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FAIXXX10.1177/1071100717717221Foot & Ankle InternationalKerkhoff et al

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Foot & Ankle International®

Sports Participation, Functional

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© The Author(s) 2017
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DOI: 10.1177/1071100717717221
https://doi.org/10.1177/1071100717717221

Arthrodesis: Midterm Follow-up journals.sagepub.com/home/fai

Yvonne R. A. Kerkhoff, MD1, Noël L. W. Keijsers, PhD2,

and Jan Willem K. Louwerens, MD, PhD1

Abstract
Background: Ankle arthrodesis provides satisfactory functional outcome based on basic daily activities, but information
regarding more demanding tasks is limited. Also, studies reporting longer term survival and complication rates are sparse
and concern small study populations. This study reports functional outcome with more focus on demanding tasks and
sports and reports the mid- to long-term union and complication rates in a large study population.
Methods: Between 2005 and 2010, an ankle arthrodesis was performed on 185 ankles. Clinical results were retrospectively
assessed with the Foot Function Index (FFI), visual analog scale (VAS) for pain, and the Foot and Ankle Ability Measure
(FAAM). Information regarding sports pre- and postoperatively was obtained through a questionnaire. In addition,
postoperative complications, reoperations, and failures (defined as nonunion of the ankle arthrodesis) were determined.
Mean follow-up time was 8 years.
Results: FFI scores significantly improved, the FAAM ADL score was 70%, and the mean VAS for pain at the ankle/hindfoot
at follow-up was 20. Sports participation slightly diminished from 79.5% prior to the onset of disabling complaints to 68.9%
postoperatively. Of the patients, 73.1% were able to hike with a median hiking time of 40 minutes (range, 2-600 minutes).
Kneeling could be performed on average 10 minutes (range, 2-60 minutes) in 39.8% and jumping down from steps by
23.5% of the patients. A small selection of patients was able to sprint (14%), and 16.8% of the patients were able to run
a median distance of 60 meters (range, 3-1000 meters). Failure occurred in 9.2% and other postoperative complications
were present in 21.6%, requiring reoperation in 8.6% of the cases.
Conclusion: Ankle arthrodesis led to satisfactory functional outcome and pain reduction. Most patients remained active
in sports, but a transition to less demanding sporting activities was seen. The complication and failure rates were similar
with previous literature, and the incidence of nonrevision secondary surgery was relatively low.
Level of Evidence: Level III, retrospective comparative study

Keywords: ankle arthrodesis, functional outcome, sports participation, complications, adjacent joint arthrodesis

