complex biomechanics of the ankle are difficult to reproduce in the revision implants that are currently available [72]. The underlying causes of osteolysis around a total ankle arthroplasty are not fully understood and believed to be multifactorial [72]. Osteolysis in the ankle has been compared with that around the hip, and thought to be due to an immune reaction related to the activation of receptor activator of nuclear factor kappa-B ligand [72]. Histological studies suggest that polyethylene particles of a certain size may not cause osteolysis around a total ankle arthroplasty in the same manner as around a total hip arthroplasty [72].

Classification

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

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

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

Takakura Ankle Osteoarthritic Stage: This radiographic classification system is used to categorize ankle arthritis [42]. In a systematic review of supramalleolar osteotomy, the Takakura classification was reported in 14 studies, with 74 ankles (10.1%) at stage 1, 200 ankles (27.4%) at stage 2, 302 ankles (41.4%) at stage 3a, 137 ankles (18.8%) at stage 3b, and 17 ankles (2.3%) at stage 4 [42].

Other Considerations: Neither the Tanaka staging system nor the Canadian Orthopaedic Foot and Ankle Society classification is reliable to aid in surgical decision making for the arthritic ankle [134]. Glazebrook et al. divided complications in total ankle arthroplasty into three grades based on the likelihood of revision surgery: high grade due to infection, loosening, or component failure; intermediate grade due to technical error, subsidence, or periprosthetic fracture; and low grade due to wound problems and intraoperative fracture [72]. Patients with a high-grade complication in total ankle arthroplasty were more than twice as likely to require further surgery compared to other grades [72].

Clinical Presentation

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

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

In patients with rheumatoid arthritis, using a second-generation prosthesis, total ankle replacement can provide reliable relief of pain and good functional results at intermediate-term followup, although the incidence of osteolysis warrants close followup [18]. For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation [34]. Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients [33].

While most patients had reduced pain following total ankle replacement, persistent pain is not infrequent even in otherwise uncomplicated cases, often caused by soft-tissue impingement [52]. In general, the group with a fixed-bearing implant demonstrated improvements in ankle moment and ground reaction forces, while the mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome [21].

Periprosthetic joint infection after total ankle arthroplasty is a dreaded complication with devastating consequences; surgeons must be prepared to diagnose and manage potential infections to improve outcomes [53]. The authors present a diagnostic and treatment algorithm to assist surgeons in managing painful total ankle arthroplasty, emphasizing that fusion should be considered for complex cases such as those with extensive heterotopic ossification or recurrent stiffness following revision [25]. Endoscopic posterior ankle decompression and release after total ankle arthroplasty is technically demanding and should be reserved for the experienced foot and ankle arthroscopists [51].

Investigations

Plain radiography: AP, mortise, and lateral weight-bearing ankle x-rays are the initial imaging modality but may not demonstrate subtle osteochondral lesions [93]. Radiographic evaluation is used for the assessment of posterior malleolar fractures and the posterior pilon variant in operatively treated ankle fractures [98]. The ankle fracture spur sign is pathognomonic for a variant ankle fracture [98]. Radiographic identification of the primary lateral ankle structures has been described [50]. Gravity stress radiographs assess the effect of ankle position on deltoid ligament integrity and medial clear space measurements [50]. Stability criteria for nonoperative ankle fracture management have been described [98].

MRI: Magnetic resonance imaging is sensitive for all osteochondral lesions, but the edema pattern frequently overestimates the severity of injury [93]. Linear fluid signal deep to subchondral bone on MRI indicates an unstable osteochondral injury [93]. MRI has a sensitivity of 92% for predicting stable versus unstable osteochondral lesions [93]. MRI is used for the diagnosis of ligamentous and chondral pathology in the ankle [49]. Specific indications include the evaluation of traumatic ligamentous injuries of the ankle and foot [49], osteochondral lesions of the talus [49], ruptures of the tibialis posterior tendon [49], and sports injuries involving the ankle [49]. MRI is also used for the evaluation of chronic Achilles tendon ruptures [49], peroneal tendon abnormalities [95], and anterolateral soft tissue impingement of the ankle [49]. In chronic ankle instability, MRI is used for the pre-operative evaluation of the anterior talofibular ligament [49, 50] and for the evaluation of syndesmotic injury after lateral ankle sprain [50]. MR arthrography is used for the evaluation of tibiofibular syndesmotic ligaments [49]. Three-Tesla magnetic resonance imaging is used for the evaluation of posterior tibial tendon dysfunction with relevance to clinical staging [49]. MRI findings are associated with symptoms in patients with chronic ankle sprain [49]. MRI is used for the diagnosis of plantar plate injury with reference to intraoperative findings [49]. MR imaging is used for the evaluation of entrapment neuropathies of the lower extremity, including the knee, leg, ankle, and foot [101]. MRI lacks additional diagnostic value for stability assessment of the ankle mortise in supination-external rotation-type ankle fractures [98].

