MEDICINE

REVIEW ARTICLE

Total Ankle Replacement

Indications, Implant Designs, and Results

Alexej Barg*, Matthias D. Wimmer*, Martin Wiewiorski, Dieter C. Wirtz,

Geert I. Pagenstert, Victor Valderrabano

SUMMARY steoarthritis of the ankle is an increasing issue in

Background: About 1% of adults suffer from painful osteoarthritis of the ankle.
O the healthcare sector (1, e1, e2). Approximately
1% of the adult population suffers from painful ankle
The current literature contains no information on the percentage of such
osteoarthritis (2). The psychological and physical limi-
patients who derive long-term relief of symptoms from conservative treatment.
tations associated with advanced ankle osteoarthritis
Advanced ankle osteoarthritis can be treated with non-joint-preserving
measures, such as total ankle replacement and ankle fusion. are at least as marked as those of patients with osteo-
arthritis of the knee or hip (2). Degenerative changes of
Methods: This review is based on selected relevant publications, guidelines the ankle, in contrast to osteoarthritis of the knee or hip,
from Germany and abroad, and the authors’ personal experience.
are usually posttraumatic (Table 1, eTable 1) (3, e3, e4).
Results: Before surgery is considered, conservative measures such as Both poorly healed fractures to the lower extremity (4,
physiotherapy and orthopedic aids should be used to the fullest possible e5) and repetitive ligament injuries (5) can play a major
extent. No randomized trials have yet been published comparing total ankle role. The main causes of secondary osteoarthritis of the
replacement with ankle fusion. Total ankle replacement with newer types of ankle include rheumatic diseases, hemophilia, hemo-
prosthesis yields good to very good intermediate-term and long-term results, chromatosis, gout, avascular necrosis, and postinfec-
with mean success rates of up to 90% at 10 years (range, 68–100%).
tious states (1, e1).
Independent risk factors for the failure of ankle replacement are age over 70
This review article uses the current literature to
years (odds ratio [OR] 3.84), primary osteoarthritis (OR 7.19), post-traumatic
osteoarthritis (OR 6.2), and type of prosthesis (e.g., single hydroxyapatite explain the indications and the absolute and relative
coating: OR 15.04). The average range of motion of the replaced ankle joint is contraindications for total ankle replacement. It also
25° to 30°, with values as high as 60°. presents the results of current clinical studies on post-
operative functional outcomes and the probability of
Conclusion: Total ankle replacement is a good treatment option for complete,
success of ankle replacement surgery.
end-stage ankle arthritis. It can restore joint function and make the patient
mobile with little or no pain. There are, however, many contraindications to be
taken into account. There is a need for further studies of the biomechanics of Selective literature search
arthritic and replaced ankle joints and for long-term follow-up studies of total This review article is based on a selective literature
ankle replacement. search in established databases. The following medical
databases were searched, with no date restriction: Med-
►Cite this as:
line, Cochrane, EmbaseTM, Cinahl, Google Scholar,
Barg A, Wimmer MD, Wiewiorski M, Wirtz DC, Pagenstert GI, Valderrabano V:
Total ankle replacement—indications, implant designs, and results. ScienceDirect, and SpringerLink. The search terms
Dtsch Arztebl Int 2015; 111: 177–84. DOI: 10.3238/arztebl.2015.0177 used were the following: “total ankle replacement,”
“total ankle arthroplasty,” “ankle replacement,” “ankle
arthroplasty,” and “ankle prosthesis.” All articles
written in languages spoken by the authors (German,
English, and French) were included.
The digital indices of the following orthopedic
journals were also searched for the above-mentioned
search terms: Foot and Ankle International; Journal of
Bone and Joint Surgery, American Volume; Bone &
Joint Journal (formerly known as the Journal of Bone
and Joint Surgery, British Volume); Clinical Ortho-
*Shared authorship: Barg and Wimmer have equally contributed to the article paedics and Related Research; Foot and Ankle Clinics
Department of Orthopaedics, University of Utah, USA: Dr. med. Barg
of North America; Journal of Foot and Ankle Surgery;
Department of Orthopedic and Trauma Surgery, University Hospital Bonn:
and Der Orthopäde. In addition, the bibliographies of
Dr. med. Wimmer, Prof. Dr. med. Wirtz the identified original and review articles were
Osteoarthritis Research Center Basel, University Hospital Basel, Switzerland: Dr. med. Wiewiorski searched for further studies.
Department of Orthopedics and Traumatology, Schmerzklinik Basel, Switzerland: The literature search was performed by two of the
Prof Dr. med. Dr. phil. Valderrabano authors (AB and MDW), independently of each other.

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MEDICINE

TABLE 1

Etiology of advanced ankle osteoarthritis, based on a selection of clinical and epidemiological studies*

Etiology of ankle osteoarthritis, % (absolute values)