Ankle arthrodesis is still the primary treatment for end-
stage osteoarthritis of the ankle joint. Functional outcome
scores after ankle arthrodesis are satisfactory and improve
significantly compared with preoperative scores.7-10,17,22,23,28
Most patients are satisfied with the outcome. However,
these results are mainly based on questionnaires that focus
on pain and disability in basic daily activities like walking
and stair climbing. Information concerning the performance
of more demanding tasks is limited.
Mid- and long-term studies concerning ankle arthrodesis
show union rates between 83% and 99%.6-10,17,19,20,22,28
Apart from delayed or nonunion, few other complications,
including superficial and deep infections and removal of
hardware due to pain, are reported in small numbers.7,9,10,22,28
These results are mainly derived from small study groups
with a short follow-up duration. Studies reporting both
mid- and long-term survival and complication rates and
functional outcome are sparse and concern study popula-
tions only up to 70 patients.7,10,28
One of the concerns after ankle fusion is progressive
degeneration of adjacent joints. This progression, most
often in the subtalar joint, is reported in 10% to 37% of the
cases.7,10,14,23,28 However, similar rates have been reported
after ankle arthroplasty, and thus it can be doubted that this
1
Department of Orthopaedics, Sint Maartenskliniek, Nijmegen, The
Netherlands
2
Research Department, Sint Maartenskliniek, Nijmegen, The Netherlands
Corresponding Author:
Yvonne R. A. Kerkhoff, MD, Department of Orthopaedics, Sint
Maartenskliniek, PO Box 9011, 6500 GM Nijmegen, The Netherlands.
Email: kerkhoffyvonne@gmail.com
2 Foot & Ankle International 00(0)
is an issue solely related to ankle arthrodesis.2,12,27 The inci-
dence of adjacent joint fusion due to the accelerated degen-
eration is not known, and thus clinical relevance remains
unclear.
Thus, information regarding performance on the level
of challenging functioning and mid- and long-term sur-
vival and complications after ankle arthrodesis is insuffi-
cient in the current literature. Therefore, the purpose of the
present study was to gain more insight into the function,
especially at the level of more physically demanding tasks
and sports participation after arthrodesis of the ankle.
Second, the aim was to determine mid- to long-term union
and complication rates in a large study population.
Frequency of adjacent joint arthrodesis during follow-up
was evaluated to determine whether this corresponded to
the rates of radiological progressive osteoarthritis described
previously in the literature. Since appropriate alignment of
the ankle arthrodesis is important for successful long-term
outcome and function,3,16,18,25 radiological alignment pre-
and postoperatively was measured. In addition, the rela-
tionship of alignment and the occurrence of postoperative
complications were analyzed.
Methods
Between 2005 and 2010, a primary open isolated ankle
arthrodesis was performed in 185 ankles (182 patients) at
the Sint Maartenskliniek (Nijmegen, the Netherlands).
Indications for surgery were disabling pain with matching
radiographic degenerative joint changes. Patients who
underwent an arthroscopic procedure, extensive mid- or
forefoot fusion prior to arthrodesis, arthrodesis in the pro-
cess of acute fracture treatment, and fusion in the context
of neuromuscular disease were excluded. All cases were
available for analysis of complications at a mean ± SD
follow-up period of 7 ± 2.96 years and 159 of the 185
ankles for retrospective radiological evaluation. Eighteen
patients died of causes unrelated to surgery, and 32 patients
were lost to follow-up. In addition, failure occurred in 12
cases, and 1 patient was treated elsewhere for metastatic
melanoma in the context of which a partial foot amputation
was conducted. Consequently, 122 cases were available for
clinical evaluation with the use of questionnaires.
Demographic data and the underlying diagnoses are shown
in Table 1. All patients provided written informed consent,
and the study was approved by the internal review commit-
tee of the Sint Maartenskliniek and by the Medical Ethical
Committee of the Slotervaart hospital (P1617).
Operative Technique and Postoperative
Management
A single-incision lateral approach was used. The fibula
was osteotomized approximately 7 cm proximal to the
Table 1.  Patient Characteristics.
Characteristic Value
Total number of ankles 185
Sex, male/female, No. 126/59
Age at surgery, mean ± SD, y 57.0 ± 12.2
Body mass index, kg/m2, mean ± SD 27.5 ± 4.9
Affected side, right/left, No. 110/75
Smoking status negative, % 83.7
Diagnosis, %
  Primary osteoarthritis 45.7
  Posttraumatic osteoarthritis 51.1
  Rheumatoid arthritis 3.3
distal tip and turned away posteriorly. This was followed
by decortication (with or without the use of saw cuts) of
the talocrural joint and secured with 2 cannulated com-
pression screws. The fibula was then replaced and attached
to the distal part of the tibia with 1 or 2 cortical screws.
Slight differences in applied technique were present.
Postoperatively, patients were mobilized in a short leg
cast for 12 weeks, the first 6 weeks nonweightbearing, fol-
lowed by 6 weeks weightbearing. After 12 weeks, the plas-
ter was converted to a removable walker, which was used
less after 4 weeks.
Functional Outcome Scores
Clinical results were retrospectively assessed with the use
of the Foot Function Index (FFI) score, visual analog scale
(VAS) for pain, and the Foot and Ankle Ability Measure
(FAAM) questionnaire. In addition, participation in sports
after surgery was analyzed, and patient satisfaction was
determined with the use of a questionnaire in which
patients were asked whether the operation had resolved
the pain and improved their daily functioning, if they were
satisfied with the outcome of the surgery, whether they
would undergo the same surgery again under the same
conditions, and if they would recommend this operation to
relatives. The sport questionnaire asked which sport they
performed before surgery (concerning sports activities
performed in the past, previous to the onset of disabling
complaints) and after surgery. In addition, the question-
naire evaluated whether they were able to sprint (eg, to
catch a bus) and to kick a ball with the fused ankle.
Furthermore, they were asked if and for how long they
were able to hike, run, and kneel (eg, during gardening)
and from how many steps they dared to jump down.
The 18-item 5-point validated Dutch version of the FFI
was used.13 This score ranges from 0 to 100, with 0 indicat-
ing no pain and no limitations and 100 indicating severe
pain and limitations. The VAS for pain (0 = no pain, 100 =
the worst pain imaginable) was divided into different
Kerkhoff et al 3

