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Foot and Ankle Surgery 14 (2008) 1–10

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Review

Ankle arthrodesis
Aneel Nihal M.D., FRCS (Orth.)a, Richard E. Gellman M.D.b,c,
John M. Embil M.D., FRCPCd,e, Elly Trepman M.D.e,f,g,*
a
Southside Health Service District, Logan Hospital, South Brisbane, Queensland, Australia
b
Summit Orthopaedics, Portland, OR, USA
c
Department of Orthopaedics and Rehabilitation, Oregon Health Sciences University, Portland, OR, USA
d
Section of Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
e
Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
f
Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
g
Grand Itasca Clinic & Hospital, Grand Rapids, MN, USA
Received 5 March 2007; received in revised form 3 July 2007; accepted 20 August 2007

Abstract

Numerous techniques for ankle arthrodesis have been reported since the original description of compression arthrodesis. From the early
1950s to the mid 1970s, external fixation was the dominant technique utilized. In the late 1970s and 1980s, internal fixation techniques for
ankle arthrodesis were developed. In the 1990s, arthroscopic ankle arthrodesis was developed for ankle arthrosis with minimal or no
deformity. The open technique is still widely used for ankle arthrosis with major deformity. For complex cases that involve nonunion,
extensive bone loss, Charcot arthropathy, or infection, multiplanar external fixation with an Ilizarov device, with or without a bone graft, may
achieve successful union. The fusion rate in most of the recently published studies is 85% or greater, and may depend on the presence of
infection, deformity, avascular necrosis, and nonunion.
# 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
4. Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
5. Evaluation of ankle arthrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
6. Arthrodesis position and evaluation of deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
7. Techniques for ankle arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
7.1. Arthrodesis in situ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
7.2. Realignment (open) arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
7.3. Surgical approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
7.4. External fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7.5. Internal fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7.6. Role of bone graft in ankle fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
8. Sequelae of ankle arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
9. Results of treatment with ankle arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
9.1. Arthrosis: open ankle arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

* Corresponding author at: Health Sciences Centre, MS673-820 Sherbrook Street, Winnipeg, Manitoba, Canada R3A 1R9. Tel.: +1 206 407 3671.

1268-7731/$ – see front matter # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.fas.2007.08.004
2 A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

9.2. Rheumatoid arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

9.3. Arthroscopic ankle arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
9.4. Complex and revision arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1. Introduction 3. Indications

Ankle arthrosis is one of the common problems for which The painful ankle may result from primary osteoarthritis
patients present to the foot and ankle orthopaedic surgeon. or arthritis secondary to trauma, rheumatological conditions,
The treatment of ankle arthrosis includes nonsurgical and or sepsis. Ankle arthrodesis is indicated for severe ankle pain
surgical options. Nonsurgical treatment of ankle arthrosis resulting from arthrosis that interferes with standing and
may include limitation and modification of activities, non- walking (Table 1). Deformity of the ankle that interferes
steroidal anti-inflammatory drugs, nutritional supplements with shoe wear and gait, including ankle equinus, valgus, or
including glucosamine and grape seed extract, a cane or varus malalignment, may be managed with ankle arthrodesis
crutches, physical therapy including movement reeducation if other corrective joint-sparing surgery is not feasible.
(Feldenkrais method), shoe modification with a rocker Tibiotalar instability with advanced arthritic changes
bottom sole, a locked ankle-foot orthosis (AFO) with a solid resulting from recurrent ankle sprain, failed ligament
ankle cushion heel (SACH), a custom molded leather ankle reconstruction, or neurological diseases may be an indica-
brace, or a patellar tendon-bearing AFO [1–3]. Surgical tion for arthrodesis. Failed total ankle replacement
treatment options include arthroscopic debridement [2,3], secondary to component loosening or infection may be
synovectomy, excision of impinging osteophytes [3], joint salvaged with component removal and arthrodesis
distraction [4,5], or arthrodesis [6–11]. Results of debride- [14,29,30]. Arthrodesis may also be indicated for salvage
ment for advanced arthrosis may be limited. Total ankle of instability and bone destruction resulting from Charcot
prosthetic replacement for the treatment of ankle arthrosis arthropathy [31,32] or osteomyelitis [33].
has been associated with complications and failures The reported frequency of involvement of the ankle and
including early loosening, subsidence, malalignment of hindfoot in rheumatoid arthritis varies between 9% and 70%
the components, malleolar impingement, soft tissue imbal- [9]. Rheumatoid arthritis of the ankle may be associated with
ance, infection, and dislocation [12–15]. Despite recent arthritic involvement of the other joints of the foot.
renewed interest in total ankle arthroplasty [16–20], ankle Associated hindfoot, midfoot, and forefoot deformities
arthrodesis remains the primary surgical treatment option may contribute to pain and functional impairment and will
for disabling ankle arthrosis in most patients. need careful evaluation before proceeding with ankle
arthrodesis.

2. History Table 1
Indications for ankle arthrodesis
Early ankle arthrodesis [21] was accomplished by I. Arthritis/arthrosis
removing the articular cartilage from the body of the talus Primary osteoarthritis of ankle joint
and the mortise. In the early 1900s, arthrodesis was Postraumatic arthritis
performed for post-poliomyelitis paralysis to stabilize the Ankle fracture (bimalleolar, trimalleolar, or pilon)
ankle and foot. In 1951, compression arthrodesis was Fracture or avascular necrosis of body of talus
Dislocation or fracture-dislocation of ankle
introduced, using external fixation without bone graft [22].
The advantages of compression included the elimination of Inflammatory arthropathy
Rheumatoid arthritis
both shear forces and gaps between the bony surfaces.
Seronegative arthritis
Compression arthrodesis was originally described with an Gout or pseudogout
anterior transverse incision and transection of the tendons, Hemophilic arthropathy
nerves and vessels [22]. Although the technique of Sequela of septic arthritis or posttraumatic infection
performing ankle fusion has markedly evolved to spare II. Neurological
these vital structures, the concept of compression remains a Poliomyelitis
foundation of modern methods of arthrodesis. Compression Charcot-Marie-Tooth disease
and direct contact between bony surfaces may be achieved Cerebral paralysis (stroke)
Charcot arthropathy
using internal or external fixation [23]. More recently,
arthroscopic methods of examining the ankle joint [24–26] III. Miscellaneous
Failed total ankle replacement
have been extended to include arthroscopic debridement and
Severe equinus contracture secondary to compartment syndrome of leg
arthrodesis [27,28].
 A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10
4. Contraindications
Ankle arthrodesis is avoided, if possible, in children and
adolescents with open growth plates. Progressive, recurrent,
or severe complex deformities in the adult may be difficult to
correct. Smoking is associated with greater risk of nonunion
[7]. Impaired vascular status may contribute to an increased
risk of wound complications, infection, and amputation.
Medical conditions that place the patient’s life at risk and the
presence of peripheral vascular disease are carefully
weighed against the potential benefit of the operation.
The diabetic, neuropathic foot is no longer considered an
absolute contraindication to ankle arthrodesis because the
risk of ulceration, infection, and amputation may be greater
with an unstable, neuropathic ankle that is not stabilized
with fibrous union or bony arthrodesis [32].
5. Evaluation of ankle arthrosis
History and physical examination provide basic informa-
tion about the etiology of the patient’s ankle arthrosis, severity
of the symptoms, and functional impairment. The diagnosis
may be confirmed with anteroposterior, mortise, and lateral
weight-bearing radiographs of the ankle. Computed tomo-
graphy (CT) and magnetic resonance imaging (MRI) may
provide more detailed information about bone and cartilage
involvement. Arthroscopic evaluation is an invasive diag-
nostic procedure and is usually deferred in arthrosis unless
debridement or excision of impinging osteophytes or loose
bodies is planned for temporary pain relief and to delay ankle
arthrodesis. In cases where the source of pain is equivocal,
fluoroscopically guided injection of the ankle or subtalar joint
with a local anesthetic drug (lidocaine, 1% or bupivacaine,
0.5%, with no epinephrine), mixed with a contrast agent to
confirm intra-articular location of the injection and exclude
the potential for communication between the ankle joint and
adjacent joints or tendon sheaths, may confirm or exclude the
ankle joint as the primary source of pain [34].
6. Arthrodesis position and evaluation of deformity
The goal of ankle arthrodesis is to create a pain-free
plantigrade foot for weightbearing. Attention to the position
and alignment of the foot in relation to tibia and leg is
crucial. Ideal alignment includes neutral ankle flexion, 0–58
of valgus, and neutral to slight external rotation position.
Malalignment of the foot may have adverse effects on the
biomechanics of the lower extremity, leading to persistent
pain following a solid arthrodesis.
Excessive dorsiflexion may cause heel pain and ulcer, and
plantarflexion may cause metatarsalgia and genu recurvatum
(‘‘back knee’’) gait. Valgus, varus, internal rotation, or
external rotation malunion may be associated with increased
stresses and laxity of the collateral ligaments of the knee.
3
Valgus or varus malunion may also result in painful callus at
the first and fifth metatarsal, respectively. Valgus malunion
can lead to subtalar joint arthrosis and posterior tibial tendon
dysfunction that may be treated with realignment subtalar
arthrodesis. Limb shortening may occur.
Preoperative planning for all ankle arthrodesis cases
should include an evaluation of the patient’s mechanical axis
and any potential malalignment, especially in the distal tibia
or foot that could lead to uneven weight distribution on the
foot. Normal alignment in the frontal plane is such that the
anatomic axis of the tibia shaft falls just medial to the mid-
body of the talus and just medial to the weightbearing point
of the calcaneus. Normal alignment in the sagittal plane,
noted on a lateral radiograph, should show that the anatomic
axis of the tibia intersects the lateral talar process. During the
arthrodesis, all attempts are made to preserve normal
alignment; on the lateral view the foot may be translated
slightly posterior to the normal sagittal line to decrease stress
on the midfoot joints during gait.
Bone loss in the distal tibia or talus that alters these
relationships may lead to arthrodesis malunion. Correct
alignment is achieved by careful positioning of the talus
beneath the distal tibia following resection of cartilage and
preparation of the bone surfaces with small osteotomes or
drilling the subchondral plate. Areas of avascular bone are
excised if possible. In some cases of avascular necrosis of
the entire talar body, the talus can be left in place if it remains
structurally intact without collapse. Defects are addressed
with bone grafts or greater bone resection opposite the defect
to create stable and parallel surfaces for arthrodesis. The
decision is guided by the degree of deformity and whether
there is a focal, contained bone loss or more peripheral,
structural bone loss. In general, deformities that would
create unacceptable limb shortening from extensive bone
resection may be treated with larger bone grafts and
supplemental stabilization with an Ilizarov-type multiplanar
external fixator. In cases of limb shortening greater than
2.5 cm, limb lengthening with distraction osteogenesis may
be considered [35].
7. Techniques for ankle arthrodesis
Arthrodesis techniques [36] can be broadly classified into
two categories: arthrodesis in situ and realignment arthrod-
esis. Various surgical approaches and fixation methods may
be considered depending on the status of the soft tissues,
degree of deformity and bone quality, and experience of the
surgeon.
7.1. Arthrodesis in situ
Arthrodesis in situ is indicated for cases with minimal or
no deformity, and may done with arthroscopy [37–40] or
minimal arthrotomy and percutaneous screw fixation [41].
Surgical exposure is minimized, resulting in decreased
4 A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10
wound morbidity and smaller scars. Postoperative pain and
duration of inpatient hospital stay are decreased compared
with open ankle arthrodesis. Minimal soft tissue stripping
may contribute to a high frequency of union (greater than
90%), faster time to fusion [41], and greater patient
satisfaction. The apparently lower morbidity with in situ
arthrodesis may be a result of selection bias for less complex
cases that do not require correction of major deformity. A
disadvantage of in situ arthrodesis is that major deformity or
bony deficiency may not be correctible. However, mild
deformity (especially mild equinus) may be corrected, and
successful arthrodesis may be achieved in complex cases
such as previous nonunion [42].
Arthroscopic ankle arthrodesis requires specialized
equipment, instruments, and arthroscopic experience, and
the procedure may be technically more demanding than
open arthrodesis. After arthroscopic ankle debridement and
excision of articular cartilage through anteromedial and
anterolateral portals, fixation is achieved using two or three
cannulated screws placed separately from the tibia and the
fibula to the talus [10,40,43,44]. If additional intraoperative
or postoperative fixation is required, a Charnley clamp may
be used to supplement tibiotalar screw fixation [38].
Complications may include saphenous, sural, deep peroneal,
and superficial peroneal nerve injury [45].
The minimal arthrotomy technique is done using two
small anterior (1.5 cm) incisions, one medial to the tibialis
anterior tendon and one lateral to the peroneus tertius tendon
[41]. The arthrotic tissue and remaining articular cartilage
are debrided, and fixation is accomplished with percuta-
neous tibiotalar lag screws [41].
7.2. Realignment (open) arthrodesis
Realignment arthrodesis is indicated for cases with major
deformity or bone loss. This may include ankles with severe
varus or valgus deformity or talar collapse resulting from
trauma, avascular necrosis, or Charcot arthropathy. Excision
of articular cartilage and bony contact are achieved with direct
visualization. The major advantage of open arthrodesis over
the minimal arthrotomy method is that severe deformities of
the ankle may be corrected with appropriate bone cuts, and
bone deficiency or loss of height may be improved with a bone
graft. Disadvantages of open ankle arthrodesis include the
wide surgical exposure and soft tissue stripping that may be
associated with greater postoperative pain, delayed wound
healing, wound infection, dehiscence, nonunion, and neuro-
vascular injury. Recovery and time to fusion may be more
prolonged after open arthrodesis.
7.3. Surgical approaches
Several surgical approaches to the ankle may be
considered for arthrodesis depending on the deformity,
fixation technique, condition of the soft tissues, and the
surgeon’s preference and experience (Table 2). The lateral
approach is a common approach used for ankle fusion [46].
A 10–12 cm longitudinal incision is made directly over the
distal fibula, with care taken to avoid injury to the sural
nerve. The approach is in the interneural plane between the
sural nerve (posterior) and the superficial peroneal nerve
(anterior). The fibula is osteotomized obliquely approxi-
mately 6 cm proximal to the distal tip or 2–4 cm proximal to
the level of the tibial plafond. The distal fibula is then
removed and may be used as autogenous bone graft.
Debridement of the medial side of the joint may be done
from either the lateral wound or from a supplemental medial
incision about the medial malleolus.
The medial approach may used to expose the tibiotalar
joint through a longitudinal incision either directly over or
anterior to the medial malleolus. The medial malleolus may
be excised or retained as a medial buttress [47]. The
remaining joint surface is denuded and decorticated.
The anterior approach may provide good access to the
entire ankle joint, but may place the anterior neurovascular
structures at risk. An anterior approach had been used with a
transverse incision between the tips of the medial and lateral
malleolei, including section of the extensor tendons and
neurovascular bundle [22]; however, this approach may
cause postoperative adhesions between tendons, numbness,
swelling, and vascular compromise [48], and is not
recommended. The anterior longitudinal approach involves
a slightly curved longitudinal incision, with dissection either
between the tibialis anterior and extensor hallucis longus
tendons [49] or between the extensor hallucis longus and
extensor digitorum longus tendons [50–52]. In both
Table 2
Surgical approaches and fixation for ankle arthrodesis
Surgical approaches
I. Open ankle arthrodesis
Anterior approach
Transverse incision
Longitudinal incision
Posterior approach
Lateral approach
Medial approach
Combined medial and lateral approach
II. Arthroscopic arthrodesis
III. Mini-arthrotomy arthrodesis
Methods of fixation
I. External fixation
Charnley external fixation
Calandruccio apparatus
Ilizarov frame
Hoffman double frame external fixator
Triangular external fixator with a metatarsal pin
Any other conventional external fixator
II. Internal fixation
Screws
Plates
Intramedullary nail
III. No fixation (cast immobilization)
 A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10
instances, the neurovascular bundle is exposed and
protected. The anterior longitudinal approach may be used
for realignment arthrodesis of the deformed ankle or when
anterior plate fixation is done [53,54].
A combined anteromedial and anterolateral longitudinal
two-incision approach has also been described. The
anteromedial incision is made between the tibialis anterior
and extensor hallucis longus tendons and the anterolateral
incision is made between the extensor digitorum longus or
peroneus tertius and the peroneal tendons. However, with
this combined approach there is a risk of skin bridge necrosis
between the two incisions.
In a posterior approach, the patient is positioned prone
and a longitudinal incision is made either medial to the
Achilles tendon to avoid injury to the sural nerve [55] or
lateral to the Achilles tendon where the sural nerve can be
identified and protected. The Achilles tendon is then divided
and a Z-plasty lengthening can be done if a preoperative
equinus deformity is present. The ankle joint is approached
by creating a plane between the peroneal tendons and the
medial neurovascular bundle and flexor hallucis longus
tendon. Through this approach both the ankle and subtalar
