Modern Total Ankle Arthroplasty Versus Ankle Arthrodesis: A Systematic Review and Meta-Analysis

SLR - March 2021 - Jonathan D. Furmanek

Level of Evidence:  Level III

Scientific Literature Review

Reviewed By: Jonathan D. Furmanek, DPM
Residency Program: Medstar Health Podiatric Surgery Residency – Washington, DC

Podiatric Relevance: With the growth and evolution of both total ankle arthroplasty (TAA) and ankle arthrodesis (AA), 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 highlights the importance of systematic reviews to provide data to help guide the discussion of surgical options for patients presenting with this pathology.

Methods: An electronic PubMed database search was performed to identify publications reporting outcomes following TAA and/or AA published in the English language from January 1, 2006 until July 31, 2016. The review sought primary research publications reporting complication and/or re-operation rates following TAA or AA, with interventions consisting of arthrodesis with internal fixation using open or arthroscopic techniques or TAA using a third-generation implant approved for use in the United States, in studies with a minimum of 50 ankles. Non-generalizable patient cohorts, outcomes following revision cases, and kinship data were excluded from this search. For each study, the  demographic, complication, re-operation, failure, and revision data were extracted. A meta-analysis was then performed using a random-effects meta-regression model for all data.

Results: A systematic literature search revealed 136 publications, with 35 articles meeting all eligibility criteria for meta-analysis. Of the included studies, 23 reported on TAA and 15 on AA (six arthroscopic AA, nine open AA). There was a significantly lower rate of TAA aseptic loosening compared to AA nonunion (4.3 percent and 7.4 percent respectively, p-value Ã0.01), however no significant difference was found in the overall revision rate following TAA compared to AA (7.2 percent and 6.3 percent respectively, p-value 0.65). 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). The most common complication for patients who underwent TAA was wound complication (9.3 percent) followed by intra or post-operative fracture (6.9 percent). Nonunion (7.4 percent) was the most common complication for patients who underwent AA, followed by wound complication (6.5 percent).

Conclusions: Despite not being statistically significant, the wound complication rate following arthroscopic AA (2.3 percent) was lower than that of TAA (9.3 percent) and open AA (7.8 percent); which inherently makes sense given the typical nature of arthroscopic incisions being small compared to open techniques. Additionally, this study demonstrated that third generation implants have lower rates of TAA aseptic loosening compared to AA nonunion (4.3 percent and 7.4 percent respectively). Yet this was not found to be clinically impactful, as no statistically significant difference was found in overall revision rate. 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. As of now, intermediate data suggest similar outcomes of TAA and AA, however a lack of high-quality literature exists to date. In conclusion, the current literature does not strongly favor one procedure over another for the treatment of end-stage tibiotalar arthritis in the general population.