CT: CT scans are helpful for identifying bony lesions, determining the integrity of subchondral bone, identifying cysts, and preoperative planning for osteochondral lesions [93]. Axial CT imaging is used to assess normal tibiofibular relationships at the syndesmosis [98]. Preoperative computed tomography scans are used in operative planning for malleolar ankle fractures [98]. CT and MR imaging are used for the evaluation of the postoperative ankle and foot [49].

Other Considerations: The design rationale for current total ankle replacement implants and instruments should be carefully evaluated as midterm clinical results are few and often unvalidated by independent practitioners [12]. No level I or II studies have been published regarding the design features of current total ankle replacements [12]. Total ankle arthroplasty may be considered in ankles with deformity of >20° [47]. Total ankle arthroplasty for moderate and severe varus arthritic deformity showed similar satisfactory clinical and radiographic outcomes as those obtained by patients in the neutral group when postoperative neutral alignment was achieved [73]. Treatment of patients with a painful total ankle arthroplasty requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options [6]. A diagnostic and treatment algorithm exists to assist surgeons in managing painful total ankle arthroplasty [25]. Fusion should be considered for complex cases of painful total ankle arthroplasty, such as those with extensive heterotopic ossification or recurrent stiffness following revision [25]. Fluoroscopy can be used to assess if the syndesmosis is reduced [98]. Ultrasonographic examination is used for the evaluation of the deltoid ligament in bimalleolar equivalent fractures [98]. Point-of-care ultrasonography is used in the diagnosis and management of superficial peroneal nerve entrapment [101]. Radiographic evaluation of the normal distal tibiofibular syndesmosis has been described [98].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions. Total ankle replacement is considered when surgical intervention is required for end-stage ankle arthritis or specific pathologies, with patient selection guided by shared decision-making and individual risk profiles [127].

Operative

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

Implant Selection: The design of total ankle arthroplasty systems is evolving as understanding of failure modes increases and surgical techniques refine; some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up [1]. While there is consensus that the procedure will continue to be implanted in carefully selected patients, it is premature to make definitive comments about the in vivo performance of uncemented second-generation replacements due to limited long-term data [11]. Third-generation implants feature improved bearing surfaces and fixation, while fourth-generation systems incorporate 3D printing and patient-specific instrumentation [45]. Modern fixed-bearing total ankle arthroplasty demonstrated excellent implant survival, improved plantar flexion and total range of motion, and good-to-excellent functional outcomes at a mean follow-up of 5.2 years [112]. Patients undergoing total ankle arthroplasty with a fixed-bearing implant with a modular intramedullary stem for end-stage ankle arthritis experience significant improvement in alignment, pain scores, quality-of-life measures, and subjective function [65]. The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after arthroplasty are encouraging [48].

Outcomes and Comparison to Arthrodesis: Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort where treatment was tailored to patient presentation, although rates of reoperation and major complications were higher after ankle replacement [8]. Although revision rates were similar, total ankle replacement patients underwent a greater number of additional procedures [17]. When both procedures are performed by the same group of surgeons, patients undergoing TAA or AA for end-stage ankle arthritis have significant improvement in overall function, ankle-specific function, and pain at 48 months after surgery, with better functional improvement in the TAA group [145]. Findings suggest that total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed [9]. The trend of improved outcomes indicates that modern ankle replacement designs are performing well provided the surgery is done well, and that additional procedures such as the Strayer procedure may be required [81].

