Orthopaedics & Traumatology: Surgery & Research 100 (2014) 761–766

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Original article

Comparison of quality of life following total ankle arthroplasty and

ankle arthrodesis: Retrospective study of 54 cases
F. Dalat a,∗ , F. Trouillet b , M.H. Fessy a,c , M. Bourdin c , J.-L. Besse a,c
a
Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Service de Chirurgie Orthopédique, Traumatologique et de Médecine du Sport,
chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France
b
Hospices Civils de Lyon, Hôpital Renée-Sabran, Service de Chirurgie Orthopédique, 83400 Hyères, France
c
Université Lyon 1, IFSTTAR, LBMC UMR-T 9406, Laboratoire de Biomécanique et Mécanique des Chocs, 69675 Bron cedex, France

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The benefit of ankle arthroplasty compared to arthrodesis continues to be debated, but the
Accepted 30 July 2014 quality of life after these two interventions has rarely been assessed. We conducted a case-control study
to compare quality of life and functional and athletic ability.
Keywords: Hypothesis: Functional results, athletic ability, and quality of life after total ankle arthroplasty (TAA) are
Total ankle arthroplasty better than after ankle arthrodesis.
Ankle arthrodesis Material and methods: Two continuous series of 59 TAAs and 46 arthrodeses (operated on between 1997
Quality of life
and 2009) were evaluated retrospectively using a questionnaire including the functional items of the
Functional results
AOFAS score, the Foot Function Index (FFI) score, the Foot Ankle Ability Measure (FAAM), and the SF-36.
Results: Eighty-three responses (79% of the overall series) were matched in two groups: 32 TAAs [age
at the intervention, 51.4 years (range, 21–63 years); follow-up, 52.2 months (range, 30–146 months);
age at revision, 55.8 years (range, 26–67 years); BMI, 27.7 (range, 21.7–36.7)] and 22 arthrodeses [age
at intervention, 50.1 years (range, 24–72 years); follow-up 57.9 months (range, 12–147 months); age at
revision 54.9 years (range, 31–75 years); BMI, 26.8 (range, 17.6–37)] (NS on all items between the two
groups). The pain results were better after TAA, but with no statistically significant difference: AOFAS
pain, (/40) 28.1 ± 8.2 vs. 24.5 ± 9.6; FFI pain, 16.6 ± 18.8 vs. 24.3 ± 21.5. The overall FFI score (/100) was
better (P = 0.048) after TAA (16.2 ± 16.5 vs. 24.8 ± 18.2). The overall mean athletic level compared to the
state prior to the injury was relatively low in both groups, but significantly (p = 0.007) higher in the TAA
group: FAAM sports score (/100), 49.5 ± 24.4 vs. 29.8 ± 26.2. The quality-of-life scores, SF-36 physical
health, mental health, and general health were not significantly different after TAA and arthrodesis:
mental health score, 63.1 ± 14.7 vs. 57.8 ± 21.5; physical health score, 61.3 ± 17.8 vs. 53.7 ± 23.9, overall
score, 63.2 ± 16.4 vs. 55.9 ± 23.5.
Discussion: Very few publications describe activities and quality of life after TAA and arthrodesis. Despite
weaknesses, this comparative study demonstrates a tendency toward better functional results after TAA
than after ankle arthrodesis, without the difference between the two groups being very significant. On
the other hand, there was no difference in terms of quality of life. After the doubts raised by publica-
tions on severe periprosthetic osteolysis at the intermediate term with certain TAA models, these results
encourage pursuit of implantation and development of TAA.
Level of proof: Comparative retrospective. Level III study.
© 2014 Elsevier Masson SAS. All rights reserved.

