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. 2020 Nov 30;12(3):8279. doi: 10.4081/or.2020.8279

Modern total ankle arthroplasty versus ankle arthrodesis: A systematic review and meta-analysis

Cort D Lawton 1,✉, Adam Prescott 1, Bennet A Butler 1, Jakob F Awender 1, Ryan S Selley 1, Robert G Dekker II 1, Earvin S Balderama 2, Anish R Kadakia 1
PMCID: PMC7726823  PMID: 33312482

Abstract

The controversy in surgical management of end-stage tibiotalar arthritis with Total Ankle Arthroplasty (TAA) versus Ankle Arthrodesis (AA) has grown in parallel with the evolution of both procedures. No randomized controlled trials exist due to the vast differences in surgical goals, patient expectations, and complication profiles between the two procedures. This makes high quality systematic reviews necessary to compare outcomes between these two treatment options. The aim of this study was to provide a systematic review with meta-analysis of publications reporting outcomes, complications, and revision data following third-generation TAA and/or modern AA published in the past decade. Thirtyfive articles met eligibility criteria, which included 4312 TAA and 1091 AA procedures. This review reports data from a mean follow-up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort. There was no significant difference in overall complication rate following TAA compared to AA (23.6% and 25.7% respectively, P-value 0.31). Similarly, there was no significant difference in revision rate following TAA compared to AA (7.2% and 6.3% respectively, P-value 0.65). Successful treatment of end-stage tibiotalar arthritis requires an understanding of a patients’ goals and expectations, coupled with appropriate patient selection for the chosen procedure. The decision to proceed with TAA or AA should be made on a case-by-case basis following an informed discussion with the patient regarding the different goals and complication profiles for each procedure.

Key words: Total ankle arthroplasty, ankle arthrodesis, tibiotalar arthritis, ankle arthritis

Introduction

The controversy in surgical management of end-stage tibiotalar arthritis with Total Ankle Arthroplasty (TAA) versus Ankle Arthrodesis (AA) has grown over the past few decades, in parallel with the evolution of both procedures. Surgical goals, patient expectations, and complication profiles are vastly different between these two procedures, making randomized controlled trials difficult to execute. This lack of highquality data has resulted in debate over which procedure should be the gold standard treatment for a patient with end-stage tibiotalar arthritis.

Ankle arthrodesis has previously been accepted as the gold standard treatment over the past few decades. Results following AA are predictable, with reliable pain relief once fusion is achieved, and good to excellent intermediate-term outcomes.1-6 However, critics of AA cite high complication rates, alterations in foot and ankle biomechanics, and variability in long-term results.7-10 There is concern that elimination of a major motion segment through fusion places unnatural stress on adjacent joints, accelerating adjacent joint degeneration.8,9 Furthermore, arthrodesis has been shown to negatively affect functional status at longterm follow-up.11 For these, and other reasons, authors have pushed for the evolution of treatment with joint-sparing procedures, specifically TAA.

First-generation TAA implants were plagued with unacceptably high complication rates and poor long-term survivorship, resulting in significant resistance to accept this treatment option.12 Since the introduction of the first-generation TAA implants, surgical techniques and implant design has significantly evolved. Studies reporting results following treatment with modern third-generation TAA designs show improved survivorship over older generation implants, and more favorable functional outcomes compared to patients treated with AA.13-19 Despite these encouraging early findings, long-term outcome data following treatment with a third-generation TAA are lacking.

There has been significant evolution of both procedures over the past few decades. Greater attention to soft tissue management during AA, including the popularization to arthroscopic fusion techniques, have led to lower complication rates, higher fusion rates, and more predictable outcomes following arthrodesis.1,4,20 Likewise, current third-generation TAA designs and refined surgical techniques have improved outcomes, and lowered complication rates following TAA.15,16,21 To date, there are no randomized controlled trials comparing outcomes following TAA to AA. Due to the vast difference between these two treatment options, a randomized controlled trial comparing the two is unlikely. As both procedures continue to evolve, systematic reviews will prove necessary to help guide decision making when treating patients with end-stage tibiotalar arthritis. Current systematic reviews include outdated TAA implants and AA techniques, limiting analysis of the current state of both procedures. In this study we report data from a systematic review and meta-analysis comparing outcomes following TAA and AA with modern surgical techniques and implant designs from studies published in the past decade.

Materials and Methods

The PRISMA guidelines were followed to conduct this systematic review and metaanalysis.

Table 1.

Demographics.

