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otal Ankle Arthroplasty asurrent Treatment for Ankle Arthritis

amal Ahmad, MD

Arthritis of the ankle can cause pain, joint incongruence, diminished motion, and functionaldisability. The traditional surgical treatment for ankle arthritis that has failed nonsurgicalmanagement is joint arthrodesis. However, ankle arthrodesis is not without shortcomings,which include the development of gait dysfunction and adjacent joint arthritis. Suchproblems promoted interest in total ankle arthroplasty (TAA) as early as the 1970s. Incontrast to arthrodesis, TAA can have a wider variety of complications rather than ones thatare worse. It is critical to view the shortcomings of modern TAA with a careful analysis ofthe literature. Several studies suggest that surgeon factors may play a role in certaincomplications. Other texts conclude that patient characteristics may be related to certaindifficulties with TAA. These factors include age and pre-operative deformity. In an appro-priate patient population, TAA performed by experienced surgeons reliably provides highclinical scores and satisfaction. Modern TAA is highly predictable in providing good toexcellent clinical results that are as good, if not better, than ankle arthrodesis. TAA offerspatients significantly improved function and decreased pain with high satisfaction rates. Byconserving ankle motion, TAA approximates more of a normal gait pattern than arthrodesis.TAA also reliably decreases stresses on joints adjacent to the ankle such as the subtalarjoint. For the right patient, ankle arthroplasty rather than arthrodesis is the better treatmentoption.Semin Arthro 21:247-252 © 2010 Elsevier Inc. All rights reserved.

KEYWORDS arthritis, ankle, joint, arthrodesis, arthroplasty

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he ankle is a constrained mortise-and-tenon type jointthat consists of the distal tibial plafond and fibula artic-

lating with the dome of the talus. Arthritis of the ankle canause pain, joint incongruence, diminished motion, andunctional disability. Most ankle arthritis is posttraumatic,hich includes cartilaginous injury and ligamentous instabil-

ty.1 Other causes of arthritis include infection, talar osteone-rosis, and Charcot neuroarthropathy.2

For patients with ankle arthritis who have not respondedo nonsurgical management, the traditional surgical treat-ent is joint arthrodesis. Albert first described this proce-ure in 1879.3 Since then, there have been numerous modi-cations in technique.4 Currently, the most common methodf achieving an ankle arthrodesis is through a lateral trans-bular approach with internal screw fixation. Upon osteot-my, the distal fibula can either be used as bone graft or as a

othman Institute Orthopaedics, Thomas Jefferson University Hospital,Philadelphia, PA.

ddress reprint requests to Jamal Ahmad, MD, Rothman Institute Orthopae-dics, Thomas Jefferson University Hospital, 925 Chestnut Street, Phila-

ddelphia, PA 19107. E-mail: Jamal.ahmad@rothmaninstitute.com

045-4527/10/$-see front matter © 2010 Elsevier Inc. All rights reserved.oi:10.1053/j.sart.2010.09.006

ateral strut to increase stability. To date, fusion rates rangerom 80% to 100%, and patient satisfaction rates are typicallyreater than 80%.5,6 Certainly, arthrodesis is predictable anduccessful in treating arthritis.

However, ankle arthrodesis is not without shortcomings.isks of surgery include infection, wound problems, mal-nion, and nonunion. Through meta-analysis of the litera-ure, Haddad et al7 found the risk of nonunion to be 10%,ith most of these patients requiring further surgical treat-ent. For the majority of patients who achieve full healing of

he arthrodesis, the time of convalescence can be difficult.ime to achieve complete bone healing ranges from 12 to 20eeks.8,9 The postoperative recovery involves some form of

mmobilization and restricted weight-bearing activities,hich can cause significant leg muscle atrophy. Even after

he ankle arthrodesis is fully healed though, patients mayevelop profound dysfunction in the long term. Many au-hors make note of significant limitations with walking in-lines, accommodating uneven ground, driving, and athleticctivities.5,10 Formal gait studies after ankle arthrodesis show

ecreased cadence and stride with decreased hind foot and

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idfoot motion.11 Gait and function are further affected ifatients develop adjacent joint arthritis. Coester et al12 foundhat all patients with an ankle arthrodesis had developeddjacent joint arthritis in the hind foot and/or midfoot within0 years after surgery, which likely occurs as the result of the

ncreased demands on the foot with the ankle fused. All theforementioned problems can worsen if an arthrodesis is per-ormed in patients with bilateral ankle arthritis. To date,here is scant literature regarding how patients function withoth ankles fused. However, it is logical to reason that ailateral ankle arthrodesis can be as limiting to a patient, ifot more so, than a unilateral fusion. Although ankle arthro-esis is a valid treatment option for arthritis, its risks andequelae cannot be ignored.