1. Introduction (TAA) [1–4]. The expected advantages of TAA compared to TTA

In cases of advanced ankle joint disease, the surgical options are
essentially tibiotalar arthrodesis (TTA) and total ankle arthroplasty
∗ Corresponding author. Tel.: +04 78 86 59 30; fax: +04 78 86 59 34.
E-mail addresses: fred.dalat@hotmail.fr (F. Dalat), jean-luc.besse@chu-lyon.fr
(J.-L. Besse).
are maintenance of joint amplitudes and restoration of the ankle’s
kinematics, providing the patient with better functional recupera-
tion while improving quality of life [1,2]. The disadvantages of TAA
are its complications that can require explanation of the prosthe-
sis and difficult secondary arthrodesis with significantly inferior
results compared to first-line TTA [3,4]. The 10-year survival rate
of TAA procedures is lower than for the hip and knee [5]. In addi-
tion, the benefit of arthroplasty compared to arthrodesis continues
to be debated.

http://dx.doi.org/10.1016/j.otsr.2014.07.018
1877-0568/© 2014 Elsevier Masson SAS. All rights reserved.
762 F. Dalat et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 761–766
105 ankles
Operated between
January 1997 and
July2009
59 total ankle
arthroplasty
5 lost to 3 reoperated 32 TAA
follow-up and 19 included arthrodesis
excluded
Fig. 1. Distribution of patients according to group. TAA: total ankle arthroplasty.
Most studies report the survival rate, radiological results [6],
and the analysis of failures for each of the two surgical procedures
[7]. Few series have evaluated the functional results as well as the
return to daily and sports activities for each of the procedures.
To provide new arguments to guide the surgeon’s and patient’s
choice between total ankle arthroplasty and tibiotalar arthrode-
sis, we conducted a case-control study to compare TAA and TTA
for the following: quality of life and functional and athletic abil-
ity. We hypothesized that the functional results, athletic ability,
and quality of life after arthroplasty would be better than after
arthrodesis.
2. Material and methods
2.1. Patients
Between January 1997 and July 2009, 105 ankle arthropathies
(103 patients) were performed, taking into account the patients’
choice after they had been informed of the procedures (59 TAAs
and 46 arthrodeses). The minimum follow-up was 12 months. All
patients received a functional evaluation questionnaire on their
ankle by post. Those patients who had not responded within
1 month were recontacted twice by telephone at 2-month intervals.
We received 83 responses (79.0%).
To make the two groups homogenous, we excluded patients
with multiple joint or bilateral ankle injuries and those with
associated procedures during the surgical intervention: for TAA
(ligament tightening, osteotomy) and for TTA (associated sub-
talar or talonavicular arthrodesis), the presence of lower-limb
unhealed fractures, neurological impairment, as well as neuro-
pathic feet, unhealed arthrodeses, and surgical revisions for any
cause (infection, non-union, early loosening, periprosthetic bone
cyst grafting).
According to these criteria, our retrospective case-control study
included 54 patients, all operated on following the same protocol
and divided into two groups (a group of 32 TAAs and a group of
22 ankle arthrodeses) (Fig. 1).
46
arthrodesis
22 1 reoperated 12 lost to 1 died
and 10 follow-up
included excluded
2.2. Surgical technique
All patients having undergone a TAA were operated on with the
same surgical technique by a single senior surgeon (JLB). The pros-
thesis implanted was the ankle evolutive system (AES) (Biomet
Inc., Valence, France) [8], an evolved version of the Buechel Pap-
pas implant. This three-component mobile-bearing prosthesis was
made in chromium–cobalt alloy. All patients underwent postop-
erative active self-rehabilitation of the ankle beginning on the 1st
day and with no weight-bearing for the first 3 weeks. They resumed
weight-bearing with a removable cast for the following 3 weeks.3
The patients in the TTA group were all operated on with the
same surgical technique (anterolateral approach, titanium staple
or screw fixation) by three surgeons. After the intervention, the
ankles were immobilized in a cast for 3 months (6 weeks with no
weight-bearing, 6 weeks with weight-bearing).
2.3. Method used to evaluate the results
All patients were evaluated retrospectively using the functional
and pain items of the American Orthopaedic Foot and Ankle Society
(AOFAS) score [9], the Foot Function Index (FFI) score [10,11], the
Foot Ankle Ability Measure (FAAM) score [12,13], the SF-36 ques-
tionnaire [14,15], and a questionnaire established by Bonnin et al.
[16] comprising 13 items on sports activities.
The FFI score, a three-part questionnaire, included nine items
for the pain part, five to analyze limitations in activity and nine to
assess problems in daily living. The result of each part was con-
verted to an analogic visual scale from 0 (the best function) to 100
(the worst function).
The FAAM score included a functional assessment for daily life
(21 items) and for sports activities (eight items). Each response
was graded from 0 to 4 (0 = impossible and 4 = no difficulty); if the
patient did not participate in any of the activities proposed on the
questionnaire for a reason other than ankle injury, this item was
removed. Adding the points of the corresponding items gave the
FAAM daily living, sports activity, and overall scores.
 F. Dalat et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 761–766 763

