Skip to main content


Log in

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

  • Original Article
  • Published:
HSS Journal ®



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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others


  1. Barg A, Elsner A, Anderson AE, Hintermann B. The effect of three-component total ankle replacement malalignment on clinical outcome: pain relief and functional outcome in 317 consecutive patients. J Bone Joint Surg Am. 2011;93(21):1969–1978.

    Article  PubMed  Google Scholar 

  2. Barg A, Elsner A, Chuckpaiwong B, Hintermann B. Insert position in three-component total ankle replacement. Foot Ankle Int. 2010;31(9):754–759.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  4. Cho J, Yi Y, Ahn TK, et al. Failure to restore sagittal tibiotalar alignment in total ankle arthroplasty: its relationship to the axis of the tibia and the positioning of the talar component. Bone Joint J. 2015;97B(11):1525–1532.

    Article  Google Scholar 

  5. Datir A, Xing M, Kakarala A, Terk MR, Labib SA. Radiographic evaluation of INBONE total ankle arthroplasty: a retrospective analysis of 30 cases. Skelet Radiol. 2013;42(12):1693–1701.

    Article  Google Scholar 

  6. Doets HC, Brand R, Nelissen RG. Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. J Bone Jt Surg Am. 2006;88(6):1272–1284.

    Article  Google Scholar 

  7. Espinosa N, Walti M, Favre P, Snedeker JG. Misalignment of total ankle components can induce high joint contact pressures. J Bone Joint Surg Am. 2010;92(5):1179–1187.

    Article  CAS  PubMed  Google Scholar 

  8. Fukuda T, Haddad SL, Ren Y, Zhang L-Q. Impact of talar component rotation on contact pressure after total ankle arthroplasty: a cadaveric study. Foot Ankle Int. 2010;31(5):404–411.

    Article  PubMed  Google Scholar 

  9. Gross CE, Hamid KS, Green C, Easley ME, DeOrio JK, Nunley JA. Operative wound complications following total ankle arthroplasty. Foot Ankle Int. 2017;38(4):360–366.

    Article  PubMed  Google Scholar 

  10. Hunt KJ, Hurwit D. Use of patient-reported outcome measures in foot and ankle research. J Bone Jt Surg Am. 2013;118(16):e118(1–9).

    Article  Google Scholar 

  11. King CM, Schuberth JM, Christensen JC, Swanstrom KM. Relationship of alignment and tibial cortical coverage to hypertrophic bone formation in Salto Talaris total ankle arthroplasty. J Foot Ankle Surg. 2013;52(3):355–359.

    Article  PubMed  Google Scholar 

  12. Labek G, Thaler M, Janda W, Agreiter M, Stockl B. Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. Bone Joint J. 2011;93-B(3):293–297.

    Article  Google Scholar 

  13. Lee K-B, Kim M-S, Park K-S, Cho K-J, Primadhi A. Effect of anterior translation of the talus on outcomes of three-component total ankle arthroplasty. BMC Musculoskelet Disord. 2013;14(1):260.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Mani SB, Do H, Vulcano E, et al. Evaluation of the foot and ankle outcome score in patients with osteoarthritis of the ankle. Bone Joint J. 2015;97-B(5):662–667.

  15. Nodzo SR, Miladore MP, Kaplan NB, Ritter C. Short to midterm clinical and radiographic outcomes of the Salto total ankle prosthesis. Foot Ankle Int. 2014;35(1):22–29.

    Article  PubMed  Google Scholar 

  16. Ramaskandhan JR, Kakwani R, Kometa S, Bettinson K, Siddique MS. Two-year outcomes of MOBILITY Total Ankle Replacement. J Bone Joint Surg Am. 2014;96(7):e53.

    Article  Google Scholar 

  17. Rippstein PF, Huber M, Naal FD. Management of specific complications related to total ankle arthroplasty. Foot Ankle Clin. 2012;17(4):707–717.

    Article  PubMed  Google Scholar 

  18. Saltzman CL, Tochigi Y, Rudert MJ, McIff TE, Brown TD. The effect of agility ankle prosthesis misalignment on peri-ankle ligaments. Clin Orthop Relat Res. 2004;424:137–142.

    Article  Google Scholar 

  19. Spirt AA, Assal M, Hansen ST. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004;86-A(6):1172–1178.

    Article  Google Scholar 

  20. Tochigi Y, Rudert MJ, Brown TD, McIff TE, Saltzman CL. The effect of accuracy of implantation on range of movement of the Scandinavian Total Ankle Replacement. J Bone Jt Surgery Br. 2005;87-B(5):736–740.

  21. Tochigi Y, Suh J-S, Amendola A, Pedersen DR, Saltzman CL. Ankle alignment on lateral radiographs. Part 1: sensitivity of measures to perturbations of ankle positioning. Foot Ankle Int. 2006;27(2):82–87.

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  PubMed  Google Scholar 

  23. Ware J, Kosinski M, Keller S. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220–233.

    Article  Google Scholar 

  24. Williamson ERC, Demetracopoulos CA, Ellis SJ. Conversion of ankle autofusion to total ankle replacement using the Salto XT revision prosthesis. Foot Ankle Surg. 2016;22(3):e11–e16.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Guilherme H. Saito MD.

Ethics declarations

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.

Additional information

Level of Evidence: Level III: Retrospective Cohort Study

Electronic supplementary material


(PDF 1224 kb)


(PDF 1225 kb)


(PDF 1224 kb)


(PDF 1224 kb)


(PDF 1224 kb)


(PDF 1224 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nielsen, N.M., Saito, G.H., Sanders, A.E. et al. Sagittal Tibiotalar Alignment May Not Affect Functional Outcomes in Fixed-Bearing Total Ankle Replacement: A Retrospective Cohort Study. HSS Jrnl 16 (Suppl 2), 300–304 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: