Management of the Failed Total Ankle Replacement



TAR survivorship at 10 years ranges from 70% to 90%

Latest NJR annual report (2021) can be found here


Causes of TAR failure

(see NJR A2 form)

  • infection
  • aseptic loosening
  • lysis / cyst formation
  • malalignment / instability
  • implant fracture
  • wear of polyethylene component
  • meniscal insert dislocation
  • component migration / subsidence / dislocation
  • unexplained pain
  • stiffness
  • soft tissue impingement


Diagnosis of TAR failure

  • Clinical: pain, swelling, alignment, instability
  • Radiographs
    • look for loosening, alignment, subsidence, cysts
    • weight-bearing radiographs (AP/mortice & lateral), Saltzman view
  • CT or SPECT if loosening suspected but x-rays equivocal
  • Inflammatory markers for consideration of infection
  • Aspiration or biopsy (percutaneous or arthroscopic)



Revision options

Revision arthroplasty

  • larger units will have more experience
  • limited implants currently available: Inbone, Invision, Salto XT
  • bigger implants = more bone sacrificed = salvage options increasingly limited
  • must address alignment and stability

*awaiting image upload*

FIgure 1 Examples of revision options: Inbone (left) is modular; Salto X (right)


  • tibiotalar (ankle) or tibio-talo-calcaneal (TTC)
    • TTC indicated if insufficient bone stock or significant subtalar arthritis
  • reasonable long-term results and patient satisfaction
  • higher non-union rate than primary arthrodesis
  • most require bone graft:
    • particulate cancellous graft
    • bulk graft (large bone loss):
      • tricortical iliac crest wedges
      • femoral head or distal tibial allograft
      • custom trabecular metal


  • final salvage option
  • BKA allows good rehabilitation with well-fitting prosthesis


Prevention of failed TAR

Choose the optimal patient:

  • older patient or one with lower physical demands
  • other joint problems e.g. ipsilateral foot or knee or contralateral ankle arthritis
  • good alignment and ligamentous stability

Avoid poor patient choice:

  • neuromuscular deformity
  • previous infection
  • poor soft tissues / vascularity
  • osteonecrosis / osteoporosis may cause problems with bony fixation

Choose the optimal surgeon:

  • implant-trained, higher volumes
  • supportive infrastructure and colleagues, research team
  • access to complex case MDT
  • regional network for revision cases



Most reported complications are preventable with good patient selection and surgical technique.

Failed TARs need appropriate investigation, work-up and team discussion before proceeding with appropriate revision / salvage options.



What is NOT considered an inclusion criterion for TAR surgery?

  • Fair hindfoot alignment
  • Low demand patients older than 60 y/o
  • Good bone quality patients with no significant co-morbidities
  • Contralateral knee joint problems
  • None of the above



Vickerstaff JA, Miles AW, Cunningham JL. A brief history of total ankle replacement and a review of the current status. Med Eng Phys. 2007 Dec;29(10):1056-64. doi: 10.1016/j.medengphy.2006.11.009. Epub 2007 Feb 14. PMID: 17300976

Saltzman CL. Total ankle arthroplasty: state of the art. Instr Course Lect. 1999;48:263-8. PMID: 10098052

Conti SF, Wong YS. Complications of Total Ankle Replacement. Clinical Orthopaedics and Related Research: October 2001 - Volume 391 - Issue - p 105-114

Henry JK, Rider C, Cody E, Ellis S, Demetracopoulos C. Evaluating and Managing the Painful Total Ankle Replacement. Foot Ankle Int 2021 Oct;42(10):1347-1361