Total ankle replacement vs arthrodesis: Which is better for end-stage ankle osteoarthritis?

Total ankle replacement (TAR) and ankle fusion (AF) or arthrodesis both improve the Manchester–Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores in patients with end-stage ankle osteoarthritis at 52 weeks after surgery, reports a study. The two surgical treatments also show similar clinical scores and number of harms.

However, TAR results in greater wound healing complications and nerve injuries, while AF leads to greater thromboembolism and nonunion.

This multicentre, parallel-group, open-label randomized trial, conducted in 17 National Health Service trusts across the UK, sought to determine which surgical treatment was superior in terms of clinical scores and adverse events.

Patients with end-stage ankle osteoarthritis, aged 50‒85 years, and suitable for either procedure were randomly assigned to TAR or AF surgical treatment. Change in MOXFQ-W/S domain scores between baseline and 52 weeks after surgery was the primary outcome. Blinding was not possible.

Three hundred three patients (mean age 68 years, 71 percent men) were randomized between 6 March 2015 and 10 January 2019. Of these, 21 withdrew before surgery, and 281 clinical scores were included in the analysis.

Both surgical treatment groups showed improvements in the mean MOXFQ-W/S scores at 52 weeks. The adjusted difference in the change in MOXFQ-W/S scores from baseline was ‒5.6 (95 percent confidence interval [CI], ‒12.5 to 1.4), indicating that TAR was better than AF, but the difference did not reach clinical or statistical significance.

Adverse event rates were similar between groups (109 vs 104), but more wound-healing issues occurred in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7 percent.

In a post hoc analysis, TAR demonstrated superiority of fixed-bearing over AF (‒11.1, 95 percent CI, ‒19.3 to ‒2.9).

This study was limited by its 52-week data and its pragmatic design, which created heterogeneity of implants and surgical techniques.

“End-stage ankle osteoarthritis causes severe pain and disability,” the investigators said.