Ankle Arthroplasty

  • Jin Woo LeeEmail author
  • Kwang Hwan Park


Osteoarthritis of the ankle joint commonly arises as a result of sports injuries or as posttraumatic arthritis. Ankle arthrodesis is the conventional treatment for osteoarthritis of the ankle joint with severe pain and limitations in daily activity. However, due to the development of surgical instruments and implants in combination with continuous studies evaluating postoperative complications, rapid progress in total ankle arthroplasty procedures has recently been achieved. However, on performing total ankle arthroplasty, numerous variables, such as ligament balancing, preoperative malalignment, and arthritis, in nearby joints should still be considered. Avoiding and overcoming postoperative complications (e.g., postoperative infection, malalignment, osteolysis, subsidence) are important aspects that must also be considered. Precise diagnosis and preoperative planning can lower failure rates. In this chapter, we introduce the history of total ankle arthroplasty, patient selection for total ankle arthroplasty, implants, precautions during surgery, and surgical approaches.


Ankle osteoarthritis Total ankle arthroplasty Surgical techniques Complication 


  1. 1.
    Thomas RH, Daniels TR. Ankle arthritis. J Bone Joint Surg Am. 2003;85-A(5):923–36.CrossRefGoogle Scholar
  2. 2.
    Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, Alliman KJ, Alvine FG, et al. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up. J Bone Joint Surg Am. 2004;86-a(6):1161–71.CrossRefGoogle Scholar
  3. 3.
    Courville XF, Hecht PJ, Tosteson AN. Is total ankle arthroplasty a cost-effective alternative to ankle fusion? Clin Orthop Relat Res. 2011;469(6):1721–7. Scholar
  4. 4.
    Hintermann B, Valderrabano V. Total ankle replacement. Foot Ankle Clin. 2003;8(2):375–405.CrossRefGoogle Scholar
  5. 5.
    Saltzman CL. Perspective on total ankle replacement. Foot Ankle Clin. 2000;5(4):761–75.PubMedGoogle Scholar
  6. 6.
    Pyevich MT, Saltzman CL, Callaghan JJ, Alvine FG. Total ankle arthroplasty: a unique design. Two to twelve-year follow-up. J Bone Joint Surg Am. 1998;80(10):1410–20.CrossRefGoogle Scholar
  7. 7.
    Lord G, Marotte JH. Total ankle prosthesis. Technic and 1st results. Apropos of 12 cases. Rev Chir Orthop Reparatrice Appar Mot. 1973;59(2):139–51.PubMedGoogle Scholar
  8. 8.
    Dini AA, Bassett FH 3rd. Evaluation of the early result of Smith total ankle replacement. Clin Orthop Relat Res. 1980;(146):228–30.Google Scholar
  9. 9.
    Kitaoka HB, Patzer GL. Clinical results of the Mayo total ankle arthroplasty. J Bone Joint Surg Am. 1996;78(11):1658–64.CrossRefGoogle Scholar
  10. 10.
    Goldberg AJ, Sharp RJ, Cooke P. Ankle replacement: current practice of foot & ankle surgeons in the United kingdom. Foot Ankle Int. 2009;30(10):950–4. Scholar
  11. 11.
    Barg A, Elsner A, Chuckpaiwong B, Hintermann B. Insert position in three-component total ankle replacement. Foot Ankle Int. 2010;31(9):754–9. Scholar
  12. 12.
    Rippstein PF, Naal FD. Total ankle replacement in rheumatoid arthritis. Der Orthopade. 2011;40(11):984–6, 8-90. Scholar
  13. 13.
    Wood PL, Crawford LA, Suneja R, Kenyon A. Total ankle replacement for rheumatoid ankle arthritis. Foot Ankle Clin. 2007;12(3):497–508., vii. Scholar
  14. 14.
    Luck JV, Jr., Kasper CK. Surgical management of advanced hemophilic arthropathy. An overview of 20 years’ experience. Clin Orthop Relat Res 1989(242):60–82.Google Scholar
  15. 15.
    van der Heide HJ, Novakova I, de Waal Malefijt MC. The feasibility of total ankle prosthesis for severe arthropathy in haemophilia and prothrombin deficiency. Haemophilia. 2006;12(6):679–82. Scholar
  16. 16.
    Barg A, Knupp M, Kapron AL, Hintermann B. Total ankle replacement in patients with gouty arthritis. J Bone Joint Surg Am. 2011;93(4):357–66. Scholar
  17. 17.