joints may be exposed and fused [56–58].
7.4. External fixation
The popularity of external fixation in ankle arthrodesis
had declined with improvements in internal fixation
instruments and techniques due to the more labor-intensive
management of external fixation both intraoperatively and
postoperatively. However, external fixation remains useful
when extensive soft tissue compromise or bone loss
precludes internal fixation or casting. The early techniques
of compression arthrodesis with external fixation described
by Charnley and Calandruccio provided acceptable fusion
rates, but the frames are not as versatile or rigid as current
Ilizarov or equivalent devices [22,35,55,59,60].
Other external fixators may be used for ankle arthrodesis,
such as the Hoffmann external fixator with anterior sliding
tibial bone graft for arthrosis associated with severe post-
traumatic equinus deformity [61] and the triangular external
fixator with a metatarsal pin [62]. Ankle arthrodesis with the
Ilizarov ring external fixator has been used for treatment of
nonunion, ongoing sepsis including infected nonunion,
malunion, and limb length discrepancy; this may result in
solid union with a clinically satisfactory, plantigrade foot,
providing an alternative to amputation in some cases
[33,35,60,63–65]. Complication rates of greater than 50%
with circular wire fixators have been reported, presumably
because of the complexity of the underlying pathology of
ankles for which this method was indicated [60].
7.5. Internal fixation
Various methods of internal fixation have been described
including screws, angled blade plate, T plate, Wolf blade
5
plate, intramedullary nail, and compression blade plate
[6,36,53,54,66–70]. Some of these internal fixation
techniques may not be applicable if ankle anatomy is
distorted by deficient bone stock, major deformity, previous
failed total ankle replacement, previous osteomyelitis,
previous wound problem or plastic surgery flap, associated
foot deformity, arthrosis in other joints, osteonecrosis of the
talus, or Charcot arthropathy. Preoperative planning is
important for proper selection of surgical approach and
fixation method to achieve a painless, plantigrade foot for
walking.
In some cases, ankle arthrodesis is combined with triple
arthrodesis (pantalar fusion) for limb salvage as an
alternative to amputation [71]. Retrograde intramedullary
nail technique may be useful for fusion in Charcot
deformities [31,72], rheumatoid patients, and fixed equinus
deformity [69,73]. Anterior sliding graft with rigid internal
fixation is another option for treatment of pseudarthrosis,
arthritis after infection, or talar osteonecrosis, but has a
complication rate of 33% [74,75].
7.6. Role of bone graft in ankle fusion
Bone graft may be an important component of an ankle
arthrodesis if potential for union may be compromised by
factors such as infection [12], osteonecrosis of the talus [70],
bone defects [30,71], and previous nonunion [76]. However,
a bone graft is not routinely required in primary ankle
arthrodesis is the absence of these complicating factors. In
Charnley’s primary compression ankle arthrodesis, bone
graft was not used [22]. Open transfibular ankle arthrodesis
with internal screw fixation may achieve union in greater
than 90% of cases without bone graft [36]. Arthroscopic
ankle arthrodesis usually does not require a bone graft
because of the extensive cancellous surface exposed with
minimal soft tissue disruption [44].
Potential sources of autogenous bone graft for ankle
arthrodesis may vary depending on the type and amount of
graft required. Available bone stock may depend on previous
trauma or surgery. The iliac crest is a reliable source of
cancellous and cortical bone but is associated with donor site
morbidity [77]. Local bone graft may be used from the distal
fibula [76,78] or tibia [79,80]. Arthrodesis with an anterior
tibial sliding bone graft may avoid the morbidity of iliac
crest bone graft [74,81].
If non-structural bone graft is required, the excised distal
fibula or medial malleolus may be ground in a bone mill to
increase the bony surface area for promotion of union. The
distal tibia is an excellent source of cancellous bone graft for
procedures in the foot [82], but this site is usually
unavailable for ankle arthrodesis because of proximity to
the arthrodesis. The proximal tibia may provide adequate
cancellous graft for ankle arthrodesis and avoid iliac crest
morbidity [42]. Demineralized bone matrix has been used
for ankle arthrodesis, with union rates comparable to
autogenous bone graft [83].
6 A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

