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C OPYRIGHT Ó 2011
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Current Concepts Review
Results of Total Ankle Arthroplasty
Mark E. Easley, MD, Samuel B. Adams Jr., MD, W. Chad Hembree, MD, and James K. DeOrio, MD
Investigation performed at Duke University Medical Center, Durham, North Carolina
ä
Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence.
ä
Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides
equal pain relief and possibly improved function compared with ankle arthrodesis.
ä
On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the
retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to
twelve years.
ä
Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation
without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or softtissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions,
and/or polyethylene exchange.
ä
A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.
End-stage ankle arthritis is as debilitating as end-stage hip arthritis1, yet total joint arthroplasty has not displaced arthrodesis
for end-stage ankle arthritis. Recent prospective controlled
trials and meta-analyses have suggested that, for end-stage
ankle arthritis, modern total ankle arthroplasty affords equivalent pain relief and perhaps better function than ankle arthrodesis2,3. In this article, we review the current results of total
ankle arthroplasty and factors that may affect the interpretation
of these results.
Mean efficacy outcomes and patient satisfaction with the
result of total ankle arthroplasty at intermediate-term followup uniformly suggest improvement from preoperative values.
Pain subscores and functional outcomes are equal to and may
exceed those of ankle arthrodesis. With few exceptions, implant
survivorship has been reported to range from 70% to 98% at
three to six years and from 80% to 95% at eight to twelve years,
on the basis of the 2240 total ankle arthroplasties from multiple
studies with adequate follow-up to determine implant survi-
vorship4-27. Only one study, Anderson et al.28, noted a survivorship of 70%; in all other studies reviewed, the implant
survivorship was >79% for three to twelve years. Some studies
include longer follow-up of the same patients or implants from
previous studies or represent a different analysis of the same
patients9,11,17,18. The majority of the implants contributing to
these survivorship curves had a satisfactory radiographic appearance. However, the radiographic appearance of some of
the metal implants also included in these survivorship analyses has suggested impending failure with loosening and
subsidence. For select implants, revision surgery may allow
for the retention of the original metal implants. Repeat surgery in total ankle arthroplasty does not imply a failure of
total ankle arthroplasty, as some repeat surgery is for relieving
impingement, improving alignment, bone-grafting cysts, and/
or exchanging the polyethylene component to prolong implant
survival. Confounding variables, such as a prolonged learning curve for surgeons implanting total ankle replacements
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in
support of any aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months
prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written
in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to
influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the
online version of the article.
J Bone Joint Surg Am. 2011;93:1455-68
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and the use of newer prosthetic designs and operative techniques, make it difficult to identify the reasons for success or
failure.
Factors to Consider in Total Ankle Arthroplasty
Underlying Cause of Arthritis
Degenerative, inflammatory, and posttraumatic arthritis of the
ankle are the primary indications for total ankle arthroplasty
(see Appendix). According to some authors, the results of total
ankle arthroplasty are less favorable in patients with posttraumatic arthritis than in patients with osteoarthritis and
inflammatory arthritis23,29,30. This may be because total ankle
arthroplasties for posttraumatic arthritis are frequently performed in younger patients and patients who have undergone
prior surgery to the ankle14,30-33. A study that analyzed data in
a joint registry and a meta-analysis of studies on total ankle
arthroplasty have suggested a trend of less favorable implant
survivorship in patients with inflammatory arthritis compared
with those with osteoarthritis 31,34. Other authors have noted
that they always consider total ankle arthroplasty in patients
with rheumatoid arthritis, when technically possible, and they
reported identical functional outcomes after total ankle arthroplasty in patients with osteoarthritis and in those with
posttraumatic arthritis35. Rippstein et al. reported better func-
Fig. 1-A
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tional outcome after total ankle arthroplasty in patients with
inflammatory arthritis than in those with osteoarthritis36.
Age
The age of the patients receiving a total ankle arthroplasty in
studies of currently available total ankle arthroplasty implants
frequently has been less than fifty years; however, mean ages
have consistently ranged from fifty to sixty years2,34,37. Several
reports have suggested that the survivorship of implants and
functional outcomes after total ankle arthroplasty are less favorable in younger patients2,15,31,32. In a study of 303 total ankle
arthroplasties, Spirt et al. reported five-year implant survivorship of 74% and 89% for patients under and over the age of
fifty-four years, respectively15. Those authors also calculated
that patients with a median age of fifty-four years or less had a
1.45-times greater risk for reoperation and a 2.65-times greater
risk of implant failure than patients over the age of fifty-four.
The combination of younger age and hindfoot arthrodesis14
or osteoarthritis33 may lead to a relative increase in failure
rates after total ankle arthroplasty. Nonetheless, Kofoed and
Lundberg-Jensen, in a comparative study of a mobile-bearing
prosthesis (Figs. 1-A through 1-D), including early-generation
cemented and uncemented total ankle arthroplasty components, demonstrated that the survivorship of total ankle
Fig. 1-B
Figs. 1-A through 1-D A seventy-year-old man with end-stage ankle arthritis who was managed with a mobile-bearing total ankle arthroplasty. Fig. 1-A
Anteroposterior weight-bearing radiograph of the ankle showing slight varus talar tilt but adequate alignment to allow consideration of a total ankle
arthroplasty. Fig. 1-B Preoperative lateral radiograph showing slight anterior talar translation relative to the tibia.
