Alternatives to ankle replacement surgery and ankle fusion

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

This article is part of a series of articles we have prepared for our patients on the various stages of ankle instability and ankle osteoarthritis. This article is for the patient with significant ankle degeneration or post-traumatic injury damage who has been recommended for ankle replacement and ankle fusion surgery.

There are many people who benefit from ankle replacement and ankle fusion surgery. For some people, there are no alternatives if their ankle is significantly fused by bone spurs or they have had a previous injury and surgery for a traumatic ankle injury and their ankle is held together by plates and screws that now need to be replaced.

While contacted by these people, these are typically not the people we see in our clinics.  Sometimes we can help people with their ankle instability by treating and strengthening the ligaments that hold the ankle, heel, foot complex together. Stronger ligaments mean more natural stability. This can also help with excessive cramping in the calf area following surgery. However, failures of shifting hardware, bone breakage from the prosthetic device, and other complications post-surgery would present significant challenges to finding realistic non-surgical options.

When should you consider alternatives to ankle replacement surgery and ankle fusion? If you are like the many patients we see, you are considering this surgery because:

So why did you or are you avoiding surgery?

If you are like the people that contact our center, you may have the same reasons as some of the examples we hear:

If I get the fusion I will not be able to do my job.

I had a bad ankle break, now I have post-traumatic ankle osteoarthritis. I am now bone on bone at the tibiotalar joint where the tibia meets the talus. I am 44 years old and my doctors are recommending fusion. If I get the fusion I will not be able to do my job.

I had a very traumatic ankle injury thirty years ago.

I had a very traumatic ankle injury thirty years ago, they had to use bones from my hip to rebuild it. I have had pain ever since but at least I could function and remain active and do physical work. Now it is getting hard to walk with the pain, I am considering surgery but my surgical team can’t decide if fusion or ankle replacement is better. 

Ten years ago I was told I must have surgery

Ten years ago I was told to have an ankle fusion, it was the only way to help my pain. I decided against it and continued to be able to walk and be active. I love to run, I love to walk. But now it is getting progressively worse. I said no to surgery that I “must get,” ten years ago, I want to be able to say no now.

If you do not have a story like this but have had a lot of ankle pain and suddenly ankle surgery was recommended to you once physical therapy and cortisone failed, then you may be balking at getting the surgery because:

Are there options, how do you know what they are?


We will try to offer you good and realistic information about ankle surgery in this article.

Before the ankle replacement surgery and ankle fusion surgery recommendation.
Ankle swelling and inflammation that would not go away

You are likely in your situation because the damage to your ankle ligaments, including the talofibular ligament, has brought about an advanced degree of ankle instability that causes the ankle bones to abnormally rub together and have a degenerative effect on the joint. This unrelenting joint degeneration has resulted in chronic pain and instability, often demonstrated by ankle popping and frequent subluxations and dislocations.

If you are contemplating ankle replacement surgery read this amazing piece of research on ankle replacement failure

Researchers at Dartmouth College and Duke University published a February 2019 (1) study in which they wanted to examine why ankle replacement hardware fails. Why patients need to have a second surgery to replace this failure and what can possibly be done to prevent this failure. The research was published in the journal Foot & Ankle International.

Here are their learning points:

This is what we found so amazing: metal on metal problems replaced bone on bone problems in ankle replacement patients

Loosening and polyethylene fracture in the ankle following replacement surgery can mimic ankle instability and cartilage breakdown.

What does this mean?

It is all about ankle instability, the hardware failed because it was too loose. The loose component then rubbed unnaturally against the polyethylene causing the “polyethylene” cartilage to fail. When this happens doctors have to go in, tighten the component, and replace the damaged parts.

Revision of primary total ankle arthroplasty, while effective for many, has considerable risks of failure and reoperation

MAYBE, you try to do this with your own ankle with regenerative medicine injections. Naturally make the body tighten the ankle, provide stability, which allows cartilage to regenerate.

A July 2022 study in the journal Bone and joint open (16) wrote: “Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty fails, it can either undergo revision to another ankle replacement, revision of the total ankle arthroplasty to ankle arthrodesis (fusion), or amputation.” To address this problem, the researchers set out to “assess the outcomes of revision total ankle arthroplasties with respect to surgery type, functional outcomes, and reoperations.” In reviewing the date of previously published research on all-cause reoperations of revision ankle arthroplasties, the researchers found 26.9% of revision ankle arthroplasties required further surgery and 13.0% needed to be converted from replacement to fusion. 14.4% of revision ankle arthroplasties failed and 8% of conversion to fusions failed. The researchers then suggested that revision of primary total ankle arthroplasty, while effective for many, has considerable risks of failure and reoperation, especially in those with periprosthetic joint infection. Further, in those who undergo conversion of total ankle arthroplasty to fusion, there are high rates of nonunion.