regions (calf, Achilles tendon, ankle, forefoot, midfoot,

heel, dorsum of the foot, and toes) to specify the location of
the pain. Also, the validated Dutch version of the FAAM
questionnaire was used.24 This questionnaire consists of an
activities of daily living (ADL) and sports subscale con-
taining, respectively, 21 and 9 items with answer options
given on a 5-point Likert scale. A higher score represents a
higher level of function in each subscale. Also, patients had
to rate their functioning in ADL and sports with a percent-
age ranging from 0 to 100 (0 indicating an inability to per-
form ADL or sport activities) and complete an overall
4-point rating scale for function, ranging from normal to
severely abnormal.
Patients received study information and the question-
naires by mail. All questionnaires were completed at a mean
± SD follow-up of 8 ± 1.7 years. The FFI score was also
completed preoperatively in 101 cases.
Figure 1.  Radiological measurement of alignment of the ankle.
Postoperative Complications (α) The frontal tibiotalar angle (FTTA). (β) The sagittal tibiotalar
angle (STTA). The dotted lines were used to determine the
Postoperative complications, reoperations, and failures tibial mechanical axis.
were determined. Failure was defined as nonunion of the
ankle arthrodesis. Reoperations were defined as all second- Table 2.  FFI and FAAM Scores.
ary operations, excluding revision arthrodesis. In addition,
the frequency of arthrodesis during follow-up of 1 or more Characteristic Value
of the tarsal joints was recorded. FFI, mean ± SD  
  Pain subscore 18.5 ± 23.1
  Disability subscore 27.8 ± 21.8
Radiological Evaluation
FAAM, mean ± SD, %
Weightbearing anteroposterior and lateral radiographs,   ADL subscale 70.0 ± 22.3
made preoperatively and at 20 to 26 weeks postoperatively,   ADL global 0-100 rating scale 70.4 ± 24.4
were measured for alignment of the ankle. On the antero-   Sport subscale 29.2 ± 27.8
posterior radiographs, the frontal tibiotalar angle (FTTA)   Sport global 0-100 rating scale 43.0 ± 28.6
was measured, with an ideal angle of 0 to 5 degrees of val- FAAM overall level of function, %
gus.3 The FTTA was defined as the superomedial angle  Normal 10.9
between the mechanical axis of the tibia and the axis of the   Nearly normal 67.2
talus, a line drawn through the talar shoulders.21,25,26 On the  Abnormal 18.5
lateral radiographs, the sagittal tibiotalar angle (STTA) was   Severely abnormal 3.4
measured, with a normal mean angle of 106 degrees.21,26 ADL, activities of daily living; FAAM, Foot and Ankle Ability Measure;
The STTA is the anterosuperior angle between the mechani- FFI, Foot Function Index.
cal axis of the tibia and the axis of the talus, defined by a
line drawn from the inferior aspect of the posterior talar
tubercle to the most inferior aspect of the talar neck.21,25,26 Results
The measurement protocol is shown in Figure 1.
Functional Outcome
The postoperative FFI and FAAM scores are shown in
Statistical Analysis
Table 2. Pre- and postoperative FFI scores could be com-
Descriptive statistics were used for analysis of patient char- pared in 54 cases. The mean ± SD preoperative pain sub-
acteristics, complications and reoperations, and clinical and score improved from 49.5 ± 18.9 to 20.0 ± 25.1 and the
radiological outcome. Preoperative and postoperative clini- disability subscore from 54.5 ± 18.1 to 25.8 ± 20.7. This