Table 1
Demographic characteristics of the total ankle arthroplasty and tibiotalar arthrodesis groups.

Total ankle arthroplasty, n = 32 Arthrodesis, n = 22 p

Sex 13 (40.6%) 19 (59.4%) 7 (31.2%) 15 (68.2%) ns

Mean BMI 27.7 kg/m2 ± 3.9 [21.7–36.7] 26.8 kg/m2 ± 5.2 [17.6–37] ns
Mean age at intervention 51.4 years ± 9.8 [21–63] 50.1 years ± 13.1 [24–72] ns
Mean age at revision 55.8 years ± 9.9 [26–67] 54.9 years ± 11.4 [31–75] ns
Mean follow-up 52.2 months ± 21.9 [30–146] 57.9 months ± 43.1 [12–147] ns

BMI: body mass index.

The SF-36, a generalist quality-of-life score, evaluated the Table 2

Etiologies resulting in ankle joint destruction.
patients’ physical and mental health, vitality, general health per-
ceptions, and social functioning. Total ankle arthroplasty Arthrodesis
The sports activity questionnaire analyzed patients’ participa- n = 32 n = 22
tion in 13 sports distributed into three groups (light, intermediate, Post-traumatic osteoarthritis 29 (91%) 21 (95%)
or intensive). For each activity, patients indicated whether they par- Post-fracture 19 19
ticipated in this sport and if so how often as well as the intensity of Post-instability 10 2
Inflammatory diseases 3 (9%) 1 (5%)
any pain.
TAA: total ankle arthroplasty.

2.4. Statistical analysis
The statistical analysis was carried out with StatViewTM (SAS
Institute Inc, Cary, NC, USA). Considering the variables in each group
were not normally distributed, we used the non-parametric Mann-
Whitney test to compare the results of the two groups, with P < 0.05
considered significant.
3. Results
The two groups were statistically comparable in terms of sex,
mean BMI, mean age at surgery, and mean follow-up (Table 1) as
well as for the distribution of etiologies. Post-traumatic osteoarthri-
tis was the most frequent etiology (91% TAA vs. 95% TTA). In the
other cases, osteoarthritis was secondary to inflammatory arthritis
with isolated involvement of the ankle (Table 2).
Seventy-seven percent of the patients who underwent TTA were
satisfied or very satisfied with the intervention versus 81% of the
patients undergoing TAA, but this result was not statistically sig-
nificant.
The patients in the TAA group presented less pain than those in
the TTA group on both the AOFAS (28.1 ± 8.2 vs. 24.5 ± 9.6) and FFI
(16.6 ± 18.8 vs. 24.3 ± 21.5) scores, but with no significant differ-
ence (Table 3). The results on the pain items of the AOFAS, FFI, and
SF-36 scales were correlated.
According to the AOFAS, FFI, and FAAM scores, all of the items
evaluating the functional results and the difficulties encountered
in daily life were better for the arthroplasty group than for the
arthrodesis group (Table 3). However, this trend was not statis-
tically significant for all items. The mean overall sports level was
relatively low in both groups, but significantly (P = 0.007) higher in
the AAT group: the FAAM sports score, 49.5 ± 24.4 vs. 29.8 ± 26.2.
The patients operated on for a TAA or a TTA participated in the
same types of sports, for the most part non-contact sports (station-
ary or outdoor cycling, swimming, and hiking): 47% cycling and 49%
swimming for the TAA group. The patients in both groups took part
in sports activities with the same intensity.