Study Year published Study design Recruitment period Number ankles Prosthesis / fusion technique (n) Mean age in years (range) Mean follow up in years (range) Post-traumatic, % Idiopathic, % Inflammatory, % Other, %
Total Ankle Arthroplasty
Gross et al. 2016 Prospective 2007-2013 455 INBONE (219) / STAR (151) / Salto (85) 62.0 3.7 71.9(327) 13.6(62) 8.1(37) 6.4(29)
Demetracopoulos et al. 2015 Prospective 2007-2011 395 INBONE (214) / STAR (104) / Salto (77) 63.1 3.5 (2-5.4) 69.1(273) 17.7(70) 5.8(23) 7.3(29)
Lewis et al. 2015 Prospective 2007-2012 249 INBONE 63.2 3.3 69.5(173) 20.5(51) 4.0(10) 6.0(15)
Daniels et al. 2015 Prospective 2001-2005 111 STAR 61.9 +/- 11.7 7.6 +/- 2.3 (2-9.6) 54.1(60) 14.4(16) 19.8(22) 11.7(13)
Hsu et al. 2015 Retrospective 2008-2012 59 INBONE 57.2 +/- 11.2 (32-79) 2.9 (2-5.4) 59.3(35) 33.9(20) 6.8(4) 0.0 (0)
Adams et al. 2014 Retrospective 2007-2010 194 INBONE 64.0 (23-88) 3.7 (2.2-5.5) 68.0(132) 22.2(43) 4.1(8) 5.7(11)
Choi et al. 2014 Retrospective 2004-2011 173 HINTEGRA 66.0 +/- 7.9 (43-84) 5.0 (2-9.3) NR NR NR NR
Gaudot et al. 2014 Retrospective 1997-2009 66 Salto 64.0 (38-79) 2.0 (0.3-5) 45.5(30) 15.2(10) 6.1(4) 33.3(22)
Deleu et al. 2014 Retrospective 2008-2012 50 HINTEGRA 54.9 +/- 12.2 (30-77) 3.8 (2-6) 68.0(34) 14.0(7) 18.0(9) 0.0 (0)
Barg et al. 2013 Retrospective 2000-2010 722 HINTEGRA 61.1 +/- 12.6 (19.8-90) 6.3 +/- 2.9 (2-12.2) 79.1(571) 9.6(69) 0.0 (0) 11.4(82)
Rodrigues-Pinto et al. 2013 Prospective 2005-2011 119 Salto 55.6 (24-81) 3.2 (1.5-6) 65.5(78) 10.1(12) 24.4(29) 0.0 (0)
Noelle et al. 2013 Retrospective 2005-2010 100 STAR 63.0 (41-80) 3.0 81.0(81) 8.0(8) 9.0(9) 2.0(2)
Brunner et al. 2013 Prospective 1996-2000 77 STAR 56.9 +/- 13.9 (22.3-84.5) 12.4 (10.8-14.9) 70.1(54) 29.9(23) 0.0 (0) 0.0 (0)
Nodzo et al. 2013 Retrospective 2007-2011 75 Salto 60.6 (41-82) 3.6 (2-6.1) 49.3(37) 40.0(30) 10.7(8) 0.0 (0)
Schweitzer et al. 2013 Prospective 2007-2009 67 Salto 63.0 (34-86) 2.8 (2-4.5) 76.1(51) 16.4(11) 6.0(4) 1.5(1)
Bleazey et al. 2013 Retrospective 2008-2011 58 INBONE 59.5 +/- 10.9 NR 48.3(28) 43.1(25) 8.6(5) 0.0 (0)
Nunley et al. 2012 Retrospective 1998-2008 82 STAR 63.3 +/- 10.1 5.1 (2-9) 52.4(43) 34.1(28) 12.2(10) 1.2(1)
Schenk et al. 2011 Prospective 2001-2007 218 Salto 56.8 +/- 11.2 3.5 59.2(129) 29.4(64) 11.0(24) 0.5(1)
Bonnin et al. 2011 Retrospective 1997-2000 98 Salto 56.0 +/- 13.0 (26-81) 8.9 (6.8-11.1) 43.9(43) 14.3(14) 27.6(27) 14.3(14)
Mann et al. 2011 Prospective 1998-2000 84 STAR 61.4 (33-86) 9.1 (2.6-11) 56.0(47) 25.0(21) 17.9(15) 1.2(1)
Bai et al. 2010 Retrospective 2005-2007 67 HINTEGRA 56.0 (27-77) 3.2 (2.1-4.5) 55.2(37) 44.8(30) 0.0 (0) 0.0 (0)
Saltzman et al. 2009 Prospective 2000-2006 593 STAR 63.1 +/- 11.9 NR 58.2(345) 26.5(157) 8.6(51) 6.7(40)
Wood et al. 2008 Prospective 1993-2000 200 STAR 59.6 (18-83) 7.3 (5-13) 12.5(25) 28.0(56) 59.5(119) 0.0 (0)
Total / Adjusted Mean 2008-2016 Prospective (11) Retrospective (12) 1993-2013 4312 INBONE (993) STAR (1502) Salto (805) HINTEGRA 1012) 61.4 (54.9-66) 4.9 (2-12.4) 63.6 (2633/4139) 20.0 (827/4139) 10.1 (418/4139)6.3 (261/4139)
Ankle Arthrodesis
Chalayon et al. 2015 Retrospective 2002-2013 215 Open 56.0 +/- 14.0 (18-88) NR 74.6(156) 0.0 (0) 0.0 (0) 27.4(59)
Nodzo et al. 2014 Retrospective 2006-2011 56 Open 49.4 0.3 73.2(41) 21.4(12) 0.0 (0) 5.4(3)
Gordon et al. 2013 Retrospective 2004-2009 82 Open 56.1 (18-75) 3.9 (0.6-8.3) 63.4(52) 20.7(17) 8.5(7) 7.3(6)
Townshend et al. 2013 Retrospective NR 30 Open 54.7 +/- 11.5 NR 13.3(4) 63.3(19) 13.3(4) 10.0(3)
Hendrickx et al. 2011 Retrospective 1990-2005 66 Open 47.0 +/- 13.0 9.0 +/- 4.1 87.9(58) 0.0 (0) 0.0 (0) 12.1(8)
Zwipp et al. 2010 Retrospective 1994-2000 94 Open 53.0 (34-69) 5.9 (4.8-7.8) 88.3(83) 5.3(5) 0.0 (0) 6.4(6)
Saltzman et al. 2009 Prospective 2000-2005 66 Open 57.1 +/- 12.3 NR 65.2(43) 28.8(19) 6.5(4) 0.0 (0)
Nielsen et al. 2008 Retrospective 1994-2005 49 Open 53.0 (20-84) NR 65.3(32) 20.4(10) 4.1(2) 10.2(5)
Muckley et al. 2007 Retrospective 1993-2001 137 Open 49.0 (21-79) 3.5 (1-7.5) 98.5(135) 1.5(2) 0.0 (0) 0.0 (0)
Jain et al. 2016 Retrospective 2007-2013 52 Arthroscopic 59.4 (27-80) 2.7 (0.7-6.5) 73.1(38) 9.6(5) 5.8(3) 11.5(6)
Townshend et al. 2013 Retrospective NR 30 Arthroscopic 59.4 +/- 10.6 NR 76.7(23) 13.3(4) 3.3(1) 6.7(2)
Yoshimura et al. 2012 Retrospective 2005-2010 50 Arthroscopic 63.0 (40-81) 3.5 (1.2-6.6) 78.0(39) 0.0 (0) 4.0(2) 18.0(9)
Dannawi et al. 2010 Retrospective 1999-2007 55 Arthroscopic 63.0 +/- 12.2 (32-84) 4.7 +/- 1.7 (1.7-7.7) 43.6(24) 36.4(20) 14.5(8) 5.5(3)
Nielsen et al. 2008 Retrospective 1994-2005 58 Arthroscopic 51.0 (23-80) NR 63.8(37) 13.8(8) 10.3(6) 12.1(7)
Gougoulias et al. 2007 Retrospective 1998-2005 78 Arthroscopic 54.0 +/- 14.0 (18-81) 1.8 (0.5-5.7) 48.7(38) 38.5(30) 5.1(4) 7.7(6)
Total / Adjusted Mean 2016-2007 Prospective (1) Retrospective (14) 1990-2013 1118 Open (9) Arthroscopic (6) 54.4 (47-63) 4.0 (0.3-9) 71.8 (803/1118) 13.5 (151/1118) 3.7 (41/1118)11.0 (123/1118)
Open 2015-2007 Prospective (1) Retrospective (8) 1990-2013 795 Open (9) 53.1 (47-57.1) 4.5 (0.3-9) 76.0 (604/795) 10.6 (84/795) 2.1 (17/795) 11.3 (90/795)
Arthroscopic 2016-2007 Prospective (0) Retrospective (6) 1994-2013 323 Arthroscopic (6) 57.8 (51-63) 3.0 (1.8-4.7) 61.6 (199/323) 20.7 (67/323) 7.4 (24/323) 10.2 (33/323)
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Search Strategy