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Fig. 1-C
Fig. 1-D
Fig. 1-C Postoperative anteroposterior weight-bearing radiograph showing satisfactory coronal plane alignment. Fig. 1-D Postoperative lateral radiograph
showing satisfactory sagittal plane realignment of the ankle.
arthroplasty components was comparable for patients under
and over fifty years of age38.
Preoperative Deformity and/or Instability
The degree of ankle deformity and instability that can be adequately treated with total ankle arthroplasty continues to increase4,5,26. Despite these advances, coronal plane deformity
exceeding 10° to 15° remains a relative contraindication to total
ankle arthroplasty6-8,16,39,40 (Figs. 1-A, 1-C, 2-A, and 2-B). Implant survivorship typically diminishes with increasing preoperative coronal plane deformity7,16. Sagittal plane deformity,
typically with relative anterior translation of the talus on the
tibia, or component malrotation may also result in persistent
postoperative deformity, subluxation and edge-loading of the
polyethylene, osteolysis, and potential early implant failure6,7,40,41
(Figs. 1-B and 1-D).
The Ankle-Subtalar Joint Complex
The ankle is only one component of the ankle-hindfoot complex27,42,43, and with ankle arthritis, compensatory deformity
may develop in the hindfoot. Total ankle arthroplasty occasionally requires adjunctive procedures to the hindfoot, midfoot, and forefoot in order to create a plantigrade foot on which
to position the total ankle arthroplasty components4,14,17,44 (Fig.
3). Although necessary in select cases of total ankle arthro-
plasty, hindfoot arthrodesis may lead to diminished survivorship of total ankle arthroplasty components in younger, higherdemand patients14. Even when patients have equal subscores for
pain, the efficacy outcomes for patients who had total ankle
arthroplasty with hindfoot arthrodesis will be inferior to those
of patients who had isolated total ankle arthroplasty, since
outcomes scoring for the ankle includes hindfoot range of
motion35,44 (Figs. 4-A and 4-B).
Mobile-Bearing Compared with Fixed-Bearing Implants
Whereas total ankle arthroplasty implants used in patients worldwide are almost exclusively mobile-bearing three-component designs, most total ankle arthroplasty components in the United
States have been fixed-bearing two-component designs. Mobilebearing devices have metal tibial and talar components articulating
with an unattached polyethylene meniscus (Fig. 5); fixed-bearing
prostheses have the polyethylene component secured to the metal
tibial component (Fig. 6). The U.S. Food and Drug Administration (FDA) requires that three-component total ankle arthroplasty
prostheses, for implantation in patients in the United States,
achieve noninferiority status relative to ankle arthrodesis. The
FDA’s demand was recently satisfied in a prospective controlled trial for a single three-component total ankle arthroplasty prosthesis approved for use without cement in the
U.S.3. Without a similar FDA-regulated trial, other three-
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Fig. 2-A
Fig. 2-B
Figs. 2-A and 2-B Anteroposterior weight-bearing ankle radiographs of a seventy-three-year-old woman with end-stage ankle arthritis who had a mobilebearing total ankle arthroplasty. Fig. 2-A Preoperative radiograph demonstrating moderate-to-severe talar tilt for which total ankle arthroplasty should only
be considered if the tibiotalar joint can be successfully realigned. Fig. 2-B Radiograph made a year postoperatively showing satisfactory realignment. The
procedure included medial soft-tissue release.
component designs may not be implanted in patients in the
United States.
Interpreting the Results of Total Ankle Arthroplasty
Clinical Studies
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 fixedbearing designs (Table I and Appendix). Without uniform outcome
measures being applied to all studies, comparison of the results from
the different case series is challenging 2,34,37. Debate remains over
which outcome measures are most appropriate in the assessment
of total ankle arthroplasty 2,34,37,45, and there are few comparative
studies3,7,35,38,46. Recently, investigations of total ankle arthroplasty
with good and fair-quality evidence3,7,35 and studies with longerterm follow-up of previous prospective case series6,9,18 have been
presented or published, but there are too few to improve the
recommendation for total ankle arthroplasty in the management
of end-stage ankle arthritis from a Grade C to a Grade B or A.
Functional outcome assessment with use of commonly
applied scoring systems for total ankle arthroplasty (American
Orthopaedic Foot & Ankle Society [AOFAS]47, Kofoed46, Mazur
et al.48, and the New Jersey Orthopaedic Hospital system [also
referred to as the Buechel-Pappas system]49) suggested uniform
improvement in all studies, with follow-up scores generally
ranging from 70 to 90 points (maximum, 100 points)2,34,37 (see
Appendix). 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%3-5,9,12,14,17-21,25-27 (see Appendix); follow-up data for patient
satisfaction ratings rarely exceeded five years. On the basis of
the survivorship data on 2240 implants in the studies reviewed
in the present article, with the removal of a metal component
or conversion to arthrodesis designated as the end point, the
implant survivorship ranged from 70% to 98% at three to six
years and 80% to 95% at eight to twelve years4-27 (see Appendix). Only one study, Anderson et al.28, noted the low survivorship of 70%, with six of twelve failures being attributed to
technical error; for all other studies, implant survivorship was
‡79% for three to twelve years. These ranges in survivorship are
supported by two recent meta-analyses34,37 (see Appendix).
