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Total ankle replacement: is pre-operative varus deformity a predictor of poor survival rate and clinical and radiological outcomes?

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The objective of this study was to compare survival rate and clinical and radiological outcomes of a cementless mobile-bearing total ankle replacement (TAR) between two groups of patients, affected by end-stage ankle arthritis, with or without a pre-operative varus deformity.


A total of 81 patients (81 ankles) were included in the study and divided in two groups. Group A, “varus” group, includes 11 patients with pre-operative varus deformity of more than 10 ° and group B, “neutral” group, includes 70 patients, with a varus/valgus deformity of less than 10 °. American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and Short Form (SF)-12 score were used to compare clinical outcomes. Radiological parameters, complications, and survival rate at last follow-up were also recorded.


In both groups, all clinical and radiological parameters improved after surgery (p < 0.05) without statistically significant difference. Complications were similar between two groups. Overall in three cases, an implant revision was necessary: 1 in group A (9%) at 3.1 years follow-up and 2 (3%) in group B at 3.8 years, without statistically significant difference (p > 0.001).


Severe varus malalignment should not be considered a contraindication for a mobile-bearing TAR. Nevertheless, TAR in severe deformity should be performed only by experienced surgeons.

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  1. Hobson SA, Karantana A, Dhar S (2009) Total ankle replacement in patients with significant preoperative deformity of the hindfoot. J Bone Joint Surg (Br) 91(4):481–486

    Article  CAS  Google Scholar 

  2. Demetracopoulos CA, Halloran JP, Maloof P, Adams SB Jr, Parekh SG (2013) Total ankle arthroplasty in end-stage ankle arthritis. Curr Rev Musculoskelet Med 6(4):279–284

    Article  PubMed  PubMed Central  Google Scholar 

  3. Frigg A, Germann U, Huber M, Horisberger M (2017) Survival of the Scandinavian total ankle replacement (STAR): results of ten to nineteen years follow-up. Int Orthop 41(10):2075–2082.

    Article  PubMed  Google Scholar 

  4. Shock RP, Christensen JC, Schuberth JM (2011) Total ankle replacement in the varus ankle. J Foot Ankle Surg 50(1):5–10

    Article  PubMed  Google Scholar 

  5. Kim HJ, Suh DH, Yang JH, Lee JW, Kim HJ, Ahn HS, Han SW, Choi GW (2017) Total ankle arthroplasty versus ankle arthrodesis for the treatment of end-stage ankle arthritis: a meta-analysis of comparative studies. Int Orthop 41(1):101–109.

    Article  PubMed  Google Scholar 

  6. Zhao Y, Zhu Y, Yan G, Cheng S (2017) Letter regarding article by Hyun Jung Kim et al.: total ankle arthroplasty versus ankle arthrodesis for the treatment of end-stage ankle arthritis: a meta-analysis of comparative studies. Int Orthop 41(1):111.

    Article  PubMed  Google Scholar 

  7. Gramlich Y, Neun O, Klug A, Buckup J, Stein T, Neumann A, Fischer S, Abt HP, Hoffmann R (2018) Total ankle replacement leads to high revision rates in post-traumatic end-stage arthrosis. Int Orthop 42(10):2375–2381.

    Article  PubMed  Google Scholar 

  8. Di Iorio A, Viste A, Fessy MH, Besse JL (2017) The AES total ankle arthroplasty analysis of failures and survivorship at ten years. Int Orthop 41(12):2525–2533.

    Article  PubMed  Google Scholar 

  9. Trajkovski T, Pinsker E, Cadden A, Daniels T (2013) Outcomes of ankle arthroplasty with preoperative coronal-plane varus deformity of 10° or greater. J Bone Joint Surg Am 95(15):1382–1388

    Article  PubMed  Google Scholar 

  10. Usuelli FG, Maccario C, Pantalone A, Serra N, Tan EW (2017) Identifying the learning curve for total ankle replacement using a mobile bearing prosthesis. Foot Ankle Surg 23(2):76–83

    Article  PubMed  Google Scholar 

  11. Trincat S, Kouyoumdjian P, Asencio G (2012) Total ankle arthroplasty and coronal plane deformities. Orthop Traumatol Surg Res 98(1):75–84

    Article  CAS  PubMed  Google Scholar 

  12. Kim BS, Choi WJ, Kim YS et al (2009) Total ankle replacement in moderate to varus deformity of the ankle. J Bone Joint Surg (Br) 91(9):1183–1190

    Article  CAS  Google Scholar 

  13. Von Elm E, Altman DG, Egger M et al (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61:344–349

    Article  Google Scholar 

  14. Barg A, Zwicky L, Knupp M, Henninger HB, Hintermann B (2013) HINTEGRA total ankle replacement: survivorship analysis in 684 patients. J Bone Joint Surg Am 95(13):1175–1183