An electronic PubMed database search was performed to identify publications reporting outcomes following TAA and/or AA published in the English language from January 1st, 2006 until July 31st, 2016. The search terms utilized include: total ankle arthroplasty; ankle replacement; ankle arthrodesis; and ankle fusion. To ensure inclusion of all relevant publications, the electronic database search was supplemented by a manual review of references in all reviews and primary full text articles identified. Two authors screened all titles, abstracts, and selected full text articles independently, with studies determined to be relevant, irrelevant, or uncertain according to study eligibility criteria. Conflicts were resolved by consensus discussion.

Selection of Articles

The review sought primary research publications reporting complication and/or re-operation rates following TAA or AA, which could be extracted from the general data. Article titles and abstracts were screened using three general criteria: i) primary research data; ii) the intervention included TAA using a third-generation implant approved for use in the United States (Implants included: HINTEGRA, STAR, Salto, INBONE) or AA achieved with internal fixation through an open or arthroscopic technique; iii) complication, re-operation, and/or revision rates were reported.

Article titles and abstracts satisfying the criteria above were selected for full text review. Full text articles were then examined and selected based on the inclusion and exclusion criteria below.

Inclusion criteria: i) primary research data; ii) published in the English language from January 1st, 2006 to July 31st, 2016; iii) report on a minimum of 50 ankles; iv) the intervention consisted of arthrodesis with internal fixation using open or arthroscopic techniques or TAA using a third-generation implant approved for use in the United States (Implants included: HINTEGRA, STAR, Salto, INBONE); v) complication, re-operation, and/or revision rates were reported.

