Review Article
History and Recent Development of Total Ankle Arthroplasty
2026 Volume 1 Issue 1 Pages 2-8
Details
2026 Volume 1 Issue 1 Pages 2-8
Since the first total ankle arthroplasty (TAA) was performed in 1970, the number of TAA procedures for end-stage ankle osteoarthritis has gradually increased as an alternative to arthrodesis. There are two types of TAAs: mobile-bearing and fixed-bearing. Each has its own advantages and disadvantages, but both have evolved over time from the first generation to the fourth generation, with improvements addressing earlier limitations. Although fourth-generation TAAs were introduced to the market in the early 2010s and long-term outcomes remain uncertain, early reports have shown favorable survival rates of 92%-98% and significant improvements in functional and pain scores two years after surgery. The design of TAA devices has advanced through improvements in mechanisms, anatomical shapes, materials, and surgical approaches. These advancements have improved, and will continue to improve clinical outcomes and survival rates with each new generation.
Table 2
Characteristics of TAA in Each Generation.
Before the advent of ankle arthroplasty, ankle arthrodesis was the only available surgical option for end-stage ankle arthritis and was regarded as the gold-standard treatment.1 Since the first total ankle arthroplasty (TAA) was performed in 1970, the number of TAA procedures has gradually increased as an alternative to arthrodesis surgery. A large cohort study of TAA and ankle arthrodesis utilization in the United States from 2016 to 2017 revealed that of the 6,577 cases of end-stage ankle osteoarthritis surgically treated in outpatient settings during that period, 2,233 cases (24.6%) were treated with a TAA.2 There has been much discussion about the clinical outcomes of arthrodesis versus TAA for end-stage ankle osteoarthritis. Several studies have compared the outcomes of individual TAA implants with those of ankle arthrodesis, corroborating findings that survivorship and clinical improvements lead to similar survival rates, better pain reduction, and decreased reoperation rates.3-6 The advantages of TAA over arthrodesis include significantly lower rates of aseptic loosening compared to nonunion in arthrodesis,7 improved satisfaction scores and superior realization of preoperative goals,8 better functional outcomes with respect to gait, range of motion, and functional ability,1 and a greater total arc of movement with subsequently less compensatory movement in adjacent joints and facilitates better preservation of those joints from degenerative changes.9 With few exceptions, implant survivorship following TAA has been reported between 70% and 98% at 3 to 6 years, and between 80% and 95% at 8-12 years, based on data from 2,360 procedures across multiple studies with adequate follow-up.10-34 Compared with previous models, the fourth-generation TAA, which began to be used in the early 2010s, has made significant advances. Although only short-term clinical results of less than 10 years have been reported for fourth-generation TAA, outcomes surpassing those of arthrodesis are being reported. In this article, we review the history of TAA and its recent developments.
Before explaining the history of TAAs, we need to explain the difference between fixed-bearing TAAs and mobile-bearing TAAs (Table 1). Two-component fixed-bearing TAAs offer the advantage of stable articulation with a lower risk of subluxation.35-38 However, they may present increased shear forces at the bone-implant interface, potentially raising the risk of tibial component loosening.39 Three-component mobile-bearing TAAs provide more flexible articulation with lower shear forces at the bone-implant interface.40-43 However, this bearing type is more susceptible to excessive anterior, posterior, or lateral subluxation of the polyethylene spacer, possibly leading to malleolar impingement.44 Both designs have undergone advancements in shape and materials over time to mitigate potential risks while preserving their advantages. There is no conclusive evidence to verify the superiority of either type,45-47 as published clinical studies of TAAs have, by and large, carried Grade-C recommendations (fair, conflicting, or poor-quality evidence, i.e., level III, IV, or V) for mobile- or fixed-bearing designs.17 Nunley et al.48 conducted a prospective randomized trial to evaluate the clinical outcomes and imaging findings of mobile-bearing and fixed-bearing TAA. A comparison of clinical outcomes revealed no significant differences between the mobile-bearing and fixed-bearing TAAs in terms of the Visual Analog Scale, American Orthopaedic Foot and Ankle Society, Short Form 36, the Foot and Ankle Disability Index, and the Short Musculoskeletal Functional Assessment scores. In contrast, based on imaging evaluations, fixed-bearing TAAs were significantly better in terms of talar component lucency/cyst formation, subsidence, malalignment, and heterotopic ossification. The Food and Drug Administration in the United States requires that TAAs demonstrate non-inferiority to ankle arthrodesis in prospective controlled trials. Although most TAAs approved by the Food and Drug Administration for use without cement in the United States are fixed-bearing TAAs, only the Scandinavian Total Ankle Replacement approved for use as a mobile-bearing TAAs without cement.17,48,49
Two-Component Fixed-Bearing Versus Three-Component Mobile-Bearing TAA.
