Management of Ankle Osteoarthritis (2026)

Intra-articular hyaluronic acid alone is not recommended for the treatment of symptomatic ankle osteoarthritis, however, there may be a benefit for short term improvement in pain and function when combined with corticosteroid.

Three high-quality RCTs evaluated IA hyaluronic acid versus saline control with 1.5-6 month follow-up.^8–10 Cohen 2008 found saline superior to HA across multiple outcomes at 1.5, 3, and 6 months (AOS Total, WOMAC Total, Pain scores).⁸ DeGroot 2012 found no differences between HA and saline.⁹ Kubo 2022 showed DF-HA reduced adverse events but no improvement in patient-reported outcomes.¹⁰ Meta-analysis confirmed no benefit of HA over saline. 

Two high-quality RCTs compared combination IA therapy (HA + corticosteroid) to corticosteroid monotherapy.^11,12 Gomes 2023 found combination superior for VAS Pain at 1 month and for both AOFAS Total and VAS Pain at 3 months, with trends persisting at 6 months.¹¹ Woo 2025 found combination superior for AOS Total at 1.5 and 3 months.¹² Both studies consistently demonstrated combination therapy provides superior improvement in disease-specific ankle outcomes and pain scores versus corticosteroid alone at 1.5-3 months. However, neither study compared combination therapy to placebo, so absolute efficacy cannot be determined.

Benefits/Harms: 

Hyaluronic Acid Alone: No demonstrated benefit over saline placebo. Generally well-tolerated but multiple injections required (3-5 weekly), with potential for post-injection pain/effusion and false patient expectations. 

Hyaluronic Acid combined with Corticosteroid: Improved pain and ankle-specific function at 1.5-3 months versus corticosteroid alone. Combination of adverse events from both agents. Multiple Hyaluronic Acid combined with Corticosteroid: Improved pain and ankle-specific function at 1.5-3 months versus corticosteroid alone. Combination of adverse events from both agents. Multiple injections required (3 weekly), increased cost versus corticosteroid alone, and no long-term (>6 months) safety data.

Cost Effectiveness/Resource Utilization: 

Hyaluronic Acid Alone: HA costs $500-2000+ per injection series. Given lack of efficacy versus placebo, routine use represents poor resource utilization. 

Hyaluronic Acid combined with Corticosteroid: Significantly more expensive than corticosteroid alone (additional $500-2000+). Incremental benefit must be weighed against cost and lack of placebo comparison. Requires multiple clinic visits versus single corticosteroid injection.

Acceptability: 

Hyaluronic Acid Alone: Despite use in knee OA, ankle-specific evidence demonstrates lack of efficacy. Patients should be counseled that high-quality evidence does not support benefit over placebo. Stakeholder resistance expected given widespread HA marketing.

Hyaluronic Acid combined with Corticosteroid: May be acceptable to patients willing to undergo multiple injections for added benefit. Higher cost may limit accessibility, insurance coverage may be limited, and some hesitancy given HA alone showed no benefit versus placebo. Shared decision-making should emphasize incremental (not absolute) benefit, cost, and treatment burden.

Feasibility: 

Hyaluronic Acid Alone: Widely available and technically feasible, but feasibility does not override lack of efficacy. 

Hyaluronic Acid combined with Corticosteroid: Feasible in most practices performing IA injections. Requires availability of both agents and ability to schedule multiple visits. Less feasible in rural settings or for patients with transportation/scheduling limitations.

Future Research: 

Hyaluronic Acid Alone: Investigation of patient subgroups, different HA formulations, comparison to non-surgical interventions, longer-term outcomes, and mechanistic studies to understand ineffectiveness in ankle OA. 

Hyaluronic Acid combined with Corticosteroid: Critical need for comparison to placebo/control, comparative effectiveness versus other non-surgical interventions, optimal injection protocols, patient characteristics predicting response, long-term outcomes and safety, cost-effectiveness analyses, and stratification by OA severity. 

Intra-articular platelet-rich plasma is not routinely suggested for the treatment of symptomatic ankle osteoarthritis.

One high-quality RCT (Paget 2023) compared two platelet-rich plasma (PRP) injections to saline with 12-month follow-up.13 Saline was superior to PRP at 1.5 months (AOFAS, VAS Pain), 3 and 6.5 months (EQ-5D QOL), and 12 months (patient satisfaction). No significant differences between PRP and saline for AOS Total, SF-36, FAOS subscales, or AAS Total at any time point. No sustained benefit of PRP through 12 months.

Benefits/Harms: No demonstrated benefit over saline. PRP requires blood draw and centrifugation (additional time/discomfort). Generally well-tolerated with no serious adverse events but creates false expectations given lack of efficacy. 