cal results were compared with the use of paired t tests. A P improvement was statistically significant in both subscores
value of ≤.05 was considered significant. All data were ana- (P < .0001).
lyzed using SPSS Statistics 22 (SPSS, Inc, an IBM The mean ± SD VAS for pain of the ankle at follow-up
Company, Chicago, IL). was 20.4 ± 26.2. This was followed by pain in the forefoot
4 Foot & Ankle International 00(0)
Figure 2.  Participation in sports before the onset of disabling pain and after surgery.
and midfoot, with a VAS of 14.6 ± 23.0 and 12.7 ± 21.6,
respectively. Most patients (89.3%) were satisfied with the
surgery and would choose to undergo the same procedure
again (90.1%). Also, 86.7% reported pain reduction follow-
ing surgery, and an improvement in daily functioning was
seen in 79.3%. The participation in sports before the onset
of disabling pain and after surgery is shown in Figure 2. If
patients were active in sports after surgery, they conducted
the sport on average 3 times a week with a mean duration of
73 minutes at a time.
The percentages of patients with regard to their ability to
sprint, run, hike, kneel, kick a ball, and jump down from
steps are shown in Figure 3. Patients who were able to hike
(73.1%) reported a median hiking time of 40 minutes
(range, 2-600 minutes), and if there was a possibility to run
(16.8%), a median running distance of 60 meters (range,
3-1000 meters) was achievable. Kneeling (eg, at gardening)
could be performed by 39.8% of the patients with a median
time of 10 minutes (range, 2-60 minutes). Most patients
who were able to jump off steps could jump off 2 steps
(46.4%), 35.7% could jump off more than 2 steps, and
17.9% off 1 step.
Most patients (77.9%) wore normal shoes after surgery,
and 22.1% wore orthopaedic shoes on a regular basis.
Postoperative Complications
Failure, defined as nonunion of the ankle arthrodesis,
occurred in 17 of the 185 ankles (9.2%). In 14 cases, revi-
sion surgery was performed. In the 3 cases without a
revision, the patient experienced little or no symptoms or
limitations, and therefore no intervention was carried out.
In 40 of the 185 cases (21.6%), other postoperative compli-
cations, excluding nonunions, were reported. Conservative
treatment was sufficient for 24 (13.0%) of these complica-
tions (Table 3), and 16 of the 40 cases (40%) required a
second operation. In 11 of these 16 ankles, the reason for
reoperation was pain due to irritation of the hardware,
which was removed. There was a deep infection in 3 ankles,
which was treated with operative debridement and antibi-
otic treatment. Removal of a large osteophyte behind the
medial malleolus causing a tarsal tunnel syndrome was per-
formed in 1 ankle. In 1 other ankle, postoperative hemor-
rhage in a patient with anticoagulant treatment required
debridement of the hematoma.
Adjacent Joint Arthrodesis
During follow-up, pain due to osteoarthritis of the subtalar
joint, confirmed by injection of this joint, was reported in
13 cases (7.0%). In 4 patients, a subtalar arthrodesis was
performed for this reason; the other cases were treated
conservatively.
Radiological Outcome
Preoperatively, the mean ± SD frontal tibiotalar angle
(FTTA) was 85.1 ± 12.6 degrees, which improved signifi-
cantly to 88.2 ± 6.0 degrees (P = .001). The sagittal tibiota-
lar angle (STTA) was 107.9 ± 7.6 degrees before surgery
Kerkhoff et al 5

