Surgical success is a synthesis of systematic preoperative assessment, meticulous surgical planning, and methodical performance of the operative procedure.

A prerequisite for success is correct patient selection. The ideal candidate is an elderly individual with limited physical demands, low body mass index, a well-aligned and stable hindfoot, normal bone stock, good preservation of peripheral vascularity, and healthy periarticular soft tissues. TAA is indicated to preserve remaining motion in special circumstances in which end-stage OA affects both ankles, or is present in a foot stiffened by adjacent joint degeneration or previous subtalar or midfoot arthrodesis. TAA should be avoided in young patients with high functional demands, severe hindfoot malalignment, neuroarthropathy, active infection, talar avascular necrosis, and poor soft-tissue envelope.

Modern TAA designs are cementless three-component systems comprised of two metallic components and an interposed ultra-high-molecular-weight polyethylene (UHMWPE) insert. Irrespective of manufacturer, the surgical approach and general operative principles are similar.

Most surgeons favor an anterior approach to the ankle. A 15-cm longitudinal incision is made over the anterior aspect of the ankle. The extensor retinaculum is incised, the interval between the tendons of the tibialis anterior and extensor hallucis longus (EHL) is entered, and the joint capsule is incised longitudinally to expose the ankle joint. The most distal part of the anterior tibial margin and its osteophytes are removed with an osteotome to expose the tibial plafond and talar dome. The tibial resection parameters that must be considered for correct component placement are varus/valgus alignment, slope, height, rotation, and translation. The tibial and talar cuts are made with the specific instrumentation provided. The medial and lateral gutters must routinely be cleared of osteophytes and impinging soft tissue. Trial implants are sized and inserted, and their position and ankle alignment verified by fluoroscopy and on-table clinical assessment of ankle ROM. The final prosthesis is subsequently implanted, and once again final position and alignment are confirmed clinically and radiologically. Meticulous hemostasis is ensured to avoid a postoperative hematoma that can exert pressure on the surrounding soft tissues, leading to skin necrosis, or can act as a source of infection. Careful closure is performed, beginning with the joint capsule. Careful attention is given to the extensor retinacular repair, as it forms an important barrier between the ankle joint and the more superficial incision. The subcutaneous layer and skin are closed in layers. Staples are not recommended for closure, particularly in the tenuous central portion of the incision directly overlying the ankle joint. A soft dressing and postoperative splint are carefully applied.

The TAA procedure can be fraught with technical errors, as demonstrated by the literature validating the existence of
a “learning curve” during which surgeons acquire skills and experience before they become proficient at performing TAA. Keeping in mind several technical pearls will contribute to a better surgical outcome. Careful soft-tissue dissection, the avoidance of unnecessary retraction, and methodical wound closure cannot be overemphasized since good soft-tissue handling is paramount to successful wound healing. Repair of the extensor retinaculum is crucial, as it prevents bowstringing of the tibialis anterior tendon exerting direct pressure on the undersurface of the surgical wound, which can rapidly culminate in disastrous wound necrosis or dehiscence. Long-standing soft-tissue contractures must be recognized and released in order to balance the ankle joint. Clearance of the gutters must be a routine part of each surgery to avoid postoperative impingement pain. Preexisting ankle instability may predispose to prosthesis subluxation or dislocation, and must therefore be recognized and corrected through ligamentous reconstructive procedures during TAA surgery. Tendon pathology—such as fissures, ruptures, or dislocations—should be addressed. Achilles tendon lengthening is indicated in patients with heel equinus contracture, but should be used sparingly and cautiously due to the risk of chronic heel cord pain postoperatively. Symptomatic peritalar joint arthritis should be considered for fusion in the same setting. Hindfoot and first ray osteotomies and tendon transfers may be required in some cases to balance the foot.