Meta-Analyses
To our knowledge, there are three systematic reviews of total ankle
arthroplasty in the literature (Table II): (1) a review of all modern (the
most current version) mobile-bearing and fixed-bearing prostheses37;
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Fig. 3
Lateral weight-bearing ankle radiograph of a sixty-fiveyear-old man after total ankle arthroplasty for the treatment of end-stage ankle arthritis and hindfoot varus.
Lateral displacement calcaneal osteotomy and first
metatarsal dorsiflexion osteotomy were performed to
treat the hindfoot varus concomitantly with a mobilebearing total ankle arthroplasty with establishment of a
plantigrade foot.
(2) a review of all three-component, meniscal-bearing prostheses34;
and (3) a comparison of mainly second-generation total ankle
arthroplasty prostheses and ankle arthrodesis2.
Fig. 4-A
Uniformly, the authors of the meta-analyses cautioned
that most of the studies analyzed fail to meet methodological
standards, lacked key data elements, and contained variability
Fig. 4-B
Figs. 4-A and 4-B Radiographs of a sixty-five-year-old woman, made seven years after a fixed-bearing total ankle arthroplasty for the treatment of inflammatory
arthropathy. She was pain-free despite adjacent talonavicular joint arthritis that had not been addressed operatively. Fig. 4-A Lateral radiograph. Fig. 4-B
Weight-bearing anteroposterior radiograph showing that the fixed-bearing total ankle arthroplasty components remained well-aligned.
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noted in Table II. The majority of reported results were for one
particular design, and the authors did not identify differences
in performance ratings when comparing that design against the
other prostheses analyzed.
Haddad et al.2, in a systematic review of both total ankle
arthroplasty and ankle arthrodesis, included ten studies with
852 total ankle arthroplasties, with both mobile and fixedbearing designs, and thirty-nine studies with 1262 ankle
arthrodeses (Table II). The mean AOFAS scores were 78.2
points and 75.6 points for total ankle arthroplasty and ankle
arthrodesis, respectively, and the mean subscores for pain,
function, and alignment for total ankle arthroplasty were 34.5,
37.4, and 9.4 points, respectively.
In the review of total ankle arthroplasty studies by
Haddad et al.2, the meta-analytic mean results were excellent
for 38% of the patients, good for 30.5%, fair for 5.5%, and poor
for 24%. When these percentages were also calculated as a ratio
of the number of patients with a particular outcome divided by
the total of ninety-two patients reporting the outcome, fortyeight patients (52.2%) had an excellent result; twenty-eight
(30.4%), a good result; four (4.3%), a fair result; and twelve
(13%), a poor result. In studies lacking such detail for total
ankle arthroplasty, good results were noted for 388 (80.5%) of
the 482 patients and poor results were observed in ninety-four
Fig. 5
A mobile-bearing, three-component total ankle replacement. Note that the
polyethylene is independent of the tibial component.
in operative procedures, evaluation tools, and reporting of
outcomes. Therefore, generalizations about total ankle arthroplasty outcomes derived from meta-analyses of the existing body of literature for total ankle arthroplasty are
difficult to make in a reliable manner. Several recent investigations of total ankle arthroplasty have better evidence and
longer follow-up periods and, if they were included, may have
improved the conclusions that could be drawn from these
meta-analyses3,7,9,18,26.
Gougoulias et al.37 identified thirteen eligible studies
comprising 801 mobile-bearing and 304 fixed-bearing prostheses (Table II). Including only the results of current total
ankle arthroplasty designs, the authors noted that functional
outcome scores improved in all studies and no one prosthesis
demonstrated superiority over another. Residual pain was
common after total ankle arthroplasty, with pain reported in
27% to 60% of the ankles. Some patients had clinically and
radiographically acceptable implants but unexplained pain that
prompted conversion to arthrodesis in select patients18,25.
Stengel et al. 34 identified eighteen eligible studies of
mobile-bearing total ankle arthroplasty with a mean follow-up
period of 44.2 months (range, 35.9 to 52.4 months). The efficacy outcome for the ten eligible studies (497 patients) that
used 100-point scales (Kofoed46 or AOFAS47) and the survivorship rates for the six studies that provided such data are
Fig. 6
A fixed-bearing, two-component total ankle replacement. Note that the
polyethylene is fixed to the tibial component.
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TABLE I Recommendations for Care: Grades of Recommendation
for Treatment of End-Stage Ankle Arthritis with
Total Ankle Arthroplasty
Grade of
Recommendation*
Type of implant
Mobile-bearing total ankle
arthroplasty
Fixed-bearing total ankle
arthroplasty
Etiology of ankle arthritis
Total ankle arthroplasty for
osteoarthritis
Total ankle arthroplasty for
posttraumatic arthritis
Total ankle arthroplasty for
inflammatory arthritis
Other factors
Coronal plane alignment
<10° to 15° varus or valgus
>10° to 15° varus or valgus
Patient age
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C
C
C
C
C
C
I
C
*C = conflicting or poor-quality evidence (Level-IV or V studies) not
allowing a recommendation for or against intervention and I =
insufficient evidence to make a recommendation.
patients (19.5%). With respect to the low rate of patient satisfaction, their analysis included the results of one study of a
fixed-bearing two-component prosthesis50 that were inferior to
those in most studies of total ankle arthroplasty, including other
studies of the same prosthesis8,51.