Cost Effectiveness/Resource Utilization: PRP costs a patient an out-of-pocket expense of $500-1500+ per injection plus blood draw and preparation costs. Complete lack of efficacy versus placebo represents very poor resource utilization.

Acceptability: Despite popularity of "regenerative" treatments, ankle-specific evidence does not support use. High out-of-pocket cost limits accessibility. Patients should be counseled that high-quality evidence demonstrates no benefit over placebo.

Feasibility: Requires specialized equipment and technical expertise, increasingly available but feasibility does not override lack of efficacy. 

Future Research: Investigation of specific PRP formulations (leukocyte-rich vs. poor, concentration levels), patient subgroups, different injection protocols, mechanistic studies, economic analyses, comparison to other treatments, and longer-term outcomes. 

In the absence of sufficient evidence, it is the opinion of the workgroup that intra-articular corticosteroid injections are an option for short-term symptomatic relief in patients with symptomatic ankle osteoarthritis.

No studies meeting inclusion criteria directly compared intraarticular (IA) corticosteroid to control. Two high-quality studies (Gomes 2023, Woo 2025) compared corticosteroid only to combination therapy, not control. The workgroup recognizes corticosteroid injections are commonly used based on anti-inflammatory mechanisms, clinical experience suggesting short-term benefit, and generally favorable safety profile. These injections can be used as short-term symptom relief to facilitate physical therapy, a diagnostic/prognostic tool or a bridge to surgical decision-making. These injections provide short-term pain relief (weeks to months), and while not disease-modifying, may still be clinically meaningful for selected patients when framed within shared decision-making.

Benefits/Harms: Clinical experience suggests potential short-term pain relief, though magnitude and duration in ankle osteoarthritis (OA) is not evidence-based. Well-documented adverse effects include steroid flare, theoretical cartilage damage with repeated injections, rare systemic effects, infection risk, and potential to mask progressive joint damage.

Cost Effectiveness/Resource Utilization: Relatively inexpensive compared to other IA injections. Cost-effectiveness cannot be determined without efficacy data versus placebo. 

Acceptability: Widely accepted by surgeons and patients. Concerns about repeated injections and cartilage damage may limit acceptability for some. 

Feasibility: Highly feasible - readily available, inexpensive, performed in office setting. 

Future Research: High-priority RCTs comparing IA corticosteroid to placebo, dose-response studies, comparative effectiveness versus other treatments, long-term safety studies, patient characteristics predicting response, and optimal timing/frequency of injections. 

In the absence of sufficient evidence, it is the opinion of the workgroup that in patients with mild to moderate symptomatic ankle osteoarthritis who wish to avoid surgical intervention, the use of skilled physical therapy may improve patient-reported outcomes and potentially affect disease progression.

No studies meeting inclusion criteria were identified evaluating skilled physical therapy (in-clinic or virtual, with or without manual therapy) in patients with symptomatic ankle osteoarthritis (OA).

Clinical Takeaway 

In the absence of direct evidence, expert consensus supports the use of skilled physical therapy to improve patient-reported outcomes and potentially affect disease progression or the need for invasive interventions in patients with symptomatic ankle osteoarthritis.

Clinical Implications 

Based on expert consensus: 

• Skilled physical therapy can be administered to improve patient-reported outcomes, including pain, function, and quality of life, in patients with symptomatic ankle OA.
• It may also affect progression of OA symptoms and the need for invasive interventions, although the magnitude of these effects is unknown.
• Physical therapy may include patient education and self-management strategies, progressive therapeutic exercise (strength, power, endurance, and task-specific functional training), neuromuscular and motor control interventions (balance, proprioception, and movement coordination training), manual therapy (joint mobilization, manipulation, and soft tissue techniques), gait retraining, and development and progression of a home exercise program. Individualized treatment should consider patient history, presence of instability, OA etiology, and functional status.
• Physical therapy should be integrated into a multimodal management plan, which may include activity modification, bracing, and pharmacologic interventions.

 Limitations 

• No primary studies were available; recommendations rely solely on expert consensus. 
• Effects on long-term outcomes, disease progression, or timing of invasive interventions are unknown. 
• Variation in physical therapy modalities and delivery methods has not been formally studied in ankle OA. 

Future Research 

• Conduct randomized controlled trials and high-quality observational studies assessing skilled physical therapy in ankle OA.
• Evaluate specific therapy modalities, delivery methods (in-clinic vs. virtual), and long-term outcomes.
•  Assess cost-effectiveness and integration with multimodal management strategies.

Benefits and Harms: 

• Potential benefits: Symptom relief, improved function, and potential delay of invasive interventions. 
• Potential harms: Minimal; mostly fatigue, soreness, or injury from inappropriate exercises. Serious adverse events appear uncommon, although harms are not consistently reported.

Cost-Effectiveness and Resource Utilization: 

• Physical therapy is generally accessible but requires provider time and patient commitment. 
• Virtual therapy may reduce barriers to access and cost but requires further study. 