Complications and Risk Factors: Peroperative complications affected 12% (n =71) of operations in a French cohort [28]. Malleolar fracture occurred in 53 cases (35 medial, 18 lateral), secondary either to component oversizing or to a faulty surgical movement, requiring longer immobilization but without impact on the final result [28]. The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation [67]. Tobacco cessation appeared to reverse the effects of smoking, allowing total ankle arthroplasty to be an effective and safe procedure for providing pain relief and improving function in former smokers, as they had perioperative complication rates and outcomes similar to nonsmokers [71].

Revision and Salvage: Arthroscopic treatment is an effective and potentially advantageous alternative to open treatment of impingement after total ankle replacement [90]. Prosthetic talar replacement is a useful procedure for patients with osteonecrosis of the talus as it maintains ankle function [64]. The combination of a total ankle arthroplasty and a custom-built talar prosthesis secured to both the calcaneus and the navicular may be useful in the treatment of rare cases of large, trauma-induced bone defects [63]. This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA [70].

Perioperative and Postoperative Management: Modern uncemented ankle replacements are stable enough to allow weight-bearing within the first week after bilateral surgical procedures, warranting a large-scale randomized controlled trial of weight-bearing following ankle replacement [139]. Published studies of total ankle arthroplasty have overwhelmingly carried a Grade-C recommendation (fair evidence or conflicting, or poor-quality, evidence, i.e., level III, IV, or V) for mobile or fixed-bearing designs [26]. Functional outcome assessment with use of commonly applied scoring systems for total ankle arthroplasty suggested uniform improvement in all studies, with follow-up scores generally ranging from 70 to 90 points (maximum, 100 points) [26]. On the basis of data on 1888 patients in the studies reviewed that assessed patient satisfaction, the rates of patient satisfaction typically exceeded 90%, but ranged from 80% to 97% [26].

Complications

General Failure and Revision Rates: Clinical outcomes after total ankle replacement have historically been less satisfactory than arthrodesis, with significantly higher surgical revision rates driven mainly by periprosthetic cysts [74]. Pooled data indicate a higher overall complication rate after ankle arthrodesis, but a higher reoperation rate for revision after total ankle replacement [79]. Although revision rates were similar, total ankle replacement patients underwent a greater number of additional procedures compared to arthroscopic and open ankle arthrodesis [17]. Recent data from patients operated between 2005 and 2010 demonstrate increasing utilization and lower complication rates for total ankle replacement compared with ankle arthrodesis [14]. A relatively high rate of reoperation was noted after total ankle arthroplasty with a second-generation device [46].

Periprosthetic Osteolysis and Loosening: The prevalence of periprosthetic osteolysis after total ankle arthroplasty is considerable, and its development negatively affects clinical outcomes [151]. In a cohort of 144 ankles, 22 cases (15.3%) of periprosthetic osteolysis were identified, with 8 ankles (5.6%) revised for aseptic loosening or component subsidence and 14 cases (9.7%) treated with curettage, bone graft, and polyethylene liner exchange [132]. In this same cohort, the overall survivorship was 91.1% at a mean follow-up of 7.3 years when only metallic component revision was considered as failure [132]. Survivorship was 81.1% in the valgus alignment group compared to 97.7% in the varus group and 90.9% in the neutral group at a mean follow-up of 7.3 years [132]. The incidence of osteolysis in total ankle replacement for rheumatoid arthritis warrants close followup [18].

Infection (PJI): Periprosthetic joint infection after total ankle arthroplasty is a dreaded complication with devastating consequences [53]. In a cohort of 144 ankles, 1 case (0.7%) of deep infection was successfully treated by revision total ankle arthroplasty through 2-stage reconstruction [132]. A history of bariatric surgery is not an important predictor of joint infection within 5 years after primary total ankle arthroplasty [156].