The implant survival rates in the meta-analysis by Haddad
et al.2 were lower than those for the other meta-analyses. The
mean survivorship in this meta-analysis was diminished by
the poor implant survival rates reported in the case series
by Anderson et al.28 and a comparative study by Kofoed
and Lundberg-Jensen38. With five-year survivorship of 70%,
Anderson et al.28 acknowledged that their results and survivorship were negatively influenced by a so-called learning curve and
an incomplete inventory of talar component sizes for their initial
cases. Furthermore, the prosthesis they used did not consistently
have the titanium spray that is currently used on this mobilebearing prosthesis. Likewise, the comparative study by Kofoed
and Lundberg-Jensen included the early cemented and uncemented versions of the mobile-bearing prosthesis that are
now abandoned38.
Joint Registries
The apparent advantages offered by joint registries (see Appendix) are that (1) data on a large number of operative procedures are available for analysis; (2) outcomes are not limited
to procedures performed in centers of excellence; (3) surgeon,
hospital, and region-specific trends in practices can be studied;
and (4) uniform evaluation tools are used to facilitate comparisons31,32,52,53. In 2007, eighteen surgeons from eighteen
hospitals reported their results extracted from New Zealand’s
National Joint Registry53. Only two surgeons had performed
more than twenty-five total ankle arthroplasties. New Zealand’s
registry included 202 total ankle arthroplasties performed in
183 patients, with 7% that had failed at a mean follow-up of
twenty-eight months. Implant selection by all of the surgeons
participating in the registry consisted of only two prostheses
with meaningful follow-up data for study: one two-component,
fixed-bearing implant (58%) and one three-component, mobilebearing implant (22%). The overall five-year survival rate was
86%, and most failures were due to aseptic loosening. A patientbased questionnaire, extrapolated from the Oxford twelve-item
hip-scoring system54 and completed at six months by 74% of the
patients in the registry who had a total ankle arthroplasty, was
described as a useful audit tool, with five-year failure-free rates of
95% for the patients with so-called good scores and 65% for those
with poor scores.
Sweden’s national joint registry included 531 primary
mobile-bearing total ankle arthroplasties (492 patients) reported
between 1993 and 200532 (see Appendix). Seventy-three percent
of the total ankle arthroplasties had been performed by three
surgeons in four hospitals. The reported revision rate of 19% in
this patient cohort was subject to a learning curve, with the
busiest three surgeons noting an improvement in implant survivorship of 70% for the first thirty total ankle arthroplasties and
86% for the subsequent 132 total ankle arthroplasties. As the
surgeons gained experience with the procedure, and the design
of the implants and the instruments used to make the bone cuts
for the prostheses improved, the unacceptable rate of technical
errors was lessened32,52.
The published analysis of total ankle arthroplasties included in the Norwegian Arthroplasty Register includes 257
primary total ankle arthroplasties in 245 patients (mean age,
fifty-eight years) with an average follow-up of four years31 (see
Appendix). Meaningful data from this database are given for an
early version of one mobile-bearing prosthetic design (1996 to
2002) and a modern version of the same prosthesis (2000 to
2005). Fewer revisions due to aseptic loosening of the tibial
component were performed in patients with the modern
prosthesis than in those with the earlier design32,40,55. The authors reported a five-year and ten-year survivorship of 89% and
76%, respectively. These calculations include the outdated cemented two-component versions of a mobile-bearing prosthetic design that is no longer used. A total of twenty-one
revisions were performed in 216 mobile-bearing implants. Six
revisions were done for aseptic loosening; five involved the
early design whereas only one involved the modern design.
Those authors defined revision as reoperation and did not
designate removal of a metal component or conversion to arthrodesis as the end point for their overall survivorship analysis
as is commonly reported in other studies3,7,14,37. Recalculation of
this registry’s survivorship without the six polyethylene exchanges and the three other reoperations without removal of
the metal components would make this study’s survivorship
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TABLE II Meta-Analyses
No. of Eligible
Studies
No. of
Ankles
Type of Prostheses
Analyzed
Mean Age
(yr)
13
1105
Mobile and fixed
bearing
58.9
34
18
1107
Mobile bearing
only
2
10
852
Mobile and fixed
bearing
Study
37
Gougoulias et al.
(2010)
Stengel et al.
(2005)
Haddad et al.
(2007)
Cause of Ankle Arthritis (% of ankles)
Trauma
Idiopathic
Autoimmune
Other
34
24.20
31.20
1
56.2
27.7
24.6
37.5
10.2
58
27.1
32.1
38.9
1.9
*Reported as good, excellent, satisfied, or satisfied with minimal reservation; percentage is based on number of patients who responded (may
differ from number of implants). †Based on only six studies reporting survivorship data. §NR = not distinguished from reoperation rate.
data consistent with those from other studies of modern total
ankle arthroplasty.
The outcomes of 515 primary mobile-bearing total ankle
arthroplasties included in the Finnish Arthroplasty Register
were published in 201052. Three centers each performed 100
total ankle arthroplasties or more, four centers performed
between ten and fifty total ankle arthroplasties, and ten centers
accounted for less than ten total ankle arthroplasties each. The
five-year survival rate was 83%, with any reason for revision
surgery as the end point, and 95%, with only aseptic loosening
as the end point. Their analysis of the results failed to show a
measurable difference in implant survival rates between high
and low-volume hospitals. Despite the fact that the metal
implants were well-fixed to bone, several total ankle arthroplasties showed ligamentous instability, which the authors
attributed to the learning curve for total ankle arthroplasty
and persistent ligament attenuation secondary to preoperative
deformity.
