By Mr Ali Abbasian FRCS (Tr & Orth), Consultant Orthopaedic Foot and Ankle Surgeon, London
If you have severe ankle arthritis, you may be choosing between an ankle replacement and an ankle fusion. Both operations reliably reduce pain. This guide explains how they differ, what the research shows, and how surgeons like myself decide which suits each patient.
Key points
- Most ankle arthritis can be managed without surgery at first.
- Both operations relieve pain and improve walking.
- Ankle replacement keeps movement; ankle fusion may last longer.
- Age, bone quality, health, activity and the other joints in your leg guide the choice.
- Most people return to low-impact activity after either operation.
On this page
- What is end-stage ankle arthritis?
- Do I need surgery?
- What is the difference between ankle replacement and ankle fusion?
- What does the research show?
- How long does an ankle replacement last?
- What happens to the other joints after a fusion?
- Who is suited to each operation?
- Can I play sport after ankle surgery?
- What are the risks of each operation?
- Questions to ask your surgeon
- Quick comparison
- Frequently asked questions
What is end-stage ankle arthritis?
End-stage ankle arthritis means the cartilage covering the joint has worn away, so bone rubs on bone. It causes pain, swelling and stiffness, and often makes walking on uneven ground or slopes difficult.
Unlike hip and knee arthritis, most ankle arthritis follows an old injury, such as a fracture or repeated sprains that left the ankle unstable. It can also be caused by inflammatory conditions such as rheumatoid arthritis. Because of this, people with ankle arthritis are often younger than those needing a hip or knee replacement.
Do I need surgery?
Not always. Many people manage well for years with:
- painkillers and anti-inflammatory medicines
- changing activities, for example cycling or swimming instead of running
- weight loss, which reduces the load on the ankle
- supportive boots, an ankle brace or shoes with a rocker sole
- physiotherapy
- a steroid injection into the joint
If the arthritis is less advanced, joint-preserving surgery may help. This includes keyhole surgery to remove bone spurs, or realigning the bones when the joint is wearing unevenly.
Surgery to replace or fuse the ankle is usually considered when these measures no longer control the pain and it is limiting your daily life.
What is the difference between ankle replacement and ankle fusion?
Total ankle replacement removes the worn joint surfaces and replaces them with metal implants and a plastic liner, much like a hip or knee replacement. The ankle keeps its up-and-down movement. You can read more in my ankle replacement FAQ guide.
Ankle fusion (arthrodesis) removes the remaining cartilage and joins the bones with screws or a plate. The painful joint stops moving, and the joints in the foot take over some of its work. In suitable patients, a fusion can be done through keyhole (arthroscopic) surgery, with smaller cuts and often a quicker recovery.
The main trade-off is simple: replacement keeps movement, fusion lasts longer.
What does the research show?
- Similar results at one year. The UK TARVA trial, run across 17 NHS hospitals, compared the two operations directly in patients aged 50 to 85. Both gave large improvements in pain and walking, with no meaningful difference between them.1
- Similar results at over 10 years. A Canadian study following patients for an average of 13 years found long-term function was similar when the operation suited the patient.2
- Fusion needs less further surgery. A 25-year study of around 41,000 patients in England found replacements are more likely to need further surgery, and the gap grows over time.3
- Early versus late complications. Replacement has fewer complications in the first couple of years; fusion has fewer in the long term.4
How long does an ankle replacement last?
An ankle replacement is a mechanical joint, so it will not last forever. Studies suggest around 1 to 2% fail each year, which means roughly 1 in 10 to 1 in 5 need further surgery within 10 years. Modern implant designs may do better, but long-term results are still being gathered.
If a replacement wears out or loosens, it can usually be revised with new implants or converted to a fusion. Both are bigger operations than the first one.
What happens to the other joints after a fusion?
The foot and ankle contain around 30 joints. After a fusion, the joints next to the ankle take over much of its movement, so many people walk almost normally and others cannot tell they have had surgery.
The downside is that these joints carry extra load. Over 10 to 20 years, most show signs of wear on X-ray, although only some cause symptoms. This is why the health of your other foot joints matters so much when choosing between the two operations.
Who is suited to ankle replacement or ankle fusion?
Age
Younger, active patients put more strain on an implant over more years. One study found patients under 70 had nearly four times the risk of implant failure of those over 70.5 Older, less active patients are often good candidates for replacement.