Future Research: 

• Prospective trials to define effectiveness, optimal modalities, long-term outcomes, and cost implications are needed.

In patients with mild to moderate symptomatic ankle osteoarthritis who wish to avoid surgical intervention, group education and exercise including a home exercise program, may improve satisfaction, pain, and global rating of change.

A single moderate quality article suggests that exercise combined with education is superior to general advice alone to improve the average pain levels, stiffness at its worst, and the global rating of change scores in individuals with ankle osteoarthritis.14 The exercise plus education group participated in group physiotherapy for 6 weeks, then transitioned to a home exercise program for the remainder of the study duration. Outcome differences between groups peaked at the 8-week time frame and were less pronounced at the 12-week follow-up.

Limitations: 

• Recommendation is based upon a single, moderate quality study 
• The study is a feasibility study with small sample size 
• The participants in the study who were provided with a home exercise program had first received 6 weeks of supervised group physiotherapy, which may have impacted the results as it pertains to the effectiveness of the home program.  

Benefits & Harms: 

• Possible benefits include relief of pain and stiffness with improved global rating of change for individuals who perform a prescribed home exercise program following supervised physical therapy.
• Potential harm is largely minimal and primarily associated with the effects of exercise, such as fatigue and muscle soreness.

 

Outcome Importance: 

• Individuals with ankle osteoarthritis may benefit from group education and exercise, including a home exercise program. Inclusion of a home exercise program following discharge from a supervised group exercise program may assist in maintaining or further improving the benefits.

 Cost Effectiveness/Resource Utilization: 

• Use of a home exercise program could potentially mitigate costs associated with more invasive interventions. 
• Performance of a home-based exercise program is a cost-effective intervention as minimal equipment is needed. 
• Use of a home exercise program may reduce the number of physical therapy visits needed, thus minimizing costs. 

Feasibility: 

• Use of a home exercise program is very feasible for individuals with ankle osteoarthritis to perform. Little if any equipment is necessary for completion of the program and the time commitment is minimal. 

Future Research: 

• Conduct randomized controlled trials examining the effectiveness of home exercise programs for symptom relief and quality of life improvement for individuals with ankle osteoarthritis. 
• Assess optimal dosing of home exercise programs for individuals with ankle osteoarthritis.  
• Evaluate effectiveness of specific exercises to be included within a home exercise program for individuals with ankle osteoarthritis. 

In the absence of sufficient evidence, it is the opinion of the workgroup that there is no reliable evidence regarding intra-articular stem cell therapy for symptomatic ankle osteoarthritis.

No studies meeting inclusion criteria evaluated intraarticular (IA) stem cell therapies for ankle osteoarthritis (OA). Efficacy, safety, optimal protocols, and appropriate patient selection cannot be determined. Patients should be counseled about investigational nature and lack of evidence.

Benefits/Harms: 

Cannot be assessed. Stem cell therapies are marketed despite lack of rigorous evidence with significant heterogeneity in products, preparation methods, and protocols. Patients should be fully informed about investigational nature.

Cost Effectiveness/Resource Utilization: 

IA stem cell therapy can typically range from approximately, $3,000-$10,000+, and is usually not covered by insurance. High cost and lack of evidence raise significant value concerns.

Acceptability: 

Marketing drives demand despite lack of evidence. Ethical concerns exist regarding offering expensive therapies without established efficacy.

Feasibility: 

Limited availability - requires specialized facilities, expertise, and regulatory compliance with significant variation in products and protocols.

Future Research: 

High-priority, IRB-approved investigational therapies within clinical trials examining the standardization of cell preparation and protocols, dose-finding studies, identification of appropriate patient populations, long-term safety and efficacy data, mechanistic studies, cost-effectiveness analyses, and comparative effectiveness studies should be conducted.

In the absence of sufficient evidence, it is the opinion of the workgroup that in patients with symptomatic ankle osteoarthritis, prescription opioids should not be used in the management of OA.

The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain recommends against opioids for chronic pain management, emphasizing non-pharmacologic and non-opioid pharmacologic therapies. When opioids are used, the CDC recommends the lowest effective dosage for the shortest duration necessary.

Benefits:

Opioids are associated with no demonstrated benefit in ankle OA specifically. Theoretical short-term pain relief is possible, though the magnitude of benefit versus non-opioid analgesics is unclear and likely minimal based on general OA literature.

Harms:

Extensive and well-documented harms include addiction/dependence risk, overdose mortality risk, tolerance and dose escalation, opioid-induced hyperalgesia, constipation, nausea/vomiting, sedation and cognitive impairment, increased fall and fracture risk, respiratory depression, immunosuppression, and potential for diversion/misuse. Chronic opioid use is associated with worse functional outcomes in musculoskeletal conditions.