Periprosthetic Fracture and Intraoperative Complications: Peroperative complications affected 12% (n =71) of operations in a French cohort of total ankle arthroplasties [28]. Malleolar fracture occurred in 53 cases (35 medial, 18 lateral), secondary to component oversizing or faulty surgical movement, requiring longer immobilization but without impact on the final result [28]. In a French cohort of 128 rheumatoid arthritis patients, there were not significantly more malleolar fractures (n =8), although involvement was medial in seven of the eight cases [28]. Six cracked pilons due to tibial component impaction, one talar neck fracture, five cases of peroperative bearing instability, three defective implant fixations (two talar, one tibial), and two cases of tendon sectioning were reported in a French cohort [28]. No vascular lesions were reported in a French cohort of total ankle arthroplasties [28]. Postoperative X-ray found 90% (n =535) satisfactory positioning in a French cohort, with 31 of 57 defective implantations concerning imprecise positioning (16 frontal, 10 sagittal malalignment, and 5 poor talar positioning) [28]. Bearing stability issues concerned 14 ankles (4 frontal instability, 10 sagittal centering) in a French cohort [28]. Nine implants showed immediate tibial radiolucency and three talar components were oversized in a French cohort [28].

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

Wound and Soft Tissue Complications: Operative wound complications following total ankle arthroplasty have been documented [31]. Soft tissue reconstruction after total ankle arthroplasty is a recognized management strategy [31]. Blood transfusion during total ankle arthroplasty is associated with increased in-hospital complications and cost [31]. Association of cigarette use with complication rates and outcomes following total ankle arthroplasty has been studied, with tobacco cessation appearing to reverse the effects of smoking [71]. Former smokers had perioperative complication rates and outcomes similar to nonsmokers after total ankle arthroplasty [71].

Heterotopic Ossification and Impingement: Heterotopic ossification after total ankle arthroplasty has been reported [31]. Anterior heterotopic ossification at the talar neck after total ankle arthroplasty has been described [31]. Arthroscopic decompression for medial ankle impingement after total ankle arthroplasty is indicated for persistent symptomatic soft tissue or bony medial gutter impingement when the prosthesis is stable and in acceptable alignment [136]. Arthroscopic debridement is contraindicated in the presence of prosthesis loosening, subsidence, incorrect implant sizing, inadequate polyethylene insert size, or bone infection requiring open procedures [136]. Arthroscopic debridement is contraindicated in the presence of complications such as deep periprosthetic infection requiring revision total ankle arthroplasty [136].

Salvage and Revision Surgery: Revision arthroplasty may be considered as an alternative to arthrodesis when treating patients with a failed Agility total ankle implant, although the complication rate remains high and technical demands are substantial [153]. Secondary arthrodesis after total ankle arthroplasty is a documented procedure [31]. Revision of failed total ankle arthroplasty to a hindfoot fusion is a documented procedure [31]. Salvage of failed total ankle arthroplasty with fusion using structural allograft and internal fixation is a documented procedure [31]. Outcome after salvage arthrodesis for failed total ankle replacement has been evaluated [31].

Other Considerations: Compared with primary osteoarthritis, fracture posttraumatic osteoarthritis was associated with a markedly higher complication rate after total ankle arthroplasty and was at higher risk of failure requiring prosthesis explant [66]. Patient risk factors do not impact 90-day readmission and emergency department visitation after total ankle arthroplasty [152]. Published studies of total ankle arthroplasty have overwhelmingly carried a Grade-C recommendation for mobile or fixed-bearing designs [26]. Without uniform outcome measures being applied to all studies, comparison of the results from the different case series is challenging [26]. There are few comparative studies on total ankle arthroplasty [26].

Recovery

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

Full activity (months): Return to sport is common following successful surgery. Two-thirds of patients were active in sports after total ankle arthroplasty [110].

Complete recovery / outcome plateau (months): Anatomical restoration of the talus is a key structural milestone. In the majority of cases, an anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty [22].

Functional milestones: Patient-reported outcomes and physical activity levels improve significantly. The mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome [21]. The majority of patients met current health-enhancing physical activity recommendations after total ankle arthroplasty [110].

Other Considerations: For young patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint, the Return To Run clinical pathway may serve as an alternative or adjunct to arthrodesis and arthroplasty [115].

