What Is the Success Rate of Ankle Replacement Surgery?

Ankle replacement surgery succeeds in keeping the implant in place and functioning for roughly 80 to 90 percent of patients at five years, with that figure gradually declining over longer periods. At ten years, registry data from multiple countries show survival rates in the range of about 66 to 86 percent, depending on the implant design, the surgeon’s experience, and how “success” is defined. Those numbers have been climbing over the past two decades as implant technology and surgical technique have improved, but they still trail behind the track record of hip and knee replacements. Understanding what shapes those odds, and what life looks like after the procedure, requires looking well beyond one headline number.

What the Survival Numbers Actually Show

The most commonly cited measure of ankle replacement success is implant survival, meaning the percentage of prostheses still functioning without needing to be removed or replaced at a given time point. A large analysis of the Swedish Ankle Register, covering 780 cases, found overall survival of about 81 percent at five years and 69 percent at ten years, though when one older implant design was excluded the ten-year figure rose to 78 percent.¹ That Swedish data skews a bit pessimistic because it includes earlier-generation devices that are no longer widely used.

A more recent study pooling global joint registry data showed wide variation across countries and time horizons: five-year survival ranged from 80 to 91 percent, ten-year from 66 to 84 percent, and fifteen-year from 56 to 78 percent.² At the higher end, a long-term follow-up of 683 patients who received the HINTEGRA implant reported survival of about 93 percent at five years, 86 percent at ten, and 82 percent at fifteen.³ A separate series following 200 STAR implants found roughly 76 percent still surviving at nearly 16 years, with a steady but low rate of decline over time.⁴

The spread in these figures is real and reflects differences in implant design, patient populations, surgical volume, and how registries define failure. A review of the literature cited mean success rates of up to 90 percent at ten years with newer prosthesis types, though the range in individual series stretched from 68 to 100 percent.⁵ So when someone asks “what is the success rate,” the honest answer is a range, not a single number, and where you land in that range depends heavily on circumstances.

How Patients Feel After Surgery

Implant survival tells you whether the device is still in place. It does not tell you whether the person walking around on it is happy. Patient-reported outcomes fill that gap, and the results are generally encouraging. A study of 126 patients found that pain and function scores improved steadily from before surgery through two years afterward. At two years, about 72 percent described themselves as satisfied or very satisfied with their ankle, while roughly 12 percent were dissatisfied.⁶ A separate analysis of STAR implant recipients at intermediate-to-long-term follow-up also found marked improvements in self-reported pain, function, and quality of life.⁷

Activity level after surgery seems to matter for how good those outcomes get. A study looking at patient activity before and after ankle replacement found that about 82 percent of patients maintained or increased their activity levels, and those who became more active showed substantially greater improvement in foot and ankle function scores than those who became less active.⁸ This does not mean pushing harder always helps; it suggests that the people who are able to stay active tend to report better results, which is partly cause and partly selection effect.

Ankle Replacement Versus Fusion

The main alternative to ankle replacement is ankle fusion, where the joint is permanently locked in place by fusing the bones together. Fusion eliminates the arthritic joint pain but also eliminates ankle motion, which changes how you walk and puts more stress on neighboring joints. Replacement preserves motion but introduces the risk that the implant wears out or loosens over time. The question of which is better has no tidy answer because the tradeoffs shift depending on patient age, activity level, and goals.

A randomized trial comparing the two procedures in patients aged 50 to 85 found no statistically significant difference in walking and standing function scores at one year. Wound-healing problems were more common after replacement (about 13 percent versus 6 percent), while bone nonunion, which is a failure of the fused bones to heal together, affected roughly 12 percent of fusion patients though only about half of those had symptoms.⁹ A post-hoc analysis in that same trial showed that fixed-bearing replacements did significantly outperform fusion on the walking and standing measure.

A systematic review comparing the two over a two-year horizon found nearly identical patient-reported outcome scores and similar revision rates, but the reoperation rate for ankle replacement was about two and a half times higher than for fusion.¹⁰ Reoperations include smaller interventions like a polyethylene liner swap, not just full revision, which is why the reoperation number runs higher than the revision number.