Outcome Importance:

Pain relief and functional improvement are critical for ankle osteoarthritis (OA) patients. However, opioids provide only symptomatic masking without addressing underlying pathology. The risk-benefit ratio is unfavorable given well-documented harms, lack of disease-modifying effects, and availability of alternative treatments.

Cost Effectiveness/Resource Utilization:

Opioids are relatively inexpensive medications ($10-100/month depending on formulation). However, true costs include monitoring requirements (prescription drug monitoring program checks, urine drug screens, frequent follow-up visits), management of side effects and complications, treatment of opioid use disorder when it develops, overdose events and emergency department visits, and societal costs of the opioid epidemic.

Acceptability:

Patient perspectives vary. Some patients request opioids for pain relief, influenced by prior prescribing practices and direct-to-consumer pharmaceutical marketing. However, increasing public awareness of opioid risks and the epidemic has shifted attitudes. From provider perspective, growing recognition of opioid harms, regulatory scrutiny, liability concerns, and professional guidelines have reduced willingness to prescribe opioids for chronic non-cancer pain.

Feasibility:

The recommendation against opioids is highly feasible given availability of multiple alternative treatments. Barriers to alternatives should be addressed rather than defaulting to opioids.

Future Research:

While the workgroup recommends against opioids based on known harms and lack of evidence, potential research questions include:

1. Epidemiologic studies: What is the current prevalence of opioid prescribing for ankle OA? Has prescribing changed over time in response to guidelines and the epidemic?
2. Comparative effectiveness: For patients with ankle OA already on opioids, what are outcomes of opioid tapering/discontinuation versus continuation? Does tapering improve or worsen function?
3. Alternative analgesics: What is the comparative effectiveness of non-opioid analgesics (NSAIDs, acetaminophen, topical agents, gabapentinoids) versus placebo specifically for ankle OA?
4. Multimodal pain management: What multimodal approaches (physical therapy + NSAIDs + injections + psychological support) provide optimal pain control without opioids?

 

 

In the absence of sufficient evidence, it is the opinion of the workgroup that in patients with symptomatic ankle osteoarthritis the use of NSAIDs and/or acetaminophen may be used for initial symptomatic relief, when no other medical contraindications exist.

In the absence of direct evidence, expert consensus supports the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for symptomatic relief in ankle osteoarthritis (OA) as part of a multimodal management plan, with consideration of patient-specific safety risks.

Clinical Implications 

Based on expert consensus: 

• NSAIDs or acetaminophen can be administered to patients with symptomatic ankle OA to improve patient-reported outcomes. 
• Their effect on OA progression or need for invasive intervention is unknown. 
• Choice of therapy should consider patient comorbidities, contraindications, and potential adverse effects (e.g., gastrointestinal, renal, cardiovascular for NSAIDs; hepatotoxicity for acetaminophen). 
• Topical NSAIDs may be preferred in patients at higher risk of systemic adverse events. 
• These medications should be integrated into a multimodal management plan, including activity modification, bracing, and physical therapy. 

Limitations 

• No primary studies specifically evaluated NSAIDs or acetaminophen in ankle OA. 
• Recommendations rely solely on expert consensus and extrapolation from other joints (e.g., knee or hip OA). 
• Long-term effectiveness, impact on structural disease progression, and ability to delay invasive intervention remain unknown. 

Future Research 

• Conduct randomized controlled trials or high-quality observational studies evaluating NSAIDs and acetaminophen in ankle OA. 
• Assess short- and long-term effects on patient-reported outcomes, OA progression, and need for surgical intervention. 
• Compare oral versus topical formulations regarding efficacy, safety, and tolerability. 
• Evaluate integration with multimodal management strategies and cost-effectiveness. 

 Benefits and Harms: 

• Potential benefits: Symptom relief, improved function, and quality of life. 
• Potential harms: NSAIDs carry gastrointestinal, renal, and cardiovascular risks; acetaminophen carries hepatotoxicity risk, particularly at high doses or with chronic use. 

Cost-Effectiveness and Resource Utilization: 

• NSAIDs and acetaminophen are inexpensive and widely available. 
• Long-term cost-effectiveness and impact on delaying invasive interventions remain unknown. 

Future Research: 

• Prospective trials and health economic analyses evaluating effectiveness, safety, and cost implications are needed. 
• Studies should examine integration of pharmacologic treatment within multimodal management strategies. 

In the absence of sufficient evidence, it is the opinion of the workgroup that in patients with symptomatic ankle OA, durable medical equipment may improve patient reported outcomes, and affect progression of OA symptoms, or need for invasive intervention.

