Background: End-stage ankle osteoarthritis affects approximately 29,000 patients annually in the United Kingdom. Total ankle replacement (TAR) and ankle fusion (arthrodesis, AF) represent the two principal surgical interventions when conservative management fails. This comprehensive review synthesizes evidence from randomized trials, systematic reviews, and registry data from six countries.

Methods: This review integrates evidence from the TARVA randomized controlled trial (303 patients), multiple systematic reviews and meta-analyses, national joint registry data, and large database studies (>2,500 patients).

Results: The TARVA trial showed significant functional improvement in both groups at one year with no statistically significant difference in the primary outcome (adjusted mean difference -5.6, 95% CI -12.5 to 1.4, p=0.12). Fixed-bearing TAR demonstrated superiority over AF in post hoc analysis (p=0.008). Registry data demonstrate TAR survivorship of 90.2% at 5 years and 86.2% at 10 years. TAR complications: wound healing 13.8%, nerve injury 4.3%, revision 9-20% at 5 years. AF complications: nonunion 16% at 3 years, infection 6.2%, progressive adjacent joint arthritis 24-100%. Return to sports: 61.9% for TAR versus limited participation after AF. Cost-utility analysis showed TAR cost-effective over lifetime despite higher initial costs.

Conclusion: Both procedures effectively improve pain and function. Patient selection is critical: TAR suits older (>50 years), low-demand patients with preserved motion and good bone stock. AF preferred for younger, high-demand patients, severe deformity, or poor bone quality. Modern TAR implants show improved survivorship; AF offers excellent durability with adjacent joint degeneration concerns.

Keywords: Ankle arthritis, Ankle arthrodesis, Complications, Patient selection, Return to sports, Total ankle replacement