Study Study type Patients (ankles)
Primary Secondary Posttraumatic
(e6) RS, SC, clinical 45 (51) 25.5% (13) 54.9% (28) 19.6% (10)
(6) PS, SC, clinical 684 (722) 9.5% (69) 11.4% (82) 79.1% (571)
(e7) PS, SC, clinical 47 (50) 6.0% (3) 8.0% (4) 86.0% (43)
(e8) PS, SC, clinical 49 (50) 16.0% (8) 18.0% (9) 66.0% (33)
(e9) PS, MC register, clinical 245 (257) 20.6% (53) 55.3% (142) 24.1% (62)
(e10) PS, SC, clinical 80 (83) 33.7% (28) 25.3% (21) 41.0% (34)
(e11) RS, SC, clinical 111 (123) 52.8% (65) 18.7% (23) 28.5% (35)
(e12) RS, SC, clinical 61 (62) 19.4% (12) 4.8% (3) 75.8% (47)
(e13) RS, SC, clinical 45 (52) 50.0% (26) 26.9% (14) 23.1% (12)
(e14) RS, SC, clinical 126 (132) 46.2% (61) 25.0 (33) 28.8% (38)
(e15) PS, SC, clinical 43 (50) 54.0% (27) 32.0% (16) 14.0% (7)
(e16) PS, SC, clinical 396 (404) 16.6% (67) 13.6% (55) 69.8% (282)
(e17) PS, SC, clinical 80 (84) 25.0% (21) 19.0% (16) 56.0% (47)
(e18) PS, SC, clinical 82 (82) 34.2% (28) 13.4% (11) 52.4% (43)
(e19) RS, SC, clinical 95 (100) 26.0% (26) 29.0% (29) 45.0% (45)
(e20) PS, SC, clinical 229 (229) 13.8% (32) 4.0% (9) 82.2% (188)
(e21) PS, SC, clinical 106 (106) 52.8% (56) 20.8% (22) 26.4% (28)
(e22) PS, SC, clinical 233 (240) 30.8% (74) 17.9% (43) 51.3% (123)
(3) PS, SC, epidemiological 639 (639) 7.2% (46) 23.2% (148) 69.6% (445)
(7) PS, MC, clinical 593 (593) 26.5% (157) 15.3% (91) 58.2% (345)
(e23) RS, SC, clinical 100 (100) 30.0% (30) 44.0% (44) 26.0% (26)
(e24) RS, MC, clinical 501 (517) 13.9% (72) 25.9% (134) 60.2% (311)
(e25) PS, MC register, clinical 515 (515) 19.2% (99) 59.2% (305) 21.6% (111)
(e26) RS, SC, clinical 303 (306) 25.2% (77) 10.1% (31) 64.7% (198)
(e27) RS, SC, clinical 103 (103) 71.8% (74) 18.5% (19) 9.7% (10)
(e28) PS, SC, clinical 65 (68) 13.2% (9) 16.2% (11) 70.6% (48)
(e3) RS, SC, epidemiological 390 (406) 8.9% (36) 12.8% (52) 78.3% (318)
(e29) PS, SC, clinical 66 (66) 0.0% (0) 10.6% (7) 89.4% (59)
(e4) RS, SC, clinical 226 (233) 5.6% (13) 23.2% (54) 71.2% (166)
(e30) PS, SC, clinical 96 (100) 64.0% (64) 27.0% (27) 9.0% (9)
(e31) RS, SC, clinical 90 (99) 40.4% (40) 12.1% (12) 47.5% (47)
Total/mean 6218 (6389) 21.5% (1373) 22.6% (1373) 56.0% (3575)

*Clinical (total ankle replacement) and epidemiological (etiology of ankle osteoarthritis) studies with at least 50 patients were included.
MC, multicenter; PS, prospective; RS, retrospective; SC, single-center

History and implant designs surgical approach and no cementation. Today there
Most first-generation ankle replacements performed in are several commercially available ankle implant
the 1970s and early 1980s were two-component types (Figure 1). All implant designs can be
cemented implants. The rate of aseptic loosening for all classified by surgical technique and implant
first-generation implant types was extremely high, properties (eTable 2) (8).
occurring in almost 90% of implants (8).
Second-generation ankle implants (from the Diagnosis and preoperative planning
mid-1980s onwards) show improved implant shapes A clinical and radiological diagnosis of osteoarthritis of
and better surgical technique: bone-conserving the ankle can be made by the patient’s treating

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physician on the basis of clinical and radiological FIGURE 1

examination, as described.
The first step in preoperative diagnosis is to take a
clinical history. All available documents should be
evaluated: it is important to note which, if any, treat-
ment options have already been administered. Further
information such as BMI (body mass index), physical
activity levels, previous and/or current treatment,
severity of pain, limitations in everyday private and/or
occupational activities, intake of analgesics, and con-
comitant diagnoses (diabetes mellitus, osteoporosis,
polyneuropathy, etc.) should be recorded.
Clinical examination begins with examination of the
foot/hindfoot on standing, sitting, and walking. Hind-
foot alignment (valgus, varus, or neutral) is assessed
from behind, with the patient standing. Stability is de-
termined with the patient seated, using the talar tilt test
(examination of medial and lateral ankle inversion) and a b c
the anterior drawer test (which tests for increased
anterior translation of the talus) (9). Mobility of the Modern ankle implant types
subtalar joint is measured using a goniometer under a) Components with tibial stem b) Components with bars c) Flat components
load (10). Mobility of the ankle is measured manually,
with the ankle fixed and free (e32).
Radiological examination includes conventional
weight bearing radiographs: dorsoplantar and lateral severe osteonecrosis of the talus (more than one third of
views of the foot, anteroposterior (mortise) and lateral the talus); neuromuscular diseases; neuroarthropathies
views of the ankle, and Saltzman view (hindfoot align- (e.g. patients with Charcot foot); and patients with
ment view to assess inframalleolar alignment [11]) severe circulatory disorders (19). In patients with
(Figure 2). Supramalleolar alignment is determined concomitant significant ligament instabilities and/or
using the of medial distal tibial angle (12, e33). In pa- deformities that cannot be corrected intraoperatively,
tients with knee deformities, a whole leg radiograph arthrodesis of the ankle should be performed instead of
(orthoradiogram) is also taken. Optionally, computed joint replacement. Metal allergies are also a contraindi-
tomography or magnetic resonance imaging may be cation (20, 21).
performed; these can provide important additional in- Relative contraindications include severe osteoporo-
formation. sis, poor bone quality (e.g. due to steroid treatment),
diabetes mellitus, smoking, and excess weight, al-
Indication for surgery though the literature shows that good outcomes can be
Conservative therapy should be administered before achieved in some of these cases [22]). There may be an
surgery is indicated. This includes intensive physio- increased rate of aseptic loosening of implant compo-
therapy (local antiphlogistic therapy, muscle and move- nents in patients who engage in high levels of sporting
ment exercises to prevent stiffness of the joint, muscle activity (23, 24). Low-impact exercise (walking,
strength development, gait training) and possibly swimming, cycling, golf), however, is recommended
intra-articular hyaluronic acid viscosupplementation postoperatively (19, 24).
and orthopedic adaptation of footwear (13, 14).
The ideal indication for total ankle replacement is Surgical technique
advanced, complete osteoarthritis of the ankle (primary, An anterior approach is usually used for ankle replace-
secondary, or posttraumatic) with good bone quality, ment surgery (eFigure 1). In patients with a history of
neutral alignment, good stability, and preserved mobil- previous ankle surgery, the surgical approach can be
ity of the ankle. Further special indications include pa- modified in order not to compromise postoperative
tients with bilateral osteoarthritis of the ankle (15, e34). wound healing (e38, e39). Depth preparation is per-
Total joint replacement can also be performed as formed beneath the tendon of the tibialis anterior
revision arthroplasty in patients with failed ankle muscle in order to preserve the anterior neurovascular
prosthesis (16, 17, e35). However, revision ankle bundle, which in most cases lies behind the tendon of
arthroplasty, like revision joint replacement in general, the extensor hallucis longus muscle or between the
is a technically demanding surgical procedure. Patients tendons of the extensor hallucis longus and extensor
with painful non-union or malunion of previous ankle digitorum longus muscles (e40). Bone resection is per-
arthrodesis are another specific indication for total formed using an oscillating saw. Additional procedures
ankle replacement (18, e36, e37). for patients with concomitant deformities and/or
Absolute contraindications include acute or chronic instabilities should be performed after insertion of the
infections, with or without osteomyelitis or osteitis; implant components (eTable 3) (25, 26, e41, e42).