In the absence of conclusive evidence, durable medical equipment (DME), including ankle-foot orthoses (AFOs), bracing, canes and walkers, and shoe modifications, should be considered as part of a comprehensive, individualized management plan for patients with symptomatic ankle osteoarthritis (OA). These devices may provide symptom relief, improve stability, and support functional mobility, particularly for patients with pain, instability, or gait deviations. Clinicians should recognize the current evidence is insufficient to determine effects on structural disease progression or future need for invasive interventions, and decisions should be guided by patient-specific factors, clinical judgment, and patient preferences.

Benefits & Harms: 

Benefits 

• Symptom relief/reduced pain 
• Improved gait mechanics 
• Reduced falls risk 
• Improved stability and ability to perform ADLs 

Harms 

• Skin breakdown 
• Device discomfort 
• Patient adherence and use 
• Out of pocket costs 

Outcome Importance: 

Pain reduction, physical function (walking, transfers), balance and fall prevention, patient-reported quality of life, ability to participate in daily activities, and adverse events (skin issues, falls) are outcomes that may be favorably affected through the use of appropriate DME.

 Cost Effectiveness/Resource Utilization: 

• Custom vs off the shelf items
• Low cost compared to surgical interventions
• Should consider payer coverage, patient ability to pay, and potential future savings from reduced falls or delayed surgical interventions

Acceptability: 

Generally acceptable to patients and clinicians when devices are used as part of a tailored plan and fit/comfort is optimized.

Feasibility: 

• Widely used and available in most clinical settings
• Custom orthoses and specialist fitting require access to orthotists and may be limited by geographic location, insurance, or cost
• Requires clinician assessment, prescription, fitting, and follow-up for adjustments and support to improve adherence

Future Research: 

• RTC’s comparing specific DME types 
• Studies of adherence, patient preferences, and strategies to improve comfort 
• Longitudinal studies to determine device on progression and need for invasive interventions 

 

In the absence of sufficient evidence, it is the opinion of the workgroup that in patients with symptomatic ankle osteoarthritis, weight reduction may improve patient reported outcomes and affect progression of OA symptoms.

No studies meeting inclusion criteria were identified when evaluating the influence of weight reduction on patient reported outcomes and the progression of symptoms in patients with symptomatic ankle osteoarthritis (OA).

Clinical Implications: 

Based on expert consensus: 

• Weight reduction is an option to improve patient-reported outcomes, including pain, function, and quality of life, in patients with symptomatic ankle OA. 

• The effect of weight reduction on the progression of symptomatic ankle osteoarthritis is unknown.
• In the absence of evidence against the use of weight reduction to prevent the progression of ankle OA in patients with symptomatic ankle OA, a discussion between the surgeon and the patient is required to determine if the patient is a suitable candidate for an initial trial period of this modality prior to other invasive interventions.
• Weight reduction should be integrated into a multimodal nonoperative management plan for patients with symptomatic ankle OA prior to surgical intervention.

Limitations: 

• No primary studies specifically evaluated weight reduction and progression of symptomatic ankle OA.
• Despite established evidence on the effect of weight gain and weight loss on the progression of OA in other joints, like the knee, the long-term outcomes and disease progression after weight loss, or timing of invasive interventions are unknown.

Benefits and Harm: 

• Potential benefits: Potential benefits of weight loss include symptom relief, improved function, improved overall quality of life, reduction in cardiovascular risks or thromboembolic events in the event of a surgical intervention, and potential delay of invasive interventions.

• Potential harms: Potential harm is minimal, including possible progression of symptoms, persistent pain and discomfort, and a possible delay in appropriate surgical intervention.

Cost-Effectiveness and Resource Utilization: 

• Weight loss programs are universally available today and affordable.
• Modalities may include both non-pharmacologic and pharmacologic interventions.
• The only cost may involve patient commitment. 

Future Research: 

• Conduct randomized controlled trials examining the effect of weight loss on the progression of symptomatic ankle OA.
• Further research is needed to determine those patients with symptomatic ankle OA who are the best candidates for weight loss programs.
• Conduct long term observational and case controlled prospective studies on patient reported outcomes after a structured weight loss program in patients with symptomatic ankle OA.
• Assess cost-effectiveness of integration of a standard weight loss program in patients who present with symptomatic ankle OA.
• Long term prospective trials are also needed to define the effectiveness of weight loss programs based on patient reported outcomes and to define the stage at which a patient is no longer benefiting from this modality.
• Long term prospective trials are needed to examine the effects of GLP-1s on patient reported outcomes and adverse events.

Additional Citations Not Meeting Inclusion Criteria

1. Solanki P et al. Association between weight gain and knee osteoarthritis: a systematic review. Osteoarthritis Cartilage. 2023 Mar;31(3):300-316. doi: 10.1016/j.joca.2022.10.023. Epub 2022 Nov 26. PMID: 36511280. 