    Article  PubMed  Google Scholar 

  15. Chua JR, Castrejon I, Pincus T (2017) Assessment of pain and other patient symptoms in routine clinical care as quantitative, standardised, “scientific” data. Clin Exp Rheumatol 107(5):13–20

    Google Scholar 

  16. Jenkinson C, Layte R, Jenkinson D et al (1997) A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies? J Public Health Med 19:179–186

    Article  CAS  Google Scholar 

  17. Leigheb M, Janicka P, Andorno S et al (2016) Italian translation, cultural adaptation and validation of the “American Orthopaedic Foot and Ankle Society’s (AOFAS) ankle-hindfoot scale”. Acta Biomed 87:38–45

    PubMed  Google Scholar 

  18. Nosewicz TL, Knupp M, Bolliger L, Hintermann B (2012) The reliability and validity of radiographic measurements for determining the three-dimensional position of the talus in varus and valgus osteoarthriticankles. Skelet Radiol 41(12):1567–1573

    Article  Google Scholar 

  19. Braito M, Dammerer D, Reinthaler A, Kaufmann G, Huber D, Biedermann R (2015) Effect of coronal and sagittal alignment on outcome after mobile-bearing total ankle replacement. Foot Ankle Int 36(9):1029–1037

    Article  PubMed  Google Scholar 

  20. Joo SD, Lee KB (2017) Comparison of the outcome of total ankle arthroplasty for osteoarthritis with moderate and severe varus malalignment and that with neutral alignment. Bone Joint J 99-B(10):1335–1342

    Article  PubMed  Google Scholar 

  21. Colin F, Bolliger L, Horn Lang T et al (2014) Effect of supramalleolar osteotomy and total ankle replacement on talar position in the varus osteoarthritic ankle: a comparative study. Foot Ankle Int 35(5):445–452

    Article  PubMed  Google Scholar 

  22. Haskell A, Mann RA (2004) Ankle arthroplasty with preoperative coronal plane deformity: short-term results. ClinOrthopRelat Res 424(424):98–103

    Google Scholar 

  23. Horisberger M, Valderrabano V, Hintermann B (2009) Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma 23(1):60–67

    Article  Google Scholar 

  24. Queen RM, Adams SB Jr, Viens NA et al (2013) Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am 95(21):1927–1934

    Article  PubMed  Google Scholar 

  25. Wood PL, Deakin S (2013) Total ankle replacement. The results in 200 ankles. J Bone Joint Surg (Br) 85(3):334–341

    Google Scholar 

  26. Burns PR, Dunse A (2017) Tibiotalocalcaneal arthrodesis for foot and ankle deformities. Clin Podiatr Med Surg 34(3):357–380

    Article  PubMed  Google Scholar 

  27. Coetzee JC (2008) Management of varus or valgus ankle deformity with ankle replacement. Foot Ankle Clin 13(3):509–520

    Article  PubMed  Google Scholar 

  28. Lawton CD, Butler BA, Dekker RG 2nd, Prescott A, Kadakia AR (2017) Total ankle arthroplasty versus ankle arthrodesis-a comparison of outcomes over the last decade. J Orthop Surg Res 12(1):76

    Article  PubMed  PubMed Central  Google Scholar 

  29. Valderrabano V, Pagenstert G, Hintermann B (2005) Total ankle replacement-three- component prosthesis. Tech Foot Ankle Surg 41(1):42–54

    Article  Google Scholar 

  30. Usuelli FG, Maccario C, Manzi L, Tan EW (2016) Posterior talar shifting in mobile-bearing total ankle replacement. Foot Ankle Int 37(3):281–287

    Article  PubMed  Google Scholar 

  31. Hunt KJ, Hurwit D (2013) Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am 95(16):e118(1–9)

    Article  Google Scholar 

  32. Dodd A, Daniels TR (2017) Total ankle replacement in the presence of talar varus or valgus deformities. Foot Ankle Clin N Am 22:277–300

    Article  Google Scholar 

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Correspondence to Federico Giuseppe Usuelli.

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Conflict of interest

Dr. Federico G. Usuelli reports personal fees from Geistlich and grants and personal fees from Zimmer, outside the submitted work.

Dr. Claudia A. Di Silvestri reports grants from Zimmer, outside the submitted work.

Dr. Riccardo D’Ambrosi, Dr. Annalisa Orenti, and Dr. Filippo Randelli declare that they have no conflict of interest.

Ethical approval and informed consent

All procedures were conducted according to the 1964 Declaration of Helsinki. Prior to participation in the study, all subjects signed an informed consent form. The Institutional Ethical Committee approval was received before performing the study.

This article does not contain any studies with animals performed by any of the authors.

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Level of Evidence: III.

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Usuelli, F.G., Di Silvestri, C.A., D’Ambrosi, R. et al. Total ankle replacement: is pre-operative varus deformity a predictor of poor survival rate and clinical and radiological outcomes?. International Orthopaedics (SICOT) 43, 243–249 (2019).

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