Sagittal Tibiotalar Alignment May Not Affect Functional Outcomes in Fixed-Bearing Total Ankle Replacement: A Retrospective Cohort Study

  • Natalie M. Nielsen
  • Guilherme H. SaitoEmail author
  • Austin E. Sanders
  • Scott J. Ellis
  • Carolyn M. Sofka
  • Constantine A. Demetracopoulos
Original Article



In total ankle replacement (TAR), correct positioning of the implant is crucial. Malposition of the components may increase contact pressures and diminish prosthesis survival. The effect of sagittal tibiotalar alignment on functional outcomes after fixed-bearing TAR remains unclear, however, and no studies have compared fixed-bearing implants with respect to the anteroposterior (AP) position of the talar component.


The purposes of this study were (1) to evaluate the effect of sagittal tibiotalar alignment on functional outcomes in fixed-bearing TAR and (2) to compare post-operative sagittal tibiotalar alignment in two types of fixed-bearing implants.


In a retrospective analysis of 71 primary TARs performed at a single center, we studied the INBONE™ II Total Ankle System and the Salto Talaris® Ankle. Radiographic measurements of the tibial axis–talus (T-T) ratio and the AP offset ratio were performed before and after surgery, respectively, and we evaluated Foot and Ankle Outcome Scores (FAOSs) and the 12-item Short Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scales pre-operatively and at 2 years after surgery. The Pearson correlation and independent-samples t test were used to evaluate differences in FAOSs, SF-12 MCS scores, and SF-12 PCS scores regarding post-operative sagittal alignment.


Post-operative sagittal tibiotalar alignment was neutral in 39 ankles and anterior in 32 ankles. We observed no significant between-group differences in clinical outcome scores. Patients with a Salto Talaris Ankle prosthesis had a greater AP offset ratio (0.12) than patients with an INBONE II implant (0.05). However, the greater translation did not correlate with outcome scores.


At the 2-year follow-up, no correlation between the post-operative AP offset ratio and functional outcome scores was observed between the two fixed-bearing-implant groups. Further studies with longer follow-up are needed to determine whether the difference in sagittal alignment has an effect on functional outcomes in the long term.


total ankle arthroplasty component alignment ankle replacement radiologic analysis ankle arthritis 


Compliance with Ethical Standards

Conflict of Interest

Natalie M. Nielsen, MD, Austin E. Sanders, BA, and Carolyn M. Sofka, MD, declare that they have no conflicts of interest. Guilherme H. Saito, MD, reports fees as a consultant from Wright Medical Technology, outside the submitted work. Scott J. Ellis, MD, reports fees as a consultant from Wright Medical Technology. Constantine A. Demetracopoulos, MD, reports fees as a consultant from Integra LifeSciences and Wright Medical Technology.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all patients for being included in this study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Supplementary material

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Copyright information

© Hospital for Special Surgery 2019

Authors and Affiliations

  1. 1.Foot and Ankle Service, Department of Orthopedic SurgeryHospital for Special SurgeryNew YorkUSA
  2. 2.Department of Radiology and ImagingHospital for Special SurgeryNew YorkUSA

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