In the absence of sufficient evidence, it is the opinion of the workgroup that, in patients with symptomatic ankle osteoarthritis who have failed non-operative care and desire joint preservation, arthroscopic debridement, or periarticular realignment osteotomy, are options that may improve patient-reported outcomes and/or delay progression to joint-sacrificing procedures.

No eligible comparative studies evaluating arthroscopic debridement, periarticular osteotomy, or distraction arthroplasty vs appropriate controls in patients with ankle osteoarthritis (OA). Most available studies were case series, technique reports, or retrospective cohort studies with no relevant comparator, small sample size, or outcomes below inclusion thresholds. Therefore, this recommendation is based on expert consensus.

Benefits and Harms 

Potential benefits: 

• Pain relief and improved functional scores
• Delay or avoidance of joint-sacrificing procedures
• Preservation of motion and potential restoration of alignment or joint mechanics

Potential harms:

• Procedure-specific complications (infection, neurovascular injury, hardware problems, nonunion/malunion for osteotomy, pin-site infection for distraction)
• Longer rehabilitation time and higher resource utilization (distraction)
• Possible progression to end-stage arthritis despite intervention

 Outcome Importance 

For younger or more active patients, delaying arthrodesis or arthroplasty while maintaining ankle motion aligns with patient preferences, emphasizing activity, motion, and avoidance of fusion or implant surgery. Preservation of joint motion and pain relief are important considerations in patients with ankle arthritis, especially those who want to lead an active lifestyle.

Cost Effectiveness/Resource Utilization 

Surgery is generally costly, however, distraction is more costly than supramalleolar osteotomy (SMO), which is more costly than arthroscopy. Arthroscopy, being minimally invasive and commonly available, represents the least resource-intensive option but may yield more limited benefit in advanced OA.

Distraction and osteotomy require specialized equipment, prolonged rehabilitation, and extended follow-up, which increase cost compared to arthroscopy.

 Acceptability 

This will depend on both surgeon and patient factors. The joint-preserving options discussed in the recommendation are widely accepted among surgeons experienced in reconstructive foot and ankle surgery. However, acceptability varies by institutional expertise, access to postoperative resources, and patients' willingness to commit to a prolonged recovery (distraction). Additionally, older and lower demand patients may opt for total ankle (TAR) or ankle arthrodesis (AA).

 Feasibility 

Arthroscopy is feasible in most centers with arthroscopic capabilities. Osteotomy and distraction require more advanced surgical expertise, preoperative planning, and infrastructure support (distraction). 

Future Research 

• Identify clear indications/contraindications for each joint-preserving technique
• Evaluate comparative outcomes (ie. pain, function, time to conversion to fusion/TAA, impact on subsequent outcomes after fusion/TAA)
• Standardize PROMs and long-term follow-up
• Investigate cost-effectiveness and value-based frameworks for joint-preserving surgery in ankle OA

 Summary 

No eligible comparative evidence currently supports or refutes the use of arthroscopic debridement, periarticular osteotomy, or distraction arthroplasty for the treatment of ankle OA.

However, based on clinical experience and non-comparative literature, these procedures may offer meaningful symptomatic relief and delay more definitive joint-sacrificing options for appropriately selected patients seeking motion preservation.

 

Additional Citations Not Meeting Inclusion Criteria

Arthroscopy 

• Hassouna et al., 2007 — 5yr survival analysis. Reports durable symptom improvement and survivorship without immediate conversion to arthrodesis/TAA in select cases (when impingement/focal pathology coexists with early OA).ⁱ  
• Herrera-Pérez et al., 2019; 2020 — Post-debridement motion-facilitation associated with improved symptoms and function in degenerative ankles.ii, ii

? Short- to mid-term pain and functional improvement in carefully selected patients with early/moderate ankle OA w/impingement or focal lesions

Osteotomy

• Ahn et al., 2015 — Distal tibial osteotomy (without fibular osteotomy) for medial ankle arthritis with mortise widening. Demonstrated improved alignment and associated with pain relief and functional improvement in varus OA with preserved joint space.iv
• Krähenbühl et al., 2017; 2019 — SMO techniques/outcomes in ankle OA. Repeatedly showed pain/functional improvement and joint-space realignment in asymmetric OA. Realignment improved load distribution and PROMs; many patients delayed conversion to arthrodesis/TAA.v, vi
•  Lai et al., 2022 — Reported clinically meaningful gains (pain/function) in intermediate-stage OA after SMO.vii

? Can offload diseased compartments, improve patient-reported outcomes, and delay conversion to fusion/TAA in appropriately selected asymmetric varus/valgus OA with residual cartilage.