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a b c d
Figure 2: Preoperative conventional X-ray in standing position of 67-year-old female patient with posttraumatic ankle osteoarthritis following open reduction and
internation fixation for trimalleolar luxation fracture 4 years earlier: a) mortise view of ankle; b) lateral view of foot and ankle; c) dorsoplantar view of foot; d) Saltzman
view of hindfoot

Aftercare composed of pain, function, and range of motion; mini-

We recommend immobilization using plaster cast of the mum score, 0 points; maximum score, 100 points). Pain
lower leg or a stabilizing boot for six weeks after sur- level is determined using the visual analogue scale
gery. During this period full weight may be borne with (VAS) from 0 (no pain) to 10 (worst possible pain)
the aid of two elbow crutches, depending on the sever- (e59). Quality of life can be analyzed using the SF-36
ity of the patient’s complaints. In patients with reduced questionnaire (36-Item Short Form Health Survey)
bone quality and/or who have undergone additional (e60).
procedures such as corrective osteotomy, we recom-
mend 15 kg partial weightbearing for six weeks after Results/literature review
surgery. Thromboprophylaxis is administered during For a long time arthrodesis of the ankle was the first-
immobilization (27). Clinical and radiological follow- line treatment for patients with advanced osteoarthritis
up examination is performed after six weeks (Figure 3). of the ankle, which is not surprising given how uni-
After this, intensive outpatient physiotherapy begins: formly disappointing the results of first-generation total
gait training, proprioception exercises, gradual increase ankle replacement were. Precise analysis of failures led
to full weightbearing, local antiphlogistic therapy to the development of new implant designs, acceptance
including lymph drainage, active and passive ankle of which is steadily increasing among orthopedic
mobility therapy, extension exercises, and therapy to surgeons.
strengthen the triceps surae muscle. However, it is difficult to find well conducted, con-
Compression stockings are used for patients with trolled, prospective studies in the literature, and in par-
persistent edema or soft-tissue swelling. The following ticular there are no comparisons of two-component and
sports can be recommended after full mobilization and three-component implant types (30). Saltzman et al. (7)
full weightbearing ability have been attained: low- published the first results of a prospective study com-
impact (e.g. walking, swimming, cycling, golf) or paring ankle arthrodesis (66 cases) and total ankle
medium-impact (e.g. jogging, tennis, skiing) (24). replacement (593 patients) and demonstrated that pa-
Contact sports and sports that involve jumping should tients with total ankle replacement had less pain and
be avoided (24). better functional outcomes postoperatively, with com-
Clinical and radiological follow-up examinations are parable postoperative complication rates. Although
performed six weeks, three months, six months, and postoperative complications (poor wound healing, in-
one year after surgery and then annually. The most im- fections) were observed more frequently in patients
portant tools/questionnaires (28) that can be used to undergoing ankle replacement than in those undergoing
record functional postoperative outcomes following arthrodesis of the ankle—6.2% versus 1.5%— the
total ankle replacement are the American Orthopaedic difference was not statistically significant (p = 0.087).
Foot and Ankle Society (AOFAS) Ankle–Hindfoot The Buechel–Pappas score (score composed of pain,
Score (29) (score composed of pain, function, and function, deformity, and mobility; minimum score, 0
alignment; minimum score, 0 points; maximum score, points; maximum score, 100 points) (e61) was used to
100 points); and the Kofoed Ankle Score (e58) (score assess functional outcome. Patients with total ankle

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replacement had significantly better functional out-

comes: Buechel–Pappas score 46.7 ± 13.0 versus 26.3
± 17 (p<0.001). The two groups had comparable post-
operative pain levels: 1.6 ± 1.8 versus 1.8 ± 2.0 (p =
0.607). Further studies are planned by the authors but
have not yet been published (7).
Despite increasing acceptance, total ankle replace-
ment remains a technically demanding procedure with
a flat learning curve. Intraoperative complications are
not uncommon; they include fractures of the medial
and/or lateral malleolus in 0 to 23% of cases and tendon
injuries (posterior tibial tendon, flexor hallucis longus,
flexor digitorum longus) and nerve injuries (superfi-
cial/deep peroneal nerve) in 0 to 10% of cases (31,
e62–e66). Difficult steps during surgery include correct
component positioning, particularly of talar compo-
nents (e62, e66). Incorrect tibial component positioning
can be found in 0 to 16% of all cases, and incorrect talar a b
component positioning in 0 to 36% of all cases (e62).
Numerous in vitro biomechanical studies have shown Figure 3: Postoperative X-ray of 67-year-old female patient 6 weeks after total ankle
replacement: a) mortise view of ankle; b) lateral view of ankle
that incorrect positioning of implant components has
adverse biomechanical consequences such as reduced
ankle mobility, pathological tension of the periarticular
ligaments, and unfavorable intra-articular pressure dis-
tribution (e67–e70). We have shown in a clinical study Postoperative improvement in ankle mobility was
that patients with suboptimal positioning of talar com- relatively low, with values between 0° and 14° (35).
ponents have a higher rate of persisting pain and worse Zaidi et al. (36) published a systematic review of the
ankle mobility (32). literature and meta-analysis of 58 publications with a
Postoperative outcomes following total ankle re- total of 7942 ankle replacements. The success rate after
placement are steadily improving (Table 2; eTable 4) 10 years was 89%, with an annual failure rate of 1.2%
but lag behind those of total knee and hip replacements (95% confidence interval [CI]: 0.7 to 1.6). The mean
(Table 3). Labek et al. (33) investigated cumulative AOFAS Ankle–Hindfoot Score rose from 40 (95% CI:
outcomes on the basis of worldwide joint replacement 36 to 43) preoperatively to 80 (95% CI: 76 to 84) post-
registers. Outcomes following total hip and knee operatively. The range of motion of the ankle on which
replacements were comparable, with 1.29 and 1.26 surgery was performed improved from a mean of 23°
revisions per 100 component years. This means that (95% CI: 19 to 26°) preoperatively to 34° (95% CI: 26
after 10 years 13 out of every 100 patients need to to 41°) postoperatively (36).
undergo revision surgery. The outcomes following We performed a survivorship analysis of implant
medial partial replacement were somewhat worse, with components in 684 patients who received a total of 722
1.53 revisions per 100 component years. Total ankle ankle replacements (6). The mean follow-up time in
replacement was associated with the worst outcomes, this prospective study was 6.3 ± 2.9 years. The prob-
however, with 3.29 revisions per 100 component years, ability of success of the implant components was 94%
resulting in revision surgery for 33 out of every 100 pa- after five years and 84% after 10 years. These results
tients within 10 years (33). The causes and frequency are comparable with those of current clinical studies
of failure of total ankle replacement are different from (Table 2, eTable 4). The following factors were
those of hip and knee replacements: the main causes of identified as independent risk factors for ankle replace-
failure are aseptic loosening of tibial and/or talar com- ment failure:
ponents, persisting pain, and septic loosening (Table 3) ● Age under 70 years (odds ratio [OR]: 3.84)
(34). ● Etiology of ankle osteoarthritis (OR for primary
In 2010, Gougoulias et al. (35) performed a system- osteoarthritis: 7.19; OR for posttraumatic osteo-
atic review of the literature including 13 level IV arthritis: 6.20)
studies with a total of 1105 ankle replacements. Seven ● Implant generation (OR for single hydroxyapatite
different implant types were used. The mean failure coating: OR: 15.04) (6).
rate (defined as replacement of one or both implant For a long time a change of approach—removal of
components or implant removal and conversion to the implant components followed by arthrodesis—was
arthrodesis of the ankle) five years after implantation the standard procedure in cases of ankle replacement
was 10%, but there was great variation in failure rates failure. The current literature describes various surgical
between different centers, ranging from 0% to 32%. techniques and fixation methods for such arthrodesis
The percentage of patients in the included studies with after prosthesis removal: bone allografts, autografts, or
persisting complaints was between 27 and 60%. replacement materials (e.g. porous metals such as