Table 3
Results for the different functional scores studied in the total ankle arthroplasty (TAA) and tibiotalar arthrodesis (TTA) groups.

Score TAA TTA Mann-Whitney statistics

AOFAS [9]
Pain (/40) 28.1 ± 8.2 24.5 ± 9.6 ns
Limitation of activities (/10) 7.3 ± 1.9 6.2 ± 2.3 P = 0.049
Walking distance (/5) 4.5 ± 1.0 4.3 ± 1.2 ns
Terrain (/5) 3.03 ± 1.6 2.1 ± 1.7 P = 0.04
Overall/100 69.7 ± 17.3 61.8 ± 21.7 ns

FFI [10,11]
Pain (/100) 16.6 ± 18.8 24.3 ± 21.5 ns
Difficulties (/100) 22.7 ± 22.4 36.0 ± 24.1 P = 0.02
Limitations of activities (/100) 11.1 ± 15.8 14.4 ± 18.0 ns
Overall (/100) 16.2 ± 16.5 24.8 ± 18.2 P = 0.048

FAAM [12,13]
Daily activities (/100) 77.6 ± 19.8 63.4 ± 19.4 ns
Subjective evaluation 70.3 ± 19.9 58.8 ± 23.6 ns
Daily activities (/100)
Sports (/100) 49.5 ± 24.4 29.8 ± 26.2 P = 0.007
Subjective evaluation 58.4 ± 18.1 41.3 ± 31.1 P = 0.01
Sports activities (/100)
Overall subjective ankle function
Normal 6.3% 4.5%
Nearly normal 78.1% 50%
Abnormal 15.6% 41%
Very abnormal 0% 4.5%

TAA: total ankle arthroplasty; TTA: tibiotalar arthrodesis; ns: non-significant difference; AOFAS: American Orthopaedic Foot and Ankle Society; FFI: Foot Function Index;
FAAAM: Foot Ankle Ability Measure.
764 F. Dalat et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 761–766

Table 4
Results of SF-36 scores ([14,15]).

Total ankle arthroplasty Arthrodesis Mann-Whitney statistics

Physical activity 68.6 ± 25.2 59.8 ± 30.0 ns

Limitations due to physical condition 59.4 ± 39.0 44.3 ± 44.3 ns
Physical pain 62.5 ± 20.1 53.5 ± 27.2 ns
General health 61.6 ± 17.7 58.0 ± 23.7 ns
Vitality 54.5 ± 15.9 53.0 ± 18.3 ns
Social functioning 76.2 ± 18.3 65.4 ± 24.7 ns
Physical health 67.6 ± 14.8 64.5 ± 16.1 ns
Limitations due to mental condition 66.7 ± 40.6 50.0 ± 46.9 ns
General health perceptions 52.3 ± 11.6 53.4 ± 22.2 ns
Mean physical health score 61.3 ± 17.8 53.7 ± 23.9 ns
Mean mental health score 63.1 ± 14.7 57.8 ± 21.5 ns
Overall SF-36 score 63.2 ± 16.4 55.9 ± 23.5 ns

ns: non-significant difference.

The SF-36 quality-of-life physical health, mental health, and
general health were better after arthroplasty but this difference
between the two groups was not statistically significant (Table 4).
4. Discussion
According to this comparative study, the patients with a
total ankle prosthesis had fewer activity limitations (AOFAS) and
problems on rough ground than those who had undergone an
arthrodesis procedure. Moreover, the overall FFI score and the
subjective feeling concerning ankle function were better after
arthroplasty than after arthrodesis. Patients with a TAA implant
had a higher FAAM sports score, but the sports activities remained
limited in both groups.
This study had weaknesses that may have resulted in bias. This
was a retrospective study reporting results at the medium term

Table 5
Studies reporting functional results and quality of life after total ankle arthroplasty (TAA) and tibiotalar arthrodesis (TTA).