Distraction

• Nguyen & Saltzman, 2016 — PROM improvement with delay of joint-sacrificing surgery, especially in younger/active patients.viii
• Greenfield et al., 2019 — Pain/function gains and extended time-to-conversion to fusion/TAA in selected near-end-stage OA.ix
• Barg et al., 2013 — Summarized multi-center experiences: symptom relief with motion preservation, highlighting patient-selection principles.x

? Symptom relief and postponement of joint-sacrificing surgery, particularly in younger, motivated patients seeking motion preservation. However, without comparative data, the magnitude and durability of benefit relative to continued non-operative care or joint-sacrificing procedures remain unclear.

 

Reference Citations
i. Hassouna H, Kumar S, Bendall S. Arthroscopic ankle debridement: 5-year survival analysis. Acta Orthop Belg. 2007;73(6):737-740.
ii. Herrera-Perez M, Alrashidi Y, Galhoum AE, Kahn TL, Valderrabano V, Barg A. Debridement and hinged motion distraction is superior to debridement alone in patients with ankle osteoarthritis: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2019;27(9):2802-2812. doi:10.1007/s00167-018-5156-3
iii. Herrera-Pérez M, García-Paños JP, González-Martín D, Ramírez-De Paz R, Herrera-Navarro L. Hinged Motion Distraction Surgery for Ankle Osteoarthritis. Tech Foot Ankle Surg. 2020;19(1):14-18. doi:10.1097/BTF.0000000000000262

iv.Ahn TK, Yi Y, Cho JH, Lee WC. A cohort study of patients undergoing distal tibial osteotomy without fibular osteotomy for medial ankle arthritis with mortise widening. J Bone Joint Surg Am. 2015;97(5):381-388. doi:10.2106/JBJS.M.01360
v. Krahenbuhl N, Zwicky L, Bolliger L, Schadelin S, Hintermann B, Knupp M. Mid- to Long-term Results of Supramalleolar Osteotomy. Foot Ankle Int. 2017;38(2):124-132. doi:10.1177/1071100716673416
vi. Krähenbühl N, Susdorf R, Barg A, Hintermann B. Supramalleolar osteotomy in post-traumatic valgus ankle osteoarthritis. Int Orthop. 2020;44(3):535-543. doi:10.1007/s00264-019-04476-x
vii. Lai L, Wang Y, Wu Y, et al. Outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomy. J Orthop Surg. 2022;30(3):10225536221132769. doi:10.1177/10225536221132769
viii. Nguyen M, Saltzman C, Amendola A. Outcomes of Ankle Distraction for the Treatment of Ankle Arthritis. Instr Course Lect. 2016;65:311-319.
ix. Greenfield S, Matta KM, McCoy TH, Rozbruch SR, Fragomen A. Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis. Strateg Trauma Limb Reconstr. 2019;14(2):65-71. doi:10.5005/jp-journals-10080-1429

In the absence of sufficient evidence, it is the opinion of the workgroup that in patients with end-stage ankle OA, who have failed non-operative treatment, either Ankle Arthrodesis (Fusion) or Total Ankle Arthroplasty (Replacement) can be utilized to improve patient reported outcomes.

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.

In the absence of sufficient evidence, it is the opinion of the workgroup that postoperative physical therapy may improve patient reported outcomes, range of motion, return to work/activity, strength, and gait restoration.

Physical therapy may include patient education and self-management strategies, progressive therapeutic exercise (strength, power, endurance, and task-specific functional training), neuromuscular and motor control interventions (balance, proprioception, and movement coordination training), manual therapy (joint mobilization, manipulation, and soft tissue techniques); gait retraining, and development and progression of a home exercise program. While no evidence met our full inclusion criteria for this question, Uselli et.al. provided relevant information on fast-track protocols, which may be of use to clinicians. Enhanced recovery after TAR surgery programs, also called fast-track protocols, in patients with ankle osteoarthritis, is also a viable option. There is no convincing evidence to suggest that immediate postoperative weight bearing without a cast is not a viable option in well selected patients.

Usuelli et al developed a selection score for proper patient selection with a low risk for perioperative complications who were appropriate for a fast-track protocol which included cast removal on post op day 1 and immediate protected weightbearing (Fast-Track Protocol) compared to the standard post op protocol of non-weight bearing and application of cast for a period of three weeks prior to weight bearing activity.i Stratification was based on the presence or absence of eight validated predictive variables (including body mass index >30, the state of anxiety or depression, functional preoperative status, fixed ankle equinus, the coronal malalignment, operative time, the surgical accessory procedures, and the bone quality) that may affect the outcome of TAR. Using this selection criteria, no significant differences were found in both clinical and radiologic date between the “standard protocol” versus the “Fast-track protocol” patients at different time points after surgery.

Benefits & Harms: 

Potential Benefits 

• Earlier mobilization and weightbearing may accelerate functional recovery and reduce deconditioning.

• Early removal of the cast could allow for advanced cryotherapy (Game Ready) and low-intensity electromagnetic field (Limfa) therapy with a potential benefit on postoperative edema and inflammation.ii
• Potential for improved patient satisfaction and faster return to activities for appropriately selected patients.