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MEDICINE

TABLE 2

Clinical outcomes following total ankle replacement: probability of survival of implant components*

Study Study type Implant type No. of implants Probability of survival of implant components
(e72) RS, SC Agility 207 76% after 9 years
(22) RS, SC HINTEGRA 123 93% after 6 years
(6) PS, SC HINTEGRA 722 94% after 5 years, 84% after 10 years
(e74) RS, MC Salto (388), AES (173), HINTEGRA (22), 592 88% after 71 months
STAR (9)
(e79) PS, SC Buechel–Pappas 115 74.2% (normal sulcus) after 20 years,
(normal sulcus 40; deep sulcus 75) 92% (deep sulcus) after 12 years
(e9) PS, MC STAR (216), TPR (32), HINTEGRA (6), AES (3) 257 89% after 5 years, 76% after 10 years
(e85) PS, MC BOX 158 96.1% after 4 years
(e86) PS, MC STAR (318), Buechel-Pappas (92), 531 78% after 5 years, 62% after 10 years
AES (69), HINTEGRA (29), Mobility (23)
(e87) PS, MC STAR (322), Mobility (132), AES (115), 780 81% after 5 years, 69% after 10 years
Buechel-Pappas (109), CCI (66), HINTEGRA (36)
(e11) RS, SC STAR 123 86% (patients with preoperative deformity up to 10°),
75% (patients with preoperative deformity 10 to 30°)
after 5 years
(e88) PS, MC Agility (117), STAR (45), Mobility (29), Ramses (11) 202 86% after 5 years
(e90) RS, SC Mayo 204 79% after 5 years, 65% after 10 years,
61% after 15 years
(e14) RS, SC Agility 132 86% after 9 years, 63% after 11 years
(e92) PS, SC STAR 100 85.7% (patients under 50) and
91.6% (patients over 50) after 5 years,
75% (patients under 50) and
80.6% (patients over 50) after 10 years
(e96) PS, MC BOX 189 97% after 4 years
(e16) PS, SC INBONE (211), STAR (122), Salto-Talaris (71) 404 90% and 97.6% after 3.2 years with and without
arthrodesis of the hindfoot
(21) RS, MC Salto (91), HINTEGRA (39), AES (20), 183 86% (88.4% high-volume centers; 84.9% low-volume
Coppelia (17), STAR (11), Ramses (4), Akile (1) centers) after 5 years
(e22) PS, SC Mobility 240 97.7% after 4 years
(e102) RS, SC Salto 401 86.6% (all patients), 85.1% (posttraumatic osteoarthritis),
95.6% (rheumatoid arthritis), 87.9% (patients under 55)
after 5 years
(e25) PS, MC AES (298), STAR (217) 515 83% after 5 years
(e26) RS, SC Agility 306 80% (89% in patients over 54) after 5 years
(e108) PS, SC STAR 200 92.7% after 5 years
(e109) RS, MC Salto 109 97.5% after 2 years
(e111) PS, SC STAR 200 93.3% after 5 years, 80.3% after 10 years
(e112) PS, SC Buechel-Pappas (100), STAR (100) 200 79% (Buechel-Pappas) and 95% (STAR) after 6 years
(e30) PS, SC Mobility 100 97% after 3 years, 93.6% after 4 years

*Clinical studies (total ankle replacement) with at least 100 patients were included.
AES: Ankle Evolutive System; BOX: Bologna–Oxford; MC: multicenter; PS: prospective; RS: retrospective; STAR: Scandinavian Total Ankle Replacement; TPR: Thomson, Prichard and Richard;
SC: single-center

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Trabecular Metal™) can be used to bridge the defect TABLE 3