Exclusion criteria included: i) non-generalizable patient cohorts; ii) outcomes following revision cases; iii) kinship data (for publications on the same patient population the largest series was used).

Quality Assessment

The methodology of studies included in this review was evaluated with the modified Coleman Methodology Score (CMS) as utilized in previous studies (Supplementary Table S1).22,23 Two authors independently assessed the methodological quality of each study, and discrepancies in CMS scores were reviewed by a third author, with conflicts resolved by consensus discussion. The CMS score is between 0 and 100; with 100 indicating the study has a robust design and largely avoids biases or confounding factors (Supplementary Table S2).

Data Extraction

The study demographic, complication, re-operation, failure, and revision data were extracted from the selected full text articles. For continuous data, preferably the mean, range, and standard deviation were extracted. If not presented in the study, the mean and range were calculated whenever possible. Protocol-defined data from each eligible study were extracted and confirmed by two independent authors, and differences were resolved prior to data entry. Demographic data for included studies can be seen in Table 1 (demographics metaanalysis results can be seen in Table 2).

Complication, non-revision re-operation, and revision data were extracted from each study (Tables 3-6). There was significant heterogeneity between studies with respect to reporting this data. In cases where data was not explicitly stated within an article, attempts were made to calculate these rates using data reported within the study. The studies included in this review were inconsistent when reporting the complications of interest. When a data point of interest was not explicitly stated or could not be confirmed within the text, it was designated in the tables as Not Reported (NR).

Intra-operative and post-operative fractures were combined for our analysis, and reported as a single overall fracture rate. Failure rate was defined as a TAA requiring revision of implants, conversion to fusion, or below knee amputation or an AA resulting in non-union or requiring revision fusion or below knee amputation regardless of whether or not a patient decided to pursue further surgical intervention. Revision of TAA was defined as removal of the tibial and/or talar component with subsequent placement of an antibiotic spacer, revision of metal components, conversion to arthrodesis, or amputation. Revision AA was defined as return to the operating room for revision fusion or conversion to amputation.

Statistical Analysis

Data from each study was pooled for analysis. Cumulative study totals and adjusted means were reported for demographic, complication, and revision data. Adjusted means were calculated for mean follow-up and mean age by summing each study mean multiplied by the number of ankles in their study and dividing the sum by the total number of ankles in all studies reporting the variable of interest to obtain an appropriately weighted mean. Cumulative adjusted complication and revision rates were calculated by taking the number of specific complications divided by the sum of all cases for only those studies reporting the outcome of interest.

We then performed a meta-analysis using a random-effects meta-regression model for all data. Mean age and mean follow- up were two quantitative outcomes reported by each study, however many did not report corresponding standard errors. For statistical meta-analysis to be possible, missing standard deviations were imputed with the maximum reported standard deviation. Effect sizes were measured using log transformed means for quantitative outcomes (mean age and mean follow-up), and logit transformed proportions for categorical outcomes (diagnosis, complication, and re-operation rates). For each outcome, a random-effects meta-regression model was independently fitted to each subset of studies defined by type of surgical intervention (TAA, AA, open AA, arthroscopic AA). A Wald-type test was then performed to test whether the estimates from any two of the subset models are significantly different from each other. All statistical analysis was performed using R version 3.3.2 (The R Foundation for Statistical Computing, https://www.r-project.org/).

Table 2.

Demographics meta-analysis results.

Variable TAA vs. Combined TAA vs.Open TAA vs. Arthroscopic Open AA vs. Arthroscopic
AA p-value AA p-value AA p-value AA p-value
Mean age in years Ã0.01* Ã0.01* 0.26 0.02*
Mean follow up in years 0.30 0.78 0.04* 0.39
Diagnosis
    Post-traumatic 0.15 0.18 0.58 0.36
    Idiopathic 0.13 0.16 0.56 0.40
    Inflammatory 0.06 0.02* 0.48 0.06
    Other Ã0.01* 0.04* < 0.01* 0.48
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* Indicates statistically significant difference (P-value < 0.05).

Table 3.

Complications and failure rates.