8. Sequelae of ankle arthrodesis complications remain common, including wound infection

Decreased subtalar motion and long-term degenerative
changes may occur in the subtalar, talonavicular, calcaneo-
cuboid, naviculocuneiform, tarsometatarsal, and first meta-
tarsophalangeal joints [84–89]. Long-term follow-up at an
average of 22 years after ankle arthrodesis showed more
activity limitation, pain, and disability with the fused than
opposite limb [88]. Appropriate preoperative counseling
about the potential development of arthritis in the foot is
advised for patient education prior to ankle arthrodesis.
9. Results of treatment with ankle arthrodesis
Although 50% of patients with an ankle arthrodesis may
have no handicap in performing activities of daily living,
major deficits in physical function, emotional disturbance,
and bodily pain have been documented with the Short Form-
36 Health Survey [90]. Orthopaedic shoes may be helpful in
improving gait pattern after ankle arthrodesis [91].
9.1. Arthrosis: open ankle arthrodesis
In the initial report of compression ankle arthrodesis, bony
union was achieved in 79% of ankles [22]. Union rate with this
and other open ankle arthrodesis techniques may vary from
72% to 100% [7,8,38,69,92,93]. However, numerous studies
report union rate greater than 90% (Table 3).
Complication rates as high as 48% [87] and 60% [94]
have been reported. Nonunion is less frequent with modern
compression techniques compared with initial methods with
which nonunion rates were as high as 35–40% [50,95]. In
one series, complications in 47 arthrodesis procedures with
the Charnley compression clamp included infection (19%),
nonunion (15%), and amputation (6%) [96]. In another
series of 60 arthrodesis procedures with various methods (46
Charnley, 8 modified anterior tibial sliding graft, and 6
other), complications occurred in 48% of patients, including
nonunion in 23% of patients [87].
Recent reports of open arthrodesis with an anterior plate
[68], cancellous screws [97], and a T-plate with screws [98]
have reported union in 93–95% of cases. However,
in 15% and tibial stress fracture in 6% of cases treated with
an anterior plate [68]. Factors that may increase the risk
of nonunion and other complications include smoking,
alcohol abuse, diabetes, drug abuse, psychiatric illness, and a
history of either high velocity ankle injury or open ankle
fracture [7].
9.2. Rheumatoid arthritis
In a small study using the Charnley external fixation
method, union was achieved in all 11 rheumatoid patients
(Table 4) [99]. Complications included pin track infection in
4 (36%) patients [99]. Compression arthrodesis using pins
and clamps may also be limited in rheumatoid patients
because of osteopenia [100]. Nonetheless, a union rate of
96% was achieved in 26 rheumatoid ankles (14 tibiotalar
arthrodesis and 12 tibiocalcaneal arthrodesis procedures) in
which external fixation was used in 20 (77%) ankles,
suggesting that external compression arthrodesis may be
successful in patients with rheumatoid arthritis [101].
Open ankle arthrodesis in 10 patients from a lateral
approach, using the fibula as an onlay graft in 9 cases and a
sliding tibial inlay graft in one case, resulted in union in all
cases [100]. In another study, union was achieved in all five
rheumatoid patients fixed with two longitudinal Steinmann
pins in the cast [102]. Compression screw fixation yielded a
92% union rate in 43 patients, of which 38 (88%) were
seropositive for rheumatoid factor [9], and a 90% union rate
in another study of 20 patients [103]. Intramedullary nail
fixation with counter-rotation fins was used for ankle
arthrodesis in 15 rheumatoid patients [69], and solid fusion
was achieved in all patients. Arthroscopic ankle arthrodesis
was performed in 8 rheumatoid patients (10 ankles) and
union was achieved in all (100%) ankles by an average of 10
weeks [8].
9.3. Arthroscopic ankle arthrodesis
A successful arthroscopic ankle arthrodesis was initially
reported over two decades ago [27]. Several studies have
shown that arthroscopic ankle arthrodesis is a useful
procedure in cases with minimal deformity, resulting in a

Table 3
Results and complications of open ankle arthrodesis
Method Total Union Nonunion Malunion Infection Pin track infection Reference
Charnley compression 19 15 (79%) 4 (21%) – – – [22]
Charnley compression 47 40 (85%) 7 (15%) 2 (4%) – 9 (19%) [96]
T plate on lateral side 11 10 (91%) 1 (9%) – – 3 (27%) [67]
Compression blade plate 17 16 (94%) 1 (6%) 1 (6%) 1 (6%) – [54]
Screws from talus to tibia 18 17 (94%) 1 (6%) 1 (6%) – – [36]
Screws from tibia to talus 16 16 (100%) 0 (0%) 1 (6%) – – [39]
Crossed screws 40 38 (95%) 2 (5%) – – – [11]
Anterior sliding graft with screws 27 25 (93%) 2 (7%) – 2 (7%) – [74]
Total 195 177 (91%) 18 (9%) 5 (3%) 3 (2%) 12 (6%)
 A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10 7