Key Evidence

• [L4] The design of total ankle arthroplasty systems is evolving as understanding of failure modes increases and surgical techniques refine; some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up. [1] (10.5435/jaaos-d-16-00715)
• [L4] Intermediate results for second-generation total ankle arthroplasty are promising but should be interpreted with care due to the poor history of earlier prostheses and technical difficulties. [2] (10.5435/jaaos-d-25-00638)
• [L4] Total ankle replacement is a good treatment option for complete, end-stage ankle arthritis. [3] (10.3238/arztebl.2015.0177)
• [L4] Treatment of patients with a painful total ankle arthroplasty is complex and requires careful consideration of symptom history, workup, and nonsurgical and surgical treatment options. [6] (10.5435/jaaos-d-14-00017)
• [L3] The authors do not recommend the use of the Mayo total ankle arthroplasty, particularly in younger patients who have had a previous operative procedure on the ipsilateral ankle or foot. [7] (10.2106/00004623-199407000-00003)
• [L2] Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation; rates of reoperation and major complications were higher after ankle replacement. [8] (10.2106/jbjs.l.01597)
• [L5] The findings suggest that total ankle arthroplasty can provide durable restoration of joint function over the long term when appropriately indicated and executed. [9] (10.2106/jbjs.26.00501)
• [L4] The results of total ankle arthroplasty have not been comparable with those of replacements of other major joints of the lower extremity, with most implants failing to provide long-lasting pain relief or improved function over time. [10] (10.2106/00004623-199810000-00002)
• [L4] The total ankle replacement design is still evolving, and while there is consensus that it will continue to be implanted in carefully selected patients, it is premature to make definitive comments about the in vivo performance of uncemented second-generation replacements due to limited long-term data. [11] (10.1097/01.blo.0000132244.18548.40)
• [L5] The design rationale for current total ankle replacement implants and instruments should be carefully evaluated as midterm clinical results are few, often unvalidated by independent practitioners, and no level I or II studies have been published. [12] (10.5435/00124635-200809000-00005)
• [L4] Total ankle arthroplasty offers a reasonable alternative to ankle arthroplasty in carefully selected patients. [13] (10.1302/2058-5241.3.170029)
• [L3] The inclusion of new data on patients who underwent surgery between 2005 and 2010 demonstrates increasing utilization and lower complication rates for total ankle replacement compared with ankle arthrodesis. [14] (10.2106/jbjs.15.01341)
• [L4] For patients with pain at the site of a failed ankle arthrodesis, conversion to total ankle arthroplasty with the use of a three-component ankle implant is a viable treatment option that provides reliable intermediate-term results. [15] (10.2106/jbjs.i.01301)
• [L5] Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty, with specific indications for one procedure over the other being the topic of much debate. [16] (10.5435/jaaos-d-23-00743)
• [L3] Although revision rates were similar, total ankle replacement patients underwent a greater number of additional procedures. [17] (10.2106/jbjs.18.01012)
• [L4] Total ankle replacement in patients with rheumatoid arthritis, using a second-generation prosthesis, can provide reliable relief of pain and good functional results at intermediate-term followup, although the incidence of osteolysis warrants close followup. [18] (10.1097/01.blo.0000132181.46593.82)
• [L4] Total ankle replacement is likely to be successful in carefully selected rheumatoid patients with severe arthritis of the ankle that is unresponsive to conservative treatment. [19] (10.2106/00004623-198466030-00004)
• [L5] The clinical outcomes detailed in studies regarding total ankle arthroplasty, generally with small numbers and short follow-up, likely say as much about patient selection and surgeon skill as they do about the performance of any particular implant system. [20] (10.2106/jbjs.n.01084)
• [L2] In general, the group with a fixed-bearing implant demonstrated improvements in ankle moment and ground reaction forces, while the mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome. [21] (10.2106/jbjs.m.00971)
• [L3] In the majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty. [22] (10.1186/1471-2474-14-260)