A March 2022 paper from German surgeons and sports medicine specialists (17) wrote: “The number of patients with osteoarthritis of the ankle, which are treated by arthroplasty, has continuously increased in recent years. The survival time of these implants is far below the results following hip and knee arthroplasty. In some cases a failure rate of approximately 1% per year or a survival rate of 70% after 10 years has been reported. The most frequent reasons for revision of an ankle prosthesis are aseptic loosening, technical implantation errors and persisting pain.”

Ankle fusion does help many people

A December 2023 paper in the journal Foot and ankle international (18) assessed the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of the INFINITY total ankle implant.

A total of 143 prospectively enrolled patients (148 ankles) underwent total ankle replacement with a fixed-bearing total ankle implant. A total of 116 completed 2-year follow-up.

What are we seeing in this image?

This illustration demonstrates ankle instability caused by ankle ligament damage. Ankle ligament damage can be seen in symptoms of ankle popping, loss of motion, pain, arch cramping, foot, and toe pain, cracking and crepitation, loss of muscle strength, numbness in toes.

This illustration demonstrates ankle instability caused by ankle ligament damage. Ankle ligament damage can be seen in symptoms of ankle popping, loss of motion, pain, arch cramping, foot and toe pain, cracking and crepitation, loss of muscle strength, numbness in toes.

Let’s follow the path of options:

Your body is trying to fuse your ankle on its own – Anterior ankle impingement and bone spur formation

The degeneration process and clues on how to avoid surgery

One of the challenges of treating patients with advanced ankle osteoarthritis is the formation of large bone spurs in the ankle. These patients are in our clinics because they have a recommendation for fusion surgery. They do not want the fusion because it will limit their ankle range of motion and lock their ankle in an immovable position. When the patient gives us x-rays with large bone spurs present, we explain that their own body is busy doing its own fusion. The bone overgrowth or bone spurs are already locking up the ankle to help support the weight of the body. Advanced degeneration of this nature is challenging to treat in a non-surgical manner.

In November 2018 in the journal Clinical Anatomy (2), doctors from Case Western Reserve University School of Medicine and the University Hospitals Cleveland Medical Center examined the relationship between Anterior ankle impingement and bone spur formation. Here are the learning points of their research:

What does this tell us? Ankle instability and bone spur formation happen quickly. For more on this subject, please see our article Ankle impingement non-surgical treatment.

The risk of bone spurs from ankle instability – Anterior talofibular ligament [ATFL] injury and isolated calcaneofibular ligament [CFL] injuries are risk factors

Ankle instability can cause bone spurs. Listen to this May 2020 paper in the Orthopaedic Journal of Sports Medicine (3).

Learning and summary points:

Factors examined that would help predict who would be at greater risk for bone spurs:


We often hear from people who can tell their story that matches the researcher’s findings above as they suffer from a high-grade partial thickness tear of the anterior talofibular ligament at talar attachment, bone lesions with bone marrow edema in medial malleolus, and a tear in the ankle’s medial collateral ligament complex. What is the impact on a person like this? Trouble walking, running near impossible, lots of pain.

Surgery damages healthy non-injured tissue and can cause pain and complication

Research in the Journal of Foot and Ankle Surgery (4looked at the reasons why a patient will still have chronic ankle pain following ankle replacement:

In this research, the doctors suggest that total ankle replacement studies, looking for sources of pain following the procedure, tend to focus on complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence (the ankle is “caving” in), infection, bone fractures, and heterotopic ossification (bone material forms within soft tissue).

However, what is puzzling to the researchers is that even when all these problems are eliminated, patients can still experience unresolved ankle pain following an ankle replacement.

To find an answer, the researchers then initiated a cadaver study to examine the risk of injury to the anatomic structures in the back of the ankle that the ankle replacement procedure itself may cause. Replicating standard surgical procedures the doctors found that high rates of posterior structural injury were being caused by the surgery.

In particular, posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. (this can be troubling because a problem has been detected in the supportive structures of the ankle following ankle replacement) and that further study of the posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.

More problems after major ankle surgery – things don’t line up

In a study in The Journal of Foot and Ankle Surgery, (5doctors reported on the second generation of total ankle prostheses mechanisms and hardware. It was hoped this new generation of implants would address the weaknesses doctors and patients found in first-generation implants that led to complications and continued pain after surgery.