Study Number of ankles Prosthesis / fusion technique (n) Wound complication (n), % Deep infection (n), % Intra- and post-operative fracture (n), % TAA aseptic loosening / AA nonunion (n), % Overall complication rate (n), % Failure rate (n), %
Total Ankle Arthroplasty
Gross et al. 455 INBONE (219) / STAR (151) / Salto (85) NR 1.5(7) NR NR 14.1(64) 3.1(14)
Demetracopoulos et al. 395 INBONE (214) / STAR (104) / Salto (77) 6.6(26) 0.8(3) NR NR NR 5.1(20)
Lewis et al. 249 INBONE 8.4(21) 1.2(3) 3.6(9) 4.0(10) NR 8.8(22)
Daniels et al. 111 STAR 3.6(4) NR 0.9(1) NR NR 11.7(13)
Hsu et al. 59 INBONE NR 0.0 (0) 3.4(2) NR 44.1(26) 8.5(5)
Adams et al. 194 INBONE 10.3(20) 2.6(5) 3.6(7) 0.5(1) NR 10.8(21)
Choi et al. 173 HINTEGRA 7.5(13) 0.6(1) 0.6(1) 2.9(5) NR 3.5(6)
Gaudot et al. 66 Salto 3.0(2) 0.0 (0) 12.1(8) 0.0 (0) 19.7(13) 1.5(1)
Deleu et al. 50 HINTEGRA NR 4.0(2) NR NR NR 10.0(5)
Barg et al. 722 HINTEGRA NR 0.4(3) NR 5.8(42) NR 8.4(61)
Rodrigues-Pinto et al. 119 Salto 3.4(4) 1.7(2) 5.0(6) 0.0 (0) 14.3(17) 1.7(2)
Noelle et al. 100 STAR 6.0(6) 4.0(4) 2.0(2) 6.0(6) NR 11.0(11)
Brunner et al. 77 STAR 1.3(1) 1.3(1) NR 11.7(9) NR 37.7(29)
Nodzo et al. 75 Salto NR 1.3(1) 8.0(6) NR NR 1.3(1)
Schweitzer et al. 67 Salto 4.5(3) 0.0 (0) 4.5(3) 4.5(3) 34.3(23) 4.5(3)
Bleazey et al. 58 INBONE 13.8(8) 1.7(1) 6.9(4) 0.0 (0) 27.6(16) 1.7(1)
Nunley et al. 82 STAR NR NR NR NR NR 6.1(5)
Schenk et al. 218 Salto 2.3(5) 1.4(3) 2.3(5) 1.8(4) NR 16.5(36)
Bonnin et al. 98 Salto NR 1.0(1) NR 1.0(1) NR 7.1(7)
Mann et al. 84 STAR NR 3.6(3) 8.3(7) 2.4(2) 25.0(21) 10.7(9)
Bai et al. 67 HINTEGRA 11.9(8) 1.5(1) 11.9(8) 0.0 (0) 47.8(32) 1.5(1)
*Saltzman et al. 593 STAR 20.9(124) 1.2(7) 13.5(80) NR NR 4.7(28)
Wood et al. 200 STAR 2.5(5) NR 9.5(19) 12.5(25) 32.5(65) 12.0(24)
Total / Adjusted Mean 4312 INBONE (993) STAR (1502) Salto (805) HINTEGRA (1012) 9.3 (250/2687) 1.2 (48/3919) 6.9 (168/2433) 4.3 (108/2492) 23.6 (277/1175) 7.5 (325/4312)
Ankle Arthrodesis
Chalayon et al 215 Open 14.4(31) 5.1(11) 0.9(2) 9.3(20) 40.9(88) 9.3(20)
Nodzo et al. 56 Open 3.6(2) 1.8(1) NR 12.5(7) NR 12.5(7)
Gordon et al. 82 Open 2.4(2) 0.0 (0) 1.2(1) 0.0 (0) 20.7(17) 0.0 (0)
*Townshend et al. 30 Open 3.3(1) NR NR 3.3(1) NR 3.3(1)
Hendrickx et al. 66 Open 0.0 (0) 1.5(1) 0.0 (0) 6.1(4) 10.6(7) 9.1(6)
Zwipp et al. 94 Open 5.3(5) 0.0 (0) 0.0 (0) 1.1(1) 9.6(9) 2.1(2)
*Saltzman et al. 66 Open 6.1(4) 1.5(1) 3.0(2) NR NR 10.6(7)
*Nielsen et al. 49 Open NR 4.1(2) NR 16.3(8) NR 16.3(8)
Muckley et al. 110 Open 10.0(11) 7.3(8) 0.9(1) 14.5(16) 19.1(21) 14.5(16)
Jain et al. 52 Arthroscopic 0.0 (0) 0.0 (0) 0.0 (0) 7.7(4) 30.8(16) 7.7(4)
*Townshend et al. 30 Arthroscopic 3.3(1) NR NR 3.3(1) NR 3.3(1)
Yoshimura et al. 50 Arthroscopic NR 0.0 (0) NR 8.0(4) NR 8.0(4)
Dannawi et al. 55 Arthroscopic 5.5(3) 0.0 (0) 0.0 (0) 9.1(5) 23.6(13) 9.1(5)
*Nielsen et al. 58 Arthroscopic NR 1.7(1) NR 5.2(3) NR 5.2(3)
Gougoulias et al. 78 Arthroscopic 1.3(1) 0.0 (0) 0.0 (0) 2.6(2) 28.2(22) 2.6(2)
Total / Adjusted Mean 1091 Open (9) Arthroscopic (6) 6.5 (61/934) 2.4 (25/1031) 0.7 (6/818) 7.4 (76/1025) 25.7 (193/752) 7.9 (86/1091)
Open 768 Open (9) 7.8 (56/719) 3.3 (24/738) 0.9 (6/633) 8.1 (57/702) 25.0 (142/567) 8.7 (67/768)
Arthroscopic 323 Arthroscopic (6) 2.3 (5/215) 0.3 (1/293) 0.0 (0/185) 5.9 (19/323) 27.6 (51/185) 5.9 (19/323)
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Results

Article Selection

The initial search yielded 325 abstracts, of which 136 full text articles were retrieved for further review. Thirty-five articles met all eligibility criteria for inclusion in this study.1-6,14-16,20,21,24-47 Of the included studies, 23 reported on TAA and 15 on AA (6 arthroscopic AA, 9 open AA).