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The first prosthesis insertion surgery for severe osteoarthritis of the ankle was performed in 1962 with hemi-arthroplasty with a custom vitallium talar dome resurfacing implant.50 A 31-year-old man underwent surgery via a lateral approach, and contrary to expectations, the primitive implant survived; 40 years later, at age 71, the hindfoot alignment remained minimal and asymptomatic.51
The first TAA was the Lord and Marrotte implant, introduced in 1970.52 The implant featured a simple hinged design with a long-stem tibial component, similar to a femoral prosthesis. It articulated with a polyethylene talar body replacing component that was fixed into the calcaneus. Out of 25 arthroplasty procedures, seven yielded satisfactory results. At 10 years, 12 implants had failed, leading to the abandonment of the prosthesis design.51 Since the 1970s, many TAAs have been used clinically, and advancements in implant designs have been made across the world. The first generation of TAAs developed well into the 1980s, the second generation into the early 2000s, and the third generation into the early 2010s. Since the early 2010s, designs have evolved into fourth generation TAAs.1,51,53,54 Although it is difficult to clearly classify which model belongs to which generation due to the unique characteristics of each TAA and advancements that have evolved over time, the general characteristics of each generation are described below (Table 2).
Characteristics of TAA in Each Generation.
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Although prosthesis designs varied widely, first-generation implants featured a two-part design consisting of a concave polyethylene articulating surface and a convex cobalt-chrome metal component. Both constrained and unconstrained systems were developed, each associated with distinct failure mechanisms.1 Constrained designs restricted stress dissipation at the articular interface, resulting in high rates of loosening, while unconstrained systems transferred excessive stress to surrounding ligaments, contributing to malalignment. These limitations led to high failure rates and suboptimal clinical outcomes.26,55 Additionally, first-generation TAA implants used polymethyl methacrylate (PMMA) cement fixation, which required extensive bone resection to properly position the components. PMMA is also known to increase the incidence of osteolysis and bone loosening. This first generation of implants faced multiple challenges: high rates of loosening (ranging from 29% to 90% at 10 years), low satisfaction scores, and poor survivorship.26,55-57
Second-Generation TAAsThe second generation of TAAs developed two categories of implants—fixed-bearing and mobile-bearing—that aimed to mitigate the shortcomings of first-generation TAAs. Fixed-bearing implants consist of tibial, talar, and fixed polyethylene components functioning as a two-component system, offering increased constraint and stability at the expense of a higher risk of loosening. Mobile-bearing designs utilize an unconstrained polyethylene insert that articulates between the tibial and talar components, aiming to reduce stress transmission; however, several issues needed to be addressed, including polyethylene wear, instability, and translation.47,57,58 The outcomes of second-generation designs remained variable. Although a meta-analysis of 1,105 TAAs using seven different second-generation TAAs reported a mean five-year survivorship of 90%, the range varied from 68% to 100%.47 Moreover, there were notable residual complications such as implant subsidence, residual pain, and limited range of motion.47
Third-Generation TAAsThe third-generation TAA was characterized by a three-component mobile-bearing system or various semiconstrained fixed-bearing systems, a lateral approach resurfacing option, and a continued decrease in bone resection.54 Additionally, it allows for repair of the medial and lateral ankle ligaments to maintain joint stability post-operatively. In a systematic review and meta-analysis of 497 TAAs,46 standardized 100-point ankle and hindfoot scores showed a mean improvement of 45.2 points (95% confidence interval [CI] 39.3-51.1). The overall range of motion improved slightly by 6.3 degrees (95% CI 2.2-10.5). The weighted complication rates ranged from 1.6% for deep infections to 14.7% for impingement. Secondary surgery surgical intervention was required in 12.5% of cases, with secondary arthrodesis performed in 6.3%. The mean weighted five-year prosthesis survival rate was 90.6%.