Table 4
Results and complications of ankle arthrodesis in patients with rheumatoid arthritis
Method Total Union Nonunion Malunion Infection Pin track infection Reference
Cannulated screws, arthroscopic 10 10 (100%) – – – – [8]
IM nail with fins 15 15 (100%) – – – – [69]
Compression clamp 11 11 (100%) – – – 4 (36%) [99]
Screws 10 10 (100%) – – 1 (10%) – [100]
Ex.fix 20; Int. fix. 6 26 25 (95%) 1 (4%) 1 (4%) – 1 (4%) [101]
Screws 43 40 (93%) 3 (7%) 3 (7%) 2 (5%) – [9]
Total 115 111 (97%) 4 (3%) 4 (3%) 3 (3%) 5 (4%)
IM nail = intramedullary nail; Ex. Fix = external fixation; Int. fix = internal fixation.

high frequency of union with apparently faster union and
less postoperative morbidity (pain or wound healing issues)
than with open arthrodesis (Table 5) [10,38–40,104–107]. A
comparative study of arthroscopic (17 patients) and open (16
patients) arthrodesis showed that the arthroscopic method
had a comparable fusion frequency (fusion frequency:
arthroscopic 94%; open, 100%) and faster average time to
union (arthroscopic, 9 weeks; open, 15 weeks) [39]. Another
comparative study of arthroscopic compared with open
ankle arthrodesis in 36 patients (19 arthroscopic and 17
open) showed that arthroscopic arthrodesis yielded fusion
frequency comparable to open arthrodesis but with
significantly less morbidity, shorter operative time, less
blood loss, and shorter hospital stay [104]. Postoperative
pain and wound problems are less frequent after arthro-
scopic than open arthrodesis. Several studies have also
confirmed time to union of approximately 9 weeks with the
arthroscopic method [10,39,44], but a recent larger series
was noted for average time to union of 12 weeks [108].
Frequency of union in arthroscopic studies has ranged from
85% to 100% [8,10,38,40,43,44,107,109] (Table 5).
Complications of arthroscopic ankle arthrodesis may
include nonunion, malunion, superficial infection [40], deep
infection [37], neuroma formation, hardware-associated
pain that necessitates hardware removal [10], transient
synovitis, and drill bit failure (Table 5). Most reports of a
small series of cases have few complications (Table 5).
However, in a larger series of 42 patients treated with
arthroscopic ankle arthrodesis, a 55% complication rate was
noted, including four pin site infections, four patients with
pain due to hardware, four painful subtalar joints, three
nonunions, two fractures, and one deep infection [37]. In this
series, the majority of complications were minor and
treatable, and 85% of patients were satisfied with the final
results [37]. A recent larger series of 105 ankles was noted
for a nonunion rate of 8% and symptomatic hardware
removal in 22 (21%) ankles [108]. The arthroscopic fusion
technique may result in injury to the neurovascular
structures, especially the sural, superficial and deep peroneal
and saphenous nerves [45].
9.4. Complex and revision arthrodesis
A major complication of primary ankle arthrodesis is
nonunion with or without infection. These cases present a
major challenge to the orthopaedist, but the long-term
patient satisfaction with limb salvage often is preferable to
amputation.
In a series of 23 patients with pseudarthrosis following
ankle arthrodesis, revision arthrodesis (isolated ankle, 14
patients; tibiocalcaneal, 7 patients; pantalar, 2 patients) was
done (average, 1.7 years after the initial procedure) with
rigid internal screw fixation, when possible, or an external
fixator in limbs with osteoporotic bone [71]. In 14 (61%)
patients in whom bone loss was present, autogenous bone
graft was used. Twenty-one (91%) patients achieved union at
an average of 14 weeks, 19 (83%) patients were satisfied
with the revision procedure, and there were no amputations

Table 5
Results and complications of arthroscopic ankle arthrodesisa
Method Total Union Nonunion Malunion Infection Other complicationsb Reference
Cannulated screws 17 16(94%) 1(6%) 2(12%) [39]
Cannulated screws 34 33(97%) 1(3%) 1(3%) 1(3%) [44]
Crossed tibiotalar,
Charnley clamp 8 8(100%) 4(50%) [38]
Tibiotalar and fibulotalar screws 16 16(100%) 2(12%) [10]
Tibiotalar and fibulotalar screws 19 17(89%) 2(11%) 3(16%) [43]
Tibiotalar and fibulotalar screws 26 22(85%) 4(15%) 2(8%) [40]
Total 120 112 (93%) 8 (7%) 3 (3%) 2 (2%) 10 (8%)
a
A recent series of 105 ankles having arthroscopic ankle arthrodesis had complications including symptomatic hardware removal from 22 (21%) ankles,
nonunion in 9 (9%) ankles, superficial infection with 3 ankles, deep vein thrombosis and pulmonary emboli with 2 ankles, and revision of fixation, stress
fracture, and deep infection each with 1 ankle [108].
b
Others: drill broken, removal of hardware, neuroma, transient synovitis.
8 A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10
in this series [71]. In another series of 20 failed ankle fusions
(11 nonunions, 7 malunions, 1 infected nonunion, and 1
ankle with talar avascular necrosis) revised with internal
compression screw fixation, complications were frequent
but fusion was achieved in 17 (85%) ankles at an average of
6 months after surgery; three amputations were done for
chronic infection, but three other patients were dissatisfied
because of chronic pain [110]. In another study of 18
revision ankle arthrodesis procedures fixed with internal
compression screw fixation in 16 ankles, buttress plate in 1
ankle, and an external fixator in 1 ankle, union rate was 94%
but clinical results were fair or poor in 12 (67%) ankles
[111]. The Ilizarov technique was successfully used in
another series of 21 failed ankle fusions (malunion or
nonunion with or without infection); solid union and a
plantigrade foot were achieved with all ankles, and
functional results were excellent in 15 (71%) ankles [35].
Ankle arthrodesis is not contraindicated by the presence
of ongoing sepsis. In one series, 28 ankle fusions were
performed in 26 patients with ongoing sepsis and were
followed over a period of 2 years; functional limb salvage
was achieved in 25 (96%) with an overall infection arrest
rate of 92% [112]. The Ilizarov external fixator may be
useful in the management of complex tibial pathology or
failed ankle arthrodesis, with 16 (80%) of 20 treated cases
having good results and solid fusion in one series [63] and 7
(88%) of 8 ankles in another [33]. Even in the presence of
infected nonunion or osteomyelitis, successful tibiocalca-
neal fusion may be achieved using the Ilizarov technique
[64]. In a small group of four failed infected ankle fusions,
revision with compression using the Ilizarov frame resulted
in tibiocalcaneal fusion in three ankles at an average of 7
months with no evidence of residual infection [64].
Arthrodesis of the infected ankle may be particularly
challenging because of antimicrobial and wound considera-
tions, and consultations with infectious diseases and plastic
surgery specialists may be required [113]. Osteomyelitis
may be polymicrobial and associated with open draining
sinuses [114]. However, a program of radical soft tissue and
bone debridement, soft tissue transfer, intravenous anti-
biotics, and delayed ankle fusion may be successful at
achieving solid ankle arthrodesis union and limb salvage
[114]. Posttraumatic infected ankles with bone loss after
pilon fracture may be treated successfully with Ilizarov
external fixation and distraction osteogenesis to fill in the
bone defect and achieve solid ankle arthrodesis union [115].
Although arthrodesis union and eradication of infection may
be achieved after open, infected, complex ankle trauma,
treatment morbidity and cost of care may be extensive, and
major functional and psychosocial disability may remain
[116].
Successful ankle fusion may be achieved despite the
presence of avascular necrosis of the talus. In 19 patients
with avascular necrosis of the talus who underwent ankle
arthrodesis (ankle and subtalar arthrodesis, 16 [84%]
patients; isolated ankle arthrodesis, three [16%] patients)
with a variety of techniques (external fixation, 13 [68%];
internal fixation, 4 [21%]; no fixation, 2 [11%]), including
bone graft in all ankles, union was achieved in 16 (84%)
ankles [70].
In the Charcot ankle for which nonoperative treatment
had failed to achieve a stable, plantigrade foot, ankle and
hindfoot arthrodesis with a retrograde locked intramedullary
nail may be a good alternative to amputation. In Charcot
arthropathy, ankle arthrodesis with a retrograde nail in 21
patients resulted in bony union in 19 (90%) patients (follow-
up, 12–31 months) [31]. Morbidity was greater in 6 patients
who had marked deformity that necessitated talectomy; in
this group, 8 additional operations were required to achieve
union [31]. Tibial fracture, tarsal tunnel syndrome, metal
failure, and pain or stress fracture at the tip of the nail may
occur.
Failed total ankle arthroplasty may be salvaged with
removal of components and ankle arthrodesis; tricortical
iliac crest bone graft with internal plate fixation may be
successful, but external fixation may be required if infection
is present [117].
Acknowledgments
AN acknowledges support from the Paul W. Lapidus
Fellowship in Foot and Ankle Surgery and the John
Charnley Trust (U.K.) for fellowship training in the United
States of America. Editorial support from Kyle Lee
Williams, M.A. is gratefully appreciated.
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