Quality Assessment

The quality of all articles included in this study was assessed using the modified Coleman Methodology Score (CMS). Results of the modified CMS for each study can be seen in Supplementary Table S2. The mean CMS score for the TAA studies was 59.4 (Range: 39-81) compared to 41.4 (Range: 29-53) for the AA studies (pÃ0.01).

Demographics

Demographic data can be seen in Table 1. The included studies report on 4312 TAA and 1118 AA patients (795 open, 323 arthroscopic). Patients who underwent TAA were significantly older than the AA patients (61.4 years and 54.4 years respectively, pÃ0.01). There was no significant difference in mean follow-up between the TAA and AA studies (4.9 years and 4.0 years respectively, p-value 0.30). Post-traumatic arthritis was the most common diagnosis for both the TAA and AA groups. Demographics meta-analysis results can be seen in Table 2.

Complications and Failure Rates

The most common complication for patients who underwent TAA was wound complication (9.3%) followed by intra- or post-operative fracture (6.9%). Nonunion (7.4%) was the most common complication for patients who underwent AA, followed by wound complication (6.5%). See Table 3 for complication and failure rate data. Deep infection was significantly more common following open AA compared to TAA (pÃ0.01) and arthroscopic AA (p=0.04). Intra- and post-operative fractures were significantly more common following TAA compared to AA (pÃ0.01), while nonunion was significantly more common in AA patients than aseptic loosening in TAA patients (pÃ0.01). There was no significant difference in overall complication rate or failure rate between the two procedures. Complication and failure rate meta-analysis results can be seen in Table 4.

Re-Operation and Revision Rates

There was no significant difference in the non-revision re-operation rate following TAA compared to AA (11.3% and 9.8% respectively, p-value 0.47). Similarly, there was no significant difference in the overall revision rate following TAA compared to AA (7.2% and 6.3% respectively, p-value 0.65). There was no difference in the rate of revision to amputation between the two procedures (p-value 0.30). See Table 5 for reoperation and revision rate data, and Table 6 for meta-analysis results.

Discussion and Conclusions

TAA and AA continue to evolve as surgical treatment options for end-stage tibiotalar arthritis. With the growth and evolution of both procedures, the debate regarding the best surgical option has persisted. Randomized controlled trials are difficult to execute given the vast differences in surgical goals, patient expectations, and complication profiles between these two procedures. This lack of high quality data contributes to the ongoing debate over which procedure should be the gold standard treatment for end-stage tibiotalar arthritis, and highlights the importance of systematic reviews to provide data to help guide the discussion of surgical options for patients presenting with this pathology. Our review compares complication and revision rates between modern third-generation TAA implants and current AA techniques to more accurately reflect the current state of these treatment options.

Previous systematic reviews are limited, drawing few meaningful conclusions, and predominately focus on clinical outcomes and revision rates following TAA and AA. Haddad et al. reported a 7% revision rate following TAA compared to a 9% revision rate following AA at a mean follow- up of 5.1 years.48 The authors conclude the intermediate outcome of TAA appears to be similar to that of AA. Jordan et al. concluded the lack of high quality literature was insufficient to determine which treatment is superior for the management of end-stage tibiotalar arthritis.49 Van Heiningen et al. reported a systematic review in rheumatoid arthritis patients, finding an 11% re-operation rate following TAA compared to 12% following AA, with both interventions showing clinical improvement. 50 A limitation of previous systematic reviews is the inclusion of outdated TAA implants and AA techniques, which have evolved significantly over the past few decades.

Our data suggests there is a similar wound complication rate following TAA compared to open AA (9.3% and 7.8% respectively, p-value 0.85). Despite not reaching statistical significance, the wound complication rate following arthroscopic AA was lower than that of TAA and open AA at 2.3%. However, there were significantly fewer deep infections following arthroscopic AA compared to open AA (0.3% and 3.3% respectively, p-value < 0.01). Arthroscopic AA is becoming popularized, due to this techniques ability to achieve fusion, while limiting the approach related morbidity and soft tissue dissection. 4,20,44,51-53 Nielsen et al. found similar union rates; with arthroscopic AA patients having shorter hospital stays compared to open AA patients.4 Duan et al. reported a low wound complication rate of 1.5% in 68 arthroscopic ankle fusions. As fusion techniques continue to improve, the potential exists for continued improvement in fusion rates and lower complication rates than what have been seen with older techniques.

Table 4.

Complications and failure rates meta-analysis data.

Variable TAA vs. Combined TAA vs.Open TAA vs. Arthroscopic Open AA vs. Arthroscopic
AA p-value AA p-value AA p-value AA p-value
Wound complication 0.45 0.85 0.14 0.21
Deep infection 0.12 < 0.01* 0.58 0.04*
Intra- and post-operative fracture < 0.01* < 0.01* 0.02* 0.64
TAA aseptic loosening / AA nonunion < 0.01* < 0.01* 0.07 0.09
Overall complication rate 0.31 0.19 0.95 0.16
Failure 0.23 0.10 0.68 0.07
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* Indicates statistically significant difference (P-value Ã0.05).* Indicates statistically significant difference (P-value Ã0.05).