Alternative Approaches for the Assessment of
Functional Outcome
Gait Analysis with and without Functional Assessment
Ankle arthritis causes considerable reduction in functional
assessment scores, and successful total ankle arthroplasty typically improves function and gait characteristics56-59. On the
basis of a prospective comparative analysis of preoperative and
postoperative gait analysis, mobile-bearing total ankle replacements were found to improve locomotion function and
decrease energy expenditure57. Similarly, a nearly normal gait
pattern was observed in a comparative analysis of ten patients
with a mobile-bearing total ankle replacement and ten healthy,
control subjects56,60. Valderrabano et al.59 showed that patients
with ankle arthritis had significantly worse AOFAS and Short
Form-36 (SF-36) scores compared with subjects with physiologically normal ankles. At twelve months after total ankle
arthroplasty, these same patients demonstrated no differences
in spatiotemporal variables of gait analysis compared with the
same subjects with healthy ankles59. Although successful ankle
arthrodesis reliably relieves pain, the functional outcome and
gait are different from those of healthy unaffected ankles61.
Proprioception and Muscle Rehabilitation
Conti et al.62 demonstrated no difference in the results of
proprioceptive testing between arthritic ankles managed with
total ankle arthroplasty and unaffected, contralateral ankles.
Valderrabano et al.63 noted that muscle function in patients
with osteoarthritic ankles improved after total ankle arthroplasty
compared with the preoperative finding, but the improvement
did not reach the level of the healthy, contralateral leg.
Activity Levels and Sporting Activity
Three recent articles evaluated participation in sports following
total ankle arthroplasty20,29,35. In addition to the AOFAS and
visual analog scale scores, the authors used the Foot and Ankle
Ability Measure64, Foot Function Index65, University of California at Los Angeles (UCLA) activity scale66, the Activities
Rating Scale67, and the International Physical Activity Questionnaire68. The authors’ objective was not to decide what
sports may be recommended after total ankle arthroplasty but
to determine what activities patients chose to perform following total ankle arthroplasty35.
Naal et al.29, in a study of 155 total ankle arthroplasties
with two mobile-bearing implant designs in 137 patients (average age, 59.8 years), with short to intermediate-term followup, determined activity levels with use of the UCLA activity
scale66 and the Activities Rating Scale67. While 65% of the patients reported that total ankle arthroplasty had improved their
sports ability, no differences were found with regard to preoperative and postoperative participation in sports, number of
different sports, or frequency of weekly sporting activity. Most
commonly, patients participated in swimming, cycling, and
fitness and/or weight-training. Using the International Physical
Activity Questionnaire, the authors also calculated that 79% of
the patients met current guidelines for health-enhancing physical activity. The authors noted that neither sports participation
nor activity levels were associated with radiographic lucencies,
although they acknowledged that longer follow-up was needed.
Valderrabano et al.20 evaluated 152 mobile-bearing total
ankle arthroplasties in 147 patients (average age, 59.6 years)
clinically and by questionnaire at the time of early follow-up. Of
the 76% of the patients who underwent total ankle arthroplasty
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TABLE II (continued)
Outcome and/or
Patient Satisfaction*
Survivorship
(%)
Revision Rate
(%)
Arthrodesis
(%)
Functional outcome of 70-92 points, based on
100-point scale; satisfaction rates of 79%-97% at 2 yr
90 (58-100)
at 5 yr
6 (2.9-6.6 yr)
3.5
Mean improvement of 45.2 points (range,37-82 points),
based on 100-point scale at a mean of 44.2 mo
90.6 at 5yr†
NR§
6.3
Mean postop. AOFAS score of 78.2; 78% good to
excellent results
78.3 at 5 yr;
77 at 10 yr
7.2
4.9
for posttraumatic ankle arthritis, 83% reported good-to-excellent
results, with the mean AOFAS score improving from 36 to 84
points. The patients who were active in sports preoperatively
tended to be active in sports after total ankle arthroplasty.
Most commonly, patients participated in hiking, biking, and
swimming.
Bonnin et al.35 evaluated 179 mobile-bearing total ankle
arthroplasties in 170 patients (average age, 60.9 years) clinically and with a self-administered questionnaire at a mean
follow-up interval of 53.8 months. The AOFAS ankle-hindfoot
scores47 were extracted from the patient charts; the questionnaire included the Foot Function Index65 and the Foot and
Ankle Ability Measure64 scoring methods. An evaluation of
sporting activities was performed only for the ninety-eight
patients with osteoarthritis. In this retrospective case-controlled
study, the authors compared the functional outcomes of
their patients who had total ankle arthroplasty with those of
patients who had total knee arthroplasty. On the basis of an
82% response rate to the questionnaire, which showed that
76% of the patients rated their ankle as normal or nearly
normal, the authors concluded that a return to light recreational activities and a nonimpact sport is generally possible, but
that impact sports or strenuous recreational activities are rarely
possible.