    Vickerstaff JA, Miles AW, Cunningham JL. A brief history of total ankle replacement and a review of the current status. Med Eng Phys. 2007;29(10):1056–64. Scholar
  18. 18.
    Myerson MS, Miller SD. Salvage after complications of total ankle arthroplasty. Foot Ankle Clin. 2002;7(1):191–206.CrossRefGoogle Scholar
  19. 19.
    Samuelson KM, Freeman MA, Tuke MA. Development and evolution of the ICLH ankle replacement. Foot Ankle. 1982;3(1):32–6.CrossRefGoogle Scholar
  20. 20.
    Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA, et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44–6.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009;467(7):1800–6. Scholar
  22. 22.
    Kopp FJ, Patel MM, Deland JT, O’Malley MJ. Total ankle arthroplasty with the Agility prosthesis: clinical and radiographic evaluation. Foot Ankle Int. 2006;27(2):97–103. Scholar
  23. 23.
    Feldman MH, Rockwood J. Total ankle arthroplasty: a review of 11 current ankle implants. Clin Podiatr Med Surg. 2004;21(3):393–406., vii. Scholar
  24. 24.
    Rydholm U. Is total replacement of the ankle an option? Acta Orthop. 2007;78(5):567–8. Scholar
  25. 25.
    Greisberg J, Assal M, Flueckiger G, Hansen ST Jr. Takedown of ankle fusion and conversion to total ankle replacement. Clin Orthop Relat Res. 2004;424:80–8.CrossRefGoogle Scholar
  26. 26.
    Hintermann B, Barg A, Knupp M, Valderrabano V. Conversion of painful ankle arthrodesis to total ankle arthroplasty. Surgical technique. J Bone Joint Surg Am. 2010;92(Suppl 1 Pt 1):55–66. Scholar
  27. 27.
    Guyer AJ, Richardson G. Current concepts review: total ankle arthroplasty. Foot Ankle Int. 2008;29(2):256–64. Scholar
  28. 28.
    Harnroongroj T, Vanadurongwan V. The talar body prosthesis. J Bone Joint Surg Am. 1997;79(9):1313–22.CrossRefGoogle Scholar
  29. 29.
    Lampert C. Ankle joint prosthesis for bone defects. Der Orthopade. 2011;40(11):978–83. Scholar
  30. 30.
    Knupp M, Stufkens SA, Bolliger L, Barg A, Hintermann B. Classification and treatment of supramalleolar deformities. Foot Ankle Int. 2011;32(11):1023–31. Scholar
  31. 31.
    Pagenstert GI, Hintermann B, Barg A, Leumann A, Valderrabano V. Realignment surgery as alternative treatment of varus and valgus ankle osteoarthritis. Clin Orthop Relat Res. 2007;462:156–68. Scholar
  32. 32.
    Whalen JL, Spelsberg SC, Murray P. Wound breakdown after total ankle arthroplasty. Foot Ankle Int. 2010;31(4):301–5. Scholar
  33. 33.
    Lampley A, Gross CE, Green CL, DeOrio JK, Easley M, Adams S, et al. Association of cigarette use and complication rates and outcomes following total ankle arthroplasty. Foot Ankle Int. 2016;37(10):1052–9. Scholar
  34. 34.
    Althoff A, Cancienne JM, Cooper MT, Werner BC. Patient-related risk factors for periprosthetic ankle joint infection: an analysis of 6977 total ankle arthroplasties. J Foot Ankle Surg. 2018;57(2):269–72. Scholar
  35. 35.
    Raikin SM, Kane J, Ciminiello ME. Risk factors for incision-healing complications following total ankle arthroplasty. J Bone Joint Surg Am. 2010;92(12):2150–5.CrossRefGoogle Scholar
  36. 36.
    Naal FD, Impellizzeri FM, Loibl M, Huber M, Rippstein PF. Habitual physical activity and sports participation after total ankle arthroplasty. Am J Sports Med. 2009;37(1):95–102. Scholar
  37. 37.
    Valderrabano V, Pagenstert G, Horisberger M, Knupp M, Hintermann B. Sports and recreation activity of ankle arthritis patients before and after total ankle replacement. Am J Sports Med. 2006;34(6):993–9. Scholar
  38. 38.
    Lee JH, Dyke JP, Ballon D, Ciombor DM, Tung G, Aaron RK. Assessment of bone perfusion with contrast-enhanced magnetic resonance imaging. Orthop Clin. 2009;40(2):249–57.CrossRefGoogle Scholar
  39. 39.
    Bahr R, Pena F, Shine J, Lew WD, Lindquist C, Tyrdal S, et al. Mechanics of the anterior drawer and talar tilt tests. A cadaveric study of lateral ligament injuries of the ankle. Acta Orthop Scand. 1997;68(5):435–41.CrossRefGoogle Scholar
  40. 40.
    Corazza F, Leardini A, O’Connor JJ, Parenti Castelli V. Mechanics of the anterior drawer test at the ankle: the effects of ligament viscoelasticity. J Biomech. 2005;38(10):2118–23. Scholar
  41. 41.
    Frigg A, Nigg B, Hinz L, Valderrabano V, Russell I. Clinical relevance of hindfoot alignment view in total ankle replacement. Foot Ankle Int. 2010;31(10):871–9. Scholar
  42. 42.
    Lindsjo U, Danckwardt-Lilliestrom G, Sahlstedt B. Measurement of the motion range in the loaded ankle. Clin Orthop Relat Res. 1985;(199):68–71.Google Scholar
  43. 43.
    Wilken J, Rao S, Estin M, Saltzman CL, Yack HJ. A new device for assessing ankle dorsiflexion motion: reliability and validity. J Orthop Sports Phys Ther. 2011;41(4):274–80. Scholar
  44. 44.
    Valderrabano V, Nigg BM, von Tscharner V, Frank CB, Hintermann B. J. Leonard Goldner Award 2006. Total ankle replacement in ankle osteoarthritis: an analysis of muscle rehabilitation. Foot Ankle Int. 2007;28(2):281–91. Scholar
  45. 45.
    Hurowitz EJ, Gould JS, Fleisig GS, Fowler R. Outcome analysis of Agility total ankle replacement with prior adjunctive procedures: two to six year followup. Foot Ankle Int. 2007;28(3):308–12. Scholar
  46. 46.
    Min W, Sanders R. The use of the mortise view of the ankle to determine hindfoot alignment: technique tip. Foot Ankle Int. 2010;31(9):823–7. Scholar
  47. 47.
    Doets HC, Brand R, Nelissen RG. Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. J Bone Joint Surg Am. 2006;88(6):1272–84. Scholar
  48. 48.
    Haskell A, Mann RA. Ankle arthroplasty with preoperative coronal plane deformity: short-term results. Clin Orthop Relat Res. 2004;424:98–103.CrossRefGoogle Scholar
  49. 49.
    Wood PL, Sutton C, Mishra V, Suneja R. A randomised, controlled trial of two mobile-bearing total ankle replacements. J Bone Joint Surg. 2009;91(1):69–74. Scholar
  50. 50.
    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):1179–87. Scholar
  51. 51.
    Hintermann B, ProQuest. Total ankle arthroplasty historical overview, current concepts and future perspectives. 2005.Google Scholar
  52. 52.
    Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn. 1977;18(4):481–91.CrossRefGoogle Scholar
  53. 53.
    Bonasia DE, Dettoni F, Femino JE, Phisitkul P, Germano M, Amendola A. Total ankle replacement: why, when and how? Iowa Orthop J. 2010;30:119–30.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Kim BS, Choi WJ, Kim YS, Lee JW. Total ankle replacement in moderate to severe varus deformity of the ankle. J Bone Joint Surg. 2009;91(9):1183–90. Scholar
  55. 55.
    Knupp M, Pagenstert GI, Barg A, Bolliger L, Easley ME, Hintermann B. SPECT-CT compared with conventional imaging modalities for the assessment of the varus and valgus malaligned hindfoot. J Orthop Res. 2009;27(11):1461–6. Scholar
  56. 56.
    Pagenstert GI, Barg A, Leumann AG, Rasch H, Muller-Brand J, Hintermann B, et al. SPECT-CT imaging in degenerative joint disease of the foot and ankle. J Bone Joint Surg. 2009;91(9):1191–6. Scholar
  57. 57.
    Haygood TM. Magnetic resonance imaging of the musculoskeletal system: part 7. The ankle. Clin Orthop Relat Res. 1997;336:318–36.CrossRefGoogle Scholar
  58. 58.
    Buechel FFS, Buechel FFJ, Pappas MJ. Twenty-year evaluation of cementless mobile-bearing total ankle replacements. Clin Orthop Relat Res (1976–2007). 2004;424:19–26. Scholar
  59. 59.
    Cerrato R, Myerson MS. Total ankle replacement: the Agility LP prosthesis. Foot Ankle Clin. 2008;13(3):485–94, ix. Scholar
  60. 60.