Here are the learning points of this research:

Overall the second, corrective surgery was deemed successful. “Statistically significant correction in coronal alignment was achieved immediately after surgery and maintained until a final mean follow-up of 8 years, even in patients with preoperative deformity greater than 10 degrees.”

A 2017 study in the Journal of Orthopaedic Surgery and Research cited this research in trying to identify predisposing factors related to replacement component malalignment after total ankle arthroplasty surgery. (6)

In the World Journal of Orthopedics(7) doctors wrote of defining patients who may be at high risk for delayed and nonunion failed surgeries and recommending surgeons to be aware of these risk factors.

In the medical journal Acta Orthopaedica, doctors reported on the post-surgical development of tarsal tunnel syndrome, i.e. posterior tibial nerve strain due to anatomical change after total ankle replacement surgery. (8)

As reported in the Journal of Foot and Ankle surgery, and this is something that patients often do not think about – the amount of radiation they are exposed to during ankle procedures. Significant radiation exposure has been linked to these procedures and doctors now recommend trying not to send the patient to revision surgery to avoid further radiation risk. (9)

Total ankle replacement that needs to be replaced

Obviously, as the number of total ankle replacements performed increases, so has the need for revision when the first surgery fails.

In recent research from Duke University medical center, doctors examined clinical outcomes following a salvage (revision) ankle implant from a failed total ankle replacement to identify patient- and technique-specific prognostic factors and to determine the clinical outcomes and complications following ankle arthrodesis for a failed total ankle replacements.

A salvage ankle arthrodesis for a failed total ankle replacement results in favorable clinical endpoints and overall satisfaction at short-term follow-up if the patients achieve fusion. (IF THEY ACHIEVE FUSION) (10).

Malleolus malunion

As your ankle problems continued to worsen, it is very likely that you started to become an expert in ankle anatomy. At the beginning of your recommendations to ankle replacement or ankle fusion, your doctor may have discussed your malleolus with you. You came to learn that you have a medial malleolus this was that outer boney bump in the ankle that sits at the end of your tibia or shinbone. That in fact, the medial malleolus is the biggest of the three bone segments that form the ankle joint. You have a lateral malleolus, the inside bone of the ankle, and a posterior malleolus, the rear of the ankle bone complex.

A July 2021 study in the journal Foot & Ankle International (11) describes the challenges of the management of an ankle malunion involving the posterior malleolus. Here we have a paper that explores what happens when an ankle fusion is performed and the posterior ankle bone does not fuse and the surgery is needed to correct it. The doctors describe intra-articular osteotomy, the bones are shaved down and refitting to try to fuse again.  The surgeons of this study found this to be a good outcome procedure noting: “A favorable clinical outcome was associated with a short time interval from original injury (surgery) to correction surgery and a lower grade of preoperative arthritis. . . An intra-articular osteotomy via a transfibular approach (to possibly limit nerve damage in the comprised ankle area) demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced (dislocated) posterior malleolar fragment.”

Ankle Fusions – a 50-50 chance that surgery would help

Complications from ankle replacement and ankle fusion surgery are not always catastrophic and do not represent the typical ultimate outcomes for the patient. Many people have great success with these surgeries. We deal with the people who don’t. Here is an example of a story we hear.

My boyfriend was a firefighter. He was injured in the line of duty almost thirty years ago. He recovered and continued as a fireman but over time, because of the traumatic injury and the physical demands of the job he developed progressively bad pain and arthritis.

His orthopedist recommends an ankle fusion to relieve his pain and he could continue his career. That was in 2006 – 25 years after the initial injury. He had major complications including a staph infection that required extensive antibiotics and debridement procedures. He was eventually able to recover but not for months. Because of these complications, he was forced into early retirement.

The ankle fusion surgery has left him with worse pain than before the surgery. His ankle and foot are chronically swollen and he has atrophied calf muscles. Is there anything that can be done?

Further down in this article we will discuss what may help.

When ankle replacement is not indicated, ankle fusion may provide some temporary pain relief but problems with the range of motion and non-union of bones are considerable concerns.

Doctors who recommended a surgical ankle fusion or the surgical implantation of a cadaver or artificial implant may also recommend that the patient alter their lifestyles, live with the pain because typically there was only a 50-50 chance that surgery would help.

In Belgium, doctors writing in the orthopedic journal, Acta Orthopaedica Belgica, expressed concern about ankle fusion outcomes. They noted that by introducing artificial implants in ankle fusion surgery the aim is to give pain relief by abolishing the movement of the ankle joint. However, few studies describe the patient’s post-surgery experience and whether it was successful or not.

This was the major concern of the author when they set up their retrospective study about the outcome after ankle fusion or subtalar fusion. Inclusion criteria were: pre-existing idiopathic and posttraumatic osteoarthritis (osteoarthritis that just showed up or had an unknown origin), leading to joint pain.

