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Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis

Veljkovic, Andrea N. BComm, MPH, MD, FRCSC1,2,3; Daniels, Timothy R. MD, FRCSC4; Glazebrook, Mark A. MSc, PhD, MD, FRCSC5,6; Dryden, Peter J. MSc, MD, FRCSC1,7; Penner, Murray J. BSc, MD, FRCSC1,2,3; Wing, Kevin J. MD, FRCSC1,2,3; Younger, Alastair S.E. MB, ChB, ChM, FRCSC1,2,3

doi: 10.2106/JBJS.18.01012
Scientific Articles

Background: End-stage ankle arthritis is a disabling condition that has a similar effect on morbidity, pain, and loss of function to hip arthritis. We compared clinical outcomes of total ankle replacement (TAR) involving the HINTEGRA prosthesis (Integra LifeSciences), arthroscopic ankle arthrodesis (AAA), and open ankle arthrodesis (OAA) in patients with isolated, non-deformed end-stage ankle arthritis.

Methods: Patients ≥18 years old who underwent TAR, AAA, or OAA from 2002 to 2012 with a minimum follow-up of 2 years were retrospectively identified from the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database. All patients had symptomatic COFAS Type-1 end-stage ankle arthritis without intra-articular or extra-articular deformity or surrounding joint arthritis. Clinical outcomes included the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36). Revision was defined as removal of 1 or both metal ankle prosthesis components for TAR and as reoperation for malposition, malunion, or nonunion for AAA and OAA.

Results: Analysis included 238 ankles (88 TAR, 50 AAA, and 100 OAA) in 229 patients with a mean follow-up of 43.3 ± 18.5 months. The TAR group had more female patients (55%; p = 0.0318) and a higher mean age (p = 0.0005). Preoperative AOS pain, disability, and total scores were similar for all groups. SF-36 physical and mental component summary scores were similar across groups, both preoperatively and postoperatively. Improvement in AOS total score was significantly larger for TAR (34.4 ± 22.6) and AAA (38.3 ± 23.6) compared with OAA (25.8 ± 25.5; p = 0.005). Improvement in AOS disability score was also significantly larger for TAR (36.7 ± 24.3) and AAA (40.5 ± 26.4) compared with OAA (26.0 ± 26.2; p = 0.0013). However, the greater improvements did not meet the minimal clinically important difference. The TAR group underwent more reoperations than AAA and OAA groups (p < 0.0001). Revision rates were similar for all 3 groups (p = 0.262).

Conclusions: AAA and OAA resulted in comparable clinical outcomes to TAR in patients with non-deformed, COFAS Type-1 end-stage ankle arthritis. The rate of component revision in patients who underwent TAR was similar to the rate of revision for patients who underwent AAA or OAA; however, TAR patients underwent a greater number of additional procedures. Overall, AAA and TAR involving the HINTEGRA prosthesis were not significantly different surgical options in terms of short-term outcomes; patients should be counseled regarding higher reoperation rates for TAR.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

1Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada

2Footbridge Centre for Integrated Orthopaedic Care, Vancouver, British Columbia, Canada

3St. Paul’s Hospital, Vancouver, British Columbia, Canada

4Division of Orthopaedic Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada

5Division of Orthopedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada

6Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada

7Division of Orthopaedic Surgery, Vancouver Island Health Authority, Victoria, British Columbia, Canada

E-mail address for A.S.E. Younger:

Investigation performed at St. Paul’s Hospital, Vancouver, British Columbia, Canada; St. Michael’s Hospital, Toronto, Ontario, Canada; the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada; and the Vancouver Island Health Authority, Victoria, British Columbia, Canada

A commentary by Mark E. Easley, MD, is linked to the online version of this article at

Disclosure: Direct or indirect research funding support for this study was received from Integra LifeSciences Corporation (the implant manufacturer). An unrestricted research grant was received from DePuy to support data collection of the Mobility prosthesis for each patient entered in the Canadian Orthopaedic Foot and Ankle Society (COFAS) database. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work; “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this work; and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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