Post-traumatic Predominance | Arthrodesis vs TAR | Functional Outcomes | Adjacent Joint Disease
- Post-traumatic is the commonest cause (78% in Valderrabano series) - unlike hip/knee (primary OA)
- Ankle arthrodesis remains the durable reference standard - bone non-union about 12% on radiographs but only ~7% symptomatic in TARVA
- TAR for lower demand, good alignment, adequate bone stock, intact deltoid
- Accelerated adjacent (ipsilateral foot) OA is consistent at 22 years post-fusion (Coester)
- Neutral alignment critical for both fusion and replacement
- “Most ankle OA is post-traumatic (fractures, instability, osteochondral lesions)
- “Ankle tolerates less cartilage loss than hip/knee before symptoms
- “TAR contraindicated with significant varus/valgus deformity, neuropathy, AVN
- “Fusion position: neutral DF, 5 degrees valgus, 5-10 degrees ER, slight posterior translation
- “TARVA RCT (2023): no significant difference in walking/standing score at 1 year; both improve quality of life
Ankle OA is predominantly post-traumatic (78% in Valderrabano's series of 406 ankles, vs only 9% primary) - this differs from hip and knee where primary OA predominates. Causes include malunited fractures, recurrent instability, and osteochondral lesions. The latency from injury to end-stage OA averages around 20 years. Always take a detailed trauma history.
Arthrodesis is the gold standard with reliable outcomes. TAR for lower-demand patients with good alignment, adequate bone stock, and intact deltoid. Contraindications to TAR: severe deformity, AVN, neuropathy, young high-demand patients.
Optimal fusion position: neutral dorsiflexion, 5 degrees hindfoot valgus, 5-10 degrees external rotation, slight posterior translation of talus. Malposition causes significant functional impairment.
Accelerated ipsilateral foot OA is consistent at a mean 22 years post-fusion (Coester, JBJS 2001) - the subtalar, talonavicular and calcaneocuboid joints are significantly more arthritic than the contralateral side, whereas the knee is not. This drives interest in motion-preserving TAR but patient selection is critical.
- Indications
- Early disease, low demand, comorbidities
- Advantages
- Non-invasive, reversible
- Disadvantages
- Limited long-term efficacy
- Indications
- Durable reference standard, most patients
- Advantages
- Reliable pain relief, ~12% radiographic non-union (~7% symptomatic)
- Disadvantages
- Loss of motion, adjacent joint disease
- Indications
- Lower demand, good alignment, adequate bone
- Advantages
- Motion preservation, gait improvement
- Disadvantages
- Higher revision rate, strict selection
- Indications
- Malalignment with early arthritis
- Advantages
- Joint preservation, corrects deformity
- Disadvantages
- Limited to appropriate deformity patterns
- Indications
- Young patients, limited disease
- Advantages
- Joint preservation
- Disadvantages
- Limited evidence, prolonged treatment
ANKLEANKLE - Causes of Ankle Arthritis
Hook:ANKLE arthritis is mostly post-traumatic unlike hip/knee
FUSIONFUSION - Optimal Position
Hook:FUSION position must be perfect for good outcomes - neutral DF, slight valgus, ER
TARTAR - Contraindications
Hook:TAR has strict contraindications - AVN, severe deformity, neuropathy are absolute
INFECTIONINFECTION After Ankle Surgery
Hook:INFECTION management is systematic - identify organism and treat appropriately
Overview and Epidemiology
Ankle arthritis is less common than hip or knee arthritis but causes significant disability. Importantly, the etiology differs fundamentally from other large joints.
Aetiology distribution (Valderrabano et al., CORR 2009, 406 ankles):
- Post-traumatic: 78% (malleolar fractures most common, then instability and osteochondral lesions)
- Secondary (inflammatory, haemophilic, clubfoot, AVN, etc.): 13%
- Primary osteoarthritis: 9% (rare, unlike hip/knee)
These figures differ from the older "70%" estimate widely quoted; the contemporary single-centre series of end-stage patients reports closer to 78% post-traumatic. Either way, trauma dominates and primary OA is uncommon.
Key epidemiological features:
- Symptomatic ankle OA is roughly 9 times less common than knee OA; primary ankle OA is rare
- Post-traumatic OA develops after a long latency - mean about 20.9 years (range 1-52) after ankle fracture (Horisberger et al.)
- Shorter latency with pilon/plafond fractures, healing complications, and older age at injury
- The mean tibiotalar alignment in end-stage ankle OA is varus regardless of aetiology
- End-stage ankle OA causes mental and physical disability at least as severe as end-stage hip OA (Glazebrook et al., SF-36 study)
The ankle joint has the thinnest articular cartilage of major weight-bearing joints (1-1.5mm vs 3-4mm in knee). This makes it vulnerable to damage from fracture incongruity but also means it normally distributes load efficiently. Post-traumatic changes from malunion or instability rapidly lead to OA.
Natural history without treatment:
- Progressive joint space narrowing
- Osteophyte formation limiting motion
- Increasing pain and functional limitation
- Deformity development (usually varus)
- Gait abnormalities and proximal compensation
Anatomy and Biomechanics
The ankle (tibiotalar) joint is a highly constrained mortise joint with minimal inherent stability from soft tissues alone.
- Tibial plafond: Concave articular surface
- Medial malleolus: Medial buttress
- Fibula/lateral malleolus: Lateral buttress, 1cm more distal than medial
- Talus: Wider anteriorly (trapezoidal), provides stability in dorsiflexion
- Deltoid (medial): Primary restraint to valgus; deep and superficial components
- Lateral complex: ATFL, CFL, PTFL - resist varus
- Syndesmosis: AITFL, PITFL, interosseous ligament - maintain mortise width
An intact deltoid ligament is essential for TAR success. Preoperative valgus deformity with deltoid insufficiency is a relative contraindication to TAR as the implant will fail to balance properly.
- Range of motion: Primarily dorsiflexion (20 degrees) and plantarflexion (50 degrees)
- Force transmission: 5x body weight during running
- Contact area: Small (approximately 350mm²) but high congruency
- Axis of rotation: Oblique through tips of malleoli
- Subtalar joint: 25-30 degrees of motion, compensates for ankle fusion
- Talonavicular joint: Allows additional accommodation
- Hindfoot complex function interdependent
- Subtalar joint provides significant compensatory motion
- Talonavicular accommodates rotation
- Gait adaptations possible with proper fusion position
Classification Systems
Radiographic Grading
- Radiographic Features
- No features of OA
- Clinical Correlation
- Asymptomatic
- Radiographic Features
- Doubtful narrowing, possible osteophytes
- Clinical Correlation
- Minimal symptoms
- Radiographic Features
- Definite osteophytes, possible narrowing
- Clinical Correlation
- Moderate symptoms
- Radiographic Features
- Moderate osteophytes, definite narrowing, some sclerosis
- Clinical Correlation
- Significant symptoms
- Radiographic Features
- Large osteophytes, marked narrowing, severe sclerosis, deformity
- Clinical Correlation
- End-stage disease
Originally designed for knee OA but commonly applied to ankle.
Clinical Assessment
History:
- Pain location (anterior, medial, lateral)
- Relationship to activity and weight bearing
- Morning stiffness duration
- Previous trauma (fractures, sprains, instability)
- Previous surgery
- Functional limitations (walking distance, stairs, uneven ground)
- Night pain (suggests more advanced disease)
- Response to conservative treatment
Examination:
- Significance
- Reduced DF/PF, crepitus
- Implications
- Severity indicator
- Significance
- Varus/valgus tilt
- Implications
- Affects surgical planning
- Significance
- Anterior drawer, talar tilt
- Implications
- May need ligament reconstruction
- Significance
- Location guides differential
- Implications
- Anterior = impingement, medial/lateral = gutter OA
- Significance
- Antalgic, compensatory patterns
- Implications
- Functional assessment
- Significance
- Subtalar, talonavicular motion
- Implications
- Fusion compensates, TAR requires
Adequate subtalar and talonavicular motion is essential for good outcomes after ankle fusion. If these joints are already arthritic or fused, ankle fusion will cause significant stiffness. This may favor TAR if other factors permit.
- Anterior impingement test (pain with forced dorsiflexion)
- Compression/rotation test (pain with axial load and rotation)
- Silfverskiold test (gastrocnemius contracture assessment)
- Dorsalis pedis and posterior tibial pulses
- Capillary refill
- Consider ABI if concerns (diabetics, smokers)
- Discriminating features
- Anterior/diffuse ankle-line pain, dorsiflexion loss, varus tilt
- Key investigation
- Weight-bearing AP/lateral/mortise radiographs
- Discriminating features
- Hindfoot pain below the malleoli, pain on inversion/eversion, normal tibiotalar line
- Key investigation
- Broden/hindfoot views; selective subtalar local-anaesthetic injection
- Discriminating features
- Giving-way, positive anterior drawer and talar tilt, often younger
- Key investigation
- Stress radiographs; MRI of ATFL/CFL
- Discriminating features
- Focal, deep, activity-related pain, may catch/lock, often near-normal joint space
- Key investigation
- MRI (or CT) of talar dome
- Discriminating features
- Anterior pain at terminal dorsiflexion, anterior osteophytes, preserved joint space
- Key investigation
- Lateral radiograph; impingement test
- Discriminating features
- Bilateral/symmetrical, multi-joint, morning stiffness, systemic features
- Key investigation
- RF/anti-CCP, CRP/ESR, HLA-B27 if indicated
- Discriminating features
- Warm, swollen, often painless deformity in neuropathic (diabetic) foot
- Key investigation
- Radiographs (fragmentation/dislocation), HbA1c, sensory testing
- Discriminating features
- Acute hot swollen joint, rapid onset, hyperuricaemia or chondrocalcinosis
- Key investigation
- Joint aspirate for crystals; serum urate
Investigations
Weight-bearing views essential
- Weight-bearing AP ankle
- Weight-bearing lateral ankle
- Mortise view
- Hindfoot alignment view if deformity
- Joint space narrowing pattern
- Osteophyte location and size
- Subchondral sclerosis and cysts
- Deformity (varus/valgus tilt)
- Adjacent joint involvement
- Anterior drawer (ATFL integrity)
- Talar tilt (CFL integrity)
- Consider if instability suspected
Weight-bearing views are critical as they reveal functional joint space and alignment.
Management Algorithm
- 1Conservative Trial
Activity modification, bracing, NSAIDs, PT, injections
May provide long-term relief in mild disease
- 2Failed Conservative
Reassess for surgical candidacy
Most progress to surgery eventually
- 3Malalignment Present
Consider supramalleolar osteotomy if early disease
Joint preservation if appropriate
- 4End-stage Disease
Fusion vs TAR based on patient factors
Both provide reliable pain relief
First-line management
- Low-impact activities
- Weight loss if overweight
- Avoid aggravating activities
- NSAIDs (oral or topical)
- Acetaminophen
- Consider PPI protection long-term
- Ankle-foot orthosis (AFO)
- Rocker-bottom shoes
- Custom orthotics
- Corticosteroid (2-3 per year maximum)
- Hyaluronic acid (limited evidence)
- PRP (experimental)
- Strengthening periarticular muscles
- Range of motion maintenance
- Gait training
Conservative measures may delay surgery but rarely prevent eventual progression in symptomatic patients.
Surgical Technique
Anterior or lateral approach
Positioning:
- Supine with bump under ipsilateral hip
- Tourniquet at thigh
Ankle Fusion Steps
Anterior approach between tibialis anterior and EHL, or lateral transfibular approach. Protect superficial peroneal nerve.
Remove all articular cartilage from tibial plafond and talar dome. Use curettes, osteotomes, or burr. Fenestrate subchondral bone. Preserve overall contour for stability.
Position foot: neutral DF, 5 degrees valgus, 5-10 degrees ER, slight posterior translation. Compare to opposite side. Check alignment with fluoroscopy.
Multiple options: crossed screws (2-3 large fragment), anterior plate, IM nail. Compress fusion site. Confirm alignment on final fluoroscopy.
Layered closure. Posterior splint in neutral position. Non-weight bearing initially.
Crossed screws technique: 6.5-7.3mm cannulated screws, typically 2 from anterior tibia into talus and 1 from medial malleolus into talus.
Complications
Ankle arthrodesis
- Wound complications (5-10%)
- Infection (2-5%)
- DVT/PE
- Nerve injury (superficial peroneal)
- Nonunion (5-10%)
- Malunion (position errors)
- Hardware prominence/irritation
- Accelerated ipsilateral foot OA (subtalar, talonavicular, calcaneocuboid) - significantly worse than contralateral side at 22 years (Coester)
- Persistent pain
- Stress fractures
- Smoking (most significant)
- Diabetes
- AVN of talus
- Previous infection
- Technical errors
Smoking cessation is mandatory before fusion surgery.
Postoperative Care
Rehabilitation Phases
Non-weight bearing, posterior splint. Elevation. Wound check at 2 weeks.
Non-weight bearing, short leg cast. Continue elevation. Serial X-rays.
Protective weight bearing in CAM boot if union progressing. PT for adjacent joint ROM.
Wean boot. Rocker-bottom shoes. Gait training.
Union assessment with CT if radiographic healing uncertain. May require bone stimulation if delayed.
Outcomes and Prognosis
- Pain/Function
- Reliable pain relief; stiff but functional
- Reoperation/Revision
- Revision 5% (1yr) / 11% (5yr) - SooHoo
- Survivorship/Union
- Radiographic non-union ~12%, symptomatic ~7% (TARVA)
- Pain/Function
- Better ROM and gait; equivalent QoL gain to fusion
- Reoperation/Revision
- Revision 9% (1yr) / 23% (5yr) - SooHoo; 17% (COFAS)
- Survivorship/Union
- Registry survival 80-91% at 5yr, 66-84% at 10yr (Perry)
- Pain/Function
- Joint-preserving; correction of mechanical axis
- Reoperation/Revision
- Conversion to fusion/TAR over time
- Survivorship/Union
- May delay arthroplasty/fusion in malaligned early OA
- Reliable, durable pain relief and return to demanding activity
- Some difficulty on uneven ground; shoe-wear modifications may help
- Radiographic non-union about 12% but only ~7% symptomatic in the TARVA cohort
- Accelerated ipsilateral foot OA at long-term follow-up (Coester)
- Better gait kinematics and preserved ankle ROM than fusion
- Equivalent quality-of-life improvement to fusion at 1 year (TARVA)
- Higher reoperation/revision rate than fusion; careful patient selection critical
- TARVA RCT (2023, 303 patients): no statistically significant difference in the primary walking/standing score at 52 weeks; both arms improved quality of life. A post-hoc analysis favoured fixed-bearing TAR over fusion.
- COFAS prospective multicentre cohort (Daniels, 2014): comparable intermediate-term clinical scores, but higher reoperation and major-complication rates after TAR.
- STAR pivotal trial (Saltzman, 2009): TAR non-inferior to fusion for overall success, with equivalent pain relief and better function but more secondary procedures.
The choice between fusion and TAR depends on patient factors (age, demand, deformity, bone stock, deltoid competence) and surgeon experience.
Guidelines, Registries & Global Practice
Global epidemiology. Symptomatic ankle OA is far less common than knee or hip OA, and unlike those joints it is predominantly post-traumatic. In Valderrabano's series of 406 end-stage ankles, 78% were post-traumatic, 13% secondary and only 9% primary. The latency from ankle fracture to end-stage OA is long (mean ~21 years), so the disease burden falls on a relatively young, working-age population - and its disability is at least as severe as end-stage hip OA (Glazebrook).
Guidance compared, side by side:
- Position
- Both ankle fusion and TAR are recognised options for end-stage ankle OA; shared decision-making, with TAR favoured for older, lower-demand patients and fusion for high-demand or major-deformity cases
- Evidence base
- Informed by the TARVA RCT and UK practice
- Position
- No single mandated procedure; emphasise patient selection (alignment, bone stock, deltoid, demand). Arthrodesis remains the durable reference standard, TAR an accepted motion-preserving alternative
- Evidence base
- Level II-III comparative and registry data
- Position
- Technique-focused: anatomical fracture reduction to prevent post-traumatic OA; for end-stage disease, rigid compression arthrodesis (screw/plate/nail) or arthroscopic fusion in suitable joints
- Evidence base
- Expert consensus + biomechanical data
- Position
- TAR uptake higher in parts of Europe; supramalleolar osteotomy promoted for malaligned early/intermediate OA as a joint-preserving option
- Evidence base
- Cohort and registry evidence
Registry evidence. Pooled national arthroplasty registries (AOANJRR Australia, NZ Joint Registry, Norwegian and Swedish registries) show primary TAR survival of about 80-91% at 5 years and 66-84% at 10 years, with consistently higher survival in Australia and New Zealand than in Norway and Sweden (Perry et al., 2022). Population-level discharge data (SooHoo) and the COFAS prospective cohort (Daniels) both confirm higher reoperation rates after TAR than after fusion, balanced against a lower rate of subsequent subtalar fusion after TAR.
Practice variation. TAR uptake is highly variable internationally - higher in well-resourced arthroplasty centres with established revision pathways, and lower in limited-resource settings where arthrodesis (often without expensive implants) remains the default for cost, durability and lower revision-infrastructure requirements. In high-demand manual labourers and in any setting where revision capability is limited, fusion is generally preferred worldwide. Smoking cessation is a universal, evidence-based prerequisite for fusion regardless of health system, given its strong effect on non-union risk.
MCQ Practice Points
- Post-traumatic aetiology: 78% most common (Valderrabano); primary OA only 9%
- Latency from fracture to end-stage OA: mean ~21 years
- Fusion: radiographic non-union ~12%, symptomatic ~7% (TARVA)
- TAR registry survival: ~80-91% at 5 years, 66-84% at 10 years (Perry)
- Accelerated ipsilateral foot OA after fusion at 22 years (Coester)
- Fusion position: neutral DF, 5 degrees valgus, 5-10 degrees ER, posterior translation
- Etiology of ankle OA (post-traumatic predominance)
- Fusion vs TAR indications
- Optimal fusion position
- TAR contraindications
- Complications (nonunion risk factors)
- Adjacent joint arthritis incidence
- Post-traumatic OA pathophysiology
- Subtalar arthritis (hindfoot pain, different motion loss)
- Ankle instability (positive drawer, talar tilt)
- Osteochondral lesion (may be early cause)
- Inflammatory arthritis (symmetrical, systemic features)
Q: What is the most common aetiology of ankle osteoarthritis? A: Post-traumatic - 78% in Valderrabano's series, unlike the hip and knee where primary OA predominates. Only about 9% of end-stage ankle OA is primary/idiopathic.
Q: What is the optimal fusion position for ankle arthrodesis? A: Neutral dorsiflexion, 5 degrees valgus, 5-10 degrees external rotation, and slight posterior translation of the talus.
Q: What is the implant survivorship for modern total ankle replacement? A: Global registries (Perry, 2022) report about 80-91% at 5 years and 66-84% at 10 years, varying by country - quote registry figures, not single-centre best cases.
Q: What deformity threshold is a relative contraindication for TAR? A: Greater than 15-20 degrees varus or valgus deformity, as it affects implant longevity and function.
Q: What happens to adjacent joints after ankle fusion? A: Coester (JBJS 2001) showed accelerated ipsilateral foot OA at a mean 22 years - subtalar, talonavicular and calcaneocuboid joints significantly more arthritic than the contralateral side, while the knee is spared.
Exam Cheat Sheet
Key Numbers
- Post-traumatic: 78% (primary OA only 9%)
- Fusion non-union: ~12% radiographic, ~7% symptomatic
- TAR registry survival: 80-91% at 5yr, 66-84% at 10yr
- Accelerated ipsilateral foot OA at 22 years post-fusion
Fusion Position (Critical)
- Neutral dorsiflexion
- 5 degrees hindfoot valgus
- 5-10 degrees external rotation
- Slight posterior translation
TAR Contraindications
- Severe deformity greater than 15-20 degrees
- Talar AVN
- Peripheral neuropathy
- Young, high-demand patients
TAR Ideal Candidate
- Age greater than 55 years
- Lower demand activity
- Neutral alignment
- Intact deltoid ligament
Exam Traps
- Recommending TAR for severe varus
- Wrong fusion position
- Not knowing post-traumatic predominance
- Operating on active smoker
Exam Viva Scenarios
Practise clinical reasoning and management decisions out loud
“A 58-year-old woman presents with end-stage ankle arthritis following an ankle fracture 20 years ago. She has 15 degrees of varus deformity. She works as a receptionist and wants to return to walking for exercise. What are her surgical options?”
“A 65-year-old retired man presents with ankle arthritis and neutral alignment. His subtalar joint has good motion. He is a non-smoker with well-controlled diabetes. He wants to maintain ankle motion for recreational golf. Would you consider TAR?”
“A patient returns 4 months after ankle fusion with persistent pain. X-rays show incomplete union at the fusion site. He is a smoker. How would you manage this?”
Evidence Base
TARVA: TAR vs Arthrodesis RCT
- No significant difference in primary walking/standing outcome at 1 year
- Wound-healing (13.4% vs 5.7%) and nerve injury (4.2% vs under 1%) higher after TAR
- Radiographic fusion non-union 12.1% but only 7.1% symptomatic
- Post-hoc: fixed-bearing TAR favoured over fusion
Global Registry TAR Survival
- 5-year survival 80-91%
- 10-year survival 66-84%
- Between-country variation widens with time
- Even at 5 years over 80% revision-free survival
COFAS: Intermediate-term TAR vs Fusion
- Comparable patient-reported outcome scores
- Higher reoperation rate after TAR (17% vs 7%)
- Higher major complication rate after TAR (19% vs 7%)
- Treatment tailored to patient presentation
Reoperation: Population-level Data
- TAR higher major revision (HR 1.93)
- Fusion higher subsequent subtalar fusion (HR for TAR 0.28)
- TAR higher device-related infection
- Trade-off: revision risk vs adjacent-joint salvage
Adjacent Joint OA After Fusion
- Accelerated ipsilateral foot OA at 22 years
- Subtalar and talonavicular most affected
- Knee not significantly affected
- Longest follow-up series of ankle fusion
Post-traumatic Aetiology Predominance
- 78% post-traumatic
- Only 9% primary OA
- 13% secondary
- Varus alignment predominates
Optimal Fusion Position (Gait Study)
- Neutral dorsiflexion essential
- 0-5 degrees valgus (not varus)
- 5-10 degrees external rotation
- Posterior talar translation reduces knee stress
Disability Equivalent to Hip OA
- Ankle OA as disabling as hip OA
- All SF-36 subscales ~2 SD below normal
- Worse mental component than hip OA
- Justifies aggressive treatment of end-stage disease
References
- Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009;467(7):1800-1806. PMID: 18830791. doi:10.1007/s11999-008-0543-6
- Saltzman CL, Mann RA, Ahrens JE, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009;30(7):579-596. PMID: 19589303. doi:10.3113/FAI.2009.0579
- Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83(2):219-228. PMID: 11216683. doi:10.2106/00004623-200102000-00009
- Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg Am. 1987;69(7):1052-1062. PMID: 3654697
- Glazebrook M, Daniels T, Younger A, et al. Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis. J Bone Joint Surg Am. 2008;90(3):499-505. PMID: 18310699. doi:10.2106/JBJS.F.01299
- Goldberg AJ, Chowdhury K, Bordea E, et al. Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT. Health Technol Assess. 2023;27(5):1-80. PMID: 37022932. doi:10.3310/PTYJ1146
- Daniels TR, Younger AS, Penner M, et al. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014;96(2):135-142. PMID: 24430413. doi:10.2106/JBJS.L.01597
- Perry TA, Silman A, Culliford D, et al. Survival of primary ankle replacements: data from global joint registries. J Foot Ankle Res. 2022;15(1):33. PMID: 35524275. doi:10.1186/s13047-022-00539-2
- SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am. 2007;89(10):2143-2149. PMID: 17908889. doi:10.2106/JBJS.F.01611
- Horisberger M, Valderrabano V, Hintermann B. Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma. 2009;23(1):60-67. PMID: 19104305. doi:10.1097/BOT.0b013e31818915d9
- Easley ME, Vertullo CJ, Urban WC, Nunley JA. Total ankle arthrodesis. J Am Acad Orthop Surg. 2002;10(3):157-167. PMID: 12041937
- Gougoulias NE, Agathangelidis FG, Parsons SW. Arthroscopic ankle arthrodesis. Foot Ankle Int. 2007;28(6):695-706. PMID: 17592700
- Takakura Y, Tanaka Y, Kumai T, Tamai S. Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients. J Bone Joint Surg Br. 1995;77(1):50-54. PMID: 7822395
- Goldberg AJ, Bordea E, Chowdhury K, et al. Cost-utility analysis of total ankle replacement compared with ankle arthrodesis: the TARVA study. Pharmacoecon Open. 2024;8(2):235-249. PMID: 38189868. doi:10.1007/s41669-023-00449-4
- Horisberger M, Hintermann B, Valderrabano V. Alterations of plantar pressure distribution in posttraumatic end-stage ankle osteoarthritis. Clin Biomech (Bristol). 2009;24(3):303-307. PMID: 19150745. doi:10.1016/j.clinbiomech.2008.12.005
- Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494-502. PMID: 13498604. doi:10.1136/ard.16.4.494