Series Number of Age Follow-up AOFAS [9] FFI [10,11] FAAM [12,13] SF 36 [14,15]
patients (at revision) (pain/40, (/100) (/100) (/100)
total/100)

Van 7 arthrodeses 51 years 20 months 67 Phys. health: 46

Bergeyk (Blair) (39–78) (12–112) (56–78) (29–57)
et al. [29] Mental health: 61
(26–67)

Kopp et al. 43 TAAs 63 years 44.5 months 83.3 Phys. health: 49.5
[28] (agility) (32–85) (26–64) (65–100) (28.2–63.7)
Mental health: 56.1
(23.1–66.9)

Bonnin 140 TAAs 60.9 years 53.8 months Pain: 30.4 ± 7.5 Pain: 16.9 ± 19 Daily activities:
et al. [16] (Salto) (26–90) (12–125) Total: Difficulties: 74.9 ± 18
87.7 ± 9.8 31.7 ± 23 Sports: 48.9 ± 28
Limitation of Subjective sports:
activity: 13.7 ± 17 53.7 ± 28
Besse - 356 TAAs 57 years 37 months Phys. health
AFCP [27] (Salto–AES) (23–77) (12–71) 63 ± 20.7
Mental health
68 ± 20.4
General health:
66 ± 20.3

Esparragoza 16 arthrodeses 61 years (42–73) 25.2 months Total: General health:

et al. [17] (ankle and ATT) 64 years (48–77) (18–261) 45.6 ± 5.1 46.3 ± 8.0
14 TAAs (AES) Total: 62 ± 5.5 General health:
59.8 ± 8.6

Schuh et al. 21 arthrodeses 63.8 years 30 months Total:

[18] 20 TAAs ± 11.1 ± 22.0 75.6 ± 14.0
(Hintegra) 56.2 years ± 10.5 39 months ± 17.0 Total:
75.6 ± 16.0
Current 22 arthrodeses 54.9 years 57.9 months Pain: 24.5 ± 9.6 Pain: 24.3 ± 21.5 Daily activities: Phys. health:
series 32 TAAs (31–75) (12–147) Total: Difficulties: 63.4 ± 19.4 53.7 ± 23.9
(AES-Hintegra) 55.8 years 52.2 months 61.8 ± 21.7 36.0 ± 24.1 Sports: 9.8 ± 26.2 Mental health:
(26–67) (30–146) Pain: 28.1 ± 8.2 Limitation of Subjective sports: 57.8 ± 21.5
Total: activity: 14.4 ± 18.0 41.3 ± 1.1 General health:
69.7 ± 17.3 Pain: 16.2 ± 16.5 Daily activities: 55.9 ± 23.5
Difficulties: 77.6 ± 9.8 Phys. health:
22.7 ± 22.4 Sports: 9.5 ± 4.4 61.3 ± 17.8
Limitation of Subjective sports: Mental health:
activity: 11.1 ± 15.8 8.4 ± 18.1 63.1 ± 14.7
General health:
63.2 ± 16.4