Methods of Assessing Outcomes After Total
Ankle Arthroplasty
Physician-Based and Patient-Derived Outcomes
Many of the currently used outcome instruments lack validity,
reliability, responsiveness, and effectiveness for the assessment
of outcomes after total ankle arthroplasty45,64,68,69. The trend in
determining efficacy outcomes for total ankle arthroplasty is
toward patient-based rather than physician-derived methodology19,20,29,35,45,70-72, with the anticipation of garnering a meaningful understanding of patients’ pain relief and improved
function2,13,29,34,35,37,45,59,70. While the clinician-based region-specific
AOFAS47, Kofoed46, and Mazur48 scoring systems are the most
widely used outcome tools for total ankle arthroplasty, evidence
suggests that their use in total ankle arthroplasty is limited45,73-75,
with a poor correlation to the patient-derived SF-3671. Several authors favor the SF-36 in evaluating the foot and ankle1,13,20,22,34,59,76.
SooHoo et al., in two different articles, suggested that the weak
correlation between the SF-36 and AOFAS assessment tools indi-
Other
Residual pain
in 27%-60%
Results compared with
ankle arthrodesis
cates that the AOFAS scoring system is subject to poor construct
validity71,72.
A criticism of several patient-generated outcome tools,
including the SF-36 and Health Assessment Questionnaire, is
that they cannot adequately determine the region-specific
health state of patients with ankle arthritis, with or without
total ankle arthroplasty45. Likewise, the visual analog scale, while
self-reported, is not region-specific13,45. Recent patient-derived
outcomes used in total ankle arthroplasty include the Foot
Function Index and Ankle Osteoarthritis Score45,65,70,77, with the
Foot Function Index being considered a reasonable, validated
outcomes tool70,72,78.
Pain Scores and Functional Outcome
In the majority of studies of modern total ankle arthroplasty,
mean pain scores consistently improve following total ankle
arthroplasty 37, with pain relief being at least as good as that after
arthrodesis3. However, several studies have acknowledged that a
considerable number of patients are not pain-free following
total ankle arthroplasty4,6,7,9,12,14,18-22,37.
Even though physician-derived outcome assessments
may suggest good-to-excellent function in regular activities,
they often lack the sensitivity to identify a less favorable outcome with strenuous activities4,29,35. Moreover, equal pain relief
is reported by patients after total ankle arthroplasty with or
without triple arthrodesis, thus suggesting equal outcomes on
the basis of the isolated pain score. However, when physicianderived functional outcome measures are used, patients with
the combined procedure of triple arthrodesis and total ankle
arthroplasty immediately have lower functional scores than
those undergoing isolated total ankle arthroplasty, because
of the loss of hindfoot motion that occurs with hindfoot
arthrodesis.
Functional outcome measures typically include ankle range
of motion. In the present review, analysis of the studies that described ankle range of motion before and after total ankle arthroplasty suggested only marginal improvements, with the mean
increase in the sagittal plane motion arc ranging from 3° to
14°2,4,6,7,12,14,18,26,34,37,40. Range of motion is probably best assessed
with use of radiographic analysis4,17,25,36,79, although some authors
have demonstrated a satisfactory association between clinical
and radiographic assessment of range of motion after total ankle
arthroplasty21.
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Survivorship Tables
Numerous surgeons have opined that reoperation for any
reason other than revision arthroplasty or removal of any metal
component, conversion to arthrodesis, or amputation does not
constitute implant failure3,5-7,10,11,14,18,25,26. Examples of such reoperations include relief of osseous or soft-tissue impingement,
improvement of alignment or stability of the foot or ankle,
bone-grafting for cystic lesions, and/or polyethylene exchange3,14,15,17,18,22,26,34,37. Several investigators have argued that, in
the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated9,14,15,18. In
our opinion, the literature frequently presents an underestimation of reported survivorship of total ankle replacements because
of the use of all reoperations as the end point15,31 and the influence of the so-called surgeon’s learning curve7,28,32,33,40,52,80-82.
Bonnin et al.18 presented eleven-year survivorship estimates of
their mobile-bearing prostheses for all reoperations (65%) and
revision of the metal components or conversion to arthrodesis
(85%).
Radiographic Outcomes
Alignment
Alignment is typically assessed as one component of the functional
score in most physician-based efficacy outcome assessments, with a
high variability in methodology even when a goniometer is used.
Several investigators have included more accurate radiographic
assessments of alignment; however, the methodology of radiographic measurements is not uniform3,6,7,14,18,19,23-26,36,39,40,70 (Fig.
4-B).
Subsidence and/or Migration and Radiolucencies
Several studies have described implant migration, subsidence,
or radiolucencies on the basis of serial radiographs4,7,9,14,18,25,26,29,55.
Not all changes in position or radiolucencies portend diminished implant survivorship3,6,7,18,25,26,36. Progressive lucencies or
cysts may be bone-grafted with successful implant retention,
provided the implant is well-fixed at the time of reoperation2,6,7,14,18,36,45. Several investigators have explained that a minor amount of desirable settling in the first six to twelve
months, typically in the talar component, allows the prosthesis
to find its optimal position3,12,23,26,36,40,83.
Fig. 7
Anteroposterior radiograph of the ankle of a seventy-six-year-old woman,
made four years after a fixed-bearing total ankle arthroplasty for the
treatment of incongruent varus talar tilt. Despite persistent varus deformity
and osteolysis in the distal aspect of the tibia, the patient was able to
function well with minimal symptoms. She had favorable results on the
physician and patient-based outcome measures, satisfaction scores, and
survivorship analysis despite radiographic findings concerning for impending failure.
The extent of radiographic lucencies or cysts is often difficult
to assess on radiographs and may be obscured by the prosthesis,
particularly one that caps the talar dome6,7,20,26. Computed tomography is more sensitive than radiography in delineating cystic
lesions84.