Over longer time horizons, that gap in revision rates persists. A large population-level study of about 41,000 patients found that fusion had significantly lower revision rates at every time point out to 20 years. One concern surgeons sometimes raise about fusion is that locking the ankle will eventually force the neighboring joints to wear out, leading to further fusions down the road. That study found no significant difference in the 25-year risk of adjacent joint fusion between the two procedures, which cuts against the common argument that replacement protects surrounding joints.¹¹

Despite replacement’s higher revision burden, cost-effectiveness analyses have found it compares favorably. One study calculated that replacement cost about $20,200 more than fusion but produced an additional 1.7 quality-adjusted life years, landing the cost per quality-adjusted life year at roughly $11,800, well within what most health systems consider cost-effective.¹² A separate UK analysis also concluded the procedure was cost-effective, with the cost per quality-adjusted life year remaining under £4,500 even after accounting for revision rates and discounting.¹³

What Influences Whether Your Replacement Lasts

Several factors shift the odds meaningfully. Among the most significant is implant design. A meta-analysis comparing fixed-bearing and mobile-bearing prostheses found overall survivorship of about 94 percent for fixed-bearing versus 89 percent for mobile-bearing, though the difference did not reach statistical significance in the pooled analysis.¹⁴ However, a Dutch registry study did find a significant difference: revision risk at seven years was about 5 percent for fixed-bearing implants and 11 percent for mobile-bearing ones, with mobile bearings carrying roughly 2.5 times the hazard of revision.¹⁵ The field has been shifting toward fixed-bearing designs in recent years, and these registry results are part of the reason.

The underlying cause of the arthritis also matters. One review identified primary osteoarthritis and post-traumatic osteoarthritis as independent risk factors for implant failure, alongside age over 70.⁵ That said, a meta-analysis comparing inflammatory arthritis patients (like those with rheumatoid arthritis) to non-inflammatory arthritis patients found virtually identical functional outcome scores, complication rates, and survival between the two groups.¹⁶ Patients with post-traumatic arthritis from a prior fracture versus those with instability-related arthritis also showed similar outcomes and survival at six years.¹⁷

Ankle alignment matters too. If the ankle is tilted inward or outward before surgery, the surgeon needs to correct that deformity to keep the implant centered under load. Research shows that even moderate to severe deformities can be corrected with soft-tissue balancing and achieve good short-term results, particularly when the tilt is less than 25 degrees.¹⁸ A study of patients with valgus deformity averaging about 15 degrees found that the correction held over time and reoperation rates were comparable to those seen in well-aligned ankles.¹⁹ But residual uncorrected malalignment is clearly harmful to long-term implant longevity and warrants additional procedures at the time of surgery or afterward.²⁰

Why Surgeon Experience Matters More Than You’d Think

Ankle replacement is a technically demanding procedure, and the volume of surgeries a surgeon performs correlates with outcomes more strongly than many patients realize. A study defining high-volume surgeons as those performing at least 21 cases per year found that these surgeons had half the rate of overall complications, a dramatically lower rate of intraoperative fracture, and shorter hospital stays compared to lower-volume colleagues.²¹ An earlier study found that patients operated on earlier in a surgeon’s career had three times the chance of a wound complication and took about a week longer to heal than patients treated later, once the surgeon had built experience.²²

Interestingly, a French study found that high-volume centers actually documented more complications than low-volume centers but had fewer implant failures. That seems paradoxical, but it likely reflects both better detection of minor complications and better ability to manage them before they lead to implant loss.²³ The practical takeaway is worth thinking about if you are considering the procedure: asking how many ankle replacements your surgeon performs each year is a reasonable question with real implications.

The Age Paradox

You might assume younger patients would do better after ankle replacement because they tend to be healthier. The opposite is true. A large single-institution study found that patients under 55 had the highest rates of reoperation (about 20 percent), implant failure (about 6 percent), and polyethylene liner exchange (about 8 percent), compared to patients aged 55 to 70 and those over 70. Younger patients also reported worse pain scores and lower functional outcome scores at follow-up.²⁴

The most likely explanation is that younger patients place higher demands on the implant through more vigorous activity over a longer expected lifespan. They are also more likely to have post-traumatic arthritis from injuries rather than age-related wear, which can involve more complex anatomy. This does not mean ankle replacement is a bad choice for someone in their 40s, but it does mean expectations need to be calibrated differently, and the likelihood of needing further surgery at some point is higher.

