AOFAS Position Statement: Total Ankle Replacement Surgery

Background

The American Orthopedic Foot and Ankle Society (AOFAS) is a medical specialty society whose 1,800 members are orthopedic surgeons specializing in the surgical and nonoperative treatment of injuries, disease, and other conditions of the foot and ankle. The AOFAS promotes quality patient care through education, research and training of orthopaedic surgeons and other health care providers, and serves as a resource for government, industry and the health care community on issues concerning the medical and surgical care of the foot and ankle.

Patient Selection

Ankle arthritis has several accepted operative and non-operative treatment options. Operative treatment is generally considered for patients with persistent symptoms that fail to respond to appropriate and comprehensive non-operative treatment measures. Surgical options include joint debridement, distraction arthroplasty, osteotomy, arthrodesis, and total ankle arthroplasty. Traditionally, arthrodesis was the favored treatment for end stage ankle arthritis. However, the restricted motion following arthrodesis increases the stresses on the surrounding joints leading to further arthritic changes. Total ankle arthroplasty preserves motion and may be protective against further degeneration while providing equivalent pain relief.

Over the past decade, total ankle replacement surgery has evolved as an acceptable and viable alternative to ankle arthrodesis in select patients with ankle arthritis. These include adult patients with primary, post- traumatic, and rheumatoid arthritis who have moderate or severe pain, loss of mobility, and loss of function of the involved ankle. Before considering total ankle replacement, patients should have completed several months of conservative treatment, should have satisfactory vascular perfusion in the involved extremity, and must have adequate soft-tissue coverage about the ankle that affords a safe surgical approach to total ankle replacement. In such patients, high-level evidence indicates that total ankle replacement safely relieves pain and may provide superior functional results when compared to ankle fusion (1-5).  Additional concomitant or sequential surgical procedures may be required in some patients to optimize outcome.

Provider Qualifications

Total ankle replacement surgery should be performed by board-certified or board-eligible allopathic or osteopathic orthopedic surgeons with appropriate training and education. When considering total ankle replacement, patients should consult with a qualified orthopedic surgeon.

Conclusion

Total ankle replacement surgery is a safe and effective treatment option for select patients with ankle arthritis. In many patients total ankle replacement surgery substantially improves function, reduces pain, and allows for an improved quality of life. Patient mobility and quality of life factors contribute to longer independent living and to controlling overall health care costs.

References

1. Anderson T, Montgomery F, Carlsson A. Uncemented STAR total ankle prostheses. Three to eight-year follow-up of fifty-one consecutive ankles. J Bone Joint Surg Am. 85(7): 1321-9, 2003.

2. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L.: Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 89(9): 1899-1905, 2007.

3. Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, Alliman KJ, Alvine FG, Saltzman CL. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up. J Bone Joint Surg Am. 86(6): 1161-71, 2004.

4. Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ.: Prospective Controlled Trial of STAR Total Ankle Replacement Versus Ankle Fusion: Initial Results. Foot Ankle Int. 30(7): 579-96, 2009.

5. SooHoo NF, Kominski G. Cost-effectiveness analysis of total ankle arthroplasty. J Bone Joint Surg Am. 86(11): 2446-55, 2004.

Approved by the AOFAS Board of Directors, August 4, 2009

American Orthopaedic Foot & Ankle Society

6300 N. River Road, Suite 510, Rosemont, IL 60018 Tel. 847-698-4654, Fax 847-692-3315, E-mail , Web site www.aofas.orgaofasinfo@aofas.org