• [L1] Its performance in comparison to the current reference standard (that is, ankle fusion) remains to be defined in a properly designed randomized trial. [24] (10.1007/s00402-004-0765-3)
• [L5] The authors present a diagnostic and treatment algorithm to assist surgeons in managing painful total ankle arthroplasty, emphasizing that fusion should be considered for complex cases such as those with extensive heterotopic ossification or recurrent stiffness following revision. [25] (10.1302/0301-620x.99b1.37536)
• [L4] [26] (10.2106/jbjs.j.00126)
• [L4] [28] (10.1016/j.otsr.2010.03.002)
• [L4] Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. [29] (10.2106/jbjs.21.00287)
• [L3] Salvage fusion after a failed total ankle arthroplasty shows moderate rates of failure and reoperations, with nearly 25% of patients requiring revision within three years. [30] (10.1302/0301-620x.105b10.bjj-2023-0010.r1)
• [L4] Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients. [33] (10.2106/jbjs.o.00396)
• [L4] For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation. [34] (10.1097/01.blo.0000132460.27102.d6)
• [L5] Revision total ankle arthroplasty can be safe and durable and can produce excellent patient outcomes, though the failure rate of total ankle arthroplasty remains 3 to 4 times that of total knee replacements. [40] (10.2106/jbjs.22.00764)
• [L3] While normal gait is not achieved, the improvement from preoperative levels is clinically significant. [41] (10.1302/0301-620x.98b10.37614)
• [L4] [42] (10.1007/s00167-022-07144-7)
• [L4] The article summarizes design rationales and clinical outcomes for evolving total ankle arthroplasty systems, noting that third-generation implants feature improved bearing surfaces and fixation, while fourth-generation systems incorporate 3D printing and patient-specific instrumentation. [45] (10.5435/jaaos-d-23-00559)
• [L4] We noted a relatively high rate of reoperation after total ankle arthroplasty with this second-generation device. [46] (10.2106/00004623-200406000-00008)
• [L3] Our results suggested that total ankle arthroplasty may be considered in ankles with deformity of >20°. [47] (10.2106/jbjs.19.00416)
• [L4] The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging. [48] (10.2106/00004623-200406000-00007)
• [L4] This is technically demanding and should be reserved for the experienced foot and ankle arthroscopists. [51] (10.1016/j.eats.2022.01.001)
• [L4] While most patients had reduced pain following total ankle replacement, persistent pain is not infrequent even in otherwise uncomplicated cases, often caused by soft-tissue impingement. [52] (10.1302/0301-620x.95b3.31219)
• [L5] Periprosthetic joint infection after total ankle arthroplasty is a dreaded complication with devastating consequences; surgeons must be prepared to diagnose and manage potential infections to improve outcomes. [53] (10.5435/jaaos-d-23-01266)
• [L5] While the observation that favorable midterm outcomes were achieved in both younger and older patients supports the possibility that transfibular total ankle arthroplasty may be considered across a broader age spectrum, the current data do not establish equivalence between the age groups. [55] (10.2106/jbjs.26.00460)
• [L3] Clinical outcomes, complication rates, and survivorship of total ankle arthroplasty were comparable between men and women. [56] (10.1186/s13018-020-01731-5)
• [L4] Overall patient satisfaction was high as were functional outcomes, supporting ankle arthroplasty as an option in the treatment of ankle arthritis. [57] (10.1302/0301-620x.103b4.bjj-2020-0758.r1)
• [L4] Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used. [58] (10.2106/jbjs.e.00414)
• [L2] Satisfactory results can be achieved in patients with varus malalignment of ≥10°, which should not be considered a contraindication to total ankle replacement. [60] (10.2106/jbjs.l.00797)
• [L1] [61] (10.1302/0301-620x.95b11.31633)
• [L4] The combination of a total ankle arthroplasty and a custom-built talar prosthesis secured to both the calcaneus and the navicular may be useful in the treatment of rare cases of large, trauma-induced bone defects. [63] (10.2106/00004623-200408000-00024)
• [L4] Prosthetic talar replacement is a useful procedure for patients with osteonecrosis of the talus as it maintains ankle function. [64] (10.2106/jbjs.n.01272)
• [L3] Patients who undergo total ankle arthroplasty with a fixed-bearing implant with a modular intramedullary stem for end-stage ankle arthritis have significant improvement in alignment, pain scores, quality-of-life measures, and subjective function. [65] (10.2106/jbjs.m.01386)