Bone quality and general health
Fusion is usually favoured if you have:
- weak bone (osteoporosis)
- diabetes, or you smoke
- poor circulation or poor skin healing
- significant deformity or nerve damage (neuropathy)
These factors can affect fusion too, so they are discussed carefully rather than ruling anything out.6
The other joints in your leg
If the joints around your ankle are already worn, a fusion will put more load on them, so a replacement may suit you better. Arthritis in your hip or knee also affects how well you recover from either operation. Your surgeon should examine your whole leg, not just the ankle.
Activity and work
- Fusion suits heavy manual work and high-impact demands.
- Replacement suits people who need ankle movement, such as crouching, climbing ladders or walking on hills, and those with stiffness or arthritis in nearby foot joints or both ankles.6
Can I play sport after ankle surgery?
Most people return to cycling, swimming, walking, golf and dancing after either operation. Running, tennis and football are much less reliable.7
What are the risks of each operation?
Ankle replacement
- wound-healing problems
- nerve irritation
- higher chance of further surgery in later years
Ankle fusion
- bones failing to join (around 7% in the TARVA trial)1
- blood clots
- arthritis in nearby foot joints over time
Some recent research suggests modern replacements may cause fewer complications overall than fusion.8 The evidence is still developing.
Questions to ask your surgeon
- How healthy are the other joints in my foot, knee and hip?
- Which operation would you recommend for me, and why?
- How many of each operation do you perform each year?
- What would happen if the operation did not work?
- How long will I be in plaster or a boot, and when can I drive and return to work?
Ankle replacement vs ankle fusion: quick comparison
| Ankle replacement | Ankle fusion | |
|---|---|---|
| Ankle movement | Kept | Lost |
| Long-term durability | Lower | Higher |
| Best age group | Older, less active | Younger, more active |
| Bone quality | Good | Any, including weaker bone |
| Other foot joints | Already worn | Healthy |
| Work | Lighter, needs movement | Heavy manual |
| Time in plaster | About 2 weeks | 6 to 8 weeks |
| Main risks | Wound problems, revision | Non-union, nearby joint arthritis |
Frequently asked questions
Which is better, ankle replacement or ankle fusion?
Neither is better for everyone. Both relieve pain well. The right choice depends on your age, health, bone quality, activity and the other joints in your leg.
How long does an ankle replacement last?
Most last many years, but around 1 in 10 to 1 in 5 need further surgery within 10 years. Younger, more active patients are more likely to need revision.
Will I limp after an ankle fusion?
Most people walk well after fusion. The foot joints take over some movement, though walking on slopes and uneven ground can feel harder.
How long is recovery?
Recovery starts sooner after an ankle replacement, as early movement helps the new joint. Most patients spend about two weeks in plaster before starting to walk on the ankle. After an ankle fusion, the bones need time to join, so you will usually be in a cast or boot for 6 to 8 weeks before taking full weight. With either operation, improvement continues for up to a year. Your surgeon will give you a plan for your operation.
What happens if an ankle replacement wears out?
It can usually be revised with new implants or converted to a fusion. Both are bigger operations than the original replacement.
Can an ankle fusion be changed to a replacement later?
In some cases, yes, but it is a complex operation. Discuss this with your surgeon if it matters to you.
Are both operations available on the NHS?
Yes. Both are available on the NHS and privately.
Book a consultation
Mr Ali Abbasian is a Consultant Orthopaedic Foot and Ankle Surgeon at Guy’s and St Thomas’ Hospital and in private practice in London. He performs both ankle replacement and ankle fusion surgery.
This article is for general information and does not replace a personal assessment by a foot and ankle surgeon.
References
- Goldberg AJ et al. Annals of Internal Medicine, 2022.
- Glazebrook M et al. Journal of Bone and Joint Surgery, 2025.
- Hennessy et al. Foot & Ankle International, 2026.
- Liu et al. International Orthopaedics, 2023.
- Kostuj T et al. BMC Musculoskeletal Disorders, 2024.
- Ewalefo SO et al. Current Reviews in Musculoskeletal Medicine, 2018.
- Johns et al. Foot & Ankle International, 2020.
- Encinas et al. Journal of the American Academy of Orthopaedic Surgeons, 2026.