Figure 3.  The ability to sprint, run, hike, kneel, kick a ball, and jump down from steps.

Table 3.  Complications Treated Conservatively. were significantly better than preoperatively. Most patients
were satisfied with the outcome of surgery and reported
Complication Value pain reduction. Also, low-impact sports could be performed.
Total number (%) of complications 24 (13.0) Failure occurred in 17 patients (9.2%), and in 16 of the 185
  Dysesthesia/peripheral neuropathy 8 patients (8.6%), a secondary operation was necessary with
  Delayed wound healing 5 hardware removal in 69% of the cases.
  Superficial wound infection treated 5 The FFI pain and disability scores were significantly
with antibiotics improved on average 8 years after surgery, and there was
  Delayed union treated with 4 minimal pain at long-term follow-up according to the VAS
prolonged cast immobilization for pain. Also, the FAAM score in ADL was acceptable with
 Dystrophy 1 70%, indicating the achievability of adequate daily func-
  Nonunion distal fibula 1 tioning. Since the FFI and FAAM scores were not com-
monly used in previous literature, it is difficult to compare
our results to others and to determine whether there was a
and also improved significantly to 106.1 ± 7.3 degrees post- change in functional outcome during follow-up. Previous
operatively (P = .001). studies that do report the FAAM score at long-term follow-
To determine the influence of alignment on the occur- up found similar scores.7,22 Most patients could resume
rence of failure, the pre- and postoperative FTTA and STTA sports activities, but a transition to less demanding sporting
in the patients with and without failure were compared. No activities, like cycling, hiking, and fitness, was seen. This,
significant differences in both angles were found between together with the inability to run and jump down from steps
the patients with and without failure. in most patients, indicates the avoidance of peak loading of
the ankle. Although the authors admit the existence of selec-
Discussion tion bias probably in favor of the total ankle replacement
(TAR) patients group (eg, having better alignment, stability,
In the present study, evaluation of more demanding func- and quality of bone preoperatively), the results of the pres-
tional tasks and sports, together with the union and long- ent study were compared with our results of the Mobility
term complication rates after ankle arthrodesis, is reported. Total Ankle System,11 where the same questionnaires were
Eight years postoperatively, functional outcome scores completed. The FFI pain and disability scores and VAS for
6 Foot & Ankle International 00(0)
pain of the ankle seem to be similar for the groups in both
studies. The participation in sports is slightly more after
TAR compared with ankle arthrodesis, with 73% vs 69%.
However, more patients after ankle arthrodesis report the
ability to run a short distance. A higher number of patients
after fusion of the ankle report pain reduction and satisfac-
tion with the outcome of surgery compared with patients
with a TAR. Nevertheless, apart from this, a higher number
of patients with a TAR reported overall improvement in
daily functioning.
The failure rate of 9.2% found in the current study is
consistent with the nonunion rates of 1% to 17% found in
previous literature.6-10,17,20,22,28 Some surgeons performing
ankle arthrodesis arthroscopically have noted a lower
nonunion rate. In the literature, other complications are
mostly reported in small numbers. However, due to the
nonstandardized reporting of these postoperative com-
plications, overall these rates vary between 3% and
25%.1,7,9,10,15,22,28 The complication rate of 21.6% seems
relatively high, but it concerns not only reoperations but
also conservatively treated complications. When taking
into account that 69% of the reoperations were removal of
hardware, the incidence of nonrevision secondary surgery
is relatively low at 8.6%. Previous shorter term literature
describes similar failure and complication rates, indicat-
ing occurrence of complications is in the early years after
surgery.6,9,15,17,22,28
One of the concerns after ankle arthrodesis is the pro-
gressive degeneration of adjacent joints, which is reported
in 10% to 37% of the cases, mostly in the subtalar
joint.7,10,14,23,28 This development is clinically relevant only
when it leads to pain and consequently to fusion of the
affected joint. Recently, Gross et al4 reported a rate of 2.6%
of secondary arthrodesis after total ankle replacement,
although this is not known for ankle arthrodesis. A percent-
age of 2.2% was found in our study population, which is
low particularly compared with the previously reported
rates of adjacent joint osteoarthritis. Also, the discussion
remains whether this issue is solely related to arthrodesis of
the ankle with the absent ankle movement and compensa-
tory higher loading of the adjacent joints or also related to
preexisting pathology of the entire hindfoot.
The importance of appropriate alignment of the ankle
arthrodesis for long-term clinical success has been reported
previously. Malalignment can be related to persisting pain
and can lead to changes in gait pattern.3,5,16,18,25 With a mean
frontal tibiotalar angle of 88.2 degrees, the optimum of 90
degrees was closely approached. Furthermore, the previ-
ously reported optimal sagittal angle of 106 degrees was also
found in our study population. Failure of the arthrodesis
could not be attributed to possible postoperative malalign-
ment, which could have been a plausible explanation.
A few limitations have to be considered. As a conse-
quence of the retrospective study design, the FFI score was
the only questionnaire that was assessed preoperatively and
therefore the only one to compare with postoperative out-
come scores. Also, patients had planned, regular follow-up
visits up to 6 to 12 months after surgery. Thus, the follow-
up time of the patients who were lost to follow-up at the
time of the present study (n = 32) is short, and it cannot be
stated with certainty that no complications occurred after
the last visit. Furthermore, the radiographic progression of
adjacent joint osteoarthritis could not be determined due to
both this retrospective study design and the limited number
of arranged follow-up visits. However, this information has
been previously reported in other studies.7,10,14,23,28
Conclusion
Ankle arthrodesis led to long-term satisfactory functional
outcome scores and pain reduction. Most patients remained
active in sports, but a transition to less demanding sportive
activities was made. The failure rate was consistent with
previous literature, and the incidence of nonrevision sec-
ondary surgery was relatively low. After arthrodesis of the
ankle joint, fusion of adjacent joints during follow-up rarely
occurred and was similar to the incidence after total ankle
replacement. A relationship between alignment and failure
was not found in this series.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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