Such problems with ankle arthrodesis promoted interestn total ankle arthroplasty (TAA) as early as the 1970s. First-eneration systems used cement and incongruent implants.13

ibial and talar prostheses had slightly different shapes tollow for motion outside the primary plane of movementermitted by the design. The TAA design itself was of 3ifferent types: constrained, unconstrained, or cylindrical.14

n constrained TAA the ankle is treated like a hinge joint,hich only allows motion in plantarflexion and dorsiflexion.

n unconstrained TAA, more multidirectional motion is al-owed akin to a ball-and-socket joint. In cylindrical TAA,

ore of an attempt is made to recreate normal ankle anat-my. Regardless of design, initial results seemed promising.achiewicz et al15 performed mayo 15 TAAs (Mayo, Roches-er, MN) in 15 patients with 100% good-to-excellent resultsnd 100% implant survivorship by 3 years after surgery.

However, subsequent studies with longer follow-uphowed much less successful results with high rates of im-lant subsidence, loosening, and ultimately failure. Bolton-aggs et al16 performed 62 Imperial College London Hospi-

al (ICLH) and reported a 40% failure rate by 5 years afterurgery. In the mid-1990s, Kitaoka et al published 2 studiesn use of the Mayo TAA in 204 patients and found the 10-ear implant survivorship to be 65%.17,18 Both authors dis-ouraged arthroplasty as a treatment option for ankle arthri-is. However, a careful review of first-generation TAA failureshows that these problems were likely the result of pooresign and fixation. Constrained designs did not account forormal torsional stresses at the ankle, which were ultimatelyransmitted to the bone-cement interface.19 Large bony resec-ions to allow room for the prosthesis and cement worsenedhis problem. As tibial bone is more cancellous at 1 cm prox-mal to the ankle joint, the cement would have to rely on sucheaker bone for fixation.20 Even in less constrained implants

hat would theoretically allow for some distribution of tor-ional stress, cemented failures were commonly seen.21,22 Fi-ally, incongruence of tibial and talar components was notedo result in poor wear characteristics.23

With these problems of first-generation TAAs in mind, aecond and third generation of implants was developed andas been available for treating patients since the late 1990s.hese newer TAAs differ from earlier models in several im-ortant ways. The newer generation design of TAA involves

ongruent implants. Less bone is resected at the ankle for t

ncreased surface areas available for implant stability. Im-lant fixation also relies more on bony in-growth and less onement. While initial second and third generation modelssed cement for fixation, many have since been redesignedith porous coating to eliminate this need. To date, there arenly 5 newer-generation TAAs that are approved for use inhe United States by the Food and Drug AdministrationFDA). These are the Agility Ankle (DePuy, Warsaw, IN), theNBONE (Wright Medical, Arlington, TN), the Salto TalarisTornier, Grenoble, France), the Eclipse (Integra, Plainsboro,J), and the Scandinavian Total Ankle Replacement or STAR

Small Bone Innovations/Link, Hamburg, Germany).24

Second-generation TAAs are fixed-bearing implants. Thiss a semiconstrained, 2-component system in which motionccurs at the interface between the talar implant and theolyethylene attached to the distal tibial implant. The oldestnd most renowned of second-generation, fixed-bearing TAAs the Agility Ankle, which was designed by Dr Frank Alvinen 1984 and approved by the FDA in 1999.25 The tibial com-onent is made from a titanium alloy while the talar implant

s cobalt-chromium. The tibial insert has 3 sides and is placedn 20° of external rotation to account for the direction of theransmalleolar axis. Its medial and lateral walls rest flushgainst the debrided surfaces of the medial and lateral malle-li, respectively. The talar implant is semiconstrained be-ause there is some rotation and medial to lateral shift be-ween it and the polyethylene. One important characteristicf the Agility system is that it requires a fusion of the distalibiofibular syndesmosis for implant support and fixation.26

nother requirement for use of the Agility is to distract theoint with an external fixator while inserting the components.

