Findings from a study comparing the outcomes following total ankle replacement (TAR) and ankle fusion for patients with hemophilia showed significantly lower pain scores in both groups, according to a new study published in Haemophilia.

Ten out of the 11 patients who received ankle fusion successfully demonstrated bony consolidation within 3 months. Subjective outcomes using the American Orthopedic Foot and Ankle Score (AOFAS) significantly improved, with mean scores going from 28.1 to 80.3 among ankle fusion patients and from 21.5 to 68.0 in TAR patients.

“The reason to perform TAR in end-stage arthritis like in severe arthropathy of the ankle is to preserve the motion of the ankle and the physiological gait, whereas arthrodesis increases the load on adjacent joints, potentially requiring further operations,” the authors suggested.

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The replacement surgery allowed patients to maintain greater range of motion (ROM) in the ankle than the fusion group, resulting in more pain in the articular capsules and soft tissues due to scarring after many years of inflammation. Pain reduction in the replacement group took more time compared to the fusion group, although recovery took longer in the fusion group.

Fusion surgeries (129.1 ± 13.8 minutes) were shorter than replacement surgeries (152.8 ± 29.9 minutes). Length of hospitalization after fusions lasted 10.2 ± 1.6 days, while the length of hospitalization after replacements lasted 10.1 ± 1.8 days.

Investigators enrolled 19 male patients with end-stage hemophilic arthropathy, 9 with a mean age of 35.7 ± 7.8 years in the fusion group and 10 with a mean age of 49.4 ± 7 in the replacement group. Eight patients undergoing fusions and 8 undergoing replacements had hemophilia A, while 3 patients in each group had hemophilia B. Nine patients in the fusion group had severe hemophilia, while 2 had moderate hemophilia.

In the replacement group, 8 had severe hemophilia, while 3 had moderate hemophilia. Patients had HIV infection in 5 (45.5%) operations, 9 of 10 patients had hepatitis C, and 3 patients (27.3%) had both hepatitis C and B. In the fusion group, patients had HIV infection in 4 (36.4%) operations. All patients had hepatitis C, and 1 patient (9.1%) had both hepatitis C and B.

Researchers conducted musculoskeletal assessments including range of motion, pain levels, and AOFAS outcome measures. Each patient received 6-week, 12-week, and 3-year surgical follow-up where they underwent x-rays to assess for the bony union of fusions or prosthetic integration of replacements, as well as to rule out infections.

All patients except for 2 expressed willingness to undergo the surgical procedures again and were pleased with the outcomes that provided significant pain relief.


Mussawy H, Kehrer M, Strahl A, et al. Clinical and patient reported outcome in total ankle replacement compared to ankle fusion in end-stage haemophilic arthropathy. Haemophilia. Published online October 8, 2021. doi:10.1111/hae.14429