End-stage ankle arthritis

Indication

End-stage ankle arthritis refractory to non-operative management is the shared indication for all three procedures. The primary decision point is whether to preserve motion with a total ankle replacement (TAR) or sacrifice it with arthrodesis, and if choosing fusion, whether to do so through an open or arthroscopic approach. Patient age, activity level, deformity severity, bone stock, and soft-tissue envelope all influence this choice.

The techniques

• Total ankle replacement (TAR): Resurfacing of the tibial plafond and talar dome with a two- or three-component prosthesis (fixed- or mobile-bearing) to maintain tibiotalar motion.
• Open ankle arthrodesis: Anterior or anterolateral open approach with articular cartilage removal, compression across the tibiotalar joint, and internal fixation (plates, screws, or intramedullary nail).
• Arthroscopic ankle arthrodesis: Percutaneous arthroscopic debridement of the joint surfaces followed by percutaneous screw fixation, avoiding a formal arthrotomy.

What the evidence says

The TARVA RCT (303 patients, 52-week follow-up) found no clinically or statistically significant difference in MOXFQ walking/standing scores between TAR and ankle fusion (adjusted difference −5.6, 95% CI −12.5 to 1.4) [1]. Complication profiles differed: TAR had more wound-healing issues (13.4% vs 5.7%) and nerve injuries (4.2% vs <1%), while fusion had more thromboembolic events (4.9% vs 2.9%) and non-unions [2]. A 2024 meta-analysis of 13 comparative studies confirmed no difference in SF-36 scores but reported significantly higher FAAM scores for fusion (MD 8.30, 95% CI 1.01–15.60) and similar overall complication rates (RR 0.95) [3]. An earlier systematic review noted significantly higher revision rates for TAR versus arthrodesis (OR 2.28, 95% CI 1.63–3.19) [4]. For fusion technique, two meta-analyses of comparative studies (total 507–514 patients) consistently show arthroscopic arthrodesis yields higher union rates (OR 0.25 for non-union, 95% CI 0.11–0.57) [5], better clinical scores, fewer complications (0–23.8% vs 6.7–47.1%) [6], less blood loss (WMD 52 mL) [5], and shorter hospital stay (WMD 1.6 days) [5]. TAR survivorship meta-analyses report pooled 93% implant survival (95% CI 85–97%) with no significant fixed- versus mobile-bearing difference, though mobile-bearing survival declines with longer follow-up [7][8]. Gait analysis reviews find equivalent spatiotemporal parameters but greater sagittal ankle ROM after TAR [9].

What members see

The TARVA trial reports 52-week MOXFQ improvement in both arms but the between-group difference did not reach the minimal clinically important difference [1]. Members: what is your observed revision rate for TAR at 5–10 years versus your non-union rate for arthroscopic fusion? Do you see the wound-healing disparity reported in TARVA (13% vs 6%) in your practice, and how does it influence patient selection? How often do you convert a planned arthroscopic fusion to open intra-operatively, and what triggers that decision?

Cost and access

Sources do not provide direct cost comparisons. Factors driving relative cost include implant expense for TAR (absent in fusion), longer operative time for open arthrodesis versus arthroscopic, higher revision surgery rates reported for TAR [4], potential second procedure for hardware removal after fusion, and advanced imaging (CT/MRI) for TAR surveillance. Theatre time and inpatient stay are shorter for arthroscopic fusion [6][5].

Open questions

• What is the 10-year survivorship of current-generation fixed-bearing TAR implants versus mobile-bearing designs in patients under 65?
• Does arthroscopic fusion maintain its union-rate advantage in severe varus/valgus deformity (>15°) where open correction is often preferred?
• How do patient-reported outcomes diverge beyond 2 years, particularly regarding adjacent-joint arthritis after fusion versus polyethylene wear/osteolysis after TAR?
• What is the true reoperation rate for symptomatic hardware after arthroscopic versus open fusion when followed prospectively?
• Does surgeon volume/learning curve affect TAR revision rates more than it affects arthroscopic fusion non-union rates?

References

9 of 18 papers retrieved for this room are cited above. The search was limited to systematic reviews, meta-analyses and randomised trials in humans, English, 2016 onwards. Query and full result set: research/raw/ankle-arthritis.json.

1. 1Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial. Ann Intern Med 2022 · PMID 36375147 Randomized Controlled Trial
2. 2Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT. Health Technol Assess 2023 · PMID 37022932 Systematic Review
3. 3Total ankle replacement versus ankle fusion for end-stage ankle arthritis: A meta-analysis. J Orthop Surg (Hong Kong) 2024 · PMID 38607239 Meta-Analysis, Review
4. 4Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status. Br Med Bull 2017 · PMID 29186357 Systematic Review
5. 5Open versus arthroscopic ankle arthrodesis: a systematic review and meta-analysis. J Orthop Surg Res 2020 · PMID 32448398 Meta-Analysis, Systematic Review
6. 6Arthroscopic Versus Open Ankle Arthrodesis: A Systematic Review. Arthroscopy 2018 · PMID 29122435 Meta-Analysis, Systematic Review
7. 7Total Ankle Arthroplasty Survivorship: A Meta-analysis. J Foot Ankle Surg 2020 · PMID 32600863 Meta-Analysis
8. 8Fixed-bearing versus mobile-bearing total ankle replacement survivorship. A meta-analysis. Foot Ankle Surg 2024 · PMID 38388212 Meta-Analysis, Systematic Review
9. 9comparison of postoperative gait parameters after total ankle arthroplasty and ankle fusion: A systematic review. Medicine (Baltimore) 2024 · PMID 38968510 Systematic Review

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