Since its introduction, the Agility has gone through designodifications. The LP Agility Ankle was released in 2007,hich involves a broad talar component, allows for the sur-eon to mismatch component sizes, and has a front-loadingolyethylene mechanism.27 Custom-made Agility prosthesesan also be manufactured if a particular situation warrantst.28 Despite alterations from the original model, it is impor-ant to understand that the Agility’s fixed-bearing design isnchanged. Among all second-generation TAAs in currentse, the Agility Ankle has the longest follow-up at nearly 20ears. Other fixed-bearing devices that were more recentlyeleased and approved by the FDA include the INBONE,alto Talaris, and Eclipse.

In contrast to the second-generation, third-generationAAs are mobile-bearing implants. This is a 3-componentystem with less constraint in which motion occurs at 2 areas:etween the talar implant and the polyethylene and betweenhe distal tibial implant and the polyethylene. The theoreticenefit of having these 2 articulating surfaces is to reducehear stress between the TAA and the bone. In turn, this helpso increase stability and survivorship of the implant. Theldest and most renowned of third-generation mobile-bear-ng TAA is the Scandinavian Total Ankle Replacement orTAR (Small Bone Innovations/Link, Hamburg, Germany),hich was designed by Dr Hakon Kofoed.29 Initially de-

igned in 1978, the STAR has undergone several modifica-

ions and was approved by the FDA in 2007. Both the tibial

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Total ankle arthroplasty for ankle arthritis 249

nd talar components have a porous-ingrowth titaniumpray.30 The tibial insert is flat and has 2 parallel bars that pro-ide bony fixation. The talar implant is cylindrical with medialnd lateral wings. The dome of the talus has a crest that links togroove in the polyethylene meniscus. The meniscus itself is

quare and does not impinge against the malleoli. Among allobile-bearing TAAs in current use, the STAR Ankle has the

ongest follow-up at nearly 10 years. Other mobile-bearingAAs that are newer, but not approved by the FDA, include

he Hintegra (New Deal, Lyon, France) and the Buechel-appas Low Contact Stress (BP LCS) Total Ankle Replace-ent (Endotec, South Orange, NJ).Although none of the second- and third-generation TAAs

re exactly the same, many of them have similar surgicalechniques. With the exception of the BOX (Finsbury Ortho-aedics, Surrey, UK), modern TAA uses an anterior surgicalpproach to the ankle between the tibialis anterior and ex-ensor hallucis Longus tendons.31,32 A long and generousncision with thick skin flaps is recommended to maintainascularity. Retraction of these flaps is minimized to avoidxcessive tension placed upon the wound. Most modernAAs employ their own instrumentation or laminar spread-rs to distract the ankle joint.24 One notable exception is thegility, which uses an uniplanar external fixator for this pur-ose.25 Second- and third-generation TAAs involve completeartilage and minimal subchondral bone resection for im-lant placement and stability. Many systems spare the medialnd lateral malleoli and do not fuse the syndesmosis. Thegility is different from these other systems because its useequires malloeli resurfacing and an arthrodesis of the syn-esmosis.25 The actual syndesmotic fusion is performedhrough the anterior ankle incision while screw fixation islaced through a small incision at the lateral distal fibula.33

lthough the Agility does have these distinctions, it and allther current TAAs share the same goal of providing andaintaining ankle stability.All second- and third-generation TAAs depend on neutral

lignment of the implant and a stable, plantigrade position ofhe ankle itself to minimize abnormal wear patterns and max-mize the lifespan of the implant.34 Mild varus and valguseformities of the ankle that are less than 10° can be ad-ressed with bone cuts and/or larger spacers.35 Over theears, many authors have also recognized the importance ofalanced ligaments for implant and ankle stability. Residualarus alignment may require an additional deep deltoid lig-ment release and/or a lateral ankle ligament reconstruction.algus alignment may require a careful lateral ligament re-

ease and/or a deltoid ligament reconstruction. Unlike soft-issue balancing in hip and knee arthroplasty, there is nourrent standardized protocol for ligament balancing in TAA.lthough further study is required in this matter, many au-

hors have recognized that adjuvant procedures to the TAAay be necessary to benefit the patient.Although modern TAAs are designed better than the first

eneration of implants, the procedure certainly has somehortcomings. Postsurgical complications after TAA are bestategorized as intraoperative, early postoperative, and late

ostoperative.36 Intraoperative risks include malposition, l

eroneal nerve injury, and malleolar fracture.37 The superfi-ial and deep peroneal nerves are at risk because of the loca-ion of the incision. Knecht et al38 found no motor deficits,ut 21% of patients had numbness in the distribution of 1 oroth nerves. Either the lateral or medial malleolus may frac-ure due to excessive bone resection, implanting oversizedomponents, or excess joint distraction. The incidence ofalleolar fracture has been reported by some to be as high as