Table 5.

Re-operation and revision rates.

Study Number of ankles Mean follow up in years (range) Prosthesis / fusion technique (n) Non-revision re-operation rate, % Overall revision rate Revision Revision to TAA Revision rate, % Revision to AA Revision to amputation
Total Ankle Arthroplasty
Gross et al. 455 3.7 INBONE (219) / STAR (151) / Salto (85) NR 3.1(14) NR NR NR
Demetracopoulos et al. 395 3.5 (2-5.4) INBONE (214) / STAR (104) / Salto (77) 9.6(38) 5.1(20) 2.3(9) 2.5(10) 0.3(1)
Lewis et al. 249 3.3 INBONE 14.5(36) 8.4(21) 4.4(11) 3.6(9) 0.4(1)
Daniels et al. 111 7.6 +/- 2.3 (2-9.6) STAR 20.7(23) 11.7(13) 3.6(4) 7.2(8) 0.9(1)
Hsu et al. 59 2.9 (2-5.4) INBONE 23.7(14) 8.5(5) 8.5(5) 0.0 (0) 0.0 (0)
Adams et al. 194 3.7 (2.2-5.5) INBONE 11.0(21) 6.2(12) 2.1(4) 3.6(7) 0.5(1)
Choi et al. 173 5.0 (2-9.3) HINTEGRA NR 3.5(6) 2.9(5) 0.6(1) 0.0 (0)
Gaudot et al. 66 2.0 (0.3-5) Salto 3.0(2) 1.5(1) 0.0 (0) 1.5(1) 0.0 (0)
Deleu et al. 50 3.8 (2-6) HINTEGRA 18.0(9) 10.0(5) 4.0(2) 6.0(3) 0.0 (0)
Barg et al. 722 6.3 +/- 2.9 (2-12.2) HINTEGRA NR 8.4(61) 7.5(54) 1.0(7) 0.0 (0)
Rodrigues-Pinto et al. 119 3.2 (1.5-6) Salto 5.0(6) 0.8(1) 0.0 (0) 0.8(1) 0.0 (0)
Noelle et al. 100 3.0 STAR 10.0(10) 11.0(11) 7.0(7) 4.0(4) 0.0 (0)
Brunner et al. 77 12.4 (10.8-14.9) STAR 54.5(42) 37.7(29) 35.1(27) 2.6(2) 0.0 (0)
Nodzo et al. 75 3.6 (2-6.1) Salto 16.0(12) 1.3(1) 1.3(1) 0.0 (0) 0.0 (0)
Schweitzer et al. 67 2.8 (2-4.5) Salto 10.4(7) 1.5(1) 1.5(1) 0.0 (0) 0.0 (0)
Bleazey et al. 58 NR INBONE 8.6(5) 1.7(1) 1.7(1) 0.0 (0) 0.0 (0)
Nunley et al. 82 5.1 (2-9) STAR 13.4(11) 6.1(5) NR NR NR
Schenk et al. 218 3.5 Salto NR 16.5(36) 11.0(24) 5.5(12) 0.0 (0)
Bonnin et al. 98 8.9 (6.8-11.1) Salto 17.3(17) 7.1(7) 1.0(1) 6.1(6) 0.0 (0)
Mann et al. 84 9.1 (2.6-11) STAR 6.0(5) 10.7(9) 4.8(4) 6.0(5) 0.0 (0)
Bai et al. 67 3.2 (2.1-4.5) HINTEGRA 7.5(5) 1.5(1) 1.5(1) 0.0 (0) 0.0 (0)
Saltzman et al. 593 NR STAR 6.9(41) 4.7(28) NR NR NR
Wood et al. 200 7.3 (5-13) STAR 3.0(6) 12.0(24) 2.0(4) 10.0(20) 0.0 (0)
Total / Adjusted Mean 4312 4.9 (2-12.4) INBONE (993) STAR (1502) Salto (805) HINTEGRA (1012) 11.3 (310/2744) 7.2 (312/4312) 5.2 (165/3182) 3.0 (96/3182) 0.1 (4/3182)
Ankle Arthrodesis
Chalayon et al. 215 NR Open 11.2(24) 7.9(17) 0.0 (0) 7.4(16) 0.5(1)
Nodzo et al. 56 0.3 Open NR 12.5(7) 0.0 (0) 12.5(7) 0.0 (0)
Gordon et al. 82 3.9 (0.6-8.3) Open 14.6(12) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0)
Townshend et al. 30 NR Open 0.0 (0) 3.3(1) 0.0 (0) 3.3(1) 0.0 (0)
Hendrickx et al. 66 9.0 +/- 4.1 Open 0.0 (0) 9.1(6) 0.0 (0) 9.1(6) 0.0 (0)
Zwipp et al. 94 5.9 (4.8-7.8) Open 3.2(3) 1.1(1) 0.0 (0) 1.1(1) 0.0 (0)
Saltzman et al. 66 NR Open 1.5(1) 10.6(7) NR NR NR
Nielsen et al. 49 NR Open 20.4(10) 6.1(3) 0.0 (0) 6.1(3) 0.0 (0)
Muckley et al. 110 3.5 (1-7.5) Open NR 10.0(11) 0.0 (0) 10.0(11) 0.0 (0)
Jain et al. 52 2.7 (0.7-6.5) Arthroscopic 3.8(2) 7.7(4) 0.0 (0) 7.7(4) 0.0 (0)
Townshend et al. 30 NR Arthroscopic 6.7(2) 3.3(1) 0.0 (0) 3.3(1) 0.0 (0)
Yoshimura et al. 50 3.5 (1.2-6.6) Arthroscopic 12.0(6) 6.0(3) 0.0 (0) 6.0(3) 0.0 (0)
Dannawi et al. 55 4.7 +/- 1.7 (1.7-7.7) Arthroscopic 9.1(5) 9.1(5) 0.0 (0) 9.1(5) 0.0 (0)
Nielsen et al. 58 NR Arthroscopic 25.9(15) 3.4(2) 0.0 (0) 3.4(2) 0.0 (0)
Gougoulias et al. 78 1.8 (0.5-5.7) Arthroscopic 14.1(11) 1.3(1) 0.0 (0) 1.3(1) 0.0 (0)
Total / Adjusted Mean 1091 4.0 (0.3-9) Open (9) Arthroscopic (6) 9.8 (91/925) 6.3 (69/1091) 0.0 (0/1025) 6.0 (61/1025) 0.1 (1/1025)
Open 768 4.6 (0.3-9) Open (9) 8.3 (50/602) 6.9 (53/768) 0.0 (0/702) 6.4 (45/702) 0.1 (1/702)
Arthroscopic 323 3.0 (1.8-4.7) Arthroscopic (6) 12.7 (41/323) 5.0 (16/323) 0.0 (0/323) 5.0 (16/323) 0.0 (0/323)
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Table 6.

