Management of the failing ankle arthroplasty : an algorithm to assist decision-making

As total ankle arthroplasty becomes an increasingly common treatment for end-stage ankle arthritis, managing failing implants is becoming a growing challenge for orthopaedic surgeons. The UK National Joint Registry reports a 13-year cumulative revision rate of 17.01% in patients aged under 65 years, and 3.22% in those aged over 75 years. These complex cases are challenging to manage and require a structured, multidisciplinary approach. Key factors influencing management include implant and hindfoot alignment, infection, bone stock, and implant stability. Recent advances in implant design, imaging methods, surgical planning, and revision techniques have expanded the armamentarium available to orthopaedic surgeons. This article aims to provide an overview of the algorithmic assessment and management of the failing ankle arthroplasty, highlighting the importance of thorough clinical evaluation, appropriate imaging, and early identification or exclusion of periprosthetic joint infection, along with tailored treatment strategies for each underlying pathology.