0% or 30%, with most of these cases requiring internalxation.39,40 Early postoperative challenges include woundroblems and infection. Wound difficulties range from thosehat are superficial which resolve with antibiotics and topicalare to those that are deep which often necessitate furtherurgical care and plastic surgical consultation.41 Both super-cial and deep wound problems occur in 4% to 17% ofatients in published studies.42,43 The reported rate of deeperi-prosthetic infection ranges from 0.5% to 3.5%.36 Theseituations can be complex and typically require irrigation andebridement, TAA removal, and an antibiotic-impregnated

oint spacer implantation with parenteral antibiotics.A unique subacute complication seen with the use of the

gility Ankle is healing of the syndesmotic arthrodesis. In therst study with medium to long-term follow-up, Pyevich et aleported a 37% incidence of either delayed union or non-nion of the fusion.33 Late postoperative difficulties includeolyethylene wear, osteolysis, component subsidence and

oosening and subsidence, and TAA failure. Most reportedear patterns are edge loading and often present with joint

ncongruity.1,44 Osteolysis is more commonly seen in the dis-al tibia than in the talus and fibula. Reported rates of expan-ile tibial lysis are as high as 15% in second-generation TAAnd 8% in third-generation TAA.30,38 Implant subsidence andoosening is more commonly seen at the talar than the tibialomponent with rates as high as 10% at 5-10 years afterurgery.45 In studies of the Agility Ankle, implant migration isighly correlated with syndesmotic fusion nonunion. Any, ifot all, of these late postoperative problems can ultimately

ead to failure of the TAA necessitating either revision oronversion to an ankle arthrodesis. In a literature review from007, Haddad et al7 found the overall 10-year failure rate ofll modern TAAs to be 23%. Certainly, one cannot argue thatven the newer generations of TAA have their share of risks.

However, it is important to interpret the complications ofodern TAA in their proper context. Although both ankle

rthroplasty and arthrodesis share the same goal of improv-ng patients’ pain and function, they are very different proce-ures with very different means. Both have different tech-iques, instrumentation, and outcomes. The objective ofAA is to restore ankle motion through the implant. Theurpose of a fusion is to sacrifice ankle movement throughome type of fixation. Both TAA and arthrodesis share someisks, such as wound problems and infection.41,46 However,AA can have technique-related problems that would notpply to an arthrodesis. Although an intraoperative compli-ation of TAA is malleolar fracture, this does not lend itself ton arthrodesis as the lateral malleolus is often sacrificed dur-ng the procedure.4 TAA can also have implant-related prob-

ems, such as wear and loosening, which do not compare

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irectly to a fusion. In time between index and revision sur-ery, TAA failure is best compared with nonunion of anklerthrodesis. It is important to note that not all TAA failuresecessitate a conversion to an arthrodesis. Some situationsllow a revision TAA with larger or custom implants pro-ided there is sufficient remaining bone stock.28 All ankleusions that progress to failure or nonunion ultimately re-uire a revision arthrodesis.47 In contrast to arthrodesis, TAAan have a wider variety of complications rather than oneshat are worse.

It is critical to view the shortcomings of modern TAA withcareful analysis of the literature. The authors of several

tudies suggest that surgeon factors may play a role in certainomplications. To date, 3 studies have found that surgeonnexperience with TAA is significantly related to an increasedncidence of intraoperative malleolar fracture, component

alposition, and wound problems.42,48,49 Myerson et al ex-mined an initial 50 patients that received an Agility Anklend further divided this group into the first 25 and later 25atients.50 They found a greater rate of intraoperative malle-lar fracture, implant malposition, and superficial woundroblems among the former 25 patients compared with the

atter 25. As the TAA remained the same between bothroups, the authors attributed the difference to familiarityith the implant and technique. The wound is typically at