    Rippstein PF. Clinical experiences with three different designs of ankle prostheses. Foot Ankle Clin. 2002;7(4):817–31.CrossRefGoogle Scholar
  61. 61.
    Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004;86-a(6):1172–8.CrossRefGoogle Scholar
  62. 62.
    Criswell BJ, Douglas K, Naik R, Thomson AB. High revision and reoperation rates using the AgilityTM total ankle system. Clin Orthop Relat Res. 2012;470(7):1980–6. Scholar
  63. 63.
    Raikin SM, Sandrowski K, Kane JM, Beck D, Winters BS. Midterm outcome of the Agility total ankle arthroplasty. Foot Ankle Int. 2017;38(6):662–70. Scholar
  64. 64.
    Hintermann B, Barg A. The HINTEGRA total ankle arthroplasty. Operative techniques in orthopaedic surgery. 1st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. p. 4022–31.Google Scholar
  65. 65.
    Barg A, Zwicky L, Knupp M, Henninger HB, Hintermann B. HINTEGRA total ankle replacement: survivorship analysis in 684 patients. J Bone Joint Surg Am. 2013;95(13):1175–83. Scholar
  66. 66.
    Gittins J, Mann RA. The history of the STAR total ankle arthroplasty. Foot Ankle Clin. 2002;7(4):809–16.. viiCrossRefGoogle Scholar
  67. 67.
    Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR total ankle replacement: the patient perspective. J Bone Joint Surg Am. 2012;94(1):43–8. Scholar
  68. 68.
    Daniels TR, Mayich DJ, Penner MJ. Intermediate to long-term outcomes of total ankle replacement with the scandinavian total ankle replacement (STAR). J Bone Joint Surg Am. 2015;97(11):895–903. Scholar
  69. 69.
    Wan DD, Choi WJ, Shim DW, Hwang Y, Park YJ, Lee JW. Short-term clinical and radiographic results of the salto mobile total ankle prosthesis. Foot Ankle Int. 2018;39(2):155–65. Scholar
  70. 70.
    Hofmann KJ, Shabin ZM, Ferkel E, Jockel J, Slovenkai MP. Salto Talaris total ankle arthroplasty: clinical results at a mean of 5.2 years in 78 patients treated by a single surgeon. J Bone Joint Surg Am. 2016;98(24):2036–46. Scholar
  71. 71.
    Stewart MG, Green CL, Adams SB Jr, DeOrio JK, Easley ME, Nunley JA 2nd. Midterm results of the salto talaris total ankle arthroplasty. Foot Ankle Int. 2017;38(11):1215–21. Scholar
  72. 72.
    Rippstein PF, Huber M, Coetzee JC, Naal FD. Total ankle replacement with use of a new three-component implant. J Bone Joint Surg Am. 2011;93(15):1426–35. Scholar
  73. 73.
    Muir D, Aoina J, Hong T, Mason R. The outcome of the Mobility total ankle replacement at a mean of four years: can poor outcomes be predicted from pre- and post-operative analysis? Bone Joint J. 2013;95-b(10):1366–71. Scholar
  74. 74.
    Takakura Y, Tanaka Y, Kumai T, Sugimoto K, Ohgushi H. Ankle arthroplasty using three generations of metal and ceramic prostheses. Clin Orthop Relat Res. 2004;424:130–6.CrossRefGoogle Scholar
  75. 75.
    Choi WJ, Lee JW. Heterotopic ossification after total ankle arthroplasty. J Bone Joint Surg. 2011;93(11):1508–12. Scholar
  76. 76.
    Brostrom L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966;132(5):551–65.PubMedGoogle Scholar
  77. 77.
    Kilger R, Knupp M, Hintermann B. Peroneus longus to peroneus brevis tendon transfer. Tech Foot Ankle Surg. 2009;8(3):146–9. Scholar
  78. 78.
    Myerson M. Current therapy in foot and ankle surgery. Pmph Bc Decker; 1993.Google Scholar
  79. 79.
    Dwyer F. Osteotomy of the calcaneum for pes cavus. J Bone Joint Surg. 1959;41(1):80–6.CrossRefGoogle Scholar
  80. 80.
    Paulos L, Coleman S, Samuelson K. Pes cavovarus. Review of a surgical approach using selective soft-tissue procedures. J Bone Joint Surg Am. 1980;62(6):942–53.CrossRefGoogle Scholar
  81. 81.
