CONSENSUS RECOMMENDATION End-stage ankle osteoarthritis (OA) causes substantial pain and loss of function, and when non-operative measures fail, surgery is primarily aimed at improving patient-reported outcomes (PROs). Both total ankle arthroplasty (TAA) and ankle arthrodesis (AA) produce meaningful improvements in symptoms and function, with uncertainty around the magnitude of between-group differences, supporting the view that either procedure can be used to improve outcomes in appropriately selected patients. While no primary literature evaluating ankle arthrodesis or total ankle arthroplasty meeting inclusion criteria was found in our CPG, systematic reviews/meta-analyses of modern implants and techniques report improved functional outcomes after both procedures, while highlighting different complication and reoperation profiles rather than a universal for one strategy. Therefore, in the absence of sufficient evidence to mandate one approach, the workgroup opinion that either AA or TAA can be utilized to treat patients with end-stage ankle arthritis is consistent with the current body of knowledge with the acknowledgement that each intervention comes with its own set of considerations and nuances that need to be weighed when treating individual patients.
Limitations
The evidence base is constrained by (1) heterogeneity in patient selection (age, deformity, bone quality, inflammatory arthritis, post-traumatic OA), (2) variability in implant generation and surgeon experience for TAA, (3) differing definitions of complications/reoperations, and (4) limited high-quality long-term comparative data (particularly >10 years) using outcomes measures. Longer-term comparative durability and downstream effects (adjacent joint degeneration, late revisions) remain areas where confidence is lower than desired for definitive superiority claims.
Benefits and Harms
Benefits (shared): Both AA and TAA can reduce pain and improve function/quality of life in end-stage ankle OA as measured by validated outcomes.
Distinct harms/tradeoffs: Meta-analyses commonly show higher reoperation/revision burden after TAA (implant-related failure, loosening, wear, infection, conversion procedures) but higher overall complication rates after AA, reflecting different risk profiles rather than a single “safer” option.
Outcome Importance
The outcomes that matter most to patients with end-stage ankle OA are pain relief, walking tolerance, return to desired activities, and durability (avoidance of major reoperation). Systematic reviews confirm that symptom improvement is achievable with both procedures, making shared decision-making—anchored on patient priorities - essential.
Cost Effectiveness / Resource Utilization
Economic studies suggest TAA can be cost-effective over a lifetime horizon in selected cohorts, despite higher upfront implant and follow-up costs. This stated cost-effectiveness is sensitive to implant survivorship and revision risk.
Feasibility
Both AA and TAA are widely performed and feasible in modern orthopaedic practice, but feasibility is context dependent. AA is technically reproducible and less dependent on implant systems, while TAA feasibility depends more on implant availability, surgeon volume/experience, and infrastructure for long-term follow-up and revision capability. The contemporary literature emphasizes that appropriate indications and patient selection strongly influence outcomes for both strategies.
Future Research
Key gaps include: (1) longer-term (>10 year) head-to-head comparative studies using consistent PRO measures, (2) stratified analyses to define which subgroups benefit most from TAA versus AA (age, deformity, post-traumatic patterns, obesity, neuropathy, inflammatory disease), (3) standardized reporting of complications and reoperations (including “minor” vs “major” procedures), and (4) robust real-world cost-effectiveness studies incorporating revision pathways and adjacent joint outcomes. As applicable, future iterations of this CPG should also focus on expanding this PICO to include broader questions pertaining to the unique considerations of each intervention.