isk for healing problems when placed under excess retrac-ion. Wood et al showed that these difficulties occurred lessith increased surgeon experience, decreased surgical time,

nd later cases in the treatment period.42 These findings seemo be independent of the type of TAA used. Haskell et alxamined an initial series of 10 STAR ankles performed by 10ifferent surgeons and compared outcomes to later series.49

imilar to Wood et al’s study, they found a greater rate ofound problems among the initial TAAs compared with laterrocedures. TAA is certainly a highly challenging procedureith a steep learning curve and little room for error. As these

tudies have shown that surgeon experience has a role inutcomes, one must assess reported complications from TAAarefully. Not all literature is the same as some studies mayave been performed by less experienced surgeons.Surgeon technique has also been examined with respect to

ome results of TAA. One particular postsurgical outcomehat has been heavily studied is syndesmotic fusion whilesing the Agility Ankle. As mentioned earlier, Pyevich et aleported a 37% incidence of either delayed union or non-nion of the fusion.33 In 2005, Coetzee et al51 detailed the usef autologous platelet rich plasma (Symphony/PRP, DePuy,arsaw, IN) during syndesmotic fusion and found the rate of

ither delayed union or nonunion to be significantly lower at%. The authors of previous studies showed a correlationetween problems with syndesmotic fusion and componentigration.38 Thus, it is reasonable to assume that increased

se of PRP during syndesmotic fusion should decrease theisk of prosthetic loosening and ultimately increase survivor-hip of the Agility Ankle. However, this does require furtherong-term study.

Other texts conclude that patient characteristics may be

elated to certain difficulties with TAA. These factors include a

ge and preoperative deformity. Spirt et al performed thegility Ankle on patients with a wide range of ages from 26 to6 years.45 The overall 5-year TAA survival rate was 80%, but

ncreased to 89% when the authors excluded patients belowhe age of 55. Doets et al performed the LCS Buechel-Pappasnkle in a patient population with a smaller age range, butith a wider range of preoperative varus and valgus ankle

lignment.40 Through bony cuts, the authors corrected allnkle deformities. At a mean of 8 years after surgery, patientsith preoperative alignment greater than 10° had a TAA sur-ival rate of 48% with the primary mode of failure as loosen-ng. In contrast, patients with minimal deformity had a TAAurvival rate of 90%. It is important to note that Doets et alake no mention of any patients with varus or valgus defor-ity receiving ligament balancing. Since this study was per-

ormed, much attention has been placed on adjuvant liga-ent release and/or reconstruction with TAA whenanaging patients with ankle arthritis and deformity.52,53

owever, further research is needed in this matter.Although newer-generation TAAs are not without risk, it is

ritical to recognize that outcomes can be maximized whenurgeon factors are optimized. Surgeons’ experience withAA decreases the risk of malleolar fracture and wound com-lications. If the Agility Ankle is to be used, PRP should besed within the syndesmosis to increase the chances of distalibiofibular fusion.

It is also important to understand that results after TAA cane optimized through patient selection. Certain patients areot ideal candidates for a modern TAA. Osteonecrosis, neu-oarthropathy, peripheral vascular disease, poor skin integ-ity, and a history of joint infection are considered contrain-ications to modern TAA.54 There is a lack of formal studiesith regard to other patient factors, such as weight, activity

evel, and certain medical conditions. However, many rec-mmend TAA in patients who are low-demand patients,eigh less than 200 lbs, and have good bone stock to increase

mplant survival rate. Patients who are more suitable for aAA are older than 55 years of age and have minimal defor-ity or instability. Certainly, if patients have either deformity

r ligament instability, TAA should be approached with care.lthough there is no formal consensus regarding how mucheformity is tolerable, many believe that malalignment of5-20° can be treated with careful TAA bone resection and

igament balancing. Consideration should also be given tohese patients if they have preexisting bilateral ankle or adja-ent joint arthritis. Preserving ankle motion through a TAAould help decrease stresses on the contra-lateral ankle and

he ipsilateral adjacent joints.In an appropriate patient population, TAA performed by

xperienced surgeons reliably provides high clinical scoresnd satisfaction. To date, most of the literature details out-omes of the Agility, STAR, and BP LCS ankles. As a result,hese 3 systems have the longest follow-up among all theewer-generation TAAs. Studies with both intermediate and

