Comparative effectiveness of arthrodesis, total ankle replacement, and supramalleolar osteotomy in ankle osteoarthritis : a systematic review and meta-analysis

   Background. Ankle osteoarthritis remains a challenging problem, but conservative therapy fails to restore function and does not prevent the progression of degenerative changes. There is no consensus on which surgical strategy—arthrodesis, total ankle arthroplasty, or supramalleolar osteotomy – provides the optimal balance between functional outcomes and complication rates.

   Objective. To conduct a comparative meta-analysis of functional outcomes and complication rates associated with different surgical approaches to the treatment of ankle osteoarthritis.

   Materials and Methods. A literature search was performed in PubMed, Scopus, eLibrary, and CyberLeninka databases for the period 2000–2025. Nine comparative studies (2014–2024) evaluating functional outcomes using AOFAS, FAAM, and MOXFQ scales and complication rates were included. Statistical analysis was performed in R using a random-effects model (DerSimonian–Laird) with Hartung–Knapp adjustment.

   Results. Mean differences between methods did not reach statistical significance (p > 0.05). A trend toward higher functional scores was observed following supramalleolar osteotomy (MD = +3.43; 95 % CI [–9.16, 16.02]) and lower scores following arthroplasty (MD = –13.05; 95 % CI [–28.52, 2.43]). Infection risk was higher after total ankle arthroplasty (RR = 2.32; 95% CI [1.06–5.09]), with revision rates nearly twice as high (RR = 1.92; 95 % CI [0.90–4.10]). Nonunion following arthrodesis occurred in 10–12 % of cases.

   Conclusion. All three methods provide comparable functional outcomes. Arthrodesis is reliable but carries nonunion risk. Arthroplasty is associated with higher infection and revision rates. Supramalleolar osteotomy demonstrates the lowest complication rates and may be considered a joint-preserving option.

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