Potential Harm / Risks 

• If misapplied to patients who do not meet the strict selection criteria (poor bone quality, high BMI, significant deformity, psychiatric comorbidity, prolonged surgery or multiple accessory procedures), there may be increased risk of wound problems, implant early loosening, or other complications (not proven in the paper but a plausible risk). Usuelli’s study avoided such high-risk patients by selection.

• The results of the case-controlled study by Usuelli et al are not generalizable. Application of this fast-track protocol to most patients who present for TAR for OA will lead to significant complications because a lot of these patients have associated severe comorbidities which will preclude them based on the strict criteria presented by Usuelli et al.
• Evidence base is limited (nonrandomized; smaller fast-track group) so rare adverse outcomes or late implant survivorship differences may not yet be apparent.

Outcome Importance: 

TAR for OA is steadily gaining popularity with significant advancement in implant technology and improved perioperative care of these patient populations. Usuelli et al. reported comparable short-term clinical and radiographic outcomes and no increase in complications using their Fast-Track protocol, but long-term implant survivorship differences remain unknown. Demonstrating enhanced recovery protocols for rehabilitation for TAR which have been used effectively in the hip and knee patients will greatly enhance the delivery of care to this fast-evolving patient population. With future randomized controlled studies, this protocol can be extended to many high-volume practices and demanding patients without the fear of increased complications.

Cost Effectiveness/Resource Utilization: 

Direct evidence in TAR fast-track is not provided in the Usuelli paper. However, ERAS / fast-track programs in hip and knee arthroplasty have consistently shown reduced length of stay and lower early resource utilization and sometimes reduced complications — suggesting likely cost savings if similar reductions occur for TAR.

Acceptability: 

Likely acceptable to many patients (quicker mobilization) and to multidisciplinary teams familiar with ERAS for large-joint arthroplasty, but acceptability depends on clear patient selection, preop counseling, and local practice cultures. Some surgeons may be cautious until further TAR-specific evidence accumulates. 

Feasibility: 

Feasible in centers that have: 

• Multidisciplinary ERAS infrastructure (anesthesia protocols for multimodal analgesia / nerve blocks, perioperative nursing, physiotherapy for immediate mobilization).
• Surgeon experience with TAR and ability to limit operative time and accessory procedures in selected patients.  
• Pathways for early follow-up, wound checks, and clear patient education materials. In less-resourced settings or with less TAR experience, implementation should be cautious and limited to well-selected patients.

 Future Research: 

• Randomized controlled trials comparing fast-track vs standard protocols in TAR with stratification by the selection score used by Usuelli et al. (or validation of that score).
• Multicenter prospective cohorts to increase sample size, test generalizability across different implants/approaches and surgical volumes.
• Long-term follow-up (≥5–10 years) on implant survival and late complications to ensure early mobilization does not adversely affect longevity.
• Cost-effectiveness analyses specifically in TAR (hospital costs, readmissions, rehabilitation costs).
• Patient-reported outcome studies (PROMs, return to activity, satisfaction) and qualitative work on acceptability.
• Validation and refinement of the 8-variable selection scoring system in independent datasets.

 

Additional Citations Not Meeting Inclusion Criteria

1. Usuelli FG, Paoli T, Indino C, Maccario C, Di Silvestri CA. Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients. Foot Ankle Int. 2023;44(2):148-158. doi:10.1177/10711007221140841  
2. Brigido SA, Wobst GM, Galli MM, Bleazey ST, Protzman NM. Evaluating component migration after modular stem fixed-bearing total ankle replacement. J Foot Ankle Surg. 2015;54(3):326-331

In the absence of sufficient evidence, it is the opinion of the workgroup that in patients undergoing total ankle arthroplasty or ankle arthrodesis for end-stage ankle OA, perioperative TXA may reduce complications, improve patient outcomes, and decrease perioperative blood-loss.

Rationale

There is one low quality article that does not support the use of tranexamic acid (TXA) and multiple very low-quality articles that do support its use in reducing blood loos and/or wound complications.15

Benefits & Harms:

The risks are very low, TXA is generally considered very safe and is widely used. A benefit in wound complications, probably more so than blood loss would be very helpful in patients undergoing TAR or AA.

Outcome Importance:

Wound complications and blood loss in TAR/AA are important issues, especially wound complications.

Cost Effectiveness/Resource Utilization:

TXA is generally very cheap and used widely at most orthopaedic surgery centers and hospitals. 

Acceptability:

This intervention is generally very acceptable given its wide usage in total joints, spine, and pediatric orthopaedics 

Feasibility:

This intervention is generally very feasible.

Future Research:

A multi-center prospective trial would substantially strengthen the literature in this area.