Fourth-Generation TAAsFourth-generation TAAs were introduced to the United States market in the early 2010s. These implants also build upon the strengths of third-generation implants to further optimize bone integration, improve mechanical alignment, and refine surgical techniques. Fourth-generation TAAs use 3-dimensional printing technology and an improved talus and tibia designs based on computed tomography scans of end-stage ankle osteoarthritis and normal ankles, resulting in a more anatomical design. These designs feature low-profile tibial and talar components that minimize bone resection while maintaining robust surface contact.59 Furthermore, wear resistance has been significantly improved through enhancements to the insert material.60 Due to the relative novelty of these implants, long-term outcomes have yet to be fully established. Nonetheless, early clinical reports indicate favorable short-term results, with survivorship rates ranging from 92% to 98% and significant improvements in both functional outcomes and pain scores within the first two postoperative years.60-63 Long-term follow-up and studies are critical in evaluating implant survivorship after the early and mid-term periods.1
The selection of surgical approach in TAA surgery remains a subject of ongoing discussion, with the anterior and lateral approaches being the most frequently employed (Table 3). The anterior approach is the most commonly performed technique in TAA, offering direct access to the ankle joint and enabling accurate visualization of the tibial and talar surfaces.64 However, it carries inherent risks, including the potential for intraoperative medial malleolar fractures, damage to adjacent neurovascular structures,65 and a high risk of wound-healing complications.66,67 Gross et al.68 reviewed 762 primary TAAs performed via an anterior approach. Twenty-six patients (3.4%) underwent a total of 49 procedures to treat the primary wound. Compared with the control group, patients with a primary wound had a significantly longer mean operation time (214.8 vs. 189.3 minutes, p = 0.041) and showed a trend toward a longer median tourniquet application time (151 vs. 141 minutes, p = 0.060).
Anterior Versus Lateral Approaches.
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The lateral approach, involving a fibular osteotomy, offers improved visualization of the lateral and posterior aspects of the joint. In addition, this approach enables anatomically contoured osteotomies that align with the natural curvature of the ankle, thereby potentially improving implant positioning while preserving native bone stock.69 A recent report revealed that acute deep infection occurred in 2.4% of cases, but no fibular nonunion was observed.70 However, the lateral approach is associated with fibular complications and a high risk of revision surgery.65,66 There have been reports of wound infection or breakdown in 11.9% of cases, fibular nonunion in 3.5% of cases, fibular plate irritation in 3.5% of cases, and tibial nerve neuropathy in 3.5% of cases.71 Cadaveric studies have reported that the lateral approach poses a risk of injury to the first perforator of the peroneal artery and the dorsalis pedis artery.72 In addition, although it is recommended to minimize the duration of TAA surgery as much as possible,68 a previous study reported that the mean surgical time was 115 minutes (range 65-150 minutes) for the anterior approach and 179 minutes (range 105-333 minutes) for the posterior approach, presenting a statistically significant difference.68 Prolonged operative duration is generally associated with extended tissue exposure, heightened fatigue,73 risk of technical errors among the surgical team, and a reduction in the systemic physiological defenses of the body.74 A recent study also reported an association between operation time and an increased risk of surgical site infection.75
One of the major causes of wound-healing complications is the dissection of the angiosome. The angiosome refers to the anatomical blood supply areas of major vessels and consists of one supplied by the anterior tibial artery, two by the peroneal arteries, and three by the posterior tibial arteries around the ankle joint (Figure 1).76 The safest and most ideal surgical incision is placed between angiosomes to ensure that both sides of the wound receive antegrade blood flow for optimal healing.77 In the anterior approach, the angiosome of the anterior tibial artery is incised longitudinally almost at the midline, which inevitably impairs wound healing. In response, the anteromedial approach, which involves cutting between the angiosomes, has been recommended,78 and it contributes to decreasing the incidence of wound complications in performing TAAs.79
Angiosomes around the lateral (left), anterior (center), and anteromedial (right) approaches.
AT: Area supplied by the anterior tibial artery, DP: Area supplied by the deep peroneal artery, PN: Area supplied by the peroneal artery, LC: Area supplied by the lateral calcaneal artery, LP: Area supplied by the lateral plantar artery, MC: Area supplied by the medial calcaneal artery, MP: Area supplied by the medial plantar artery.
The design of TAA devices has advanced through improvements in mechanisms, anatomical shapes, materials, and surgical approaches. Consequently, these improvements have led to better clinical outcomes and survival rates with each new generation. It is anticipated that further developments will continue, similar to those observed in other total joint arthroplasty for weight-bearing joints, such as total knee and total hip arthroplasties.
Masato Takao was responsible for the overall study concept and the manuscript writing. Yasuyuki Jujo provided oversight and critical revisions. All authors contributed to the final manuscript and approved it for submission.
The authors declare that there are no conflicts of interest.
Not applicable
Masato Takao is one of the Associate Editors of Journal of Orthopaedic Foot and Ankle Science and on the journal’s Editorial Board. This author was not involved in the editorial evaluation or decision to accept this article for publication at all.