Re-operation and revision rates meta-analysis data.

Variable TAA vs. Combined TAA vs.Open TAA vs. Arthroscopic Open AA vs. Arthroscopic
AA p-value AA p-value AA p-value AA p-value
Non-Revision Re-Operation Rate 0.47 0.20 0.93 0.22
Overall Revision Rate 0.65 0.44 0.62 0.25
Revision to TAA < 0.01* < 0.01* 0.02* 0.61
Revision to AA < 0.01* < 0.01* 0.06 0.37
Revision to Amputation 0.30 0.54 0.29 0.64
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*Indicates statistically significant difference (P-value Ã0.05).

A similar evolution has been seen in TAA, with modern third-generation implants having improved survivorship over older generation designs.13-16 Our data shows a significantly lower rate of TAA aseptic loosening compared to AA nonunion (4.3% and 7.4% respectively, Pvalue Ã0.01); however, there was no significant difference in revision rates between the two procedures (P-value =0.65). Brunner et al. reported on 77 TAA patients and found an 11.7% aseptic loosening rate and 37.7% revision rate at a mean follow-up of 12.4 years, which are much higher than our systematic review averages.32 More studies on third-generation TAA implants with longer follow-up are required to compare aseptic loosening and revision rates with AA at long-term follow-up.

The current literature does not strongly favor either procedure for the treatment of end-stage tibiotalar arthritis in the general population. It is important for physicians to have knowledge of each treatments pros, cons, and complication profile to aid in counseling patients. The patient’s goals, expectations, and understanding of the differences between TAA and AA are important to consider when deciding on a treatment option. Successful treatment of endstage tibiotalar arthritis relies on appropriate patient selection, with various cases more appropriate for one treatment over the other. Ultimately, the decision to proceed with TAA or AA should be made on a caseby- case basis after an informed discussion with each patient.

There are multiple limitations of this study. The data reported is from a mean follow- up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort. Longer followup data remains necessary to determine if aseptic loosening rates and revision rates remain competitive with AA data at longer follow-up intervals. Furthermore, the methodological quality of the studies available for this analysis was poor as evident by the Coleman Methodology Scores (Supplementary Table S2). There is significant heterogeneity in the data reported in the included studies, with variations in complications reported and differences in definitions of non-revision re-operation and implant failure between articles. This made data extracting and analysis difficult and vulnerable to bias.

The current literature lacks high quality studies with long-term follow-up comparing modern TAA to AA techniques. Existing data does not strongly support one treatment over the other for the management of end-stage tibiotalar arthritis. Our data suggests at a mean follow-up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort, there is no significant difference in overall complication rate or revision rate. More data on third-generation TAA implants are necessary to compare failure and revision rates with AA at long-term follow-up. Successful treatment of end-stage tibiotalar arthritis requires an understanding of a patients goals and expectations, as well as appropriate patient selection for the chosen procedure. Ultimately, the decision to proceed with TAA or AA should be made on a case-by-case basis following an informed discussion with the patient regarding each procedure different goals and complication profiles.

Funding Statement

Funding: None.

References

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