Impending Failure or Threatened Prosthesis
Multiple studies have described favorable survivorship of some
total ankle replacements despite radiographic evidence of socalled impending or threatening failure due to progressive radiolucency or to component migration or subsidence12,22,28,40
(Fig. 7). Simply reporting survivorship at five to ten years as
retention of the original metal components with disregard for
radiographic findings may lead to a decline in longer-term
survivorship analysis as these prostheses fail. Few studies reflect
the best-case and worst-case scenarios in their survivorship
analyses to account for these radiographic findings4,18,28. Probably most appropriately, Rippstein et al. include pending metal
component exchange or conversion to arthrodesis in their
survivorship estimations36.
Progression of Adjacent Joint Arthritis
Several studies have described the development or progression
of subtalar or talonavicular arthritis after total ankle arthroplasty6,17,85, while others have noted no subtalar arthritis14,86,
although at shorter follow-up intervals. Wood et al.6, in evaluating 167 total ankle arthroplasties in 156 patients with a
minimum follow-up of five years, noted that seventy-two ankles (43%) were associated with preexisting end-stage subtalar
arthritis, seventy (42%) demonstrated no radiographic change
in subtalar arthritis, and twenty-five (15%) showed worsening
subtalar arthritis. Knecht et al.17, in reviewing 117 fixed-bearing
total ankle replacements with a minimum follow-up of two
years, noted that twenty-two (19%) had progressive subtalar
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arthritis and seventeen (15%) had progressive talonavicular
arthritis. Mann et al. observed no radiographic progression of
hindfoot arthritis at an average follow-up of ten years for forty-five
(88%) of fifty-five mobile-bearing total ankle arthroplasties; none
of the remaining patients with progression of hindfoot arthritis
was symptomatic26. SooHoo et al.85, using California’s hospital
discharge database, identified 480 total ankle arthroplasties
over a ten-year study period and suggested that the subtalar
arthrodesis rate at five years after total ankle arthroplasty was
0.7%. These studies suggest that total ankle arthroplasty does
not fully protect the adjacent hindfoot from the development
or progression of arthritis.
Arthroplasty Compared with Arthrodesis
The evaluation of outcomes after total ankle arthroplasty is
subject to comparison, either directly or indirectly, with those
after arthrodesis2,3,85,87. While the database review by SooHoo
et al. identified a higher complication rate for total ankle arthroplasty than for ankle arthrodesis85, the meta-analysis by
Haddad et al. suggested similar intermediate-term outcomes
for total ankle arthroplasty and arthrodesis2. Findings of similar
functional outcomes for total ankle arthroplasty and ankle
arthrodesis with a higher complication rate are corroborated by
the comparative analyses by Krause et al. with use of validated
outcome measures87. A recently published prospective comparison of a mobile-bearing prosthesis with ankle arthrodesis
suggested that pain relief is equal and functional outcome is
better after total ankle arthroplasty, on the basis of physicianbased and patient-based efficacy outcomes3. However, functional
outcome by traditional scoring methodology immediately sets
ankle arthrodesis at a disadvantage because of the loss of ankle
range of motion.
The current literature suggests that gait and range of
motion are better after total ankle arthroplasty, perhaps accounting for diminished rates of adjacent subtalar or talonavicular joint arthritis after total ankle arthroplasty compared
with those after arthrodesis6,7,17,61,86,88,89. Long-term outcomes
after ankle arthrodesis have demonstrated high rates of functional disability88,89, and recent reports by Greisberg et al.90 and
Hintermann et al.91 supported conversion of ankle arthrodesis
to total ankle arthroplasty in select patients.
Influence of Prosthetic Design, Instrumentation,
and Technique
Several implant design changes that have improved outcomes
in total ankle arthroplasty include uncemented components5,31,51,
augmented titanium plasma spray and hydroxyapatite coating on
the backside of the metal components for one mobile-bearing
design28,31,32,40,55, conversion of a shallow sulcus to a deep sulcus on
another mobile-bearing total ankle arthroplasty design7,10,11, addition of a hydroxyapatite coating to the medial aspect of a third type
of mobile-bearing design4,18, increased inventory of component
sizes16,28,32,33, and the use of intraoperative fluoroscopy to improve
component alignment70. Other studies have confirmed improved
fixation with double-over single-coating porous ingrowth surface
for that same mobile-bearing implant28,32. Improvement in instru-
mentation, while rarely mentioned in total ankle arthroplasty
outcome studies, most likely allows greater precision and reproducibility in performing total ankle arthroplasty26,32,52.
Survivorship is typically diminished when optimal total
ankle arthroplasty alignment is not achieved4,6,7,15,16,32,33,38,52,70,92.
Several authors have described soft-tissue balancing and adjunctive procedures for the ankle and hindfoot to allow for the
correction of deformity in the coronal plane5,15,18,26,36,44,92. Reproducible techniques in total knee arthroplasty to correct
deformity have been extrapolated to deformity correction in
total ankle arthroplasty93,94. Kofoed5 described a technique of
intra-articular correction to realign severe valgus of the ankle
with total ankle arthroplasty that is similar to an intra-articular
correction of the knee for severe genu valgum95. Bonnin et al.4
described correction of severe varus malalignment with a comprehensive medial soft-tissue release similar to that performed
for genu varum96,97. The authors added that the medial release
technique typically obviates the need for lateral ligament reconstruction, a technique frequently described for total ankle arthroplasty in ankles with varus malalignment3. Alternatively, a
sliding medial malleolar osteotomy has been described in select
patients with varus malalignment92. Mild-to-moderate preoperative anterior translation of the talus within the ankle mortise
appears to correct well with total ankle arthroplasty, even with
mobile-bearing designs7.