    Perera A, Myerson M. Surgical techniques for the reconstruction of malunited ankle fractures. Foot Ankle Clin. 2008;13(4):737–51.CrossRefGoogle Scholar
  82. 82.
    Myerson M. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;21:1047–56.Google Scholar
  83. 83.
    Hatt RN, Lamphier TA. Triple hemisection: a simplified procedure for lengthening the Achilles tendon. N Engl J Med. 1947;236(5):166–9.CrossRefGoogle Scholar
  84. 84.
    Moreau MJ, Lake DM. Outpatient percutaneous heel cord lengthening in children. J Pediatr Orthop. 1987;7(3):253–5.CrossRefGoogle Scholar
  85. 85.
    Conti SF, Wong YS. Complications of total ankle replacement. Clin Orthop Relat Res. 2001;391:105–14.CrossRefGoogle Scholar
  86. 86.
    Gould JS, Alvine FG, Mann RA, Sanders R, Walling AK. Total ankle replacement: a surgical discussion. Part I. Replacement systems, indications, and contraindications. Am J Orthop (Belle Mead NJ). 2000;29(8):604.Google Scholar
  87. 87.
    Valderrabano V, Hintermann B, Dick W. Scandinavian total ankle replacement: a 3.7-year average followup of 65 patients. Clin Orthop Relat Res. 2004;424:47–56.CrossRefGoogle Scholar
  88. 88.
    Kim B, Knupp M, Zwicky L, Lee J, Hintermann B. Total ankle replacement in association with hindfoot fusion: outcome and complications. Bone Joint J. 2010;92(11):1540–7.Google Scholar
  89. 89.
    Graves SC, Mann RA, Graves KO. Triple arthrodesis in older adults. Results after long-term follow-up. J Bone Joint Surg Am. 1993;75(3):355–62.CrossRefGoogle Scholar
  90. 90.
    Sammarco VJ, Magur EG, Sammarco GJ, Bagwe MR. Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment. Foot Ankle Int. 2006;27(9):661–6.CrossRefGoogle Scholar
  91. 91.
    Astion DJ, Deland JT, Otis JC, Kenneally S. Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am. 1997;79(2):241–6.CrossRefGoogle Scholar
  92. 92.
    Knupp M, Schuh R, Stufkens S, Bolliger L, Hintermann B. Subtalar and talonavicular arthrodesis through a single medial approach for the correction of severe planovalgus deformity. Bone Joint J. 2009;91(5):612–5.Google Scholar
  93. 93.
    Wood P, Deakin S. Total ankle replacement: the results in 200 ankles. J Bone Joint Surg. 2003;85(3):334–41.CrossRefGoogle Scholar
  94. 94.
    Anderson T, Montgomery F, Carlsson Å. Uncemented STAR total ankle prostheses: three to eight-year follow-up of fifty-one consecutive ankles. J Bone Joint Surg Am. 2003;85(7):1321–9.CrossRefGoogle Scholar
  95. 95.
    Hopgood P, Kumar R, Wood PL. Ankle arthrodesis for failed total ankle replacement. J Bone Joint Surg. 2006;88(8):1032–8. Scholar
  96. 96.
    Hintermann B, Valderrabano V, Dereymaeker G, Dick W. The HINTEGRA ankle: rationale and short-term results of 122 consecutive ankles. Clin Orthop Relat Res. 2004;424:57–68.CrossRefGoogle Scholar
  97. 97.
    Hanna RS, Haddad SL, Lazarus ML. Evaluation of periprosthetic lucency after total ankle arthroplasty: helical CT versus conventional radiography. Foot Ankle Int. 2007;28(8):921–6.CrossRefGoogle Scholar
  98. 98.
    Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004;86(6):1172–8.CrossRefGoogle Scholar
  99. 99.
    Bai L-B, Lee K-B, Song EK, Yoon TR, Seon JK. Total ankle arthroplasty outcome comparison for post-traumatic and primary osteoarthritis. Foot Ankle Int. 2010;31(12):1048–56.CrossRefGoogle Scholar
  100. 100.
    Kim B, Choi W, Kim Y, Lee J. Total ankle replacement in moderate to severe varus deformity of the ankle. Bone Joint J. 2009;91(9):1183–90.Google Scholar
  101. 101.
    Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, Alliman KJ, Alvine FG, et al. The Agility total ankle arthroplasty: seven to sixteen-year follow-up. J Bone Joint Surg Am. 2004;86(6):1161–71.CrossRefGoogle Scholar

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© ISAKOS 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryYonsei University College of MedicineSeoulSouth Korea

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