• [L3] Compared with primary osteoarthritis, fracture posttraumatic osteoarthritis was associated with a markedly higher complication rate after total ankle arthroplasty and was at higher risk of failure requiring prosthesis explant. [66] (10.5435/jaaos-d-22-01192)
• [L4] The high frequency of previous surgery on the ankle warrants caution given the increased risk of infection and non-union in this situation. [67] (10.1016/j.otsr.2016.03.015)
• [L4] Preoperative coronal plane malalignment and incongruence of the ankle can be corrected and maintained for 2 years with total ankle replacement. [69] (10.1097/01.blo.0000132248.64290.52)
• [L4] This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA. [70] (10.1302/0301-620x.99b2.bjj-2016-0504.r2)
• [L3] Furthermore, tobacco cessation appeared to reverse the effects of smoking, which allowed total ankle arthroplasty to be an effective and safe procedure for providing pain relief and improving function in former smokers as they had perioperative complication rates and outcomes similar to nonsmokers. [71] (10.1177/1071100716655435)
• [L4] [72] (10.1302/0301-620x.100b4.bjj-2017-0963)
• [L3] Total ankle arthroplasty for moderate and severe varus arthritic deformity showed similar satisfactory clinical and radiographic outcomes as those obtained by patients in the neutral group when postoperative neutral alignment was achieved. [73] (10.1302/0301-620x.99b10.bjj-2016-1275.r1)
• [L3] Clinical results were less satisfactory after total ankle replacement than after arthrodesis, with significantly higher surgical revision rates mainly due to periprosthetic cysts. [74] (10.1016/j.otsr.2018.10.014)
• [L1] Pooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. [79] (10.1186/s13018-017-0576-1)
• [L4] The article documents the trend of improved outcomes of ankle replacement surgery, indicating that modern ankle replacement designs are performing well provided the surgery is done well, and that additional procedures such as the Strayer procedure may be required. [81] (10.2106/jbjs.18.00555)
• [Paper] This case shows that arthroscopic treatment is an effective and potentially advantageous alternative to open treatment of impingement after total ankle replacement. [90] (10.1016/j.eats.2015.12.001)
• [L5] Nearly 10% of patients did not pass a brake reaction time test 6 weeks after undergoing right-sided total ankle arthroplasty, reinforcing concerns that patients driving within a few weeks of major lower-limb surgery are taking a big risk. [97] (10.1097/corr.0000000000001069)
• [L1] There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. [100] (10.2106/jbjs.n.00426)
• [L3] DTS morphological classification might affect the biomechanics properties in TAS and TTA in ankle OA. [102] (10.1186/s13018-023-03985-1)
• [L5] The new design reproduces physiologic ankle mobility and maintains complete congruence at the two articulating surfaces of the meniscal bearing over the entire motion arc, with the prospect of minimizing wear of this component. [103] (10.1097/01.blo.0000132246.26172.b7)
• [L3] The spatiotemporal parameters were not affected by the hindfoot alignment resulting from subtalar compensation. [104] (10.1186/s13018-024-04615-0)
• [L4] Stiff ankles seemed to be at a higher risk for subsidence. [105] (10.1016/j.otsr.2012.04.005)
• [L5] This CORR Insights commentary notes that the referenced cadaveric study by Buckner et al. demonstrated that component malalignment in total ankle arthroplasty leads to changes in foot kinematics and plantar pressure distributions, improving biomechanical understanding of the procedure. [106] (10.1097/corr.0000000000001316)
• [L4] Arthrodesis of the ankle joint results in significant limitation of daily activities with reduced function of the affected limb and changes in spatial and temporal movement, weight bearing profile and contact surface. [107] (10.1186/s13018-026-06842-z)
• [L5] Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes. [108] (10.5435/jaaos-d-12-00124)
• [L4] Two-thirds of the patients were active in sports after total ankle arthroplasty, and the majority of the patients met current health-enhancing physical activity recommendations. [110] (10.1177/0363546508323253)
• [L5] In this cadaver study, coronal plane malalignment in TAA altered foot kinematics and plantar pressure. [111] (10.1097/corr.0000000000001294)
• [L4] Modern fixed-bearing total ankle arthroplasty had excellent implant survival, improved plantar flexion and total range of motion, and had good-to-excellent functional outcome at a mean follow-up of 5.2 years. [112] (10.2106/jbjs.16.00090)