Developing Proficiency in Total Ankle Arthroplasty
The literature on outcomes after total ankle arthroplasty has
suggested that there is a period during which surgeons gain
experience and expertise before they are proficient at performing total ankle arthroplasty3,14,18,28,32,33,36,37,40, with several
investigations that have directly studied this issue80-82,98. Saltzman
et al.81 suggested that this so-called learning curve exists irrespective of particular training in total ankle arthroplasty and
showed, in a multicenter study, that complication rates are essentially halved as a surgeon gains experience3. Survivorship and
outcomes reported by the inventor of a prosthesis may exceed
those reported by other surgeons5,11,17,37; indeed, implant survivals of 95% at six years (based on 132 total ankle arthroplasties
in 126 patients) for one fixed-bearing design17, 95% at twelve
years (based on twenty-five total ankle arthroplasties in twentyfive patients) for one mobile-bearing prosthesis5, and 92% at
twelve years (based on seventy-five total ankle arthroplasties in
seventy-four patients) for another mobile-bearing design11 have
not been consistently reproduced7,15,28,33,70. The results reported
by Wood et al.7 suggested that, after a so-called learning curve has
been established with one prosthesis, that experience may reduce
or even eliminate the so-called learning curve with another, a
finding supported in the Swedish Ankle Arthroplasty Register32.
Complications and Their Salvage
Several investigators have directly studied the complications of
total ankle arthroplasty15,76,85,87,98, and systematic reviews have
offered dedicated analysis of complication rates in total ankle
arthroplasty2,34,37,76,85,98. Some authors’ methodology for reporting complications may be far more sensitive than that of others,
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leading to disproportionately high complication rates when
their implant survivorship is not significantly different from
those in other studies14,87.
The systematic review of the effect of complications on
outcome after total ankle arthroplasty by Glazebrook et al.76 was
based on 2386 total ankle arthroplasties from twenty studies that
met the authors’ inclusion criteria. High-grade complications of
implant failure, aseptic loosening, and deep infection were associated with high failure rates for total ankle arthroplasty.
Medium-grade complications of technical error, subsidence, and
postoperative fracture were associated with moderate failure
rates. Low-grade complications of intraoperative fracture and
problems with wound-healing demonstrated negligible failure
rates. This method of categorizing complications has been utilized by other authors26.
On the basis of the available literature of current total
ankle arthroplasty prostheses, salvage of a failed total ankle replacement does not require arthrodesis in most patients. In the
meta-analysis by Gougoulias et al.37, implant failure was reported
for 108 (9.8%) of 1105 total ankle arthroplasties at an average of
5.2 years, with sixty-seven (62%) of the failed implants managed
with revision and thirty-nine (36%), with conversion to arthrodesis. In that review, a single patient who had failure of a
total ankle replacement (<1%) had a transtibial amputation37,
slightly less than the eight (2.6%) of 306 patients reported in a
different study that considered total ankle arthroplasty as salvage
in patients who were already considering amputation15.
The meta-analyses by Stengel et al.34 and Haddad et al.2
described conversion of total ankle replacement to arthrodesis
in forty-nine of 1086 patients (a pooled estimate of 6.3%) and
twenty-nine of 572 (5.1%), respectively. Not all conversions of
total ankle replacement to arthrodesis are due to implant failure; several authors have reported intractable, unexplained
pain despite satisfactory clinical and radiographic findings as
the reason for conversion to arthrodesis2,18,31,37. In general, authors have suggested that successful revision or conversion to
arthrodesis with structural bone graft is possible2,5,11,14,18,34,37.
Some authors who reported the results of investigations dedi-
cated to repeat surgery for failed total ankle replacement99-101
found conversion to arthrodesis was favored over revision28,99,
and the rate of union in patients with osteoarthritis was higher
than that in patients with inflammatory arthritis99.
Overview
Despite the primarily weak evidence that does not allow a high
grade of recommendation and the high variability in outcomes
measures for total ankle arthroplasty, the intermediate-term efficacy outcomes, patient satisfaction, and implant survivorship
are favorable. Improved operative technique, greater familiarity
with the procedure on the part of surgeons, and advances in
implant and instrumentation design may allow enhanced implant survivorship, an improved learning curve, and a decreased
need for reoperation and revision.
Appendix
Tables showing patient demographic information, functional outcomes and patient satisfaction, implant survival
and reoperations, radiographic loosening, and registry data
from studies of total ankle arthroplasty are available with the
online version of this article at jbjs.org. n
NOTE: The authors thank the teams of Haddad et al.2, Stengel et al.34, and Gougoulias et al.37 for
their extensive reviews of the total ankle arthroplasty literature.
Mark E. Easley, MD
James K. DeOrio, MD
Department of Orthopaedic Surgery,
Duke University Medical Center,
Box 2950, Trent Drive,
Durham, NC 27710.
E-mail address for M.E. Easley: mark.e.easley@duke.edu
Samuel B. Adams Jr., MD
W. Chad Hembree, MD
Box 3000, DUMC, Trent Drive,
Durham, NC 27710
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