(37, 38, e113–e118). The alternative to converting to
ankle arthrodesis is revision ankle arthroplasty (16, 17, Most common causes of failure of total hip, knee, and ankle replacement
(given in % according to Sadoghi et al. [34])
e35, e119–e121). If possible, an implant type for which
special revision components are available, e.g. a thicker Cause of failure Total hip Total knee Total ankle
metal plate for tibial components and larger replacement replacement replacement
weightbearing area and improved fixation for talar Aseptic loosening 55.2 29.8 38
components, should be used. Revision surgery can be Luxation/instability 11.8 6.2 8.5
performed as one-stage or two-stage procedure. In the
Septic loosening 7.5 14.8 9.8
two-stage procedure, the goal of the first surgery is to
address the bone defect. After bone integration of the Periprosthetic fracture 6 3 2
autograft is achieved, the revision components can be Pathological wear 4.2 8.2 8
implanted in a second surgery (eFigure 2). Persistent pain 3.7 9.5 12
Implant failure 2.5 4.7 5.3
Conclusion
There is no gold standard treatment for advanced ankle Technical error 3.8 4.6 4.6
osteoarthritis. Both, ankle arthrodesis and total ankle
replacement are important treatment options in patients
with end-stage ankle osteoarthritis. Attaining satisfac-
tory intermediate-term and long-term postoperative th
and ankle. 9 ed. Philadelphia: Elsevier Saunders, 2014;
outcomes in patients who have undergone total ankle 1078–162.
replacement requires thorough preoperative exami-
9. Phisitkul P, Chaichankul C, Sripongsai R, Prasitdamrong I, Teng-
nation and planning, taking careful account of all trakulcharoen P, Suarchawaratana S: Accuracy of anterolateral
relative and absolute contraindications, with drawer test in lateral ankle instability: a cadaveric study. Foot
corresponding patient selection. If modern ankle Ankle Int 2009; 30: 690–5.
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11. Saltzman CL, el Khoury GY: The hindfoot alignment view. Foot
Conflict of interest statement
The authors declare that no conflict of interest exists. Ankle Int 1995; 16: 572–6.
12. Barg A, Harris MD, Henninger HB, et al.: Medial distal tibial
Manuscript received on 10 August 2014, revised version accepted on
angle: comparison between weightbearing mortise view and
3 December 2014. hindfoot alignment view. Foot Ankle Int 2012; 33: 655–61.
13. Schmid T, Krause FG: Conservative treatment of asymmetric
Translated from the original German by Caroline Devitt, M.A. ankle osteoarthritis. Foot Ankle Clin 2013; 18: 437–48.
14. Barg A, Smirnov E, Paul J, Pagenstert G, Valderrabano V: Man-
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590 Wakara Way
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2003; 24: 514–8. @ For eReferences please refer to:
www.aerzteblatt-international.de/ref1115
32. Barg A, Elsner A, Anderson AE, Hintermann B: The effect of eTables and eFigures:
three-component total ankle replacement malalignment on www.aerzteblatt-international.de/15m0177

184 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2015; 112: 177–84
 MEDICINE

REVIEW ARTICLE

Total Ankle Replacement

Indications, Implant Designs, and Results

Alexej Barg*, Matthias D. Wimmer*, Martin Wiewiorski, Dieter C. Wirtz,

Geert I. Pagenstert, Victor Valderrabano

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e97. Morgan SS, Brooke B, Harris NJ: Total ankle replacement by the
failed total ankle replacement. Clin Podiatr Med Surg 2013; 30:
ankle evolution system: Medium-term outcome. J Bone Joint
187–98.
Surg Br 2010; 92: 61–5.
e98. Nishikawa M, Tomita T, Fujii M, et al.: Total ankle replacement in e118. Donnenwerth MP, Roukis TS: Tibio-talo-calcaneal arthrodesis
rheumatoid arthritis. Int Orthop 2004; 28: 123–6. with retrograde compression intramedullary nail fixation for
salvage of failed total ankle replacement: A systematic review.
e99. Nodzo SR, Miladore MP, Kaplan NB, Ritter CA: Short to midterm Clin Podiatr Med Surg 2013; 30: 199–206.
clinical and radiographic outcomes of the salto total ankle
prosthesis. Foot Ankle Int 2014; 35: 22–9. e119. McCollum G, Myerson MS: Failure of the agility total ankle
replacement system and the salvage options. Clin Podiatr Med
e100. Reuver JM, Dayerizadeh N, Burger B, Elmans L, Hoelen M, Tulp Surg 2013; 30: 207–23.
N: Total ankle replacement outcome in low volume centers:
Short-term followup. Foot Ankle Int 2010; 31: 1064–8. e120. Deorio JK: Revision INBONE total ankle replacement. Clin Podiatr
Med Surg 2013; 30: 225–36.
e101. San Giovanni TP, Keblish DJ, Thomas WH, Wilson MG: Eight-year
results of a minimally constrained total ankle arthroplasty. Foot e121. Espinosa N, Wirth SH: Revision of the aseptic and septic total
Ankle Int 2006; 27: 418–26. ankle replacement. Clin Podiatr Med Surg 2013; 30: 171–85.

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eTABLE 1

Etiology of advanced ankle osteoarthritis, based on a selection of clinical and epidemiological studies*

Etiology of ankle osteoarthritis, % (absolute values)

Study Study type Patients (ankles)
Primary Secondary Posttraumatic
(e6) RS, SC, clinical 45 (51) 25.5% (13) 54.9% (28) 19.6% (10)
– Rheumatism: 54.9% (28)
(6) PS, SC, clinical 684 (722) 9.5% (69) 11.4% (82) 79.1% (571)
(e7) PS, SC, clinical 47 (50) 6.0% (3) 8.0% (4) 86.0% (43)
– Rheumatism: 4.0% (2) – State following fracture: 50.0% (25)
– Tuberculosis: 2.0% (1) – State following ligament injuries:
– Hemophilia: 2.0% (1) 36.0% (18)
(e8) PS, SC, clinical 49 (50) 16.0% (8) 18.0% (9) 66.0% (33)
– Rheumatism: 14.0% (7)
– Necrosis of the talus: 4.0% (2)
(e9) PS, MC register, 245 (257) 20.6% (53) 55.3% (142) 24.1% (62)
clinical – State following fracture: 22.1% (57)
– State following ligament injuries: 1.9%
(5)
(e10) PS, SC, clinical 80 (83) 33.7% (28) 25.3% (21) 41.0% (34)
– Rheumatism: 25.3% (21)
(e11) RS, SC, clinical 111 (123) 52.8% (65) 18.7% (23) 28.5% (35)
(e12) RS, SC, clinical 61 (62) 19.4% (12) 4.8% (3) 75.8% (47)
– Clubfoot: 3.2% (2)
– Postpolio: 1.6% (1)
(e13) RS, SC, clinical 45 (52) 50.0% (26) 26.9% (14) 23.1% (12)
(e14) RS, SC, clinical 126 (132) 28.8% (38) 25.0 (33) 46.2% (61)
– Rheumatism: 23.5% (31)
– Postinfection: 1.5% (2)
(e15) PS, SC, clinical 43 (50) 54.0% (27) 32.0% (16) 14.0% (7)
(e16) PS, SC, clinical 396 (404) 16.6% (67) 13.6% (55) 69.8% (282)
(e17) PS, SC, clinical 80 (84) 25.0% (21) 19.0% (16) 56.0% (47)
– Rheumatism: 17.9% (15) – State following fracture: 39.3% (33)
– Hemochromatosis: 1.2% (1) – State following ligament injuries:
16.7% (14)
(e18) PS, SC, clinical 82 (82) 34.2% (28) 13.4% (11) 52.4% (43)
(e19) RS, SC, clinical 95 (100) 26.0% (26) 29.0% (29) 45.0% (45)
– Rheumatism: 26.0% (26)
– Postinfection: 2.0% (2)
– Psoriasis: 1.0% (1)
(e20) PS, SC, clinical 229 (229) 13.8% (32) 4.0% (9) 82.2% (188)
(e21) PS, SC, clinical 106 (106) 52.8% (56) 20.8% (22) 26.4% (28)
(e22) PS, SC, clinical 233 (240) 30.8% (74) 17.9% (43) 51.3% (123)
– Rheumatism: 15.0% (36)
– Hemochromatosis: 2.9% (7)
(3) PS, SC, 639 (639) 7.2% (46) 23.2% (148) 69.6% (445)
epidemiological – Rheumatism: 11.9% (76) – State following fracture: 46.6% (298)
– Neuropathy: 4.9% (31) – State following ligament injuries:
– Hemophilia: 1.9% (12) 19.7% (126)
– Postinfection: 1.6% (10) – Traumatic osteochondral lesions:
– Gout: 0.8% (5) 3.3% (21)
(7) PS, MC, clinical 593 (593) 26.5% (157) 15.3% (91) 58.2% (345)
(e23) RS, SC, clinical 100 (100) 30.0% (30) 44.0% (44) 26.0% (26)
(e24) RS, MC, clinical 478 (489) 15.3% (75) 25.8% (126) 58.9% (228)
(e25) PS, MC register, 515 (515) 19.2% (99) 59.2% (305) 21.6% (111)
clinical
(e26) RS, SC, clinical 303 (306) 25.2% (77) 10.1% (31) 64.7% (198)
(e27) RS, SC, clinical 103 (103) 71.8% (74) 18.5% (19) 9.7% (10)

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Etiology of ankle osteoarthritis, % (absolute values)

Study Study type Patients (ankles)
Primary Secondary Posttraumatic
(e28) PS, SC, clinical 65 (68) 13.2% (9) 16.2% (11) 70.6% (48)
– Rheumatism: 7.4% (5) – State following fracture: 60.3% (41)
– Hemochromatosis: 4.4% (3) – State following ligament injuries:
– Psoriasis: 1.5% (1) 10.3% (7)
– Lupus erythematosus: 1.5% (1)
– Sclerodermia: 1.5% (1)
(e3) RS, SC, 390 (406) 8.9% (36) 12.8% (52) 78.3% (318)
epidemiological – Rheumatism: 5.4% (22) – State following fracture: 62.3% (253)
– Hemochromatosis: 2.7% (11) – State following ligament injuries:
– Hemophilia: 1.5% (6) 16.0% (65)
– Clubfoot: 1.0% (4)
– Avascular necrosis of the talus: 0.7%
(3)
– Osteochondral lesions: 0.7% (3)
– Postinfection: 0.7% (3)
(e29) PS, SC, clinical 66 (66) 0.0% (0) 10.6% (7) 89.4% (59)
– Necrosis of the talus: 4.5% (3) – State following fracture: 72.7% (48)
– Hemophilia: 3.0% (2) – State following ligament injuries:
– Rheumatism: 1.5% (1) 16.7% (11)
– Hemochromatosis: 1.5% (1)
(e4) RS, SC, clinical 226 (233) 5.6% (13) 23.2% (54) 71.2% (166)
– Flatfoot: 8.2% (19) – State following fracture: 59.2% (138)
– Rheumatism: 7.3% (17) – State following ligament injuries:
– Clubfoot: 3.4% (8) 12.0% (28)
– Osteochondral lesion: 1.7% (2)
– Postinfection: 1.3% (1.3)
– Charcot–Marie–Tooth disease: 0.9%
(2)
– Hemophilia: 0.4% (1)
(e30) PS, SC, clinical 96 (100) 64.0% (64) 27.0% (27) 9.0% (9)
– Rheumatism: 27.0% (27) – State following fracture: 9.0% (9)
(e31) RS, SC, clinical 90 (99) 40.4% (40) 12.1% (12) 47.5% (47)
Total 6218 21.5% 22.6% 56.0%
(6389) (1373) (1441) (3575)

*Clinical (total ankle replacement) and epidemiological (etiology of ankle osteoarthritis) studies with at least 50 patients were included.
MC: multicenter; PS: prospective; RS: retrospective; SC: single-center

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eTABLE 2

Classification of current ankle implant types

Surgical access Inlay type Replaced Internal implant surfaces Inlay materials Sulcus type Surface
surfaces morphology
AAA Anterior Mobile Superior HA UHMWPE None Trapezoidal
AES Anterior Mobile Superior HA UHMWPE Deep Trapezoidal
Agility Anterior Fixed Superior/medial/ Titanium UHMWPE None Trapezoidal
lateral
BOX Anterior Mobile Superior HA UHMWPE Normal Ellipsoidal
Buechel-Pappas Anterior Mobile Superior Titanium UHMWPE Deep Ellipsoidal
ESKA Lateral/medial Fixed Superior Titanium UHMWPE Normal Ellipsoidal
INBONE Anterior Fixed Superior Titanium UHMWPE Normal Spheroidal
HINTEGRA Anterior Mobile Superior/medial HA UHMWPE None Conical
Mobility Anterior Mobile Superior Titanium UHMWPE Deep Trapezoidal
Ramses Anterior Mobile Superior HA UHMWPE None Ellipsoidal
Salto Anterior Mobile Superior/medial HA UHMWPE Normal Conical
STAR Anterior Mobile Superior HA UHMWPE None Cylindrical
UHMWPE,
TNK Anterior Fixed Superior HA None Cylindrical
ceramic
Highly cross-linked
TM Total Ankle Lateral Fixed Superior Porous metal None Conical
UHMWPE

AAA: Alpha Ankle Arthroplasty; AES: Ankle Evolutive System; BOX: Bologna–Oxford; HA: hydroxyapatite; STAR: Scandinavian Total Ankle Replacement; TM: Trabecular Metal;
UHMWPE: ultra-high-molecular-weight polyethylene

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eTABLE 3

Additional procedures in patients with concomitant valgus or varus hindfoot deformity

Patients with valgus hindfoot deformity

Supramalleolar valgus deformity Supramalleolar tibial osteotomy:
– Medial closing tibial osteotomy (e43–e45)
Isolated valgus defective heel position Corrective calcaneal osteotomy:
– Medial sliding calcaneal osteotomy (e46)
Flexible pes planovalgus et abductus deformity Corrective calcaneal osteotomy:
– Lateral sliding calcaneal osteotomy (e47)
Tendon transfer:
– Flexor digitorum longus to tibialis posterior (e48)
Rigid pes planovalgus et abductus deformity Corrective arthrodesis of the hindfoot:*
– Subtalar arthrodesis (e49)
– Triple arthrodesis with or without calcaneocuboidal joint (e50)
Medial instability Medial ligament stabilization:
– Anatomical reconstruction with transosseous sutures (e51)
– Reconstruction with tendon autograft (e52)
Patients with varus hindfoot deformity
Supramalleolar varus deformity Supramalleolar tibial osteotomy:
– Medial opening tibial osteotomy (with supramelleolar deformity <10°) (e44, e45, e53)
– Lateral closing tibial osteotomy (with supramelleolar deformity >10°) (e44, e45, e53)
Flexible varus abnormal heel position Corrective calcaneal osteotomy:
– Dwyer calcaneal osteotomy (e54)
– Z-shaped calcaneal osteotomy (e55)
Rigid inframalleolar varus alignment Corrective arthrodesis of the hindfoot:
– Subtalar arthrodesis (e49)
Lateral instability Lateral ligament stabilization:
– Anatomical reconstruction with transosseous stitches (e56)
– Reconstruction with tendon autograft (e57)

*Depends on extent of deformity and degenerative changes

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eTABLE 4

Clinical outcomes following total ankle replacement: probability of survival of implant components and postoperative range of ankle motion*

Study Study type Implant type No. of implants Probability of survival of implant Mean follow-up time Postoperative range of
components motion
(e71) RS, SC Buechel–Pappas 35 97% after 5 years 5 years N/A
(3 to 150 months)
(e72) RS, SC Agility 207 76% after 9 years N/A N/A
(e73) RS, SC AES 93 90% after 5 years 42 months N/A
(13 to 73 months)
(e6) RS, SC STAR 51 70% after 5 years 52 months Total 28° (10 to 55°)
(36 to 97 months)
(22) RS, SC HINTEGRA 123 93% after 6 years 67.7 ± 27.0 months Total 35.3°± 8.1°
(29 to 126 months)
(e34) PS, SC HINTEGRA 52 91% after 5 years, 5 years Total 38°± 9°
78% after 8 years (2 to 10 years)
(6) PS, SC HINTEGRA 722 94% after 5 years, 6.3 ± 2.9 years N/A
84% after 10 years (2 to 12.2 years)
(e74) RS, MC Salto (388), 592 88% after 71 months Min. 1 year N/A
AES (173),
HINTEGRA (22),
STAR (9)
(e75) PS, SC BOX 62 91.9% after 42.5 months 42.5 months DF 8.4° ± 4.8° (0 to 20°);
(24 to 71 months) PF 17.1° ± 8.3° (0 to 30°)
(e76) RS, SC Salto 98 98% after 5 years 35 months Total 28.3° ± 7°
(24 to 68 months)
(e77) RS, SC Salto 98 85% after 10 years 8.9 years DF 8.6° ± 5.3° (−5 to 20°);
(6.8 to 11 years) PF 18.1° ± 7.8° (5 to 40°)
(e78) PS, SC STAR 77 70.7 after 10 years, 12.4 years Total 22.8°±3.5°
45.6% after 14 years (10.8 to 14.9 years)
(e8) PS, SC Buechel–Pappas 50 93.5% after 10 years 5 years Total 28° (12 to 46°)
(2 to 10 years)
(e79) PS, SC Buechel–Pappas 115 74.2% (normal sulcus) 12 years Total 25°
(normal sulcus 40; after 20 years, (2 to 10 years, (10 to 47°, normal sulcus),
deep sulcus 75) 92% (deep Sulkus) normal sulcus), total 29°
after 12 years 5 years (10 to 50°, deep sulcus)
(2 to 12 years,
deep sulcus)
(e80) PS, SC BOX 20 N/A 12 months Total 28.8° ± 11.3°
(7 to 14 months) (10 to 50°)
(e81) RS, SC Agility 42 62% after 9 years 8 years (0.5 to 11 years)
(e82) RS, SC Buechel–Pappas 30 87.6% after 5 years 5.1 ± 4 years DF 5°; PF 30°
(1 to 13 years)
(e83) PS, SC LCS (19), 93 84% after 8 years 7.2 years DF 7.1° (5.8 to 8.4°);
Buechel–Pappas (74) (0.4 to 16.3 years) PF 24.8° (22.6 to 27.2°)
(e9) PS, MC STAR (216), 257 89% after 5 years, 4 years N/A
TPR (32), 76% after 10 years (5 days to 12 years)
HINTEGRA (6),
AES (3)
(e84) PS, MC BOX 51 97.2% after 3 years 30 months Total 27.4° (16 to 53°)
(24 to 48 months)
(e85) PS, MC BOX 158 96.1% after 4 years 17 months Total 26.5° (14 to 53°)
(6 to 48 months)
(e86) PS, MC STAR (318), 531 78% after 5 years, 1 to 11 years N/A
Buechel–Pappas (92), 62% after 10 years
AES (69),
HINTEGRA (29),
Mobility (23)

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Study Study type Implant type No. of implants Probability of survival of implant Mean follow-up time Postoperative range of
components motion
(e87) PS, MC STAR (322), 780 81% after 5 years, 10 years N/A
Mobility (132), 69% after 10 years
AES (115),
Buechel–Pappas (109),
CCI (66),
HINTEGRA (36)
(e11) RS, SC STAR 123 86% (patients with preoperative 4 years N/A
deformity up to 10°) and (2 to 8 years)
75% (patients with preoperative
deformity 10 to 30°) after 5 years
(e88) PS, MC Agility (117), 202 86% after 5 years 28 to 75 months N/A
STAR (45),
Mobility (29),
Ramses (11)
(e12) RS, SC Agility 65 91% after 1 year, 3.3 years N/A
70% after 3 years, (2 to 5.9 years)
67% after 5 years
(e89) RS, SC TPR 33 85% after 10 years 10 to 23 years N/A
(e13) RS, SC STAR 52 90% after 5 years, 80 months Total 23° ± 12° (0 to 55°)
84% after 8 years (60 to 110 months)
(e90) RS, SC Mayo 204 79% after 5 years, 9 years k. A.
65% after 10 years, (2 to 17 years)
61% after 15 years
(e14) RS, SC Agility 132 86% after 9 years, 9 years DF 0° (−24 to 16°);
63% after 11 years PF 19° (−1 to 36°)
(e58) PS, SC STAR 28 70% after 12 years 1 to 12 years N/A
(e91) PS, SC STAR 52 72.7% (primary osteoarthritis) and 9 years N/A
75.5% (rheumatoid arthritis) (6 to 14 years)
after 14 years
(e92) PS, SC STAR 100 85.7% (patients under 50) and 6.8 years N/A
91.6% (patients over 50) (1 to 15 years)
after 5 years,
75% (patients under 50) and
80.6% (patients over 50)
after 10 years
(e93) PS, SC STAR (33 cemented, 58 70% (cemented) and 9.4 ± 2.7 years N/A
25 uncemented) 95.4% (uncemented)
after 12 years
(e94) PS, SC AES 38 79% after 2 years 28 months N/A
(2 to 70 months)
(e95) PS, SC LCS (19), 93 80% after 15 years 14.8 years N/A
Buechel–Pappas (74) (10.7 to 22.8 years)
(e96) PS, MC BOX 189 97% after 4 years 21 months Total 14 to 53°
(e16) PS, SC INBONE (211), 404 90% and 97.6% after 3.2 years 3.2 years N/A
STAR (122), with and without arthrodesis of the (2 to 6 years)
Salto-Talaris (71) hindfoot
(e17) PS, SC STAR 84 96% after 5 years, 9.1 years DF 4.5°; PF 34.7°
90% after 10 years (2.6 to 11 years)
(e97) RS, SC AES 38 94.7% after 6 years 57.8 months N/A
(48 to 80 months)
(e98) RS, SC TNK 27 77% after 14.1 years 72 months DF 7.5° (0 to 20°);
(15 to 169 months) PF 8.5° (−10 to 20°)
(e99) RS, SC Salto 75 98% after 3.6 years 43 months DF 8.7° ± 5.6°;
(27 to 73 months) PF 29° ± 7°
(21) RS, MC Salto (91), 183 86% (high-volume sites 88.4%; 39 ± 29 months N/A
HINTEGRA (39), low-volume sites 84.9%) (6 to 132 months)
AES (20), after 5 years
Coppelia (17),
STAR (11),
Ramses (4),
Akile (1)

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Study Study type Implant type No. of implants Probability of survival of implant Mean follow-up time Postoperative range of
components motion
(e100) RS, MC STAR 59 88% after 3 years 36 months DF 10.2° ± 6.3°;
(12 to 65 months) PF 11.3° ± 7.9°
(e22) PS, SC Mobility 240 97.7% after 4 years 32.8 ± 15.3 months DF 8.3° ± 5.3°;
(12 to 63 months) PF 13.6° ± 6.4°
(e101) RS, SC Buechel–Pappas 28 93% after 8.3 years 8.3 years Total 23° (8 to 40°)
(5 to 12.2 years)
(e102) RS, SC Salto 401 86.6% (all patients), 29 months Total 33.1° ± 13.6°
85.1% (posttraumatic (1 to 84 months)
osteoarthritis),
95.6% (rheumatoid arthritis),
87.9% (patients under 55)
after 5 years
(e103) PS, SC TPR (20), 39 87% (TPR) after 12 years, 8.6 years Total (TPR) 37°.
STAR (19) 94.3% (STAR) after 6 years (TPR: 3 to 13 years), Total (STAR) 33.5°
3.1 years
(STAR: 1 to 6 years)
(e104) PS, SC Salto Talaris 75 96% after 2.8 years 2.8 years N/A
(2 to 4.5 years)
(e25) PS, MC AES (298), 515 83% after 5 years 3.2 years N/A
STAR (217) (0.1 to 9.6 years)
(e26) RS, SC Agility 306 80% (89% in patients over 54) 33 ± 18 months N/A
after 5 years (4 to 75 months)
(e105) PS, MC Mobility 88 89.6% after 3 years, 40 months N/A
88.4% after 4 years (30 to 60 months)
(e106) RS, SC Mobility 58 84% after 4 years 32 months N/A
(14 to 49 months)
(e107) RS, SC AES (16), 21 91% after 3 years, 38 ± 26 months N/A
Salto (4), 57% after 5 years
New-Jersey (1)
(e108) PS, SC STAR 200 92.7% after 5 years 46 months N/A
(24 to 101 months)
(e109) RS, MC Salto 109 97.5% after 2 years 21.7 months Total 32°
(12 to 65 months)
(e110) RS, SC HINTEGRA 16 66.7% after 5 years 61.8 months Total 23.7°
(7 to 116 months) (12.0 to 47.5°)
(e111) PS, SC STAR 200 93.3% after 5 years, 88 months N/A
80.3% after 10 years (60 to 156 months)
(e112) PS, SC Buechel–Pappas (100), 200 79% (Buechel–Pappas) and Min. 36 months N/A
STAR (100) 95% (STAR) after 6 years
(e30) PS, SC Mobility 100 97% after 3 years, 43 months DF 7.5° (−5 to 22°),
93.6% after 4 years (4 to 63 months) PF 14° (1 to 41°)

*All available clinical studies (total ankle replacement) were included.

AES: Ankle Evolutive System; BOX: Bologna–Oxford; DF: dorsiflexion; N/A: information not available; LCS: low-contact stress; MC: multicenter; PF: plantar flexion; PS: prospective;
RS: retrospective; STAR: Scandinavian Total Ankle Replacement; TPR: Thomson, Prichard and Richard; SC: single-center

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Deutsches Ärzteblatt International | Dtsch Arztebl Int 2015; 112 | Barg et al.: eFigures III