• [L4] The findings suggest that rotational position of the leg highly influences measurements in ankle radiographs after TAR. [114] (10.1186/s13018-015-0220-x)
• [L4] The Return To Run clinical pathway may serve as an alternative or adjunct to arthrodesis and arthroplasty for young patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint. [115] (10.5435/jaaos-20-08-s48)
• [L5] The new fixed-bearing total ankle replacement showed a safe mechanical behavior and many clinical advantages. [117] (10.1186/s12891-017-1848-y)
• [L4] The investigated new in situ fixed-bearing ankle design achieved overall better short-term results than those reported in previous research. [118] (10.1097/corr.0000000000002515)
• [L5] For ankle osteoarthrosis, total ankle replacement demonstrates superior gait mechanics compared to arthrodesis, while adult acquired flatfoot deformity treatment depends on the stage of posterior tibial tendon dysfunction. [119] (10.1302/2058-5241.1.000015)
• [L5] Based on the mouse model, the findings indicate that severe ankle instability has nearly three times the chance to develop into ankle OA compared to moderate ankle instability. [120] (10.1186/s12891-022-05164-5)
• [L4] A flexion osteotomy effectively improved the congruency of the ankle joint. [125] (10.1302/0301-620x.101b6.bjj-2018-0932.r2)
• [L5] [126] (10.1097/01.blo.0000132461.34725.a7)
• [L5] The principle of nonmaleficence should not be used to exclude obese patients from total ankle arthroplasty, and patients should be counseled through shared decision-making regarding increased risks. [127] (10.2106/jbjs.24.01142)
• [L3] SMOT is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion. [128] (10.1186/s13018-021-02732-8)
• [L4] Pain and disability are significantly reduced in overweight and obese patients after successful ankle replacement or fusion. [130] (10.2106/jbjs.k.00513)
• [L3] [132] (10.2106/jbjs.17.00703)
• [L4] More information and data are needed to further investigate failure modes in ankle arthroplasties as the number of surgeries increases. [133] (10.1007/s00402-014-2067-8)
• [L4] [134] (10.5435/jaaos-d-24-00955)
• [L3] Patients with rheumatoid arthritis benefit from total ankle arthroplasty and have similar outcomes to patients with noninflammatory arthritis. [135] (10.2106/jbjs.m.01164)
• [Paper] [136] (10.1016/j.eats.2021.02.001)
• [L5] Transected mice in the CL+ATFL and CL+DL groups displayed mechanical instability of the ankle-subtalar joint complex, and some mice in the CL+DL group also suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure. [137] (10.1186/s13018-021-02683-0)
• [L4] [138] (10.1007/s004020000243)
• [L5] The commentary suggests that modern uncemented ankle replacements are stable enough to allow weight-bearing within the first week after bilateral surgical procedures, warranting a large-scale randomized controlled trial of weight-bearing following ankle replacement. [139] (10.2106/jbjs.22.00826)
• [L4] Total ankle replacement is possibly a better choice with respect to arthrodesis for highly active individuals, as it allows patients to increase participation in sports and recreation activities. [140] (10.1055/s-0037-1601408)
• [L2] When both procedures are performed by the same group of surgeons, patients who undergo TAA or AA for end-stage ankle arthritis have significant improvement in overall function, ankle-specific function, and pain at 48 months after surgery, with better functional improvement in the TAA group. [145] (10.2106/jbjs.20.01357)
• [L4] The study demonstrated that the prevalence of periprosthetic osteolysis after total ankle arthroplasty was considerable and that the development of osteolysis negatively affected clinical outcomes. [151] (10.2106/jbjs.21.01093)
• [L4] Readmissions were dominated by evaluation of wound compromise as well as DVT and PE. [152] (10.2106/jbjs.17.01149)
• [L4] Revision arthroplasty may be considered as an alternative to arthrodesis when treating patients with a failed Agility total ankle implant, although the complication rate remains high and technical demands are substantial. [153] (10.2106/jbjs.k.00920)
• [L3] A history of bariatric surgery is not an important predictor of joint infection, instrumentation removal, or ORIF within 5 years after primary total ankle arthroplasty or arthrodesis. [156] (10.5435/jaaos-d-24-01267)

See Also

• Ankle arthrodesis
• Ankle osteoarthritis
• Ankle fracture
• Chronic ankle instability
• Syndesmotic injury
• Ankle impingement

References

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