TAA: total ankle arthroplasty; AOFAS: American Orthopaedic Foot and Ankle Society; FFI: Foot Function Index; FAAAM: Foot Ankle Ability Measure.
 F. Dalat et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 761–766
with no preoperative information on physical activity, notably
sports activity. The patients in the arthrodesis group were oper-
ated on by several surgeons but following the same protocol. On
the other hand, the strong points of this study are the homogeneity
of the techniques and surgical recovery in both groups, and the fact
that there are few studies analyzing and/or comparing functional
results, quality of life, and return to sports activities after TAA and
arthrodesis [16–18].
The place of TAA compared to arthrodesis continues to be
debated. Ankle arthrodesis remains the gold standard for treating
degenerative ankle joint disease because it maintains long-term
functional results [19]. However, in a comparative meta-analysis,
Haddad et al. [7] found no difference in functional results between
ankle arthroplasty and arthrodesis according to the AOFAS score
over the medium and long terms. In another meta-analysis com-
paring the 5-year revision rate between these two interventions,
SooHoo et al. [20] noted more complications after arthroplasty
(23%) than after ankle arthrodesis (11%). Moreover, recent publica-
tions show a very high rate of severe osteolysis with the AES ankle
implant [21–24] but also with other prosthesis models [6], which
has raised doubts on the benefits of ankle implants.
Functional abilities (particularly the AOFAS pain subscore) of
our TAA group are comparable to the series reported by Bonnin
et al. [16]. Esparragoza et al. [17] observed a higher AOFAS score
for TAAs, whereas for Schuh et al. [18] there was no difference
between TAA and arthrodesis. Our subjective assessment of ankle
function at the longest follow-up was better for the TAA group (44%
arthrodesis vs. 82% TAA normal or nearly normal) and in agreement
with the Bonnin et al. study [16], which found 75% of the patients
judging the functioning of their ankle as normal or nearly normal
after arthroplasty. The FFI pain score for our arthroplasty patients
was comparable to the score reported by Bonnin et al. [16]. The
FAAM daily activity and sports scores (P < 0.007) for our arthro-
plasty patients were slightly higher than the scores for arthrodesis
patients and comparable to the same scores in the Bonnin et al.
series [16] (Table 5).
For all patients (TTA and TAA), the sports level was low, and they
were almost exclusively involved in non-contact sports. Valderra-
bano et al. [25] studied sports activities resumed after 147 Hintegra
TAAs for patients whose mean age was 59 years: 46% cycled and 34%
swam: there were better functional results in patients with regular
physical activity. Our results are comparable: 47% did cycling and
49% swimming in the TAA group. As in our series, Schuh et al. [18]
observed no difference between the TAA group and the arthrode-
sis group on the type of sports activity [18]. For Naal et al. [26],
two-thirds of the 101 patients with a TAA, and a mean 3.7 years of
follow-up, took part in a sports or physical activity. Moreover, these
authors demonstrated that there was no correlation between the
appearance of a periprosthetic radiologic translucent line and the
intensity of sports activity [26]. In the present series, as reported
elsewhere in the literature [16,18,25,26], the patients with total
ankle implants more often played non-contact sports but presented
greater discomfort during sports activity.
In 2006, during the AFCP-SOFCOT multicenter symposium,
Besse et al. [27] presented an evaluation of 356 TAAs with the
SF-36: the mean total score was 66 ± 20.3 (range, 23–97), the phys-
ical health score 63 ± 20.7, and the mental health score 68 ± 20.4;
these results were better than the study reported by Kopp et al. [28]
with the TAA agility (two components). The results of the SF-36 in
our TAA group were comparable to the French multicenter study
[27]. Esperragoza et al. [17] demonstrated better quality of life for
the TAA group, and we showed the same trend for the physical
score, but it was not statistically significant. Our results are there-
fore equivalent to those reported in the literature for each of the
groups considered; the quality-of-life scores after TAA are slightly
higher than those after arthrodesis [17,27–29] (Table 5).
765
5. Conclusion
This study has demonstrated a trend toward better results in
terms of quality of life, physical and athletic ability after total ankle
arthroplasty than after tibiotalar arthrodesis. Confirming other
studies, these data encourage the pursuit of development of total
ankle implants despite the current worries related to the osteolysis
rate.
Disclosure of interest
Jean-Luc Besse: clinical assessment contract (PTC AES) with
BIOMET (2004–2008). Michel Henri Fessy declares no conflict of
interest related to the present study but declares receiving royal-
ties from Décines France and DePuy International unrelated to the
study and is an educational consultant for Biomet and Serf. Frédéric
Dalat, Franck Trouillet, and Muriel Bourdin declare that they have
no conflicts of interest concerning this article.
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