Also, they looked for patients who were unresponsive to conservative treatment (RICE and NSAIDs), clinically and radiologically fused with an open approach between 2007 and 2011.

They excluded patients who had a preexisting joint infection, diabetes, rheumatoid arthritis, nonunion, age below 18 years, deceased, and arthroscopic fusion (This is the arthroscopic or minimally invasive technique) the doctors here looked at the open technique.

Fifteen ankle fusions and 18 subtalar fusions fulfilled the criteria. The mean age of the patients was 77 and 69 years, respectively; the average follow-up period was 3 and 4 years.

In terms of face value, half the people were helped by an open ankle fusion. Again these were the patients examined that did not have issues of nonunion – the surgery failed – that was another group. (12)

Clearly, arthroscopic ankle fusion should be favored because it offers a less demanding surgery with less hospital stay and less chance for complications. However, there are difficulties getting all the surgical instruments into the ankle during the arthroscopic procedure and some people’s ankles are not large enough to allow this procedure to be successful. But the problem remains as attested to by research in the American Journal of Orthopedics:

Ankle arthritis is a painful and functionally limiting condition that can significantly worsen the quality of life. Ankle implants (arthrodesis), a common surgical procedure for ankle arthritis, provide good pain relief, patient satisfaction, and clinical outcomes when fusion is achieved. Potential disadvantages include malunion and nonunion (FUSION IS NOT ACHIEVED), malalignment, limited range of motion (ROM), altered gait mechanics, and development of adjacent joint arthritis requiring reoperation. (13)

Ankle fusion vs Total Ankle Replacement

Here is the opinion from researchers at Northwestern University published in the Journal of Orthopaedic Surgery and Research, May 2017. Parenthesis was added for clarification for the reader.

If given the choice, researchers say total replacement is better than fusion

Duke University researchers published a December 2017 paper with the title: The Value of Motion: Patient-Reported Outcome Measures Are Correlated With Range of Motion in Total Ankle Replacement. In this paper, the researchers suggested ankle replacement would be better than fusion because of quality of life issues regarding the value of motion. (14)

The rehabilitation/complication aspect of recovery

In October of 2019, doctors at Brighton and Sussex Medical School, University of Sussex, and the Royal Sussex County Hospital in the United Kingdom published research in The Bone & Joint Journal (15) examining the considerably varying regiments of postoperative rehabilitation regimens following ankle fusion. Specifically what they were looking at was the duration of postoperative non-weight bearing.

They examined the results of 60 studies and the 2426 ankles included. They divided these people and their ankles into 4 main groups:

Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative non-weight-bearing, although the existing literature is insufficient to make definitive conclusions.

It is common for Prolotherapy doctors to see people with continued pain complaints after ankle fusion and replacement surgeries. Besides the failure of the operation to achieve the patient’s goals of greater mobility and less or no pain, often overlooked causes of this post-surgery pain are that the surgery itself may have caused injury to previously undisturbed or uninjured tissue, such as the ligaments. When performing surgery, the ligaments are stretched and pulled in order to gain access to the joint. This is typical in ankle procedures.

This article asks the reader to consider certain research before undergoing ankle fusion or replacement surgery. But what if you had surgery already or wanted to know of alternatives?

To continue your research please see our articles:

Ankle Instability and Prolotherapy

This section will deal with the question, How do WE treat chronic ankle sprains and instability?

In this video, Danielle R. Steilen-Matias, MMS, PA-C demonstrates treatment to the lateral ankle

The treatment begins immediately in the video

This is comprehensive Prolotherapy, meaning there are a lot of injections. The patient getting the injections in this video is comfortable and tolerates the treatment well. The patient in this video is having the lateral or outer ankle treated.

What are we seeing in this image?

This is an x-ray of a patient who had multiple surgeries on her ankle. The two white arrows show those areas of the joint where she had lost a significant amount of cartilage. Her ankle motion was severely restricted when we examined her and she was advised that she would be a poor candidate for our treatments.

A demonstration of how we offer PRP and Prolotherapy.

A demonstration of Stem Cell Therapy and Prolotherapy

In our clinics, stem cell therapy, which are cells taken from the patient, NOT donated “stem cells,” are used in only the most advanced cases. This is not our “go-to,” treatment. In the same way, the joint degeneration does not occur overnight, one cannot expect the repair to be achieved overnight. In more advanced cases it can take more than 1 treatment to achieve treatment goals.

The treatment begins at 1:06 of the video

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your ankle problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff


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This article was updated July 2, 2021



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