Clinical Orthopaedics and Related Research®

, Volume 469, Issue 6, pp 1721–1727

Is Total Ankle Arthroplasty A Cost-effective Alternative to Ankle Fusion?

  • Xan F. Courville
  • Paul J. Hecht
  • Anna N. A. Tosteson
Clinical Research

DOI: 10.1007/s11999-011-1848-4

Cite this article as:
Courville, X.F., Hecht, P.J. & Tosteson, A.N.A. Clin Orthop Relat Res (2011) 469: 1721. doi:10.1007/s11999-011-1848-4



Total ankle arthroplasty (TAA) implantation is increasing, as the potential for pain relief and restoration of function and risks are compared with those for ankle fusion. A previous analysis with a simple decision tree suggested TAA was cost-effective compared with ankle fusion. However, reevaluation is warranted with the availability of newer, more costly implants and longer-term patient followup data.


Considering all direct medical costs regardless of the payer, we determined if TAA remains a cost-effective alternative to ankle fusion when updated evidence is considered.

Patients and Methods

Using a Markov model, we evaluated expected costs and quality-adjusted life years (QALY) for a 60-year-old hypothetical cohort with end-stage ankle arthritis treated with either TAA or ankle fusion. Costs were estimated from 2007 diagnosis-related group (DRG) and current procedural terminology (CPT) codes for each procedure. Rates were extracted from the literature. The incremental cost-effectiveness ratio (ICER), a measure of added cost divided by QALY gained for TAA relative to ankle fusion, was estimated. To identify factors affecting the value of TAA, sensitivity analyses were performed on all variables.


TAA costs $20,200 more than ankle fusion and resulted in 1.7 additional QALY, with an ICER of $11,800/QALY gained. Few variables in the sensitivity analyses resulted in TAA no longer being cost-effective.


Despite more costly implants and longer followup, TAA remains a cost-effective alternative to ankle fusion in a 60-year-old cohort with end-stage ankle arthritis.

Level of Evidence

Level II, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Xan F. Courville
    • 1
    • 2
  • Paul J. Hecht
    • 1
  • Anna N. A. Tosteson
    • 2
  1. 1.Department of Orthopaedics, Dartmouth-Hitchcock Medical CenterLebanonUSA
  2. 2.The Dartmouth Institute for Health Policy and Clinical PracticeLebanonUSA