Complications and Infection

The most feared complication after any joint replacement is infection around the prosthesis. A systematic review of ankle replacement infections found a mean incidence of about 3.8 percent, with most infections classified as late rather than acute. When infection does develop, treatment is complex: two-stage revision, where the implant is removed, the infection is treated with antibiotics, and a new implant is inserted months later, is the most common approach.²⁵

A more recent systematic review found that infection eradication rates were reasonably high regardless of approach: about 89 percent for debridement with implant retention, 95 percent for a 1.5-stage revision, and 92 percent for a full two-stage revision. However, the stakes are significant. Among patients treated for infected ankle replacements, about 7 percent ultimately required below-knee amputation.²⁶ That amputation rate, though low overall, is much higher than what is seen with infected hip or knee replacements, and it reflects how little soft tissue and blood supply the ankle joint has to work with compared to those larger joints.

What Happens When the Implant Fails

When an ankle replacement does fail, the options are revision to a new replacement or conversion to a fusion. Revision outcomes are a step down from primary surgery, as expected. A study of 122 revision patients found an overall failure rate of about 15 percent after re-revision. Patients who had both metal components swapped actually had lower subsequent failure rates than those who only had the polyethylene liner exchanged, and adding procedures to correct alignment at the time of revision also reduced failure.²⁷ A study of a newer customized implant used specifically for revision cases found a secondary revision rate of about 7 percent at two years, with functional scores improving significantly.²⁸

Getting Back to Work and Sports

For many people considering ankle replacement, the most practical question is not how long the implant lasts on a registry graph but whether they will be able to walk comfortably, return to work, and stay active. The evidence here is broadly positive. A meta-analysis of return to sport after ankle replacement found that about 62 percent of patients were participating in sports postoperatively, and up to 92 percent were able to return to their preoperative activity level.²⁹ The most common activities were swimming, hiking, cycling, and skiing, with high-impact sports like running being much less common after replacement.³⁰

Return to work timelines depend on what the work involves. A study tracking employed ankle replacement patients found the average return to sedentary work was under three weeks, while return to physically demanding work took about 13 weeks. About 9 percent of patients retired or reduced their work role after the procedure.³¹

Recovery and Early Rehabilitation

How recovery is managed in the weeks after surgery has shifted in recent years. The traditional approach involved six weeks of immobilization in a cast with no weight on the ankle. Newer evidence suggests that allowing patients to bear weight earlier, around three weeks instead of six, produces better range of motion at six weeks, six months, one year, and even two years, without any increase in complication rates.³²³³

A randomized trial comparing early mobilization to six weeks in a walking cast found no significant differences in function, gait, pain, quality of life, or satisfaction at two years, concluding that early mobilization was a safe alternative.³⁴ The direction of the evidence is toward earlier movement being both safe and beneficial for regaining motion, though the two-year endpoint outcomes converge regardless of approach. If your surgeon still uses a six-week immobilization protocol, it is not wrong, but the newer data gives reason to discuss alternatives.

Patient-Specific Instruments and Preoperative Planning

One of the more promising advances in ankle replacement is the use of patient-specific instrumentation, where a CT scan of your ankle is taken before surgery and custom surgical guides are 3D-printed to fit your anatomy precisely. Early data suggest that these guides allow implant placement within about 2 degrees of the preoperative plan in all directions, which is tighter than the 3 degrees or more seen with conventional instruments or computer navigation.³⁵ Getting the alignment more precise should, in theory, reduce eccentric wear and loosening over time, though long-term outcome data specifically comparing patient-specific to conventional instrumentation are still accumulating.³⁶ Patient expectations before surgery, incidentally, do not strongly predict how satisfied someone ends up being afterward. A prospective study found almost no correlation between how much improvement a patient expected preoperatively and how they rated their outcome, suggesting that expectation and actual satisfaction are largely independent.³⁷ That is reassuring in a way: going in without unrealistic optimism does not mean you are setting yourself up for disappointment.