ong-term follow-up on the Agility and STAR consistentlyeport that 90% of patients have decreased pain and highatisfaction.29,33,38,55,56 Buechel et al performed intermediate

nd long-term follow-up on patients that received their BP LCS

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Total ankle arthroplasty for ankle arthritis 251

nd found 88% good to excellent clinical results.43,57,81,82oets et al used the same TAA and reported similar outcomes.40

atients improved from an American Orthopedic Foot andnkle Score Ankle-Hindfoot score of 26.5 preoperatively to7.7 at 8 years after surgery. There is limited literature re-arding the newer second and third-generation TAAs. Thisncludes 6-year follow-up on patients with a Salto TAA, inhich clinical scores improved from 32.3 before surgery to3.1 after surgery.58Certainly, more studies on more of theewer generation TAAs are needed to assess their continuederformance in the long term. However, the literature to datehows reliably high clinical scores and satisfaction rates inatients who receive TAA.To date, there are few studies that compare outcomes of

nkle arthrodesis to TAA. Haddad et al indirectly examinedoth procedures through meta-analysis, but found equivocalesults.7 The mean American Orthopedic Foot and Anklecore Ankle-Hindfoot scores for TAA and fusion were 78.2nd 75.6, respectively. Good-to-excellent results were foundn 68.5% of the TAA group and 68% of the fusion group.ates of revision surgery for TAA and arthrodesis were 7%nd 9%. Although these differences were not statistically sig-ificant, the authors admit that their results were limited byhe nature of their study and the much larger amount ofiterature pertaining to ankle fusion at the time of publica-ion. Other studies that directly compare TAA to arthrodesishow a clear difference between patients who receive eitherrocedure. Initial studies were cadaveric and focused primar-

ly upon biomechanics. In 2003, Valderrabano et al con-ucted 2 such studies that compared range of motion anddjacent joint stress between specimens with either a TAA orfusion.59,60 They showed that the TAA specimens had sig-ificantly improved range of motion, decreased stress on theubtalar and transverse tarsal joints, and a closer profile to aormal ankle joint. These findings were justified in later com-arative in vivo studies. Piriou et al61 compared gait patterns

n patients with a TAA versus an arthrodesis. They found thatAA allowed for less gait asymmetry and a more normaltride. In 2007, Soohoo et al62 compared TAA and arthrode-is with respect to the development of symptomatic subtalarrthritis. At 5 years from surgery, 2.8% of patients that had annkle fusion ultimately received a subtalar fusion comparedith 0.7% of patients that had a TAA. In 2009, Saltzman et

l63 performed a nonrandomized, prospective, multicenteromparative study to assess overall clinical outcomes afterhe STAR and ankle arthrodesis. At 2 years from surgery, theyhowed that patients with a TAA had significantly higherunctional scores. Certainly, more studies with longer fol-ow-up are needed to assess the continued performance of

odern TAA. However, the relevant literature to date showsetter overall ankle function in patients who receive TAAersus arthrodesis.

Ankle arthritis can be challenging to treat. As many condi-ions can cause joint degeneration, patients will have a wideariety of clinical and radiographic presentations. Certainly,ll patients with arthritis are amenable to an arthrodesis.lthough some fusions are more complex than others, it is

he traditional surgical treatment. However, ankle arthrode-

is has its share of risks in both the short and long-term. It isell recognized that a fusion can lead to many future prob-

ems, which include gait dysfunction and adjacent joint ar-hritis.

In preserving joint motion, ankle arthroplasty offers anxcellent alternative to arthrodesis and its sequelae. Newer-eneration TAA implants and technique are much improvedver their first-generation counterparts from the 1970s and980s. Although TAA is not perfect and still has its share ofhortcomings, its published benefits in an appropriate pa-ient population by experienced surgeons cannot be ignored.

odern TAA is highly predictable in providing good-to-ex-ellent clinical results that are as good, if not better, thannkle arthrodesis. TAA offers patients significantly improvedunction and decreased pain with high satisfaction rates. Byonserving ankle motion, TAA approximates more of a nor-al gait pattern than arthrodesis. TAA also reliably decreases

tresses on joints adjacent to the ankle, such as the subtalaroint. Ultimately, this minimizes the chances a patient willequire an arthrodesis at those joints. For all of these reasons,nkle arthroplasty rather than arthrodesis is the better treat-ent option for the right patient.

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