Similar Effectiveness for Ankle Replacement and Fusion in End-Stage Ankle OA

According to a recently published report from the UK, both total ankle arthroplasty and ankle fusion improve quality of life and result in similar clinical scores and risks after surgery in patients with end-stage ankle osteoarthritis (OA).

A few adverse events were more common with one surgery than with the other: Total ankle arthroplasty was associated with more wound healing complications and nerve injuries, while ankle arthrodesis was associated with more thromboembolic events and non-union of the ankle bones.

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The study was led by the Comprehensive Clinical Trials Unit at University College London, with the findings published online ahead of print by Annals of Internal Medicine.

Study Methods and Findings

Patients aged 50 to 85 with end-stage ankle OA were enrolled in this randomized clinical trial, which was conducted at 17 NHS Trusts across the UK. Of the 303 patients who started the study, 281 completed it and were included in the analysis of outcomes of total ankle arthroplasty versus ankle fusion surgery.

The researchers assessed the clinical response to surgery in both groups by comparing walking and standing domains of the Manchester–Oxford Foot Questionnaire preoperatively and at 52 weeks postoperatively. These standard assessments cover quality of life, pain levels, and ability to carry out daily activities.

Walking and standing domain scores improved by similar rates at 52 weeks for both groups, the researchers found. In a retrospective analysis, however, patients who underwent total ankle arthroplasty with the most common ankle implant used in the UK – a fixed bearing implant – were found to have better outcomes at 52 weeks than patients who underwent ankle fusion.

MRIs done before surgery showed that 42% of patients had OA in surrounding joints, many of them asymptomatic. Patients with surrounding joint OA had better outcomes if they underwent total ankle arthroplasty, with superior range of movement compared with ankle fusion patients.

Differences in Complications

The research also highlighted some differences in complications following surgery between the 2 procedures:

  • Wound healing was likely to take longer in total ankle arthroplasty patients than in ankle fusion patients. Total ankle arthroplasty was also more likely than ankle fusion to result in some nerve damage, leaving patients with numbness or tingling in the foot.
  • Patients who underwent ankle fusion surgery were more likely to have blood clots in their legs due to the prolonged immobilization following ankle fusion compared with total ankle arthroplasty. In addition, there was a symptomatic non-union rate of 7% for ankle fusion versus total ankle arthroplasty.

“Although the risks are not life threatening, understanding the different risks involved in each procedure is essential,” said Andrew Goldberg, an Honorary Associate Professor, UCL Surgery & Interventional Science, and the consultant orthopaedic surgeon who led the trial.

“Our aim in this trial was to provide the data that patients need to make informed decisions about these operations. We’ve clearly shown that both joint replacement and fusion provide significant patient benefits. We also found that the type of joint replacement seems to have an effect, but this needs further research.”


Goldberg AJ, Chowdhury K, Bordea E, et al for the TARVA Study Group. Total ankle replacement versus arthrodesis for end-stage ankle osteoarthritis: a randomized controlled trial. Ann Intern Med. 2022 Nov 15. doi: 10.7326/M22-2058. Online ahead of print.

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